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| Title |
Following Endodontic Microsurgery, It Is Unclear if Grafting Will Aid in Greater Reconstitution of the Cortical Plate |
| Clinical Question |
For patients requiring endodontic microsurgery, does grafting result in greater reconstitution of the cortical plate compared to not grafting? |
| Clinical Bottom Line |
Bone grafting, in most cases, does not impact the success rate defined as resolution of radiolucencies and symptoms of inflammation, except when both cortical plates are missing pre-operatively. However, there is evidence that reconstitution of the cortical plate architecture with normal contour is not predictable in absence of grafting. Therefore, the field of endodontics needs to better define successful outcomes after root-end surgery to include the reconstitution of normal bone in order to properly answer the question of whether or not these sites should be grafted to obtain the most optimal outcome. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 31543274 | Von Arx/2019 | 41 patients (47 treated roots) who underwent EMS | Prospective clinical study | | Key results | At 5 years postop all studied parameters (the resection plane, the cortical plate, the apical area, and the overall bone healing) displayed higher rates of fully healed cases when compared to the rates at 1 year postop using CBCT imaging. Resection plane and apical area parameters were judged to be fully healed in 72.3% of cases at 5 years postop whereas buccal cortical plate and overall bone healing were categorized as fully healed in only 42.6% and 38.3% of cases respectively. Grafting was not performed on any of the 41 patients for the 47 treated roots.
These percentages are far lower than what other studies in the literature have stated for success rates in endodontic microsurgery (EMS). This indicates two things:
1) Longer follow-up periods are needed for EMS cases to evaluate healing and points to that notion that using 2D radiography to determine success may be faulty as these sites are not truly healing in regards to the parameters Von Arx outlined in this prospective clinical study.
2) Bone grafting should be attempted and investigated further to determine if success rates in regards to reconstitution of the cortical plate and overall bone healing can be improved.
| | #2) 33159322 | Lui/2021 | 11 RCTs of patients with persistent apical pathosis, treated with root-end surgery | Meta-Analysis | | Key results | Regenerative techniques, such as grafting, improved periapical lesion healing after root end surgery. Overall, the use of regenerative techniques significantly improved the outcome of EMS (risk ratio: 0.42; 95% Confidence interval, 0.26-0.68; P=0.001). However, upon subgroup analysis, only the use of collagen membranes and bovine-derived hydroxyapatite was shown to have significantly improved the outcome (RR: 0.35; 95% CI, 0.17-0.75; P=0.007). Use of collagen membranes or autologous platelet concentrates alone were associated with a trend for success (RR: 0.51; 95% CI, 0.20-1.25; P=0.14) and expanded polytetrafluoroethylene membranes alone had no added benefits (RR: 2.0; 95% CI, 0.22-18.33; P=0.14).
This study supports the notion that regenerative techniques can be beneficial and aid in healing but more research needs to be conducted to determine which techniques/materials should be used and when.
| | #3) 34603623 | Montero-Miralles/2021 | 30 articles where patients underwent EMS | Systematic review of randomized trials | | Key results | This systematic review confirmed that EMS is a successful and viable option for teeth with persistent apical pathosis after orthograde treatment. The success rates for EMS at 5 and 10 years are reported as 91.5% and 93.3%, respectively. Use of the dental operating microscope led to a drastic improvement in success rates of root end surgery, by spurring the transition from conventional surgery (60% success rate) to EMS (94% success rate).
This review found that regenerative techniques are not needed to obtain healing in EMS cases but have been shown to aid in tissue regeneration especially when bone collapse is a concern.
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| Evidence Search |
“periapical surgery AND regenerative techniques”
“endodontic microsurgery AND regeneration”
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Comments on
The Evidence |
The long term prospective clinical study conducted by Von Arx et al. (2019) was very clinically applicable. A single surgeon performed all apical surgeries in a dedicated surgical room with a surgical microscope of the initial sample size that included 62 teeth in 62 patients; 41 teeth in 41 patients were available for follow-up at both 1 and 5 years postop. The CBCT imaging was independently assessed by 3 calibrated observers to reduce any bias. The fact that the same surgeon performed all apical surgeries ensures that the same protocol was followed and that there would be no variability in regards to the clinical protocol. Three calibrated examiners helps ensure accurate assessment of the radiology as well as reduce bias. Sample size could have been larger but is ample to support the clinical study especially given the long term followup.
