Endodontic surgery with ultrasonic retrotips: One-year follow-up

Analysis of the Prognostic Factors That Influence the Outcome of Periapical Surgery, including Biomimetic Membranes for Tissue Regeneration: A Review

The objective of this study was to analyze the prognostic factors that influence the outcome of periapical surgery. A systematic search of the literature was carried out using PubMed and Scopus databases between January 2000 and December 2023 with no language limitations. The PICO question of the present systematic review was: What prognostic factors may influence the outcome of periapical surgery? The most relevant randomized controlled clinical trials (RCTs), prospective clinical trials, retrospective studies, and meta-analyses (n = 44) were selected from 134 articles. The reviewed literature evidenced that bone-lesion healing could significantly be improved by the absence of deep periodontal pockets (>4 mm), localization in anterior teeth, the absence of pain and/or preoperative symptoms, a size of bone lesion < 5 mm, the use of ultrasound, the correct placement of retrograde filling material, and the use of different biomimetic membranes for guided tissue regeneration (GTR). Some preoperative and intraoperative factors could significantly improve the prognosis of periapical surgery. However, these results were not conclusive, and further high-quality research is required.

The effect of imaging modality on the evaluation of the outcome of endodontic surgery

OBJECTIVES

The aim of this study was to assess the effect of the imaging modality on the evaluation of the outcome of modern surgical endodontic treatments, based on a systematic review of the literature.

METHODS

Strict inclusion criteria were adopted in order to identify studies that assessed the outcome of surgical endodontic treatments. Treatment success rates were pooled. The effect of the imaging modality used for the outcome assessment, and the methodological quality of the studies (based on the risk of bias (ROB)), were evaluated.

RESULTS

Nineteen articles were included. The success rates assessed by periapical (PA) radiography were significantly higher than when cases were evaluated by cone beam computed tomography (CBCT; 90 and 35% respectively). This difference was mainly due to a significant proportion of cases that were assessed by CBCT as uncertain healing (48%) compared to only 4% using PA. The success rates ranged between 86 and 92% in low ROB studies, and between 19-100% in high ROB studies.

CONCLUSIONS

Outcome assessment based on CBCT may lead to significantly lower estimates of rate of success, and higher rates of uncertain healing, thus presenting a dilemma in the decision-making following surgical endodontic treatment. The success rates of studies with lower methodological quality are more variable than for high quality studies.

Outcomes reporting in systematic reviews on surgical endodontics: A scoping review for the development of a core outcome set

BACKGROUND

Evidence-informed decision-making in healthcare relies on the translation of research results to everyday clinical practice. A fundamental requirement is that the validity of any healthcare intervention must be supported by the resultant favourable treatment outcome. Unfortunately, differences in study design and the outcome measures evaluated often make it challenging to synthesise the available research evidence required for secondary research analysis and guideline development. Core outcome sets (COS) are defined as an agreed standardised set of outcomes which should be measured and reported as a minimum in all clinical trials on a specific topic. The benefits of COS include less heterogeneity, a reduction in the risk of reporting bias, ensuring all trials contribute data to facilitate meta-analyses, and given the engagement of key stakeholders, it also increases the chances that clinically-relevant outcomes are identified. The recognition of the need for COS for assessing endodontic treatment outcomes lead to the development of Core Outcome Sets for Endodontic Treatment modalities (COSET) protocol, which is registered (No. 1879) on the Core Outcome Measures in Effectiveness Trials (COMET) website.

OBJECTIVES

The objectives of this scoping review are to: (1) identify the outcomes assessed in studies evaluating surgical endodontic procedures; (2) report on the method of assessment used to measure the outcomes; (3) and assess selective reporting bias in the included studies. The data obtained will be used to inform the development of COS for surgical endodontics.

METHODS

A structured literature search of electronic databases and the grey literature was conducted to identify systematic reviews on periradicular surgery (PS), intentional replantation (IR) and tooth/root resection (RR), published between January 1990 and December 2020. Two independent reviewers were involved in the literature selection, data extraction and the appraisal of the studies identified. The type of intervention, outcomes measured, type of outcomes reported (clinician- or patient-reported), outcome measurement method, and follow-up period, were recorded using a standardised form.

