Clinical Research| Volume 47, ISSUE 11, P1703-1714, November 2021

Outcome of Periapical Surgery in Molars: A Retrospective Analysis of 424 Teeth

Published:September 06, 2021DOI:



      The objective of this retrospective study was to assess the outcome of periapical surgery in a large number of molars in order to identify possible variables that might affect the outcome.


      The healing outcome of patients undergoing periapical surgery of molars from October 1999 to October 2019 was retrospectively evaluated. Outcome was dichotomized into “healed” and “nonhealed” using well-established clinical and radiographic healing criteria. The potential influence of patient-, tooth-, and treatment-related parameters on the healing outcome was analyzed.


      A total of 424 molars in the same number of patients (45.5% male and 54.5% female) were evaluated. Three hundred seventy-two molars were classified as healed (87.7%). Three significant outcome predictors were identified: 1-year follow-up versus >1–5 years, >5–10 years, and >10 years (95.3% vs 82.2%, 76.3%, and 76.5% healed, respectively; P < .0001); root end filling material with bioceramic root repair material versus mineral trioxide aggregate (96.9% vs. 86.3% healed, respectively; P = .001); and preoperative evaluation based on cone-beam computed tomographic imaging versus 2-dimensional radiography (90.2% vs 81.4% healed, respectively; P = .02). Sex, age, tooth location, type of restoration, attachment level, presence of a post, quality of the root canal filling, technique of root end preparation, administration of antibiotics, and type of surgery had no significant impact on the healing outcome.


      The healed rate for the concave (Retroplast) and cavity (mineral trioxide aggregate, SuperEBA [Staident International, Staines, UK], and bioceramic root repair material) root end preparation technique over all follow-up periods was 84% and 88.5%, respectively. The follow-up period, root end filling material, and preoperative evaluation based on cone-beam computed tomographic imaging had a significant influence on the healing outcome.

