doi:10.1111/iej.12451
The outcome of apical microsurgery using MTA as the root-end filling material: 2- to 6-year follow-up study
M. K. C ß alısßkan1, U. Tekin2, M. E. Kaval1 & M. C. Solmaz2 1
Department of Endodontology, School of Dentistry, Ege University, Izmir; and 2Department of Oral and Maxillofacial Surgery, School of Dentistry, Ege University, Izmir, Turkey
Abstract C ß alısßkan MK, Tekin U, Kaval ME, Solmaz MC. The outcome of apical microsurgery using MTA as the root-end filling material: 2- to 6-year follow-up study. International Endodontic Journal, 49, 245–254, 2016.
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 analy-
Introduction Endodontic surgery is a reliable procedure for the treatment of teeth with persistent periradicular lesions that did not respond to initial primary or secondary root canal treatment (Gutmann & Harrison 1991). Since 1997 instead of traditional root-end surgery (TRS), apical microsurgery (AMS) was recommended for apical surgery (Kim 1997). These two techniques for root-end surgery differ significantly in the methods
Correspondence: Mehmet Emin Kaval, Department of Endodontology, School of Dentistry, Ege University, 35100 Izmir, Turkey (Tel.: +90 232 311 46 08; Fax: +90 232 388 03 25; e-mail: [email protected]).
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
sis 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 rootend filling material. Keywords: apical microsurgery, clinical outcome, mineral trioxide aggregate. Received 9 December 2014; accepted 23 March 2015
used to achieve the goal of periapical healing. The differences between TRS and AMS include the access armamentarium (standard size surgical bur versus bone cutting bur or piezo tip), the size of the osteotomy (large versus small), the instruments used (large regular versus small micro-instruments), the bevel angle (acute, in which the tip of the root is cut at approximately 2–3 mm with a 45° bevel, versus shallow, in which the apical root is resected 2–3 mm with a 0° or 10° bevel angle), the root-end preparation (bur versus ultrasonic tip to a depth of 3–4 mm), the direction of cavity preparation (off-angle versus aligned), the root-end filling material (amalgam versus biocompatible cements such as IRM, Super EBA and MTA), and the possible identification of microfractures and additional canals under the high-power
International Endodontic Journal, 49, 245–254, 2016
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Outcome of apical microsurgery C ß alısß kan et al.
magnification of the endoscope or a microscope (Setzer et al. 2010). In a recent meta-analysis and systematic review (Setzer et al. 2010), clinical success rates ranging from 43.5% to 75% with a weighted average of 59% were reported for TRS. In contrast, improved success rates ranging from 89% to 100% were presented for recent studies incorporating AMS. Significant differences in the study design and treatment protocols complicated the evaluation of the factors that influence the outcome and the assessment of an acceptable protocol for AMS (Song et al. 2011a). Typically, clinical studies on periapical surgery have evaluated the outcome with respect to the root-end filling material (von Arx et al. 2007, Song et al. 2011a). Although several AMS studies have evaluated the short-term results (Rubinstein & Kim 1999, Chong et al. 2003, Lindeboom et al. 2005a, Taschieri et al. 2005, Tsesis et al. 2006, de Lange et al. 2007, von Arx et al. 2007, Kim et al. 2008, Saunders 2008, Christiansen et al. 2009, von Arx et al. 2010, Walivaara et al. 2011, Song & Kim 2012), few recent studies have reported the long-term success of AMS (Rubinstein & Kim 2002, von Arx et al. 2012, Song et al. 2012, 2014). Additionally, the assessment of significant outcome predictors requires long-term observation; however, long-term results have been reported only in two previous studies focusing on AMS (Song et al. 2011a, von Arx et al. 2012), which could compare their results with the studies that have not been based on AMS (Lustmann et al. 1991, Rahbaran et al. 2001, Barone et al. 2010). Therefore, the aim of this study was to evaluate the influence of various predictors on the 2- to 6-year outcomes of AMS and to compare the findings with other AMS investigations.
Material and methods In this clinical study, data were collected in the Department of Endodontics at the School of Dentistry, Ege University, Izmir, Turkey, between June 2007 and December 2013. On the basis of clinical and radiologic examination, a diagnosis was made, and a treatment plan was devised for each patient. Patients were fully informed about the surgical procedure, postoperative care, follow-up examinations and alternative treatment options, and written informed consent that meets the criteria of Ege University’s Institutional Review Board was obtained from patients prior to their participation.