RESULTS

Twenty-six systematic reviews consisting of 19 studies for PS, three studies for IR and four studies for RR were selected for inclusion. Outcome measures identified for PS and IR included pain, swelling, mobility and tenderness, outcomes related to periodontal/soft tissue healing (including sinus tract), periradicular healing, tooth survival, life impact (including Oral-Health-Related-Quality-of-Life), resource use and/or adverse effects. For RR, in addition to tooth survival, endodontic complications, and adverse effects, the outcome measures were primarily periodontal-related, including pocket depth reduction, attachment gain, periodontal disease, and periodontic-endodontic lesions. The majority of outcome measures for PS, IR, and RR were assessed clinically, radiologically and/or via patient history. Specific tools such as rating scales (Visual Analog Scale, Verbal rating Scale, Numerical Rating Scale, and other scales) were used for the assessment of pain, swelling, and tenderness, and validated questionnaires were used for the assessment of oral health-related quality of life. The range of follow-up periods were variable, dependent on the outcome measure and the type of intervention.

CONCLUSIONS

Outcome measures, method of assessment and follow-up periods for PS, IR and RR were identified and categorised to help standardise the reporting of outcomes for future research studies. Additional outcome measures that were not reported, but may be considered in the COSET consensus process include loss of root-end filling material, number of clinic visits, surgery-related dental anxiety and muco-gingival aesthetic-related measures, such as scarring, black triangles, root surface exposure, and tissue discolouration.

Prognostic Factors in Endodontic Surgery Using an Endoscope: A 1 Year Retrospective Cohort Study

This retrospective study clarified the success rate of endoscopic endodontic surgeries and identified predictors accounting for successful surgeries. In this retrospective study, 242 patients (90 males, 152 females) who underwent endoscopic endodontic surgery at a single general hospital and were diagnosed through follow-up one year later were included. Risk factors were categorized into attributes, general health, anatomy, and surgery. Then, the correlation coefficient was calculated for the success or failure of endodontic surgery for each variable, the odds ratio was calculated for the upper variable, and factors related to the surgical prognosis factor were identified. The success rate of endodontic surgery was 95.3%, showing that it was a highly predictable treatment. The top three correlation coefficients were post, age, and perilesional sclerotic signs. Among them, the presence of posts was the highest, compared with the odds ratio, which was 9.592. This retrospective study revealed the success rate and risk factors accounting for endoscopic endodontic surgeries. Among the selected clinical variables, the presence of posts was the most decisive risk factor determining the success of endodontic surgeries.

The applications of ultrasound, and ultrasonography in dentistry: a scoping review of the literature

OBJECTIVES

This scoping review aims to summarize the available literature on the clinical applications of ultrasonography and ultrasound in diagnostic, therapeutic, and interventional dental applications.

MATERIALS AND METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Extension for Scoping Reviews checklist and conducted a protocol-driven scoping review of randomized controlled trials, cohort studies, cross-sectional studies, case-control studies, and case series that assessed ultrasonography or ultrasound use as a stand-alone diagnostic, therapeutic, and interventional tool in dentistry. We included studies published after 1980, study samples ≥ 10, with diagnostic, concordance, or therapeutic outcomes. We searched Ovid MEDLINE, Embase, and others (up to April 2021) and extracted information regarding study level, patient level, test or treatment level, and outcome level data.

RESULTS

Five interventional studies (related to oral medicine, temporomandibular disorders, and dental anesthesia), eight therapeutic studies (related to surgery and orthodontics), and seventy-five diagnostic studies (related to orthodontics, surgery, endodontics, oral medicine, temporomandibular disorders, restorative dentistry, and periodontology) were identified and presented in this review.

CONCLUSION

Ultrasonography has a well-established niche in diagnostic dentistry, while therapeutic and interventional ultrasounds have a smaller, yet present, niche in dentistry. However, further research is needed to report the precise estimates of the diagnostic, therapeutic, and interventional effects.

CLINICAL SIGNIFICANCE

Dentists are mostly unfamiliar with ultrasonography and ultrasound and their potential uses. This review maps the diagnostic and therapeutic applications of ultrasonography and ultrasound technology in dentistry and highlights the current challenges, gaps of knowledge, and research status of ultrasound technology in this regard.

