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JOURNAL OF ENDODONTICS Copyright 9 1990 by The American Association of Endodontists
VOL. 17, NO. 1, JANUARY 1991
CLINICAL ARTICLES Treatment Results of Apical Surgery in Premolar and Molar Teeth Shimon Friedman, DMD, Joshua Lustmann, DMD, and Vered Shaharabany, DMD
(5, 8), whereas apicoectomies in posterior teeth were investigated in four studies (13-16) on a total of 290 teeth. Ericson et al. (11) compared the treatment results of apical surgery in 155 maxillary canines, 149 premolars and 10 molars, in which the overall success rate was 53.5%. The lowest success rate of 43.8% was found in the maxillary first premolars, corroborating similar indications in previous studies that consisted mainly of anterior teeth (5, 8). Their findings suggested that apicoectomy in posterior teeth may be less successful than in anterior teeth. However, Altonen and Mattila (13) found 72% of 46 molar apicoectomies successful, while in anterior teeth the same authors found only 55% success (7). Persson (14) found 73% success after apicoectomies in 25 molars. Similar results were reported after 70 molar apicoectomies by Ioannides and Borstlap (15) and by Franz et al. (16) following 150 molar apicoectomies. These investigators concluded that the treatment results of apicoectomies in molars were comparable to those reported in anterior teeth. It appears that further information is required regarding the treatment results of apical surgery in posterior teeth. The purpose of this investigation was to study long-term treatment results and clinical manifestations following apical surgery in maxillary and mandibular premolars and molars.
The purpose of this investigation was to study longterm treatment results following apical surgery in premolars and molars. These results were assessed by reexamination of 136 roots on which apical surgery was performed. The observation period varied from 6 months to 8 yr. According to radiographic and clinical criteria, the treatment results were considered successful in 44.1% of the roots, doubtful in 22.8%, and unsuccessful in 33.1%. Clinical signs and symptoms were associated with 33.1% of the roots, occurring significantly more in roots demonstrating radiographically unsatisfactory healing. The results are discussed with reference to other studies on apical surgery in posterior and anterior teeth. However, methodological differences do not permit the drawing of direct comparisons to those studies.
Numerous studies have investigated the long-term treatment results of apical surgery (1-6). In some of these studies the reported success rate was lower than 50% (4, 6), while in others it was as high as 90% ( 1). This wide variation has been attributed to differences in indications for surgery and postoperative evaluation criteria (5-7), observation period (2, 3), and surgical techniques (5, 6). The radiographic appearance at follow-up was the dominant parameter examined in most studies. Consequently, there is limited information in the literature regarding the long-term clinical manifestations in apicoectomized teeth (7, 8). Apical surgery has been studied mostly in anterior teeth with more than 30 studies reported, some of which included over 570 teeth each (1, 2, 5, 6). Apicoectomy in anterior maxillary and mandibular teeth affords a convenience of access and visibility unobtainable in posterior teeth (9). The proximity of the root tips to the mandibular vessels and the maxillary sinus further restricts the operative access to the mandibular and maxillary posterior teeth, respectively (10). These limitations are frequently discussed along with the technical operative aspects of apicoectomy in posterior teeth (9, 10). However, with the exception of two studies (11, 12), few premolars were included in the studies of anterior teeth
M A T E R I A L S AND M E T H O D S Ninety-one patients were reexamined following apical surgery in premolar and molar teeth performed between 1980 and 1988. The patients were treated by different operators at the Department of Oral and Maxillofacial Surgery and the Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. The indication for surgery in all but two teeth was failure of nonsurgical endodontic therapy. A total of 103 teeth with 136 roots were included in the study. One-hundred & t h e roots were in females and 36 in males. The characterization of the material by age and observation period is presented in Fig. 1. The minimal observation period was 6 months and the maximal 8 yr. The distribution of the material according to tooth types is shown in Table 4. The records indicated that 14 roots had been extracted with sufficient documentation being available to allow their inclusion in the study. 30
Vol. 7, No. 1, January 1991
Results of Apical Surgery
Teeth still in situ were examined clinically for tenderness to percussion or palpation of the vestibule, and the treated regions were closely observed for the presence of swelling or sinus tracts. The sulcus depth and mobility were recorded and compared with the patient's preoperative record. In addition, the patients were questioned about the occurrence of any symptoms since surgery. For the purpose of abbreviation, the term "clinical manifestations" will be used in the following text to include any symptoms and clinical signs, unless otherwise specified. In multirooted teeth, the presence of clinical manifestations, except a sinus tract, was recorded for all of the roots of the same tooth. Radiographs were taken of the treated teeth with attention to reproduction of the exposure angulation of the postoperative radiographs. The radiographic assessment included the evaluation of the preoperative radiographs and that of any intermediate follow-up radiographs found in the patient's chart. Most radiographs were reviewed by a single examiner after a sample had been examined jointly by all three investigators. Questionable radiographs were also evaluated jointly by all investigators. The treatment results classification was based on radiographic and clinical findings. The radiographic results were recorded according to Rud et al. (17) with one difference; even a small remaining radiolucency in the periodontal ligament space was recorded as incomplete rather than complete healing. The radiographic findings were combined with the clinical findings to establish the following diagnoses: successful--complete healing radiographically, without any clinical manifestations: doubtful--incomplete or uncertain healing without any clinical manifestations, or complete healing with tenderness to percussion: and unsuccessful--incomplete or uncertain healing with tenderness to percussion, or the presence of symptoms, swelling, or a sinus tract irrespective of the radiographic appearance; or unsatisfactory healing irrespective of clinical manifestations. The radiographic and clinical findings were recorded and submitted to computerized analysis using the chi-square test. Levels of p = 0,05 were considered statistically significant.
