Success and failure of endodontic microsurgery

Minju Song; Euiseong Kim

doi:10.5395/JKACD.2011.36.6.465

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Review Article Success and failure of endodontic microsurgery: Minju Song, DDS, MSD, Euiseong Kim, DDS, MSD, PhD; 2011;36(6):-476.
DOI: https://doi.org/10.5395/JKACD.2011.36.6.465
Published online: November 30, 2011

Department of Conservative Dentistry, Microscope Center, Yonsei University College of Dentistry, Seoul, Korea.

Correspondence to Euiseong Kim, DDS, MSD, PhD. Professor, Department of Conservative Dentisty, Microscope Center, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea. 120-752 TEL, +82-2-2228-8701; FAX, +82-2-313-7575; andyendo@yuhs.ac

• Received: August 18, 2011 • Revised: September 30, 2011 • Accepted: October 5, 2011

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Abstract
REFERENCES

Abstract

In current endodontic practice, introduction of operating microscope, ultrasonic instruments, and microinstruments has induced a big change in the field of surgical retreatment. In this study, we aimed to offer key steps of endodontic microsurgery procedure compared with traditional root-end surgery, and to evaluate factors influencing success and failure based on published articles.

Endodontic microsurgery is a surgical procedure performed with the aid of a microscope, ultrasonic instruments and modern microsurgical instruments. The microscope provides magnification and illumination - essential for identifying minute details of the apical anatomy. Ultrasonic instruments facilitate the precise root-end preparation that is within the anatomical space of the canal. Modern endodontics can therefore be performed with precision and predictability, thus eliminating the disadvantages inherent in traditional periapical surgery such as large osteotomy, beveled apicoectomy, inaccurate root-end preparation and the inability to observe isthmus.

Factors influencing the outcomes of endodontic microsurgery may be diverse, but standardization of procedures can minimize its range. Among patient and tooth-related factors, periodontal status and tooth position are known to be prognostic, but there are only few articles concerning this matter. High-evidence randomized clinical trials or prospective cohort studies are needed to confirm these findings.
Keywords: Endodontic microsurgery; Periodontal involvement; Prognostic factor; Success and failure; Surgical retreatment; Tooth position

Figure 1

Example of each category of the cause of endodontic failure. Note the arrows. (a) Missing canal, MB2 with an isthmus in maxillary molar; (b) Leaky canal, gap between the gutta-percha and dentin; (c)-1 & (c)-2 apical calculus, calculus deposition due to chronic sinus tract; (c)-3 Scanning electron microscopic image of apical calculus (×30K); (d) Anatomical complexity, accessory canals that has not been touched; (e) Underfilling; (f) Crack, apical crack at lingual side of root; (g) Iatrogenic problem, broken file in mesial root in mandibular molar; (h) Overfilling, over-extended gutta-percha.9

Figure 2

Typical failure case of endodontic surgery. (a) Preoperative radiograph with periradicular radiolucency showing a root-end filling apart from the filled canal; (b) Coronal surface of the resected apical fragment. Note the missing canal (arrow) that had not been touched, even after both nonsurgical and surgical retreatments. G, Gutta-percha canal filling of nonsurgical retreatment; R, Root-end filling of surgical retreatment; (c) Immediate postoperative radiograph. Super EBA was used for the root-end filling; (d), (e), and (f) Seven-year follow-up radiographs with 3 different angles showing complete healing.10