Long-Term Prognosis of Endodontic Microsurgery-A Systematic Review and Meta-Analysis

Background and objectives: The long-term outcome of endodontic microsurgery (EMS) performed on root-filled teeth affected by post-treatment apical periodontitis (AP) has been a matter of debate, re-launched by the introduction of novel root-end filling materials which have been proven to improve the short-term outcome of EMS. The purpose of this systematic review and meta-analysis is to evaluate the clinical and radiographic long-term outcome of endodontic microsurgery in teeth diagnosed with secondary AP through radiographic evaluation. Materials and Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion and exclusion criteria were defined a priori to select the best longitudinal evidence. Only randomized clinical trials (RCT) and prospective clinical studies (PCS), with a follow-up ≥ 2-year, and exhibiting well-established clinical and radiographic outcome criteria, were selected. Results: A total of 573 articles were obtained, from which 10 fulfill inclusion criteria: 6 PCS and 4 RCT. Meta-analysis showed a pooled proportion of success rate of 91.3%, from an overall amount of 453 treated teeth included in RCT; from overall 839 included teeth in PCS, a pooled success rate of 78.4% was observed, with the follow-up time ranging from 2 to 13-years. Survival rate outcomes varied from 79 to 100% for the same follow-up period. Five prognostic factors with influence on the outcome were disclosed: smoking habits, tooth location and type, absence/presence of dentinal defects, interproximal bone level, and root-end filling material. Conclusions: High success rates and predictable results can be expected when EMS is performed by trained endodontists, allowing good prognosis and preservation of teeth affected by secondary AP.

Effect of ultrasonic root-end cavity preparation on dentinal microcrack formation: A micro-computed tomography study

Background:

Root-end preparation during surgical endodontics may produce dentinal microcrack formation and/or propagation, leading to vertical root fractures.

Aim:

This study aimed to evaluate and compare the microcrack formation and propagation during ultrasonic root-end cavity preparation, with diamond- and zirconium nitride-coated tips using micro-computed tomography (CT).

Methodology:

Twenty-eight extracted, mature, free-of-defect, mandibular premolars were decoronated and micro-CT scanned for the presence of preexisting microcracks. Samples were prepared till F4, were obturated, and were re-scanned to determine an increase in the number of microcracks. After 3 mm of root-end resection, the samples were randomly divided for ultrasonic root-end preparation into Group 1 (n = 12): preparation was done with ProUltra Surg tip, Group 2 (n = 12): preparation was done with KiS tip, and Group 3 (n = 4): no preparation was done. The samples were rescanned, and data collected were analyzed using ANOVA and Student's t-test. The level of significance was set at 5%.

Results:

Preexisting microcracks were observed in few samples. The mean percentage number increase of microcracks after root-end preparation in ProUltra Surg group was 1.25 and in KiS group, it was 0.5. The difference in mean percentage increase for the number of microcracks after root-end cavity preparation using ProUltra Surg tip and KiS tip was 0.75. However, this difference was not statistically significant (P = 0.34).

Conclusion:

Both diamond- and zirconium nitride-coated ultrasonic tips resulted in more number of dentinal crack formation and propagation when preexisting cracks were present.

Factors influencing the long-term prognosis of root tip resected teeth

Introduction: The aim of the study was to investigate possible predictive factors influencing the long-term success of root tip resection. Methods: The retrospective study included 216 patients (♂ 111, ♀ 106, median age 43.3 years). A total of 261 root tip resections were performed on these patients between 1989 and 2012. In addition to determining the success rates 5 and 10 years postoperatively, the factors gender, age, tooth type, use of bone replacement material and preoperative periodontal tooth status were examined with regard to their significance for the long-term prognosis of root tip resected teeth. Results: The evaluation showed an average success rate of 63.6% for all included teeth over the entire observation period (tooth at least one year postoperatively still in situ). The 5-year success rate was 78.2%, the 10-year success rate 63.1%. A dependence of the success rates on the tooth type could not be evaluated. However, the examination showed a clear dependence of the success on the age of the patients. Root tip resections in patients in the age group 60 years and older had significantly worse success rates compared to the age groups 20 to 39 years and 40 to 59 years. The prognosis was also significantly better for patients in the age group 20 to 39 years than for patients in the age group 40 to 59 years. Periodontally compromised teeth showed only a tendency for a poorer prognosis than periodontally healthy teeth. With regard to sex and intraoperative filling of the resection defect with bone replacement material, no differences in the success rates were found. Conclusions: A root tip resection is a good option, largely independent of the type of tooth, to preserve a tooth in the medium to long term after unsuccessful endodontic treatment. However, a revision of the endodontic treatment or even an extraction with subsequent implantation should always be considered as an alternative, especially with increasing age.