31
respectively. The differences in the results observed within these various groups were not statistically significant. Forty five roots (33.1%) were associated with clinical manifestations; of these pain was related to 17 roots, swelling to 11 roots, and a sinus tract to 19 roots. Abnormal mobility was found in two roots. Thirty roots were tender to percussion, five of which were unrelated to any other clinical manifestations. The presence of clinical manifestations is related to the type of radiographic healing in Table 5, the differences being statistically highly significant (p < 0.0001). Clinical manifestations were present significantly more in cases with radiographically unsatisfactory healing than in cases with complete healing. TABLE 1. Treatment results related to sex No.of
Treatment Results (%)
Sex Female Male
Roots
Successful
Doubtful
Unsuccessful
100 36
44 44.5
19 33.3
37 22.2
TABLE 2. Treatment results related to age Age
No, of
Treatment Results (%)
(yr)
Roots
Successful
Doubtful
Unsuccessful
13-20 21-30 31-40 41-73
47 46 23 20
46.8 50 43.5 25
23.4 21.7 21.7 25
29.8 28.3 34.8 50
TABLE 3. Treatment results related to observation period Observation
No. of
Treatment Results (%)
(yr)
Roots
Successful
Doubtful
Unsuccessful
0.5-1 1.5 2-3 >3.5
42 37 29 28
42.9 40.5 55.2 39.3
26.2 24.3 13.8 25
31 35.1 31 35.7
RESULTS Of the 136 studied roots the treatment results were successful in 60 roots (44.1%), doubtful in 31 (22.8%) and unsuccessful in 45 (33.1%). Radiographically, the healing was complete in 65 roots (47.8%), incomplete in 32 roots (23.5%), uncertain in 18 roots (13.2%), and unsatisfactory in 21 roots (15.5%). The distribution of the results by sex, age, observation period, and tooth type is presented in Tables 1 to 4, 47
46
AGE
TABLE 4, Treatment results related to tooth type No. of Tooth Location
Treatment Results (%)
Roots Successful Doubtful Unsuccessful
First premolar Second premolar Molar
39 43 12
48.7 44.2 50
12.8 20.9 41.7
35.9 34.9 8.3
l First premolar Second premolar Molar
10 4 28
20 75 35.7
20 25 28.6
60 0 28.6
TABLE 5. Clinical signs and symptoms related to radiographic appearance 13-20
21-30 31-40 41-73 (years) 0.5 1 1,5 2 2.5 3 3,5 >4
Fla 1. Distribution of roots by patients' age and observation period.
Radiographic "Healing"
No. of Roots
Presence of Clinical Manifestations (%)
Complete Incomplete Uncertain Unsatisfactory
65 32 18 21
9.2 40.C 50 81
32
Friedman et al.
Journal of Endodontics
The association of the different clinical manifestations with each other varied. The presence of pain is related to the presence of a sinus tract or swelling in Table 6. Pain occurred significantly less (p < 0.0 l) with the presence of a sinus tract than without it. There was no difference in the occurrence of pain in the presence or absence of swelling. The occurrence of tenderness to percussion in relation to the other clinical manifestations is presented in Table 7, with the differences being statistically highly significant (p < 0.0001). An additional observation from the study was that, of the 45 roots associated with treatment failure, 24 roots (53%) received no additional treatment, and 14 roots (31%) were extracted. Apical surgery was repeated on four roots (9%), and endodontic retreatment was performed on three roots (7%).
