VOLUME 44 NUMBEP 1 JANUAPY 2013 53

QUI NTESSENCE I NTERNATI ONAL

ORAL SURGERY/ENDODONTICS
85% to 95%.
15
Information on predictors for
the clinical success of endodontic surgery
is available.
610
Inconsistencies in case
selection, methodology, and surgical tech-
niques, as well as differing use of materials,
contribute to the variability of the results.
Inconsistencies in treatment modalities as a
result of the different degree of clinical
experience, various surgical techniques,
and more are inevitable, and a uniform
treatment procedure is not achievable. The
question is whether there are predictors
that are not dependent on individual surgi-
cal technique or clinical decision making.
This question can be assessed when data
is pooled from different treatment centers.
The purpose of the study was to evalu-
ate various patient- and tooth-related pre-
dictors on the outcome of apical surgery 6
to 12 months after surgery in a prospective
clinical multicenter study.
The outcome of apical surgery has been
investigated in many follow-up studies.
Poportod suoooss ratos aro botwoon 25%
and 100%, with most of them ranging from
1
Professor, Department of Oral Surgery, University of Mainz,
Mainz, Germany; Private Practice, Munich, Germany.
2
Private Practice, Munich, Germany.
3
Private Practice, Bonn, Germany.
4
Private Practice, Bodenmais, Germany.
5
Private Practice, Nuremberg, Germany.
6
Professor, Department of Oral Surgery, University of Basel,
Basel, Germany.
7
Lecturer, Department of Oral Surgery, University of Basel, Basel,
Germany.
8
Assistant Dentist, Department of Oral Surgery, University of
Basel, Basel, Germany.
9
Professor and Head, Department of Oral Surgery, University of
Mainz, Mainz, Germany. [au: edit ok?]
Correspondence: Dr Matthias Kreisler, Department of Oral
Surgery, University of Mainz, Augustusplatz 2, 5531, Mainz,
Germany. Email: matthiaskreisler@yahoo.de
Clinical outcome in periradicular surgery:
Effect of patient- and tooth-related factors
A multicenter study
Matthias Kreisler, Prof Dr Med Dent
1
/Ricarda Gockel, Dr Med Dent
2
/
Silvia Aubell-Falkenberg, Dr Med Dent
3
/Thomas Kreisler, Dr Med Dent
4
/
Christoph Weihe, Dr Med Dent
5
/Andreas Filippi, Prof Dr Med Dent
6
/
Sebastian Khl, Dr Med Dent
7
/Silvio Schtz, Dr Med Dent
8
/Bernd
dHoedt, Univ-Prof Dr Med Dent
9

