Title Endodontic Re-Surgery Results in Success Rates That Are Similar to Initial Surgical Intervention When Modern Methods and Materials Are Utilized
Clinical Question In patients with a failed apicoectomy, does endodontic re-surgery result in similar rates of success compared to initial surgical intervention?
Clinical Bottom Line Endodontic re-surgery results in similar rates of success compared to initial surgical intervention when modern methods and materials are utilized. A success rate greater than 90% can be anticipated when endodontic microsurgical techniques (use of ultrasonic, microsurgical hand instruments and surgical operating microscope) and a biocompatible root-end filling material (MTA) are employed. However, research involving re-surgeries performed with less modern techniques and less biologically compatible root-end filling materials have shown a poorer success rate compared to initial apical surgery.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
21329814Song/201154 patients (54 teeth) that required endodontic re-surgeryProspective Cohort Study
Key resultsAn overall success rate of 92.9% was found for 42 patients (42 teeth) recalled (77.8% recall rate) 12 months after endodontic re-surgery. A Kappa value for radiographic outcome revealed inter-examiner agreement of 0.76, suggesting good agreement among evaluators. All surgical procedures were performed utilizing microsurgical instruments, a surgical operating microscope, and a biologically compatible root-end filling material.
15876296Gagliani/2005164 patients (168 teeth / 231 roots) with previously unresolved periapical lesionsProspective Cohort Study
Key resultsThe patients were divided into two groups. The first group consisted of 114 teeth/162 roots that had received unsuccessful conventional root canal treatment (group AS) and the second group included 54 teeth/69 roots that had been treated unsuccessfully with apical surgery (group RS). Initial periapical surgery (group AS) and periapical re-surgery (group RS) were completed by one operator using ultrasonic retro tips, zinc-oxide EBA reinforced root end material, and 4.5x magnification loops. At the 5 year recall, outcomes for roots were as follows: Group AS- 140 (86.4%) complete healing, 12 (7.4%) incomplete healing, and 10 (6.4%) failure; Group RS- 41 (59.4%) complete healing, 12 (17.4%) incomplete healing, and 16 (23.2%) failure. Final results on outcome for the whole sample and both groups were different and statistically significant (Mann-Whitney U-test, P=0.0015). Complete healing differed in both groups by 27% (95% CI 15-40%). The intra-observer k-value for reproducibility of radiographic observations was 0.76 (observer 1) and 0.71 (observer 2); inter-observer validity was 0.79.
12193261Peterson/20018 studies/330 endodontic re-surgery patientsSystematic review of non-randomized trials
Key resultsThe weighted-average healing outcomes at a minimum 1-year follow-up period were: 35.7% success, 26.3% uncertain, and 38% unsuccessful. All studies included were published between the years of 1970-1997; 6/8 studies were published prior to 1980. Rud et al (1972) found that a majority of cases classified as uncertain healing 1 year after periapical surgery will show either complete or incomplete healing at a later recall date.
Key results-
Key results
Evidence Search Endodontic resurgery or periapical resurgery
Comments on
The Evidence
Validity: The article by Peterson and Gutmann included an extensive review of literature including non-English and international journals. Only peer-reviewed studies were included. Additionally, a weighted-average of results was calculated from the studies such that the size of the study was proportionate to its influence. The articles by Song et. al., and Gagliani et. al., had test groups that were similar at the start and were treated the same. Additionally, both studies had a recall rate greater than 75% with no apparent recall bias or competing interests. Perspective: A major weakness of the Peterson and Gutmann article is that 6 of the 8 included studies were published prior to 1980. Thus, endodontic microsurgery techniques (use of ultrasonic, microsurgical hand instruments and surgical operating microscope) and use of biocompatible root-end filling materials were not being utilized. In a meta-analysis by Setzer et. al., (2010), endodontic microsurgery versus traditional root-end surgery had a positive outcome 94% and 59% respectively. It can be inferred from this study that endodontic microsurgery techniques enhance outcomes in periapical re-surgery cases. In the Gagliani article, all surgical procedures were performed using microsurgical instruments and a biologically compatible root-end filling material. However, the surgical operating microscope was not used. The Song et. al., article was the only one in which the surgical operating microscope, microsurgical instruments, and biologically compatible root-end filling materials were used.
Applicability Endodontic re-surgery results in similar rates of success compared to initial surgical intervention when modern methods and materials are utilized. However, there is a lack of standardization of surgical instruments, techniques, and root-end filling materials used in studies assessing re-surgery outcome. Conflicting evidence as to whether periapical re-surgery offers a comparable prognosis (Song et al) or a poorer prognosis (Gagliani et. al.) than initial periapical surgery has appeared in the literature. This inconsistency is, at least in part, due to the difference in outcomes when modern endodontic microsurgery techniques are used, resulting in higher rates of successful clinical outcomes (approximately 90% success). Tooth extraction and implant placement, if not contra-indicated, could be considered an alternative to a second surgical intervention. Nonetheless, if the decision is made to maintain the natural tooth, modern endodontic surgical techniques (use of ultrasonic, microsurgical instruments and surgical operating microscope) and biocompatible root-end filling materials offer patients the best possibility for a successful outcome.
Specialty (Endodontics) (General Dentistry) (Oral Surgery)
Keywords Resurgery, re-surgery, periradicular surgery, periapical surgery, apicoectomy, root end surgery, root-end surgery, microsurgery
ID# 2959
Date of submission 11/02/2015
E-mail curtisd@livemail.uthscsa.edu
Author Darrell M. Curtis, DDS
Co-author(s) e-mail
Faculty mentor Anibal Diogenes, DDS, MS, PhD
Faculty mentor 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?)
None available
Comments and Evidence-Based Updates on the CAT
None available