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International Endodontic Journal, 49, 245–254, 2016
Patient selection and inclusion criteria were as follows: patients with a noncontributory medical history; only one affected tooth per patient; only single rooted maxillary and mandibular anterior teeth; root filled teeth with asymptomatic periradicular periodontitis of strictly endodontic origin that failed after either nonsurgical or surgical treatment; teeth with sufficient root length for root-end preparation in teeth containing post-core restoration; and teeth that exhibited an adequate coronal restoration without deficiencies and with no caries. The following exclusion criteria were applied: teeth with pathoses associated with horizontal or vertical root fracture; more than 5 mm of periodontal attachment and bone loss detected by periodontal probing; and teeth with perforation of cervical or lateral canal walls. A total of 108 patients were included. The predictors investigated were age, gender, type and location of the tooth; the quality of the root canal filling in terms of density and length was considered as ‘good’ when there was radiographically dense filling ending between 0 and 2 mm short of the apex, or 0.05) (Table 1). The calculated crude odds ratios for all predictors were not statistically significant. Therefore, further multiple logistic regression analysis was not performed. The treatment results obtained in the follow-up observation periods are presented in Table 2. Two-year follow-up was adopted as a minimum follow-up period. Most of the successful cases were considered healed
International Endodontic Journal, 49, 245–254, 2016
247
Outcome of apical microsurgery C ß alısß kan et al.
within 2 years of endodontic surgery. Complete healing was observed in 67 teeth (74.4%), 5 asymptomatic teeth (5.6%) were determined as having undergone incomplete healing, and 5 teeth (5.6%) were identified as having undergone uncertain healing. Uncertain healing was observed in 5 teeth with a lesion size of >10 mm that were followed up for up to 2–3 years and continued to have no other signs and symptoms, and a radiographically significant decrease in the size of the lesion (Fig. 1). The overall healing rate was 80%.
Small lesions with a diameter of 2–5.9 mm (25 teeth) were associated with complete healing in 23 cases (92%). The length of time required for healing to take place in these cases ranged from 3 to 9 months. On average, small lesions healed within 6 months. Complete healing was observed in 29 cases (74.4%) amongst 39 teeth with medium lesions of 6– 9.9 mm diameter, whereas incomplete healing was observed in 2 cases amongst this group (5.1%). The period of time required for healing in these cases ranged from 7 to 12 months with an average of
Table 1 Distribution of cases per preoperative variables and per healing group Cases
Uncertaina
Healed
Predictors
n
%
n
All Gender Male Female Age 16–30 31–50 51–65 Tooth location and type Maxillary anterior Mandibular anterior Quality of root canal filling Good Not good Post/screw Absent Present Previous treatment Initial Retreatment Previous apical surgery No Yes Size of periapical lesion 2–5.9 mm 6–9.9 mm 10–20 mm Biopsy Granuloma Cyst Othersb Antibiotic therapy Used Unused Postoperative healing course Uneventful Complicationc
90
100
72
%
Nonhealed
n
%
n
%
80
5
5.6
13
14.4
52 38
57.8 42.2
44 28
84.6 73.7
2 3
3.8 7.9
6 7
11.5 18.4
39 30 21
43.3 33.3 23.3
32 23 17
82 76.7 80.9
2 2 1
5.1 6.6 4.8
5 5 3
12.8 16.7 14.3
70 20
77.8 22.2
56 16
80 80
4 1
5.7 5
10 3
14.3 15
28 62
31.1 68.9
24 48
85.7 77.4
1 4
3.6 6.5
3 10
10.7 16.1
71 19
78.9 21.1
58 14
81.7 73.7
3 2
4.2 10.5
10 3
14.1 15.8
30 42
41.7 58.3
26 32
86.7 76.2
1 3
3.3 7.1
3 7
10 16.7
72 18
80 20
58 14
80.6 77.8
4 1
5.5 5.5
10 3
13.9 16.7
25 39 26
27.8 43.3 28.9
23 31 18
92 79.5 69.2
– 2 3
– 5.1 11.5
2 6 5
8 15.4 19.2
60 16 4
75 20 5
53 13 3
88.3 81.2 75
2 1 1
3.3 6.2 25
5 2 –
8.3 12.5 –
20 70
22.2 77.8
17 55
85 78.6
1 4
5 5.7
2 11
10 15.7
82 8
91.1 8.9
67 5
81.7 62.5
4 1
4.9 12.5
11 2
13.4 25
a
Uncertain cases were not included in the statistical analyses for the predictors. others: abscess, scar tissue, foreign body reaction. c complication: haematoma, infection, swelling. b
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International Endodontic Journal, 49, 245–254, 2016
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Outcome of apical microsurgery C ß alısß kan et al.
within 2 years of endodontic surgery. Complete healing was observed in 67 teeth (74.4%), 5 asymptomatic teeth (5.6%) were determined as having undergone incomplete healing, and 5 teeth (5.6%) were identified as having undergone uncertain healing. Uncertain healing was observed in 5 teeth with a lesion size of >10 mm that were followed up for up to 2–3 years and continued to have no other signs and symptoms, and a radiographically significant decrease in the size of the lesion (Fig. 1). The overall healing rate was 80%.