Lui/2021 sought to evaluate the effects of different regenerative techniques and materials on the outcome of endodontic surgery. Inclusion and exclusion criteria was good. The study includes RCTs that had good control (apical surgeries with no regenerative techniques or materials utilized) versus experimental groups (apical surgeries with regenerative techniques and materials being used), and at least a one year follow-up. This resulted in 11 RCTs being included for meta-analysis out of an initial sample of 1915.
However a weakness was that, when assessed for bias, only 2/11 articles were found to have a low chance of bias; the other 9/11 articles had concern for overall bias. This was due to the randomization process as 8/11 studies raised concern when the randomization was assessed. 6/11 studies did not specify whether the examiners were blinded to the group allocation and this created concern for bias in regards to evaluation of the radiographic results.
The result found in the meta-analysis was that regenerative techniques, in general, significantly improved the outcome of endodontic surgery at year postop. Despite the concerns for bias in the randomization process and allocation concealment for 8/11 studies the results are still applicable. Due to the nature of endodontic microsugery it is impossible to blind operators and participants as to their assigned intervention. But no deviations from assigned interventions we’re noted and therefore a low risk of bias in outcomes measurements can be assumed.
Montero-Miralles/2021 sought to evaluate the application of biomaterials in endodontic microsurgery and its influence in post-surgical tissue repair. The PubMed database was searched; yielding 131 reference that was eventually narrowed down to 30 articles using the following inclusion/exclusion criteria:
-Studies performed in humans or animals with at least a one year follow-up.
-No language restriction
-case reports, studies base on surgery and expert opinions were excluded.
Overall strengths of the study are that it highlights the current endodontic microsurgery protocol and shows high affinity for success when the DOM and MTA/Bioceramics are utilized. However a weakness is that it only looked at the PubMed database and therefore could have missed some studies that may have positively or negatively contributed to the findings. |
| Applicability |
At present, there is no clearly defined protocol after the retro prep filling is placed when performing endodontic microsurgeries. Generally, there is no consensus and a significant gap in the literature on the protocol regarding whether grafting of the site of the osseous surgery is needed to achieve full reconstitution of the bone, including the proper contours of the cortical plate. This gap is demonstrated by the findings of Lui et al. and Montero-Miralles et al. which agree that regenerative techniques have been shown to be beneficial in regards to healing; however, Montero-Miralles et al. states that regenerative techniques are not necessary to achieve healing.
Furthermore, the literature has few studies investigating the type of healing that occurs after apicoectomy is performed. The study conducted by Von Arx et al. in 2019 indicates that reconstitution of the cortical plate and total bone reformation is only occurring about 40% of the time when grafting is not performed. It also supports the notion that CBCT should be utilized to evaluate healing in these cases and proposes a new radiographic criterion to assess healing. 3D assessment of the apicoectomy sites will allow the clinician to better categorize cases as healed, partially healed or failing.
While these studies do not directly answer whether grafting is needed for full restoration of bone form and function, they do indicate the need for future research investigating the healing process and bone remodeling that occurs following EMS. Therefore, clinical studies are required to understand the role and necessity of grafting procedures in post-EMS cortical bone formation.
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| Specialty/Discipline |
(Endodontics) |
| Keywords |
Periapical Surgery, Regenerative Techniques, Endodontic Microsurgery, root-end surgery
|
| ID# |
3472 |
| Date of submission: |
12/09/2021 |
| E-mail |
hartleyj@livemail.uthscsa.edu |
| Author |
Jon Hartley |
| Co-author(s) |
Nick Dybdal-Hargreaves D.D.S., Ph.D. |
| Co-author(s) e-mail |
HargreavesND@livemail.uthscsa.edu |
| Faculty mentor/Co-author |
Anibal Diogenes, D.D.S., M.S., Ph.D. |
| Faculty mentor/Co-author e-mail |
DIOGENES@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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