Outcome of Endodontic Surgery: A Meta-analysis of the Literature-Part 3: Comparison of Endodontic Microsurgical Techniques with 2 Different Root-end Filling Materials

INTRODUCTION

The aim of the present study was to investigate the influence of root-end preparation and filling material on endodontic surgery outcome. A systematic review and meta-analysis was conducted to determine the outcome of resin-based endodontic surgery (RES, the use of high-magnification preparation of a shallow and concave root-end cavity and bonded resin-based root-end filling material) versus endodontic microsurgery (EMS, the use of high-magnification ultrasonic root-end preparation and root-end filling with SuperEBA [Keystone Industries, Gibbstown, NJ], IRM [Dentsply Sirona, York, PA], mineral trioxide aggregate [MTA], or other calcium silicate cements).

METHODS

An exhaustive literature search was conducted to identify prognostic studies on the outcome of root-end surgery. Human studies conducted from 1966 to the end of December 2016 in 5 different languages (ie, English, French, German, Italian, and Spanish) were searched in 4 electronic databases (ie, Medline, Embase, PubMed, and Cochrane Library). Relevant review articles on the subject were scrutinized for cross-references. In addition, 5 dental and medical journals (Journal of Endodontics; International Endodontic Journal; Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics; Journal of Oral and Maxillofacial Surgery; and International Journal of Oral and Maxillofacial Surgery) were hand checked dating back to 1975. All abstracts were screened by 3 independent reviewers (H.B., M.K., and F.S.). Strict inclusion-exclusion criteria were defined to identify relevant articles. Raw data were extracted from the full-text review of these selected articles independently by each of the 3 reviewers. In case of disagreement, an agreement was reached by discussion, and qualifying articles were assigned to group RES. For EMS, the same search strategy was performed for the time frame October 2009 to December 2016, whereas up to October 2009 the data were obtained from a previous systematic review with identical criteria and search strategy. Weighted pooled success rates and a relative risk assessment between RES and EMS were calculated. To make a comparison between groups, a random effects model was used.

RESULTS

Sixty-eight articles were eligible for full-text review. Of these, per strict inclusion exclusion criteria, 14 studies qualified, 3 for RES (n = 862) and 11 for EMS (n = 915). Weighted pooled success rates for RES were 82.20% (95% confidence interval [CI], 0.7965-0.8476) and 94.42% for EMS (95% CI, 0.9295-0.9590). This difference was statistically significant (P < .0005).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for RES, providing best available evidence on the influence of cavity preparation with ultrasonic tips and/or SuperEBA (Keystone Industries, Gibbstown, NJ), IRM (Dentsply Sirona, York, PA), MTA, or silicate cements as root-end filling material instead of a shallow cavity preparation and placement of a resin-based material. Additional large-scale randomized clinical trials are needed to assess other predictors of outcome.

The outcome of apical microsurgery using MTA as the root-end filling material: 2- to 6-year follow-up study

AIM

To evaluate the influence of various predictors on the healing outcome 2-6 years after apical microsurgery (AMS) using MTA as the root-end filling material.

METHODOLOGY

A total of 90 anterior teeth with asymptomatic persistent periradicular periodontitis of strictly endodontic origin that failed after either nonsurgical or surgical treatment were included. Surgery was completed under local anaesthesia using a standardized clinical protocol. Clinical and radiographic measures as well as the follow-up period were used to determine the healing outcome. For statistical analysis of the predictors, the outcome was dichotomized into healed cases and nonhealed cases. Odds ratios were calculated, and Pearson chi-square or Fisher's exact tests were used to analyse the data.

RESULTS

Clinical and radiographic assessment of AMS revealed that 80% were healed, 14.4% were nonhealed, whilst 5.6% were judged to be uncertain. None of the various predictors investigated had a significant influence on the outcome of AMS.

CONCLUSIONS

The results of this clinical study demonstrated that 80% of cases that received apical microsurgery healed when using MTA as the root-end filling material.

Evaluation of two different root-end cavity preparation techniques: A scanning electron microscope study

OBJECTIVE

In this study, we aimed to evaluate and compare the dentinal walls of root-end cavities for the presence of cracks after cavity preparation using US retrotips and Er: YAG laser.