Small lesions with a diameter of 2–5.9 mm (25 teeth) were associated with complete healing in 23 cases (92%). The length of time required for healing to take place in these cases ranged from 3 to 9 months. On average, small lesions healed within 6 months. Complete healing was observed in 29 cases (74.4%) amongst 39 teeth with medium lesions of 6– 9.9 mm diameter, whereas incomplete healing was observed in 2 cases amongst this group (5.1%). The period of time required for healing in these cases ranged from 7 to 12 months with an average of
Table 1 Distribution of cases per preoperative variables and per healing group Cases
Uncertaina
Healed
Predictors
n
%
n
All Gender Male Female Age 16–30 31–50 51–65 Tooth location and type Maxillary anterior Mandibular anterior Quality of root canal filling Good Not good Post/screw Absent Present Previous treatment Initial Retreatment Previous apical surgery No Yes Size of periapical lesion 2–5.9 mm 6–9.9 mm 10–20 mm Biopsy Granuloma Cyst Othersb Antibiotic therapy Used Unused Postoperative healing course Uneventful Complicationc
90
100
72
%
Nonhealed
n
%
n
%
80
5
5.6
13
14.4
52 38
57.8 42.2
44 28
84.6 73.7
2 3
3.8 7.9
6 7
11.5 18.4
39 30 21
43.3 33.3 23.3
32 23 17
82 76.7 80.9
2 2 1
5.1 6.6 4.8
5 5 3
12.8 16.7 14.3
70 20
77.8 22.2
56 16
80 80
4 1
5.7 5
10 3
14.3 15
28 62
31.1 68.9
24 48
85.7 77.4
1 4
3.6 6.5
3 10
10.7 16.1
71 19
78.9 21.1
58 14
81.7 73.7
3 2
4.2 10.5
10 3
14.1 15.8
30 42
41.7 58.3
26 32
86.7 76.2
1 3
3.3 7.1
3 7
10 16.7
72 18
80 20
58 14
80.6 77.8
4 1
5.5 5.5
10 3
13.9 16.7
25 39 26
27.8 43.3 28.9
23 31 18
92 79.5 69.2
– 2 3
– 5.1 11.5
2 6 5
8 15.4 19.2
60 16 4
75 20 5
53 13 3
88.3 81.2 75
2 1 1
3.3 6.2 25
5 2 –
8.3 12.5 –
20 70
22.2 77.8
17 55
85 78.6
1 4
5 5.7
2 11
10 15.7
82 8
91.1 8.9
67 5
81.7 62.5
4 1
4.9 12.5
11 2
13.4 25
a
Uncertain cases were not included in the statistical analyses for the predictors. others: abscess, scar tissue, foreign body reaction. c complication: haematoma, infection, swelling. b
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© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Outcome of apical microsurgery C ß alısß kan et al.
Table 3 Nonhealed cases by combined clinical and radiologic signs (n = 13)
(a)
(b)
Figure 3 (a) Preoperative radiograph showing a large radiolucent lesion associated with maxillary right lateral incisor. Note protruded Gutta-percha from the apex into periapical lesion. (b) The histopathologic diagnosis was periapical granuloma. Six years postoperative radiograph showing incomplete healing (scar tissue).
In the present study, the patient’s age and gender had no significant effect on the outcome of AMS; this finding is consistent with previous studies (Tsesis et al. 2006, von Arx et al. 2007), although Song et al. (2011a) reported in their retrospective study that gender (female versus male) appeared to have a positive effect on the outcome after 4 years of follow-up. Several studies have demonstrated success rates of AMS that differ significantly for different tooth types in both the maxilla and the mandible (Rubinstein & Kim 1999, Maddalone & Gagliani 2003, Taschieri et al. 2005, de Lange et al. 2007, Song et al. 2011a, von Arx et al. 2012). In the present study, the outcome of surgical treatment of maxillary and mandibular anterior teeth was assessed, which demonstrated healed rates of 80%. Similar results were reported in previous studies (Lindeboom et al. 2005a, Christiansen et al. 2009). In addition, some authors have suggested that anterior teeth tended to have a higher success rate than the other tooth groups (Kim & Kratchman 2006, de Lange et al. 2007, Song et al. 2011a) as anterior teeth are easy to access and have a simple root canal anatomy (Friedman 2008). Song et al. (2011a) suggested that preoperative signs and/or symptoms did not influence the outcome of AMS, whilst von Arx et al. (2007) reported that clinical signs or symptoms such as pain and tenderness at the initial examination were the only significant predictors for 1-year prognosis after AMS; however, this predictor lost its prognostic value after 5-year follow-up (von Arx et al. 2012). As AMS was
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Category
N
%
Increased lesion with pain and swelling No alteration in periradicular status and continued pain Periodontal consideration Further traumatic injury
6
46.2
3
23
2 2
15.4 15.4
not carried out during the acute phase of periapical pathosis or exacerbation of chronic periapical abscess, no comparison can be made with the findings of the above studies. In the present study, haematoma, infection, pain and swelling were observed as postoperative complications, as previously reported (Lindeboom et al. 2005 b, von Arx et al. 2007). The presence of infection at the postoperative clinical examination was confirmed if the patient had a swelling accompanied with localized pain/tenderness and fever. In such cases, drainage was achieved by the surgeon opening the wound deliberately. Patients with an uneventful initial healing phase (82 of 90 cases) also had a better success rate (81.7%) compared with patients with postoperative complications (8 of 90 cases) (62.5%). However, no significant difference was observed. With regard to the various aforementioned predictors, in only one study in the literature was the immediate postoperative healing course found to be related to the healing outcome after a year (von Arx et al. 2007), but this predictor was not significant for the 5-year prognosis of AMS (von Arx et al. 2012). Preoperative and/or postoperative use of antibiotics on a routine basis in surgical endodontics has always received mixed reviews (Siqueira 2002, Iqbal et al. 2007). It is well known that antibiotics do not cure an apical infection in the long term; they should thus be used only when needed. This attitude should reduce the number of penicillin-resistant bacteria and the number of patients hypersensitive to penicillin (Rud & Rud 1998). Moreover, in a randomized controlled clinical study, Lindeboom et al. (2005b) found no benefit of antibiotic therapy in terms of early healing (initial 4 weeks) after periapical surgery. In the present study, in cases in which postoperative tissue swelling was accompanied by pain, antibiotics were prescribed. There was no significant influence of the postoperative medication on the treatment outcome,