REFERENCES

1. Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endodontic Topics. 2002;1: 54-78.Article PDF
2. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature-part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2010;36: 1757-1765.Article PubMed
3. Creasy JE, Mines P, Sweet M. Surgical trends among endodontists: the results of a web-based survey. J Endod. 2009;35: 30-34.Article PubMed
4. Yang Y, Rossi FM, Putnins EE. Periodontal regeneration using engineered bone marrow mesenchymal stromal cells. Biomaterials. 2010;31: 8574-8582.Article PubMed
5. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32: 601-623.Article PubMed
6. Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and apical ramifications in response to pathologic conditions and treatment procedures. J Endod. 2010;36: 1-15.Article PubMed
7. Kim E, Fallahrastegar A, Hur YY, Jung IY, Kim S, Lee SJ. Difference in root canal length between Asians and Caucasians. Int Endod J. 2005;38: 149-151.Article PubMed
8. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. J Endod. 2008;34: 546-551.Article PubMed
9. Song M, Kim H, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodntic treatment by microscopic inspection during endodontic microsurgery. J Endod. 2011;37: 1516-1519.PubMed
10. Song M, Shin SJ, Kim E. Outcomes of endodontic micro-resurgery: a prospective clinical study. J Endod. 2011;37: 316-320.Article PubMed
11. Saunders WP, Saunders EM, Gutmann JL. Ultrasonic root-end preparation, part 2. microleakage of EBA root-end fillings. Int Endod J. 1994;27: 325-329.Article PubMed
12. De Bruyne MA, De Moor RJ. Influence of cracks on leakage and obturation efficiency of root-end filling materials after ultrasonic preparation: an in vitro evaluation. Quintessence Int. 2008;39: 685-692.PubMed
13. Christiansen R, Kirkevang LL, Hørsted-Bindslev P, Wenzel A. Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling-1-year follow-up. Int Endod J. 2009;42: 105-114.Article PubMed
14. Saunders WP. A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling. J Endod. 2008;34: 660-665.Article PubMed
15. Baek SH, Lee WC, Setzer FC, Kim S. Periapical bone regeneration after endodontic microsurgery with three different root-end filling materials: amalgam, Super EBA, and mineral trioxide aggregate. J Endod. 2010;36: 1323-1325.Article PubMed
16. Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of mineral trioxide aggregate and IRM when used as root-end filling materials in endodontic surgery. Int Endod J. 2009;42: 414-420.Article PubMed
17. Song M, Jung IY, Lee SJ, Lee CY, Kim E. Prognostic factors for clinical outcomes in endodontic microsurgery: a retrospective study. J Endod. 2011;37: 927-933.Article PubMed
18. Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery using 2 different magnification devices: preliminary results of a randomized controlled study. J Oral Maxillofac Surg. 2006;64: 235-242.Article PubMed
19. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91: 700-709.Article PubMed
20. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod. 2006;32: 412-416.Article PubMed
21. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod. 2009;35: 930-937.PubMed
22. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature. J Endod. 2009;35: 1505-1511.Article PubMed
23. Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics-the Toronto study. phases I and II: apical surgery. J Endod. 2004;30: 751-761.Article PubMed
24. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical prospective study. Int Endod J. 2000;33: 91-98.Article PubMed
25. Lindeboom JA, Frenken JW, Kroon FH, van den. A comparative prospective randomized clinical study of MTA and IRM as root-end filling materials in single-rooted teeth in endodontic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100: 495-500.Article PubMed
26. von Arx T, Frei C, Bornstein MM. Periradicular surgery with and without endoscopy: a prospective clinical comparative study. Schweiz Monatsschr Zahnmed. 2003;113: 860-865.PubMed
27. Rud J, Andreasen JO, Jensen JE. Radiographic criteria for the assessment of healing after endodontic surgery. Int J Oral Surg. 1972;1: 195-214.Article PubMed
28. Molven O, Halse A, Grung B. Observer strategy and the radiographic classification of healing after endodontic surgery. Int J Oral Maxillofac Surg. 1987;16: 432-439.Article PubMed
29. Molven O, Halse A, Grung B. Surgical management of endodontic failures: indications and treatment results. Int Dent J. 1991;41: 33-42.PubMed
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31. von Arx T, Hänni S, Jensen SS. Clinical results with two different methods of root-end preparation and filling in apical surgery: mineral trioxide aggregate and adhesive resin composite. J Endod. 2010;36: 1122-1129.Article PubMed
32. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and super-EBA as root-end filling material. J Endod. 1999;25: 43-48.Article
33. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Endoscopic periradicular surgery: a prospective clinical study. Br J Oral Maxillofac Surg. 2007;45: 242-244.Article PubMed
34. von Arx T, Jensen SS, Hänni S. Clinical and radiographic assessment of various predictors for healing outcome 1 year after periapical surgery. J Endod. 2007;33: 123-128.Article PubMed
35. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Microscope versus endoscope in root-end management: a randomized controlled study. Int J Oral Maxillofac Surg. 2008;37: 1022-1026.Article PubMed
36. Kvist T, Reit C. Results of endodontic retreatment: a randomized clinical study comparing surgical and non-surgical procedures. J Endod. 1999;25: 814-817.Article PubMed
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38. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery-radiographic findings 8 to 12 years after treatment. J Endod. 1996;22: 264-268.Article PubMed
39. Friedman S. Outcome of endodontic surgery: a meta-analysis of the literature-part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2011;37: 577-578.Article PubMed
40. Halse A, Molven O, Grung B. Follow-up after periapical surgery: the value of the one-year control. Endod Dent Traumatol. 1991;7: 246-250.Article PubMed
41. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod. 2002;28: 378-383.Article PubMed
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45. Fava LR. Calcium hydroxide in endodontic retreatment after two nonsurgical and two surgical failures: report of a case. Int Endod J. 2001;34: 72-80.Article PubMed PDF
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Tables & Figures