MATERIALS AND METHODS

Fifty single-rooted teeth were prepared by Protaper NiTi rotary system and obturated by lateral condensation. Three milimeters of root-end was resected. Twenty teeth were prepared with US retrotip (Group 1), 20 teeth with Er: YAG laser (Group 2), and 10 teeth without retropreparation (control group). The root-end surfaces were examined under a scanning electron microscope (SEM). Then the cracks of the resected root surfaces were evaluated on microphotographs.

RESULTS

No statistically significant difference was detected between US Group and Laser Group for complete, incomplete, intradentinal, and total number of cracks (P = 0.47, P = 0.80, P = 0.69, P = 0.869, respectively).

CONCLUSION

Statistical analysis revealed no significant effect of retropreparation technique on the development of apical cracks (P > 0.05).

Impact of the use of plasma rich in growth factors (PRGF) on the quality of life of patients treated with endodontic surgery when a perforation of sinus membrane occurred. A comparative study

INTRODUCTION

The aim of this retrospective investigation was to evaluate the postoperative quality of life after endodontic surgery in maxillary molars when a sinus membrane perforation occurred and platelet concentrates were used.

MATERIALS AND METHODS

Included patients were treated by microsurgical endodontic treatment in molar and premolar maxillary regions between 2007 and 2010. Patients who fulfilled the inclusion criteria were screened. Data from the quality of life questionnaire were analyzed. The use of plasma rich in growth factors (PRGF) (test group) was compared with a control group when a Schneiderian membrane perforation occurred during endodontic surgery performed with a modern technique in maxillary molars and premolars.

RESULTS

A total of 20 patients (12 in the control group and eight in the test group) fulfilled the inclusion criteria. No differences were evaluated at baseline for clinical parameters. Significantly improved patients' quality of life was observed in the test group considering symptoms as swelling, bad breath or taste, and pain. Functional activities were less impaired in the test group and swelling was significantly higher in the control group. In the test group, pain was significantly lower than the control group during the first 6 days after surgery and also, the consumption of painkillers was lower for patients belonging to the test group even if it was not statistically significant.

DISCUSSION

In general, a small sinus membrane perforation (less than 6 mm) during endodontic surgery did not cause severe complications. The use of platelet concentrates could be effective in reducing the impact on patients' quality of life, decreasing pain and surgery side effects as well as swelling.

Outcome of endodontic surgery: a meta-analysis of the literature--Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification

INTRODUCTION

The aim of this study was to investigate the outcome of root-end surgery. It identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids (contemporary root-end surgery [CRS]) were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the 2 techniques were determined by means of a meta-analysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated.

METHODS

A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (ie, Medline, Embase, and PubMed) were searched to identify human studies from 1966 up to October 2009 in 5 different languages (ie, English, French, German, Italian, and Spanish). Review articles and relevant articles were searched for cross-references. In addition, 5 dental and medical journals (ie, Journal of Endodontics, International Endodontic Journal, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral and Maxillofacial Surgery, and International Journal of Oral and Maxillofacial Surgery) dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by 3 independent reviewers (S.B.S., M.R.K., and F.C.S.). Relevant articles were obtained in full-text form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall as well as for molars, premolars, and anteriors were calculated. A random-effects model was used for a comparison between the groups.

RESULTS

One hundred one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455-0.9164) and 94% for EMS (95% confidence interval, 0.8889-0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice.

A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling

A prospective outcome study of periradicular surgery using microsurgical techniques and root-end filling with mineral trioxide aggregate (MTA) was performed. Nonhealing endodontically treated teeth (n = 321) were included in the study. Surgery was completed under local anesthesia using a standardized clinical protocol. Patients were recalled periodically and examined for signs and symptoms of failure. Thirty-nine teeth were lost from recall. Of the 276 teeth examined, 163 showed complete healing radiographically with no other signs and symptoms; 82 teeth had no symptoms but incomplete or uncertain healing, and 31 teeth showed nonhealing (three had persistent pain despite evidence of complete radiologic healing and eight teeth did not heal for reasons unrelated to the surgical treatment). The overall success rate was 88.8%, including all teeth with no clinical symptoms. In this study, the use of MTA as a root-end filling, following microsurgical techniques, showed a high success rate.