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
C ß alısß kan et al. Outcome of apical microsurgery
which is in agreement with previous studies (Tsesis et al. 2006, von Arx et al. 2012). In the present study, the preoperative status of root canal filling had no significant influence on the final treatment outcome. This finding is in agreement with previous studies (von Arx et al. 2007, Walivaara et al. 2011). Also, previous initial endodontic treatment or retreatment had no significant influence, as confirmed by Song et al. (2011a). Some studies have suggested that micro-resurgery has a poorer prognosis than initial AMS, with a weighted average success rate of 76.6 and 85.2%, respectively (Saunders 2008, Song et al. 2011a, von Arx et al. 2012). However, the differences reported were not always statistically significant. Their results correlate with the findings of the present study, in which the outcome of the first-time surgery demonstrated a higher success rate (80.6%) compared to that of micro-resurgery (77.8%). However, Gagliani et al. (2005) reported significantly different success rates, with resurgery cases not performing as well: 59% healed completely in the resurgery group compared with 86% in teeth subjected to a single surgical procedure. Interestingly, Song et al. (2011b) reported successful outcomes of periradicular resurgery to be 92.9%, a higher percentage than that reported in other studies on endodontic micro-resurgery and comparable to percentages associated with the first endodontic surgery (Chong et al. 2003, von Arx et al. 2007, Kim et al. 2008, Saunders 2008). Maddalone & Gagliani (2003) reported a higher success rate of 95.3% in teeth without a post, compared with 87.5% in teeth with a post; however, this finding has not yet been corroborated by other studies (Taschieri et al. 2005, Tsesis et al. 2006, Song et al. 2011a, von Arx et al. 2012). Similarly, the present study found no correlation between the healing rate and the absence or presence of a post or screw. Several authors have assessed the healing rate in relation to the preoperative size of the periapical lesion after AMS (Rubinstein & Kim 1999, Tsesis et al. 2006, von Arx et al. 2007, Walivaara et al. 2011). In one study, a better outcome was reported for teeth with small lesions up to 5 mm in diameter compared with teeth with larger lesions (>5 mm) (von Arx et al. 2007); meanwhile, other studies have reported no significant effect (Rubinstein & Kim 1999, Tsesis et al. 2006, Walivaara et al. 2011). The latter finding was confirmed in the present study. However, considering the lesion size, some researchers defined ‘small
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
lesions’ as those smaller than 5 mm in diameter and those larger than 5 mm in diameter as ‘large lesions’ (Tsesis et al. 2006, von Arx et al. 2007). On the other hand, others defined the ‘medium lesions’ as the lesions with a diameter of 6–9 mm (Rubinstein & Kim 1999, Walivaara et al. 2011) and considered the lesions with a diameter of larger than 9 (Walivaara et al. 2011) or 10 mm (Rubinstein & Kim 1999) as ‘large lesions’. All of the above mentioned papers did not present the upper limit of the large lesion. Nevertheless, it was suggested that a very large lesion size (>10 mm) is one of the major factors influencing the prognosis, as these lesions demonstrate a significantly lower rate of complete healing, with an increased rate of incomplete healing rather than failure (Molven et al. 1996). An unpredictable long-term outcome has been observed in cases classified as uncertain after 1 year (Molven et al. 1987, 1996). Long-term followup of surgical cases showing incomplete or uncertain healing is thus important for a complete assessment and to promote accurate healing (Molven et al. 1996, Song et al. 2014). In this study, most of the teeth had a large persistent periapical lesion with a diameter ranging from 6 to 20 mm (72.2%). The size of the periapical lesion had marginally negative influences on the outcome, but the differences were not statistically significant. The overall success rate including complete and incomplete healing was 80%. Moreover, five teeth with a lesion size of >10 mm that demonstrated uncertain healing and no clinical signs and symptoms of inflammation were followed for 2 or 3 years and are still under evaluation to reach a final conclusion. On average, small lesions had completely disappeared within 6 months, whereas teeth with a radiographically measured lesion size of 10–20 mm in diameter had a slightly lower probability of healing than cases with a lesion size of
The outcome of apical microsurgery using MTA as the root-end filling material: 2- to 6-year follow-up study
M. K. C ß alısßkan1, U. Tekin2, M. E. Kaval1 & M. C. Solmaz2 1
Department of Endodontology, School of Dentistry, Ege University, Izmir; and 2Department of Oral and Maxillofacial Surgery, School of Dentistry, Ege University, Izmir, Turkey
Abstract C ß alısßkan MK, Tekin U, Kaval ME, Solmaz MC. The outcome of apical microsurgery using MTA as the root-end filling material: 2- to 6-year follow-up study. International Endodontic Journal, 49, 245–254, 2016.