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REFERENCES

1. Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endodontic Topics. 2002;1: 54-78.Article PDF
2. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature-part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2010;36: 1757-1765.Article PubMed
3. Creasy JE, Mines P, Sweet M. Surgical trends among endodontists: the results of a web-based survey. J Endod. 2009;35: 30-34.Article PubMed
4. Yang Y, Rossi FM, Putnins EE. Periodontal regeneration using engineered bone marrow mesenchymal stromal cells. Biomaterials. 2010;31: 8574-8582.Article PubMed
5. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32: 601-623.Article PubMed
6. Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and apical ramifications in response to pathologic conditions and treatment procedures. J Endod. 2010;36: 1-15.Article PubMed
7. Kim E, Fallahrastegar A, Hur YY, Jung IY, Kim S, Lee SJ. Difference in root canal length between Asians and Caucasians. Int Endod J. 2005;38: 149-151.Article PubMed
8. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. J Endod. 2008;34: 546-551.Article PubMed
9. Song M, Kim H, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodntic treatment by microscopic inspection during endodontic microsurgery. J Endod. 2011;37: 1516-1519.PubMed
10. Song M, Shin SJ, Kim E. Outcomes of endodontic micro-resurgery: a prospective clinical study. J Endod. 2011;37: 316-320.Article PubMed
11. Saunders WP, Saunders EM, Gutmann JL. Ultrasonic root-end preparation, part 2. microleakage of EBA root-end fillings. Int Endod J. 1994;27: 325-329.Article PubMed
12. De Bruyne MA, De Moor RJ. Influence of cracks on leakage and obturation efficiency of root-end filling materials after ultrasonic preparation: an in vitro evaluation. Quintessence Int. 2008;39: 685-692.PubMed
13. Christiansen R, Kirkevang LL, Hørsted-Bindslev P, Wenzel A. Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling-1-year follow-up. Int Endod J. 2009;42: 105-114.Article PubMed
14. Saunders WP. A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling. J Endod. 2008;34: 660-665.Article PubMed
15. Baek SH, Lee WC, Setzer FC, Kim S. Periapical bone regeneration after endodontic microsurgery with three different root-end filling materials: amalgam, Super EBA, and mineral trioxide aggregate. J Endod. 2010;36: 1323-1325.Article PubMed
16. Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of mineral trioxide aggregate and IRM when used as root-end filling materials in endodontic surgery. Int Endod J. 2009;42: 414-420.Article PubMed
17. Song M, Jung IY, Lee SJ, Lee CY, Kim E. Prognostic factors for clinical outcomes in endodontic microsurgery: a retrospective study. J Endod. 2011;37: 927-933.Article PubMed
18. Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery using 2 different magnification devices: preliminary results of a randomized controlled study. J Oral Maxillofac Surg. 2006;64: 235-242.Article PubMed
19. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91: 700-709.Article PubMed
20. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod. 2006;32: 412-416.Article PubMed
21. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod. 2009;35: 930-937.PubMed
22. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature. J Endod. 2009;35: 1505-1511.Article PubMed
23. Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics-the Toronto study. phases I and II: apical surgery. J Endod. 2004;30: 751-761.Article PubMed
24. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical prospective study. Int Endod J. 2000;33: 91-98.Article PubMed
25. Lindeboom JA, Frenken JW, Kroon FH, van den. A comparative prospective randomized clinical study of MTA and IRM as root-end filling materials in single-rooted teeth in endodontic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100: 495-500.Article PubMed
26. von Arx T, Frei C, Bornstein MM. Periradicular surgery with and without endoscopy: a prospective clinical comparative study. Schweiz Monatsschr Zahnmed. 2003;113: 860-865.PubMed
27. Rud J, Andreasen JO, Jensen JE. Radiographic criteria for the assessment of healing after endodontic surgery. Int J Oral Surg. 1972;1: 195-214.Article PubMed
28. Molven O, Halse A, Grung B. Observer strategy and the radiographic classification of healing after endodontic surgery. Int J Oral Maxillofac Surg. 1987;16: 432-439.Article PubMed
29. Molven O, Halse A, Grung B. Surgical management of endodontic failures: indications and treatment results. Int Dent J. 1991;41: 33-42.PubMed
30. von Arx T, Hänni S, Jensen SS. Correlation of bone defect dimensions with healing outcome one year after apical surgery. J Endod. 2007;33: 1044-1048.Article PubMed
31. von Arx T, Hänni S, Jensen SS. Clinical results with two different methods of root-end preparation and filling in apical surgery: mineral trioxide aggregate and adhesive resin composite. J Endod. 2010;36: 1122-1129.Article PubMed
32. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and super-EBA as root-end filling material. J Endod. 1999;25: 43-48.Article
33. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Endoscopic periradicular surgery: a prospective clinical study. Br J Oral Maxillofac Surg. 2007;45: 242-244.Article PubMed
34. von Arx T, Jensen SS, Hänni S. Clinical and radiographic assessment of various predictors for healing outcome 1 year after periapical surgery. J Endod. 2007;33: 123-128.Article PubMed
35. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Microscope versus endoscope in root-end management: a randomized controlled study. Int J Oral Maxillofac Surg. 2008;37: 1022-1026.Article PubMed
36. Kvist T, Reit C. Results of endodontic retreatment: a randomized clinical study comparing surgical and non-surgical procedures. J Endod. 1999;25: 814-817.Article PubMed
37. Jesslén P, Zetterqvist L, Heimdahl A. Long-term results of amalgam versus glass ionomer cement as apical sealant after apicectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79: 101-103.Article PubMed
38. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery-radiographic findings 8 to 12 years after treatment. J Endod. 1996;22: 264-268.Article PubMed
39. Friedman S. Outcome of endodontic surgery: a meta-analysis of the literature-part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2011;37: 577-578.Article PubMed
40. Halse A, Molven O, Grung B. Follow-up after periapical surgery: the value of the one-year control. Endod Dent Traumatol. 1991;7: 246-250.Article PubMed
41. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod. 2002;28: 378-383.Article PubMed
42. Wesson CM, Gale TM. Molar apicectomy with amalgam root-end filling: results of a prospective study in two district general hospitals. Br Dent J. 2003;195: 707-714.Article PubMed PDF
43. Yazdi PM, Schou S, Jensen SS, Stoltze K, Kenrad B, Sewerin I. Dentine-bonded resin composite (Retroplast) for root-end filling: a prospective clinical and radiographic study with a mean follow-up period of 8 years. Int Endod J. 2007;40: 493-503.Article PubMed
44. Calişkan MK. Nonsurgical retreatment of teeth with periapical lesions previously managed by either endodontic or surgical intervention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100: 242-248.Article PubMed
45. Fava LR. Calcium hydroxide in endodontic retreatment after two nonsurgical and two surgical failures: report of a case. Int Endod J. 2001;34: 72-80.Article PubMed PDF
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Success and failure of endodontic microsurgery