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        • Siqueira J.F.
        • Rôças I.N.
        • Ricucci D.
        • et al.
        Causes and management of post-treatment apical periodontitis.
        Br Dent J. 2014; 216: 305-312
        • European Society of Endodontology
        Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology.
        Int Endod J. 2006; 39: 921-930
        • Kim S.
        • Kratchman S.
        Modern endodontic surgery concepts and practice: a review.
        J Endod. 2006; 32: 601-623
        • Tsesis I.
        • Rosen E.
        • Schwartz-Arad D.
        • et al.
        Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique.
        J Endod. 2006; 32: 412-416
        • Kohli M.R.
        • Berenji H.
        • Setzer F.C.
        • et al.
        Outcome of endodontic surgery: a meta-analysis of the literature - part 3: comparison of endodontic microsurgical techniques with 2 different root-end filling materials.
        J Endod. 2018; 44: 923-931
        • Carr G.B.
        Ultrasonic root end preparation.
        Dent Clin North Am. 1997; 41: 541-554
        • von Arx T.
        • Peñarrocha M.
        • Jensen S.
        Prognostic factors in apical surgery with root-end filling: a meta-analysis.
        J Endod. 2010; 36: 957-973
        • Estrela C.
        • Rabelo L.E.
        • de Souza J.B.
        • et al.
        Frequency of root canal isthmi in human permanent teeth determined by cone-beam computed tomography.
        J Endod. 2015; 41: 1535-1539
        • von Arx T.
        • Hänni S.
        • Jensen S.S.
        5-year results comparing mineral trioxide aggregate and adhesive resin composite for root-end sealing in apical surgery.
        J Endod. 2014; 40: 1077-1081
        • Rud J.
        • Rud V.
        • Munksgaard E.C.
        Periapical healing of mandibular molars after root-end sealing with dentine-bonded composite.
        Int Endod J. 2001; 34: 285-292
        • Kim S.
        • Jung H.
        • Kim S.
        • et al.
        The influence of an isthmus on the outcomes of surgically treated molars: a retrospective study.
        J Endod. 2016; 42: 1029-1034
        • Maddalone M.
        • Gagliani M.
        Periapical endodontic surgery: a 3-year follow-up study.
        Int Endod J. 2003; 36: 193-198
        • Chugal N.M.
        • Clive J.M.
        • Spångberg L.S.
        Endodontic infection: some biologic and treatment factors associated with outcome.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 96: 81-90
        • Rud J.
        • Andreasen J.O.
        • Jensen J.E.
        Radiographic criteria for the assessment of healing after endodontic surgery.
        Int J Oral Surg. 1972; 1: 195-214
        • 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
        • 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
        • Zuolo M.L.
        • Ferreira M.O.
        • Gutmann J.L.
        Prognosis in periradicular surgery: a clinical prospective study.
        Int Endod J. 2000; 33: 91-98
        • Mehta C.R.
        • Patel N.R.
        A network algorithm for performing Fisher’s exact test in r × c contingency tables.
        J Am Stat Assoc. 1983; 78: 427-434
        • Gagliani M.M.
        • Gorni F.G.
        • Strohmenger L.
        Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison.
        Int Endod J. 2005; 38: 320-327
        • von Arx T.
        • Gerber C.
        • Hardt N.
        Periradicular surgery of molars: a prospective clinical study with a one-year follow-up.
        Int Endod J. 2001; 34: 520-525
        • Setzer F.C.
        • Kohli M.R.
        • Shah S.B.
        • et al.
        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.
        J Endod. 2012; 38: 1-10
        • Tsesis I.
        • Rosen E.
        • Taschieri S.
        • et al.
        Outcomes of surgical endodontic treatment performed by a modern technique: an updated meta-analysis of the literature.
        J Endod. 2013; 39: 332-339
        • Kreisler M.
        • Gockel R.
        • Aubell-Falkenberg S.
        • et al.
        Clinical outcome in periradicular surgery: effect of patient- and tooth-related factors - a multicenter study.
        Quintessence Int. 2013; 44: 53-60
        • Shinbori N.
        • Grama A.M.
        • Patel Y.
        • et al.
        Clinical outcome of endodontic microsurgery that uses EndoSequence BC root repair material as the root-end filling material.
        J Endod. 2015; 41: 607-612
        • Song M.
        • Jung I.Y.
        • Lee S.J.
        • et al.
        Prognostic factors for clinical outcomes in endodontic microsurgery: a retrospective study.
        J Endod. 2011; 37: 927-933
        • Tsesis I.
        • Faivishevsky V.
        • Kfir A.
        • et al.
        Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature.
        J Endod. 2009; 35: 1505-1511
        • Pallarés-Serrano A.
        • Glera-Suarez P.
        • Tarazona-Alvarez B.
        • et al.
        Prognostic factors after endodontic microsurgery: a retrospective study of 111 cases with 5 to 9 years of follow-up.
        J Endod. 2021; 47: 397-403
        • Saunders W.P.
        • Saunders E.M.
        Coronal leakage as a cause of failure in root-canal therapy: a review.
        Endod Dent Traumatol. 1994; 10: 105-108
        • Jensen S.S.
        • Nattestad A.
        • Egdø P.
        • et al.
        A prospective, randomized, comparative clinical study of resin composite and glass ionomer cement for retrograde root filling.
        Clin Oral Investig. 2002; 6: 236-243
        • Wälivaara D.Å.
        • Abrahamsson P.
        • Fogelin M.
        • et al.
        Super-EBA and IRM as root-end fillings in periapical surgery with ultrasonic preparation: a prospective randomized clinical study of 206 consecutive teeth.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 112: 258-263
        • Sutter E.
        • Valdec S.
        • Bichsel D.
        • et al.
        Success rate 1 year after apical surgery: a retrospective analysis.
        Oral Maxillofac Surg. 2020; 24: 45-49
        • Zhou W.
        • Zheng Q.
        • Tan X.
        • et al.
        Comparison of mineral trioxide aggregate and iRoot BP Plus root repair material as root-end filling materials in endodontic microsurgery: a prospective randomized controlled study.
        J Endod. 2017; 43: 1-6
        • Lofthag-Hansen S.
        • Huumonen S.
        • Gröndahl K.
        • et al.
        Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: 114-119
        • Low K.M.
        • Dula K.
        • Bürgin W.
        • et al.
        Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery.
        J Endod. 2008; 34: 557-562
        • Patel S.
        • Brown J.
        • Pimentel T.
        • et al.
        Cone beam computed tomography in endodontics - a review of the literature.
        Int Endod J. 2019; 52: 1138-1152
        • Kurt S.N.
        • Üstün Y.
        • Erdogan Ö.
        • et al.
        Outcomes of periradicular surgery of maxillary first molars using a vestibular approach: a prospective, clinical study with one year of follow-up.
        J Oral Maxillofac Surg. 2014; 72: 1049-1061
        • von Arx T.
        • Jensen S.S.
        • Hänni S.
        • et al.
        Five-year longitudinal assessment of the prognosis of apical microsurgery.
        J Endod. 2012; 38: 570-579
        • Rud J.
        • Rud V.
        • Munksgaard E.C.
        Effect of root canal contents on healing of teeth with dentin-bonded resin composite retrograde seal.
        J Endod. 1997; 23: 535-541
        • de Oliveira N.G.
        • de Souza Araújo P.R.
        • da Silveira M.T.
        • et al.
        Comparison of the biocompatibility of calcium silicate-based materials to mineral trioxide aggregate: systematic review.
        Eur J Dent. 2018; 12: 317-326
        • Zhang W.
        • Li Z.
        • Peng B.
        Ex vivo cytotoxicity of a new calcium silicate-based canal filling material.
        Int Endod J. 2010; 43: 769-774
        • Kim D.
        • Kim S.
        • Song M.
        • et al.
        Outcome of endodontic micro-resurgery: a retrospective study based on propensity score-matched survival analysis.
        J Endod. 2018; 44: 1632-1640
        • von Arx T.
        • Janner S.F.
        • Hänni S.
        • et al.
        Agreement between 2D and 3D radiographic outcome assessment one year after periapical surgery.
        Int Endod J. 2016; 49: 915-925
        • Yeung A.W.
        • Jacobs R.
        • Bornstein M.M.
        Novel low-dose protocols using cone beam computed tomography in dental medicine: a review focusing on indications, limitations, and future possibilities.
        Clin Oral Investig. 2019; 23: 2573-2581