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 analy-
Introduction Endodontic surgery is a reliable procedure for the treatment of teeth with persistent periradicular lesions that did not respond to initial primary or secondary root canal treatment (Gutmann & Harrison 1991). Since 1997 instead of traditional root-end surgery (TRS), apical microsurgery (AMS) was recommended for apical surgery (Kim 1997). These two techniques for root-end surgery differ significantly in the methods
Correspondence: Mehmet Emin Kaval, Department of Endodontology, School of Dentistry, Ege University, 35100 Izmir, Turkey (Tel.: +90 232 311 46 08; Fax: +90 232 388 03 25; e-mail: [email protected]).
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
sis 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 rootend filling material. Keywords: apical microsurgery, clinical outcome, mineral trioxide aggregate. Received 9 December 2014; accepted 23 March 2015
used to achieve the goal of periapical healing. The differences between TRS and AMS include the access armamentarium (standard size surgical bur versus bone cutting bur or piezo tip), the size of the osteotomy (large versus small), the instruments used (large regular versus small micro-instruments), the bevel angle (acute, in which the tip of the root is cut at approximately 2–3 mm with a 45° bevel, versus shallow, in which the apical root is resected 2–3 mm with a 0° or 10° bevel angle), the root-end preparation (bur versus ultrasonic tip to a depth of 3–4 mm), the direction of cavity preparation (off-angle versus aligned), the root-end filling material (amalgam versus biocompatible cements such as IRM, Super EBA and MTA), and the possible identification of microfractures and additional canals under the high-power
International Endodontic Journal, 49, 245–254, 2016
245
Outcome of apical microsurgery C ß alısß kan et al.
magnification of the endoscope or a microscope (Setzer et al. 2010). In a recent meta-analysis and systematic review (Setzer et al. 2010), clinical success rates ranging from 43.5% to 75% with a weighted average of 59% were reported for TRS. In contrast, improved success rates ranging from 89% to 100% were presented for recent studies incorporating AMS. Significant differences in the study design and treatment protocols complicated the evaluation of the factors that influence the outcome and the assessment of an acceptable protocol for AMS (Song et al. 2011a). Typically, clinical studies on periapical surgery have evaluated the outcome with respect to the root-end filling material (von Arx et al. 2007, Song et al. 2011a). Although several AMS studies have evaluated the short-term results (Rubinstein & Kim 1999, Chong et al. 2003, Lindeboom et al. 2005a, Taschieri et al. 2005, Tsesis et al. 2006, de Lange et al. 2007, von Arx et al. 2007, Kim et al. 2008, Saunders 2008, Christiansen et al. 2009, von Arx et al. 2010, Walivaara et al. 2011, Song & Kim 2012), few recent studies have reported the long-term success of AMS (Rubinstein & Kim 2002, von Arx et al. 2012, Song et al. 2012, 2014). Additionally, the assessment of significant outcome predictors requires long-term observation; however, long-term results have been reported only in two previous studies focusing on AMS (Song et al. 2011a, von Arx et al. 2012), which could compare their results with the studies that have not been based on AMS (Lustmann et al. 1991, Rahbaran et al. 2001, Barone et al. 2010). Therefore, the aim of this study was to evaluate the influence of various predictors on the 2- to 6-year outcomes of AMS and to compare the findings with other AMS investigations.
Material and methods In this clinical study, data were collected in the Department of Endodontics at the School of Dentistry, Ege University, Izmir, Turkey, between June 2007 and December 2013. On the basis of clinical and radiologic examination, a diagnosis was made, and a treatment plan was devised for each patient. Patients were fully informed about the surgical procedure, postoperative care, follow-up examinations and alternative treatment options, and written informed consent that meets the criteria of Ege University’s Institutional Review Board was obtained from patients prior to their participation.