DISCUSSION The present investigation varies from other studies with respect to its postoperative evaluation criteria. R u d e t al. (17) considered some forms of remaining radiolucency as complete healing in no need of prolonged observation (2). However, in a follow-up examination after apical surgery, even a minimal radiolucency should be considered as an uncertain result that warrants continued observation. Only if it is observed over a considerable period may a minimal radiolucency be considered a success. Since a longitudinal observation was not possible in most of the present material, the radiographic criteria were chosen to be severe. Our clinical criteria were less severe than in other studies (4, 5, 7, 8, 11, 14), in which failure was decided by tenderness to percussion alone, irrespective of the radiographic appearance. Tenderness to percussion is not exclusively caused by periapical pathosis per se, and, therefore, it was not interpreted as such when present in association with radiographically complete healing. The success rate of 44% in the present study is in agreement with that reported by Ericson et al. (1 l) in maxillary premolars, but it is lower than the success rate of molar apicoectomies in previous studies (13-16). The disagreement may partly be explained by the differences in the postoperative evaluation criteria. In one study (13), the results were assessed TABLE 6. Sinus tract or swelling related to pain among 45 roots associated with clinical signs and symptoms
Presence of (%)
Pain
No. of Roots
Sinus Tract
Swelling
Present Absent
17 28
11.8 60.7
23.5 25
Total
45
42.2
24.5
TABLE 7. Tenderness to percussion related to other clinical signs and symptoms
Clinical Manifestations Present Absent Total
No. of Roots 40 96 136
Presence of Tenderness to Percussion (%) 62.5 5.2 22
radiographically without considering clinical signs and symptoms, which may be present regardless of radiographic evidence of complete healing (4, 7). Similar evaluation of the present study material would have resulted in success and failure rates of 48% and 16%, respectively, instead of 44% and 33%. Radiographieally, the criteria in two of the previous reports (13, 16) differed from those of the present investigation, allowing them to result in larger success groups. Furthermore, three studies (13, 15, 16) included mostly cases in which surgery was performed in conjunction with orthograde root canal instrumentation and obturation. The treatment success after such a procedure is higher than after apical surgery of endodontic failure cases (4-7) which was performed in the present study. The one study (14) that was comparable in methodology to the present one included only 26 teeth and is too small for a clinical study of this nature. The success rate in our study was also lower than in most studies of apical surgery in anterior teeth (1-8). Comparing their results with those of previous reports, Altonen and Mattila (13) and Persson (14) concluded that, when performed by experienced operators, the success rate of apical surgery in the posterior region is similar to that in anterior teeth. However, drawing comparisons between long-term apicoectomy studies is often impractical due to differences in methodology. In this context, it merits mentioning that even when the same investigators subsequently performed studies on anterior and posterior teeth (7, 13), the operative procedures were performed differently, possibly affecting the treatment results (13). Therefore, it appears that apical surgery in anterior and posterior teeth may be compared reliably only if they are performed within the same study. In a recent study (12), the investigated material included 74.5% premolars and molars, in which the success rate was higher than in the anterior teeth. However, two studies (5, 8) included in their material about 20% posterior teeth, with the maxillary premolars demonstrating the poorest success rate. In another study of maxillary canines and posterior teeth (11), it was found that "the results of operation of the canines were better than those of the first and second premolars." These results were attributed to the anatomy of the premolars coupled with the technical difficulty of access (11). Our study also indicates that, when performing apical surgery in premolars and molars with the indications and evaluation criteria as described, the success rate should be expected to be relatively low. In the present study, as well as in a previous one (12), no differences were demonstrated between the treatment results in premolars and molars. The majority of the molars treated in our study were first molars. It may be suggested that the premolars and the first molars are similar in terms of access difficulty and anatomical variability. This would explain the comparable success rate in both groups. However, it may also be speculated that apicoectomy in molars is more difficult, but their root anatomy is less variable. In this respect, it should be noted that the treated premolars occasionally had palatal roots, whereas both our and the previous study did not include any molar palatal roots. It was observed previously that the percentage of uncertain treatment results diminished with time until it became minimal after 4 yr (2). Our study did not confirm this observation, but our material was considerably smaller and the observation period shorter than in the previous study. Also, the previous study included a longitudinal observation of half its material
Vol. 7, No. 1, January 1991