J Korean Acad Conserv Dent. 2011;36(6):465-476. Published online November 30, 2011

DOI: https://doi.org/10.5395/JKACD.2011.36.6.465

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Ingestion and surgical retrieval of an endodontic file: a case report

Success and failure of endodontic microsurgery

Figure 1 Example of each category of the cause of endodontic failure. Note the arrows. (a) Missing canal, MB2 with an isthmus in maxillary molar; (b) Leaky canal, gap between the gutta-percha and dentin; (c)-1 & (c)-2 apical calculus, calculus deposition due to chronic sinus tract; (c)-3 Scanning electron microscopic image of apical calculus (×30K); (d) Anatomical complexity, accessory canals that has not been touched; (e) Underfilling; (f) Crack, apical crack at lingual side of root; (g) Iatrogenic problem, broken file in mesial root in mandibular molar; (h) Overfilling, over-extended gutta-percha.9

Figure 2 Typical failure case of endodontic surgery. (a) Preoperative radiograph with periradicular radiolucency showing a root-end filling apart from the filled canal; (b) Coronal surface of the resected apical fragment. Note the missing canal (arrow) that had not been touched, even after both nonsurgical and surgical retreatments. G, Gutta-percha canal filling of nonsurgical retreatment; R, Root-end filling of surgical retreatment; (c) Immediate postoperative radiograph. Super EBA was used for the root-end filling; (d), (e), and (f) Seven-year follow-up radiographs with 3 different angles showing complete healing.10

Figure 1

Figure 2

Success and failure of endodontic microsurgery