246
International Endodontic Journal, 49, 245–254, 2016
Patient selection and inclusion criteria were as follows: patients with a noncontributory medical history; only one affected tooth per patient; only single rooted maxillary and mandibular anterior teeth; root filled teeth with asymptomatic periradicular periodontitis of strictly endodontic origin that failed after either nonsurgical or surgical treatment; teeth with sufficient root length for root-end preparation in teeth containing post-core restoration; and teeth that exhibited an adequate coronal restoration without deficiencies and with no caries. The following exclusion criteria were applied: teeth with pathoses associated with horizontal or vertical root fracture; more than 5 mm of periodontal attachment and bone loss detected by periodontal probing; and teeth with perforation of cervical or lateral canal walls. A total of 108 patients were included. The predictors investigated were age, gender, type and location of the tooth; the quality of the root canal filling in terms of density and length was considered as ‘good’ when there was radiographically dense filling ending between 0 and 2 mm short of the apex, or 0.05) (Table 1). The calculated crude odds ratios for all predictors were not statistically significant. Therefore, further multiple logistic regression analysis was not performed. The treatment results obtained in the follow-up observation periods are presented in Table 2. Two-year follow-up was adopted as a minimum follow-up period. Most of the successful cases were considered healed
International Endodontic Journal, 49, 245–254, 2016
247
Outcome of apical microsurgery C ß alısß kan et al.
within 2 years of endodontic surgery. Complete healing was observed in 67 teeth (74.4%), 5 asymptomatic teeth (5.6%) were determined as having undergone incomplete healing, and 5 teeth (5.6%) were identified as having undergone uncertain healing. Uncertain healing was observed in 5 teeth with a lesion size of >10 mm that were followed up for up to 2–3 years and continued to have no other signs and symptoms, and a radiographically significant decrease in the size of the lesion (Fig. 1). The overall healing rate was 80%.
Small lesions with a diameter of 2–5.9 mm (25 teeth) were associated with complete healing in 23 cases (92%). The length of time required for healing to take place in these cases ranged from 3 to 9 months. On average, small lesions healed within 6 months. Complete healing was observed in 29 cases (74.4%) amongst 39 teeth with medium lesions of 6– 9.9 mm diameter, whereas incomplete healing was observed in 2 cases amongst this group (5.1%). The period of time required for healing in these cases ranged from 7 to 12 months with an average of
Table 1 Distribution of cases per preoperative variables and per healing group Cases
Uncertaina
Healed
Predictors
n
%
n
All Gender Male Female Age 16–30 31–50 51–65 Tooth location and type Maxillary anterior Mandibular anterior Quality of root canal filling Good Not good Post/screw Absent Present Previous treatment Initial Retreatment Previous apical surgery No Yes Size of periapical lesion 2–5.9 mm 6–9.9 mm 10–20 mm Biopsy Granuloma Cyst Othersb Antibiotic therapy Used Unused Postoperative healing course Uneventful Complicationc
90
100
72
%
Nonhealed
n
%
n
%
80
5
5.6
13
14.4
52 38
57.8 42.2
44 28
84.6 73.7
2 3
3.8 7.9
6 7
11.5 18.4
39 30 21
43.3 33.3 23.3
32 23 17
82 76.7 80.9
2 2 1
5.1 6.6 4.8
5 5 3
12.8 16.7 14.3
70 20
77.8 22.2
56 16
80 80
4 1
5.7 5
10 3
14.3 15
28 62
31.1 68.9
24 48
85.7 77.4
1 4
3.6 6.5
3 10
10.7 16.1
71 19
78.9 21.1
58 14
81.7 73.7
3 2
4.2 10.5
10 3
14.1 15.8
30 42
41.7 58.3
26 32
86.7 76.2
1 3
3.3 7.1
3 7
10 16.7
72 18
80 20
58 14
80.6 77.8
4 1
5.5 5.5
10 3
13.9 16.7
25 39 26
27.8 43.3 28.9
23 31 18
92 79.5 69.2
– 2 3
– 5.1 11.5
2 6 5
8 15.4 19.2
60 16 4
75 20 5
53 13 3
88.3 81.2 75
2 1 1
3.3 6.2 25
5 2 –
8.3 12.5 –
20 70
22.2 77.8
17 55
85 78.6
1 4
5 5.7
2 11
10 15.7
82 8
91.1 8.9
67 5
81.7 62.5
4 1
4.9 12.5
11 2
13.4 25
a
Uncertain cases were not included in the statistical analyses for the predictors. others: abscess, scar tissue, foreign body reaction. c complication: haematoma, infection, swelling. b
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Outcome of apical microsurgery C ß alısß kan et al.
within 2 years of endodontic surgery. Complete healing was observed in 67 teeth (74.4%), 5 asymptomatic teeth (5.6%) were determined as having undergone incomplete healing, and 5 teeth (5.6%) were identified as having undergone uncertain healing. Uncertain healing was observed in 5 teeth with a lesion size of >10 mm that were followed up for up to 2–3 years and continued to have no other signs and symptoms, and a radiographically significant decrease in the size of the lesion (Fig. 1). The overall healing rate was 80%.