that demonstrated the dynamic changes within the treatment results, whereas in the present study the treatment results of most cases were recorded only at one time. It was shown that reduction of the uncertain group can be demonstrated when the same material is observed at different times, but not when portions of it are examined at different times each (12). Rud et al. (2) stated that chronic periapical inflammation was usually symptomless and that clinical information did not affect the interpretation of the treatment results after apical surgery. This was supported by several studies (2, 4, 8, 13) in which only 6 to 10% of apicoectomized teeth presented with clinical manifestations. In other reports based on radiographic and clinical examinations (5, 11, 14), the number of symptomatic cases was not specified, but they appeared to be few. In this respect the finding of clinical manifestations in 33 % of the present material is somewhat surprising. However, it is in agreement with one previous study (7), in which 35% of the cases demonstrated various clinical manifestations. In both studies a correlation was demonstrated between the presence of clinical manifestations and periapical radiolucency. In another study (17), a similar correlation was observed with "objective symptoms," but not with "subjective symptoms." It is usually speculated that symptoms associated with periapical radiolucency result from pressure. The lack of pain in the presence of sinus tracts in this study supports that speculation. This also may be the reason why tenderness to percussion was found frequently in the presence of other clinical signs and symptoms. However, a histological examination of apicoectomized teeth, particularly of failures, did not substantiate this speculation, showing the majority of the lesions to be an "epithelial granuloma and squamous epithelial cyst" (19). An unexpected observation in the present study was that 53% of the failed apical surgery cases remained untreated in spite of their majority being symptomatic. In previous reports it was mentioned that 9% (7, 13) and 14% (4) of the teeth were extracted. Also in the present material 14% of the roots were extracted. Interestingly, another study regarding endodontic therapy (20) demonstrated that 54% of endodontic failures were not treated. In the same study, an additional 23% of the teeth were extracted. That report (20) and the present one suggest that clinicians are either hesitant or skeptical when faced with failure of endodontic therapy, surgical or nonsurglcal. In view of this possibility, it would seem appropriate that this particular epidemiological group be
Results of Apical Surgery
33
given more emphasis in the curriculum of basic and continuing endodontic education. Dr. Friedman is affiliated with the Department of Endodontics, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel, Dr. Lustmann is affiliated with the Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah School of Dental Medicine, and Dr. Shaharabany is affiliated with the Hebrew University-Hadassah School of Dental Medicine. Thesis submitted as a partial requirement toward a DMD degree for Dr. Shaharabany.
References 1. Harry FJ, Parkins BJ, Wengraf AM. The success rate of apicectomy. A retrospective study of 1,016 cases. Br Dent J 1970;129:407-13. 2. Rud J, Andreasen JO, Jensen JEM. A follow-up study of 1000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:215-28. 3. Mikkonen M, Kullaa-Mikkonen A, Kotilainen R. Clinical and radiologic reexamination of apicoectomized teeth. Oral Surg 1983;55:302-6. 4. Persson G, Lennartson B, Lundstrom I. Results of retrograde root-filling with special reference to amalgam and Cavit as root-filling materials. Svensk Tandlak Tidskr 1974;68:123-33. 5. Nordenram A, Svardstrom G. Results of apicectomy. A clinical-radiological examination. Svensk Tandlak Tidskr 1970;63:593-604. 6. Hirsch J-M, Ahlstrom U, Henrikson P-A, Heyden G, Peterson L-E. Periapical surgery. Int J Oral Surg 1979;8:173-85. 7. Mattila K, Altonen M. A clinical and roentgenological study of apicoectomized teeth. Odontol Tidskr 1968;76:389-407. 8. Lehtinen R, Aitasalo K. Comparison of the clinical and roentgenological state at the re-examination of root resections. Proc Finn Dent Soc 1972;68:209-11. 9. Khoury F, Hensher R. The bony lid approach for the apical root resection of lower molars. Int J Oral Maxillofac Surg 1987;16:166-70. 10. Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical considerations and clinical techniques. Int Endod J 1985;18:8-34. 11. Ericson S, Finne K, Persson G. Results of apicoectomy of maxillary canines, premolars and molars with special reference to oroantral communication as a prognostic factor. Int J Oral Surg 1974;3:386-93. 12. Rud J, Andreasen JO, Rud V. Retrograd rodfyldning med plast og dentinbinder: helingsfrekvens sammenlignet meal retrograd amalgam. Tandlaegebladet 1989;93:267-73. 13. Altonen M, Mattila K. Follow-up of apicoectomized molars. Int J Oral Surg 1976;5:33-40. 14. Persson G. Periapical surgery of molars. Int J Oral Surg 1982;11:96100. 15. Ioannides C, Borstlap WA. Apicoectomy on molars: a clinical and radiographical study. Int J Oral Surg 1983;12:73-9. 16. Franz M, Bethke K, Bier J. Wurzelspitzenamputation an 150 molaren des oberund unterkiefers. Dtsch Zahnarztl Z 1987;42:287-9. 17. Rud J, Andreasen JO, Jensen JEM. Radiographic criteria for the assessment of healing after endodontic surgery. Int J Oral Surg 1972;1:195-214. 18. Molven O, Halse A, Grung B. Observer strategy and the radiographic classification of healing after endodontic surgery. Int J Oral Maxillofac Surg 1987;16:432-9. 19. Arwill T, Persson G, Thilander H. The microscopic appearance of the periapical tissue in cases classified as "uncertain" or "unsuccessful" after apicoectomy. Odontol Revy 1974;25:27-42. 20. Petersson K, Lewin B, Hakanson J, Olsson B, Wennberg A. Endodontic status and suggested treatment in a population requiring substantial dental care. Endod Dent Traumato11989;5:153-8.
JOURNAL OF ENDODONTICS Copyright 9 1990 by The American Association of Endodontists
VOL. 17, NO. 1, JANUARY 1991
CLINICAL ARTICLES Treatment Results of Apical Surgery in Premolar and Molar Teeth Shimon Friedman, DMD, Joshua Lustmann, DMD, and Vered Shaharabany, DMD
(5, 8), whereas apicoectomies in posterior teeth were investigated in four studies (13-16) on a total of 290 teeth. Ericson et al. (11) compared the treatment results of apical surgery in 155 maxillary canines, 149 premolars and 10 molars, in which the overall success rate was 53.5%. The lowest success rate of 43.8% was found in the maxillary first premolars, corroborating similar indications in previous studies that consisted mainly of anterior teeth (5, 8). Their findings suggested that apicoectomy in posterior teeth may be less successful than in anterior teeth. However, Altonen and Mattila (13) found 72% of 46 molar apicoectomies successful, while in anterior teeth the same authors found only 55% success (7). Persson (14) found 73% success after apicoectomies in 25 molars. Similar results were reported after 70 molar apicoectomies by Ioannides and Borstlap (15) and by Franz et al. (16) following 150 molar apicoectomies. These investigators concluded that the treatment results of apicoectomies in molars were comparable to those reported in anterior teeth. It appears that further information is required regarding the treatment results of apical surgery in posterior teeth. The purpose of this investigation was to study long-term treatment results and clinical manifestations following apical surgery in maxillary and mandibular premolars and molars.
The purpose of this investigation was to study longterm treatment results following apical surgery in premolars and molars. These results were assessed by reexamination of 136 roots on which apical surgery was performed. The observation period varied from 6 months to 8 yr. According to radiographic and clinical criteria, the treatment results were considered successful in 44.1% of the roots, doubtful in 22.8%, and unsuccessful in 33.1%. Clinical signs and symptoms were associated with 33.1% of the roots, occurring significantly more in roots demonstrating radiographically unsatisfactory healing. The results are discussed with reference to other studies on apical surgery in posterior and anterior teeth. However, methodological differences do not permit the drawing of direct comparisons to those studies.
Numerous studies have investigated the long-term treatment results of apical surgery (1-6). In some of these studies the reported success rate was lower than 50% (4, 6), while in others it was as high as 90% ( 1). This wide variation has been attributed to differences in indications for surgery and postoperative evaluation criteria (5-7), observation period (2, 3), and surgical techniques (5, 6). The radiographic appearance at follow-up was the dominant parameter examined in most studies. Consequently, there is limited information in the literature regarding the long-term clinical manifestations in apicoectomized teeth (7, 8). Apical surgery has been studied mostly in anterior teeth with more than 30 studies reported, some of which included over 570 teeth each (1, 2, 5, 6). Apicoectomy in anterior maxillary and mandibular teeth affords a convenience of access and visibility unobtainable in posterior teeth (9). The proximity of the root tips to the mandibular vessels and the maxillary sinus further restricts the operative access to the mandibular and maxillary posterior teeth, respectively (10). These limitations are frequently discussed along with the technical operative aspects of apicoectomy in posterior teeth (9, 10). However, with the exception of two studies (11, 12), few premolars were included in the studies of anterior teeth
M A T E R I A L S AND M E T H O D S Ninety-one patients were reexamined following apical surgery in premolar and molar teeth performed between 1980 and 1988. The patients were treated by different operators at the Department of Oral and Maxillofacial Surgery and the Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. The indication for surgery in all but two teeth was failure of nonsurgical endodontic therapy. A total of 103 teeth with 136 roots were included in the study. One-hundred & t h e roots were in females and 36 in males. The characterization of the material by age and observation period is presented in Fig. 1. The minimal observation period was 6 months and the maximal 8 yr. The distribution of the material according to tooth types is shown in Table 4. The records indicated that 14 roots had been extracted with sufficient documentation being available to allow their inclusion in the study. 30
Vol. 7, No. 1, January 1991
Results of Apical Surgery
Teeth still in situ were examined clinically for tenderness to percussion or palpation of the vestibule, and the treated regions were closely observed for the presence of swelling or sinus tracts. The sulcus depth and mobility were recorded and compared with the patient's preoperative record. In addition, the patients were questioned about the occurrence of any symptoms since surgery. For the purpose of abbreviation, the term "clinical manifestations" will be used in the following text to include any symptoms and clinical signs, unless otherwise specified. In multirooted teeth, the presence of clinical manifestations, except a sinus tract, was recorded for all of the roots of the same tooth. Radiographs were taken of the treated teeth with attention to reproduction of the exposure angulation of the postoperative radiographs. The radiographic assessment included the evaluation of the preoperative radiographs and that of any intermediate follow-up radiographs found in the patient's chart. Most radiographs were reviewed by a single examiner after a sample had been examined jointly by all three investigators. Questionable radiographs were also evaluated jointly by all investigators. The treatment results classification was based on radiographic and clinical findings. The radiographic results were recorded according to Rud et al. (17) with one difference; even a small remaining radiolucency in the periodontal ligament space was recorded as incomplete rather than complete healing. The radiographic findings were combined with the clinical findings to establish the following diagnoses: successful--complete healing radiographically, without any clinical manifestations: doubtful--incomplete or uncertain healing without any clinical manifestations, or complete healing with tenderness to percussion: and unsuccessful--incomplete or uncertain healing with tenderness to percussion, or the presence of symptoms, swelling, or a sinus tract irrespective of the radiographic appearance; or unsatisfactory healing irrespective of clinical manifestations. The radiographic and clinical findings were recorded and submitted to computerized analysis using the chi-square test. Levels of p = 0,05 were considered statistically significant.