Small lesions with a diameter of 2–5.9 mm (25 teeth) were associated with complete healing in 23 cases (92%). The length of time required for healing to take place in these cases ranged from 3 to 9 months. On average, small lesions healed within 6 months. Complete healing was observed in 29 cases (74.4%) amongst 39 teeth with medium lesions of 6– 9.9 mm diameter, whereas incomplete healing was observed in 2 cases amongst this group (5.1%). The period of time required for healing in these cases ranged from 7 to 12 months with an average of
Table 1 Distribution of cases per preoperative variables and per healing group Cases
Uncertaina
Healed
Predictors
n
%
n
All Gender Male Female Age 16–30 31–50 51–65 Tooth location and type Maxillary anterior Mandibular anterior Quality of root canal filling Good Not good Post/screw Absent Present Previous treatment Initial Retreatment Previous apical surgery No Yes Size of periapical lesion 2–5.9 mm 6–9.9 mm 10–20 mm Biopsy Granuloma Cyst Othersb Antibiotic therapy Used Unused Postoperative healing course Uneventful Complicationc
90
100
72
%
Nonhealed
n
%
n
%
80
5
5.6
13
14.4
52 38
57.8 42.2
44 28
84.6 73.7
2 3
3.8 7.9
6 7
11.5 18.4
39 30 21
43.3 33.3 23.3
32 23 17
82 76.7 80.9
2 2 1
5.1 6.6 4.8
5 5 3
12.8 16.7 14.3
70 20
77.8 22.2
56 16
80 80
4 1
5.7 5
10 3
14.3 15
28 62
31.1 68.9
24 48
85.7 77.4
1 4
3.6 6.5
3 10
10.7 16.1
71 19
78.9 21.1
58 14
81.7 73.7
3 2
4.2 10.5
10 3
14.1 15.8
30 42
41.7 58.3
26 32
86.7 76.2
1 3
3.3 7.1
3 7
10 16.7
72 18
80 20
58 14
80.6 77.8
4 1
5.5 5.5
10 3
13.9 16.7
25 39 26
27.8 43.3 28.9
23 31 18
92 79.5 69.2
– 2 3
– 5.1 11.5
2 6 5
8 15.4 19.2
60 16 4
75 20 5
53 13 3
88.3 81.2 75
2 1 1
3.3 6.2 25
5 2 –
8.3 12.5 –
20 70
22.2 77.8
17 55
85 78.6
1 4
5 5.7
2 11
10 15.7
82 8
91.1 8.9
67 5
81.7 62.5
4 1
4.9 12.5
11 2
13.4 25
a
Uncertain cases were not included in the statistical analyses for the predictors. others: abscess, scar tissue, foreign body reaction. c complication: haematoma, infection, swelling. b
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Outcome of apical microsurgery C ß alısß kan et al.
Table 3 Nonhealed cases by combined clinical and radiologic signs (n = 13)
(a)
(b)
Figure 3 (a) Preoperative radiograph showing a large radiolucent lesion associated with maxillary right lateral incisor. Note protruded Gutta-percha from the apex into periapical lesion. (b) The histopathologic diagnosis was periapical granuloma. Six years postoperative radiograph showing incomplete healing (scar tissue).
In the present study, the patient’s age and gender had no significant effect on the outcome of AMS; this finding is consistent with previous studies (Tsesis et al. 2006, von Arx et al. 2007), although Song et al. (2011a) reported in their retrospective study that gender (female versus male) appeared to have a positive effect on the outcome after 4 years of follow-up. Several studies have demonstrated success rates of AMS that differ significantly for different tooth types in both the maxilla and the mandible (Rubinstein & Kim 1999, Maddalone & Gagliani 2003, Taschieri et al. 2005, de Lange et al. 2007, Song et al. 2011a, von Arx et al. 2012). In the present study, the outcome of surgical treatment of maxillary and mandibular anterior teeth was assessed, which demonstrated healed rates of 80%. Similar results were reported in previous studies (Lindeboom et al. 2005a, Christiansen et al. 2009). In addition, some authors have suggested that anterior teeth tended to have a higher success rate than the other tooth groups (Kim & Kratchman 2006, de Lange et al. 2007, Song et al. 2011a) as anterior teeth are easy to access and have a simple root canal anatomy (Friedman 2008). Song et al. (2011a) suggested that preoperative signs and/or symptoms did not influence the outcome of AMS, whilst von Arx et al. (2007) reported that clinical signs or symptoms such as pain and tenderness at the initial examination were the only significant predictors for 1-year prognosis after AMS; however, this predictor lost its prognostic value after 5-year follow-up (von Arx et al. 2012). As AMS was
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Category
N
%
Increased lesion with pain and swelling No alteration in periradicular status and continued pain Periodontal consideration Further traumatic injury
6
46.2
3
23
2 2
15.4 15.4
not carried out during the acute phase of periapical pathosis or exacerbation of chronic periapical abscess, no comparison can be made with the findings of the above studies. In the present study, haematoma, infection, pain and swelling were observed as postoperative complications, as previously reported (Lindeboom et al. 2005 b, von Arx et al. 2007). The presence of infection at the postoperative clinical examination was confirmed if the patient had a swelling accompanied with localized pain/tenderness and fever. In such cases, drainage was achieved by the surgeon opening the wound deliberately. Patients with an uneventful initial healing phase (82 of 90 cases) also had a better success rate (81.7%) compared with patients with postoperative complications (8 of 90 cases) (62.5%). However, no significant difference was observed. With regard to the various aforementioned predictors, in only one study in the literature was the immediate postoperative healing course found to be related to the healing outcome after a year (von Arx et al. 2007), but this predictor was not significant for the 5-year prognosis of AMS (von Arx et