31
respectively. The differences in the results observed within these various groups were not statistically significant. Forty five roots (33.1%) were associated with clinical manifestations; of these pain was related to 17 roots, swelling to 11 roots, and a sinus tract to 19 roots. Abnormal mobility was found in two roots. Thirty roots were tender to percussion, five of which were unrelated to any other clinical manifestations. The presence of clinical manifestations is related to the type of radiographic healing in Table 5, the differences being statistically highly significant (p < 0.0001). Clinical manifestations were present significantly more in cases with radiographically unsatisfactory healing than in cases with complete healing. TABLE 1. Treatment results related to sex No.of
Treatment Results (%)
Sex Female Male
Roots
Successful
Doubtful
Unsuccessful
100 36
44 44.5
19 33.3
37 22.2
TABLE 2. Treatment results related to age Age
No, of
Treatment Results (%)
(yr)
Roots
Successful
Doubtful
Unsuccessful
13-20 21-30 31-40 41-73
47 46 23 20
46.8 50 43.5 25
23.4 21.7 21.7 25
29.8 28.3 34.8 50
TABLE 3. Treatment results related to observation period Observation
No. of
Treatment Results (%)
(yr)
Roots
Successful
Doubtful
Unsuccessful
0.5-1 1.5 2-3 >3.5
42 37 29 28
42.9 40.5 55.2 39.3
26.2 24.3 13.8 25
31 35.1 31 35.7
RESULTS Of the 136 studied roots the treatment results were successful in 60 roots (44.1%), doubtful in 31 (22.8%) and unsuccessful in 45 (33.1%). Radiographically, the healing was complete in 65 roots (47.8%), incomplete in 32 roots (23.5%), uncertain in 18 roots (13.2%), and unsatisfactory in 21 roots (15.5%). The distribution of the results by sex, age, observation period, and tooth type is presented in Tables 1 to 4, 47
46
AGE
TABLE 4, Treatment results related to tooth type No. of Tooth Location
Treatment Results (%)
Roots Successful Doubtful Unsuccessful
First premolar Second premolar Molar
39 43 12
48.7 44.2 50
12.8 20.9 41.7
35.9 34.9 8.3
l First premolar Second premolar Molar
10 4 28
20 75 35.7
20 25 28.6
60 0 28.6
TABLE 5. Clinical signs and symptoms related to radiographic appearance 13-20
21-30 31-40 41-73 (years) 0.5 1 1,5 2 2.5 3 3,5 >4
Fla 1. Distribution of roots by patients' age and observation period.
Radiographic "Healing"
No. of Roots
Presence of Clinical Manifestations (%)
Complete Incomplete Uncertain Unsatisfactory
65 32 18 21
9.2 40.C 50 81
32
Friedman et al.
Journal of Endodontics
The association of the different clinical manifestations with each other varied. The presence of pain is related to the presence of a sinus tract or swelling in Table 6. Pain occurred significantly less (p < 0.0 l) with the presence of a sinus tract than without it. There was no difference in the occurrence of pain in the presence or absence of swelling. The occurrence of tenderness to percussion in relation to the other clinical manifestations is presented in Table 7, with the differences being statistically highly significant (p < 0.0001). An additional observation from the study was that, of the 45 roots associated with treatment failure, 24 roots (53%) received no additional treatment, and 14 roots (31%) were extracted. Apical surgery was repeated on four roots (9%), and endodontic retreatment was performed on three roots (7%).
DISCUSSION The present investigation varies from other studies with respect to its postoperative evaluation criteria. R u d e t al. (17) considered some forms of remaining radiolucency as complete healing in no need of prolonged observation (2). However, in a follow-up examination after apical surgery, even a minimal radiolucency should be considered as an uncertain result that warrants continued observation. Only if it is observed over a considerable period may a minimal radiolucency be considered a success. Since a longitudinal observation was not possible in most of the present material, the radiographic criteria were chosen to be severe. Our clinical criteria were less severe than in other studies (4, 5, 7, 8, 11, 14), in which failure was decided by tenderness to percussion alone, irrespective of the radiographic appearance. Tenderness to percussion is not exclusively caused by periapical pathosis per se, and, therefore, it was not interpreted as such when present in association with radiographically complete healing. The success rate of 44% in the present study is in agreement with that reported by Ericson et al. (1 l) in maxillary premolars, but it is lower than the success rate of molar apicoectomies in previous studies (13-16). The disagreement may partly be explained by the differences in the postoperative evaluation criteria. In one study (13), the results were assessed TABLE 6. Sinus tract or swelling related to pain among 45 roots associated with clinical signs and symptoms
Presence of (%)
Pain
No. of Roots
Sinus Tract
Swelling
Present Absent
17 28
11.8 60.7
23.5 25
Total
45
42.2
24.5
TABLE 7. Tenderness to percussion related to other clinical signs and symptoms
Clinical Manifestations Present Absent Total
No. of Roots 40 96 136
Presence of Tenderness to Percussion (%) 62.5 5.2 22
radiographically without considering clinical signs and symptoms, which may be present regardless of radiographic evidence of complete healing (4, 7). Similar evaluation of the present study material would have resulted in success and failure rates of 48% and 16%, respectively, instead of 44% and 33%. Radiographieally, the criteria in two of the previous reports (13, 16) differed from those of the present investigation, allowing them to result in larger success groups. Furthermore, three studies (13, 15, 16) included mostly cases in which surgery was performed in conjunction with orthograde root canal instrumentation and obturation. The treatment success after such a procedure is higher than after apical surgery of endodontic failure cases (4-7) which was performed in the present study. The one study (14) that was comparable in methodology to the present one included only 26 teeth and is too small for a clinical study of this nature. The success rate in our study was also lower than in most studies of apical surgery in anterior teeth (1-8). Comparing their results with those of previous reports, Altonen and Mattila (13) and Persson (14) concluded that, when performed by experienced operators, the success rate of apical surgery in the posterior region is similar to that in anterior teeth. However, drawing comparisons between long-term apicoectomy studies is often impractical due to differences in methodology. In this context, it merits mentioning that even when the same investigators subsequently performed studies on anterior and posterior teeth (7, 13), the operative procedures were performed differently, possibly affecting the treatment results (13). Therefore, it appears that apical surgery in anterior and posterior teeth may be compared reliably only if they are performed within the same study. In a recent study (12), the investigated material included 74.5% premolars and molars, in which the success rate was higher than in the anterior teeth. However, two studies (5, 8) included in their material about 20% posterior teeth, with the maxillary premolars demonstrating the poorest success rate. In another study of maxillary canines and posterior teeth (11), it was found that "the results of operation of the canines were better than those of the first and second premolars." These results were attributed to the anatomy of the premolars coupled with the technical difficulty of access (11). Our study also indicates that, when performing apical surgery in premolars and molars with the indications and evaluation criteria as described, the success rate should be expected to be relatively low. In the present study, as well as in a previous one (12), no differences were demonstrated between the treatment results in premolars and molars. The majority of the molars treated in our study were first molars. It may be suggested that the premolars and the first molars are similar in terms of access difficulty and anatomical variability. This would explain the comparable success rate in both groups. However, it may also be speculated that apicoectomy in molars is more difficult, but their root anatomy is less variable. In this respect, it should be noted that the treated premolars occasionally had palatal roots, whereas both our and the previous study did not include any molar palatal roots. It was observed previously that the percentage of uncertain treatment results diminished with time until it became minimal after 4 yr (2). Our study did not confirm this observation, but our material was considerably smaller and the observation period shorter than in the previous study. Also, the previous study included a longitudinal observation of half its material
Vol. 7, No. 1, January 1991