al. 2012). Preoperative and/or postoperative use of antibiotics on a routine basis in surgical endodontics has always received mixed reviews (Siqueira 2002, Iqbal et al. 2007). It is well known that antibiotics do not cure an apical infection in the long term; they should thus be used only when needed. This attitude should reduce the number of penicillin-resistant bacteria and the number of patients hypersensitive to penicillin (Rud & Rud 1998). Moreover, in a randomized controlled clinical study, Lindeboom et al. (2005b) found no benefit of antibiotic therapy in terms of early healing (initial 4 weeks) after periapical surgery. In the present study, in cases in which postoperative tissue swelling was accompanied by pain, antibiotics were prescribed. There was no significant influence of the postoperative medication on the treatment outcome,
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C ß alısß kan et al. Outcome of apical microsurgery
which is in agreement with previous studies (Tsesis et al. 2006, von Arx et al. 2012). In the present study, the preoperative status of root canal filling had no significant influence on the final treatment outcome. This finding is in agreement with previous studies (von Arx et al. 2007, Walivaara et al. 2011). Also, previous initial endodontic treatment or retreatment had no significant influence, as confirmed by Song et al. (2011a). Some studies have suggested that micro-resurgery has a poorer prognosis than initial AMS, with a weighted average success rate of 76.6 and 85.2%, respectively (Saunders 2008, Song et al. 2011a, von Arx et al. 2012). However, the differences reported were not always statistically significant. Their results correlate with the findings of the present study, in which the outcome of the first-time surgery demonstrated a higher success rate (80.6%) compared to that of micro-resurgery (77.8%). However, Gagliani et al. (2005) reported significantly different success rates, with resurgery cases not performing as well: 59% healed completely in the resurgery group compared with 86% in teeth subjected to a single surgical procedure. Interestingly, Song et al. (2011b) reported successful outcomes of periradicular resurgery to be 92.9%, a higher percentage than that reported in other studies on endodontic micro-resurgery and comparable to percentages associated with the first endodontic surgery (Chong et al. 2003, von Arx et al. 2007, Kim et al. 2008, Saunders 2008). Maddalone & Gagliani (2003) reported a higher success rate of 95.3% in teeth without a post, compared with 87.5% in teeth with a post; however, this finding has not yet been corroborated by other studies (Taschieri et al. 2005, Tsesis et al. 2006, Song et al. 2011a, von Arx et al. 2012). Similarly, the present study found no correlation between the healing rate and the absence or presence of a post or screw. Several authors have assessed the healing rate in relation to the preoperative size of the periapical lesion after AMS (Rubinstein & Kim 1999, Tsesis et al. 2006, von Arx et al. 2007, Walivaara et al. 2011). In one study, a better outcome was reported for teeth with small lesions up to 5 mm in diameter compared with teeth with larger lesions (>5 mm) (von Arx et al. 2007); meanwhile, other studies have reported no significant effect (Rubinstein & Kim 1999, Tsesis et al. 2006, Walivaara et al. 2011). The latter finding was confirmed in the present study. However, considering the lesion size, some researchers defined ‘small
© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
lesions’ as those smaller than 5 mm in diameter and those larger than 5 mm in diameter as ‘large lesions’ (Tsesis et al. 2006, von Arx et al. 2007). On the other hand, others defined the ‘medium lesions’ as the lesions with a diameter of 6–9 mm (Rubinstein & Kim 1999, Walivaara et al. 2011) and considered the lesions with a diameter of larger than 9 (Walivaara et al. 2011) or 10 mm (Rubinstein & Kim 1999) as ‘large lesions’. All of the above mentioned papers did not present the upper limit of the large lesion. Nevertheless, it was suggested that a very large lesion size (>10 mm) is one of the major factors influencing the prognosis, as these lesions demonstrate a significantly lower rate of complete healing, with an increased rate of incomplete healing rather than failure (Molven et al. 1996). An unpredictable long-term outcome has been observed in cases classified as uncertain after 1 year (Molven et al. 1987, 1996). Long-term followup of surgical cases showing incomplete or uncertain healing is thus important for a complete assessment and to promote accurate healing (Molven et al. 1996, Song et al. 2014). In this study, most of the teeth had a large persistent periapical lesion with a diameter ranging from 6 to 20 mm (72.2%). The size of the periapical lesion had marginally negative influences on the outcome, but the differences were not statistically significant. The overall success rate including complete and incomplete healing was 80%. Moreover, five teeth with a lesion size of >10 mm that demonstrated uncertain healing and no clinical signs and symptoms of inflammation were followed for 2 or 3 years and are still under evaluation to reach a final conclusion. On average, small lesions had completely disappeared within 6 months, whereas teeth with a radiographically measured lesion size of 10–20 mm in diameter had a slightly lower probability of healing than cases with a lesion size of