that demonstrated the dynamic changes within the treatment results, whereas in the present study the treatment results of most cases were recorded only at one time. It was shown that reduction of the uncertain group can be demonstrated when the same material is observed at different times, but not when portions of it are examined at different times each (12). Rud et al. (2) stated that chronic periapical inflammation was usually symptomless and that clinical information did not affect the interpretation of the treatment results after apical surgery. This was supported by several studies (2, 4, 8, 13) in which only 6 to 10% of apicoectomized teeth presented with clinical manifestations. In other reports based on radiographic and clinical examinations (5, 11, 14), the number of symptomatic cases was not specified, but they appeared to be few. In this respect the finding of clinical manifestations in 33 % of the present material is somewhat surprising. However, it is in agreement with one previous study (7), in which 35% of the cases demonstrated various clinical manifestations. In both studies a correlation was demonstrated between the presence of clinical manifestations and periapical radiolucency. In another study (17), a similar correlation was observed with "objective symptoms," but not with "subjective symptoms." It is usually speculated that symptoms associated with periapical radiolucency result from pressure. The lack of pain in the presence of sinus tracts in this study supports that speculation. This also may be the reason why tenderness to percussion was found frequently in the presence of other clinical signs and symptoms. However, a histological examination of apicoectomized teeth, particularly of failures, did not substantiate this speculation, showing the majority of the lesions to be an "epithelial granuloma and squamous epithelial cyst" (19). An unexpected observation in the present study was that 53% of the failed apical surgery cases remained untreated in spite of their majority being symptomatic. In previous reports it was mentioned that 9% (7, 13) and 14% (4) of the teeth were extracted. Also in the present material 14% of the roots were extracted. Interestingly, another study regarding endodontic therapy (20) demonstrated that 54% of endodontic failures were not treated. In the same study, an additional 23% of the teeth were extracted. That report (20) and the present one suggest that clinicians are either hesitant or skeptical when faced with failure of endodontic therapy, surgical or nonsurglcal. In view of this possibility, it would seem appropriate that this particular epidemiological group be
Results of Apical Surgery
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given more emphasis in the curriculum of basic and continuing endodontic education. Dr. Friedman is affiliated with the Department of Endodontics, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel, Dr. Lustmann is affiliated with the Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah School of Dental Medicine, and Dr. Shaharabany is affiliated with the Hebrew University-Hadassah School of Dental Medicine. Thesis submitted as a partial requirement toward a DMD degree for Dr. Shaharabany.
References 1. Harry FJ, Parkins BJ, Wengraf AM. The success rate of apicectomy. A retrospective study of 1,016 cases. Br Dent J 1970;129:407-13. 2. Rud J, Andreasen JO, Jensen JEM. A follow-up study of 1000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:215-28. 3. Mikkonen M, Kullaa-Mikkonen A, Kotilainen R. Clinical and radiologic reexamination of apicoectomized teeth. Oral Surg 1983;55:302-6. 4. Persson G, Lennartson B, Lundstrom I. Results of retrograde root-filling with special reference to amalgam and Cavit as root-filling materials. Svensk Tandlak Tidskr 1974;68:123-33. 5. Nordenram A, Svardstrom G. Results of apicectomy. A clinical-radiological examination. Svensk Tandlak Tidskr 1970;63:593-604. 6. Hirsch J-M, Ahlstrom U, Henrikson P-A, Heyden G, Peterson L-E. Periapical surgery. Int J Oral Surg 1979;8:173-85. 7. Mattila K, Altonen M. A clinical and roentgenological study of apicoectomized teeth. Odontol Tidskr 1968;76:389-407. 8. Lehtinen R, Aitasalo K. Comparison of the clinical and roentgenological state at the re-examination of root resections. Proc Finn Dent Soc 1972;68:209-11. 9. Khoury F, Hensher R. The bony lid approach for the apical root resection of lower molars. Int J Oral Maxillofac Surg 1987;16:166-70. 10. Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical considerations and clinical techniques. Int Endod J 1985;18:8-34. 11. Ericson S, Finne K, Persson G. Results of apicoectomy of maxillary canines, premolars and molars with special reference to oroantral communication as a prognostic factor. Int J Oral Surg 1974;3:386-93. 12. Rud J, Andreasen JO, Rud V. Retrograd rodfyldning med plast og dentinbinder: helingsfrekvens sammenlignet meal retrograd amalgam. Tandlaegebladet 1989;93:267-73. 13. Altonen M, Mattila K. Follow-up of apicoectomized molars. Int J Oral Surg 1976;5:33-40. 14. Persson G. Periapical surgery of molars. Int J Oral Surg 1982;11:96100. 15. Ioannides C, Borstlap WA. Apicoectomy on molars: a clinical and radiographical study. Int J Oral Surg 1983;12:73-9. 16. Franz M, Bethke K, Bier J. Wurzelspitzenamputation an 150 molaren des oberund unterkiefers. Dtsch Zahnarztl Z 1987;42:287-9. 17. Rud J, Andreasen JO, Jensen JEM. Radiographic criteria for the assessment of healing after endodontic surgery. Int J Oral Surg 1972;1:195-214. 18. Molven O, Halse A, Grung B. Observer strategy and the radiographic classification of healing after endodontic surgery. Int J Oral Maxillofac Surg 1987;16:432-9. 19. Arwill T, Persson G, Thilander H. The microscopic appearance of the periapical tissue in cases classified as "uncertain" or "unsuccessful" after apicoectomy. Odontol Revy 1974;25:27-42. 20. Petersson K, Lewin B, Hakanson J, Olsson B, Wennberg A. Endodontic status and suggested treatment in a population requiring substantial dental care. Endod Dent Traumato11989;5:153-8.