Objective: To evaluate the effect of patient- and tooth-related factors on the outcome of
apical surgery in a multicenter study. Method and Materials: A total of 281 teeth in 255
patients undergoing periradicular surgery were investigated clinically and radiographi-
cally 6 to 12 months postoperatively. Results: The overall success rate was 88.0%. Sex
was a signicant (P = .024) predictor, with a success rate of 89.8% in females and 84.0%
in males. The success rate was signicantly higher in patients 31 to 40 years of age. The
treatment of premolars resulted in a signicantly higher success rate (91.9%) than the
treatment of anterior teeth (86.1%, P = .042) and molars (86.4 %, P = .026). The loss of
the buccal bone plate and the extension of apical osteolysis to the furcation area in molars
resulted in a considerably lower success rate. Lesion size, preoperative pain, tenderness
to percussion, stula, and resurgery were signicant factors. Conclusion: There are sev-
eral factors inuencing the success rate of apical surgery that must be taken into account
when considering apical surgery as a treatment alternative. (Quintessence Int 2013;44:5360)
Key words: clinical study, endodontic surgery, predictors, success rate
54 VOLUME 44 NUMBEP 1 JANUAPY 2013
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METHOD AND MATERIALS
Patients
The patients were recruited from four pri-
vate oral surgery practices and one univer-
sity clinic. Treatment providers (n = 7) were
oral surgeons with at least 10 years of pro-
fessional experience. Patients in need of
endodontic surgery were consecutively
enrolled from May to December 2009.
Patients were not included into the trial if
one of the following criteria applied: severe
general disease (American Society of
Anesthesiologists [ASA] classes 3 and 4),
pregnancy, or known allergies to local anes-
thetics. Patients suffering from immunocom-
promising diseases such as diabetes or
systemic lupus, as well as patients treated
with chronic steroids, were also excluded.
The clinical decision for apical surgery
was based on the presence of a radio-
graphic apical radiolucency or clinical
symptoms (pain, tenderness to percussion,
tenderness to palpation on the buccal
mucosa, swelling of the buccal mucosa, or
stula). Patients were informed about the
surgical procedure, postoperative care,
follow-up examinations, and alternative
treatment options. Alternative treatment
options were a conventional revision of the
root canal treatment or tooth extraction.
Surgical technique
Surgeries were performed under local
(93.1%) or general anesthesia (6.9%) using
standard techniques. Prior to surgery,
Ultraoain DS (Hooonst Marion Poussol) witn
4% articain and 1:100,000 adrenaline or
Septanest (Septodont) with 1:100,000
adrenaline was administered as local anes-
thetic.
The choice of the respective incision
technique was based mainly on surgical
aspects such as the presence of an ade-
quate width of attached gingiva, the size of
the periradicular defect, and the need for
an undisturbed surgical access. The deci-
sion for the incision technique in each
patient was made by each surgeon involved
in the study applying the criteria mentioned
above. When maxillary molars were treated,
access to the palatal root was achieved by
raising a palatal mucoperiosteal ap using
a standard technique.
After the reection of a full mucoperios-
teal ap, osteotomies were performed to
locate the apex. The roots were resected
at approximately 80 degrees to the axis of
the tooth, and 2 to 3 mm of the root end
was removed. The pathologic soft tissue
was thoroughly debrided. A 2 to 3 mm root
end cavity was prepared ultrasonically by
means of diamond-coated retrotips. The
following materials were used to ll the
root-end cavities: polycarboxylate cement
(Durelon, 3M ESPE), glass-ionomer cement
(Ketac-Silver, 3M ESPE), mineral trioxide
aggrogato (ProPoot MTA, Dontsply), and
otnoxybonzoio aoid (Boswortn Supor EBA
Pogular-Sot, Boswortn). n oasos in wnion
an isthmus was present, root-end cavity
preparation was extended to join the two
canals in the same root. The new apex was
nished with a diamond bur or spatula.
The postoperative lesion size was deter-
mined volumetrically: After achieving com-
plete hemostasis in the cavity, the lesion
was carefully lled with saline using a
100-microliter syringe. The amount of
saline needed to ll the bone cavity was
recorded. Teeth were excluded when root
fractures were found intraoperatively. The
mucoperiosteal ap was repositioned and
sutured using 4/0 or 5/0 sutures. Magnifying
lenses, microscopes, or endoscopes were
used in all cases. Digital radiographs were
performed postoperatively with a parallel-
ing technique. All patients were given
nonsteroidal analgesics (ibuprofen
400 mg). Sutures were removed after 7
days.
Clinical and radiographic
evaluation
Treatment success was assessed clinically
and radiographically 6 to 12 months post-
operatively. Any case with pain, tenderness
to percussion, tenderness to palpation on
the buccal mucosa, or swelling of the buc-
cal mucosa at the follow-up appointment (or
earlier) was deemed a clinical failure. Digital
radiographs were taken and evaluated by
two different observers. After calibration,
the observers made independent assess-
ments of the radiographs. Cases in which
the two observers did not coincide after
independent assessment of the images
were evaluated jointly.
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Fig 1 Defect morphology: Total loss of the buccal bone plate.
Periapical healing in each case was
placed in one of the four healing catego-
ries
11,12
:
1. Category 1 (complete healing [success-
ful]): Complete bone regeneration
around the apex, with or without a rec-
ognizable periodontal ligament space.
2. Category 2 (incomplete healing [scar
tissue]): A periradicular rarefaction
(compared with a postoperative or pre-
vious follow-up radiograph) decreased
in either size or station. The rarefaction is
irregular and often has an asymmetrical
outline and an angular connection to the
periodontal space.
3. Category 3 (uncertain healing): A rar-
efaction located symmetrically around
the apex, with a funnel-shaped connec-
tion to the periodontal ligament space.
The size of the rarefaction is less than it
appears to be on the postoperative
radiograph.
4. Category 4 (unsatisfactory healing [fail-
ure]): The same radiographic signs of
uncertain healing. The area of the rar-
efaction has either enlarged or remains
unchanged compared to the immediate
postoperative condition.
Any case in which the healing pattern cor-
responded to category 3 or 4 was deemed
a failure.
Periodontal parameters (probing pocket
depth and gingival recession) were record-
ed preoperatively. Gingival recession was
expressed as the distance between the
cementoenamel junction and the free gingi-
val margin and expressed as plus, as was
the depth of the periodontal pocket. The
respective clinical attachment loss (CAL)
was calculated as the sum of both values.
After raising the access ap, a potential
total loss of the buccal bone plate along the
entire root to be apicoectomized and a
potential extension of apical osteolysis to
the furcation area were recorded (Fig 1).
Data analysis and statistics
With regard to potential predictors, the
results were analyzed separately for men
and women: patients 46 years of age or
younger, and older than 46 years; patients
younger than 31 years of age; and between
31 and 40, 41 and 50, 51 and 60, and older
than 60 years of age. Smokers and non-
smokers were also noted. The teeth were
differentiated as follows: maxillary and man-
dibular teeth, anterior teeth, premolars, and
molars; teeth with a CAL of less than 4 mm,
and 4 mm or more; teeth with the presence
or complete loss of the buccal bone (apico-
marginal lesions) (Fig 1); and teeth (molars
only) with or without the furcation involve-
ment of the apical osteolysis (Fig 2). With
regard to the postoperative bony lesion
size, two groups were analyzed: teeth with
a lesion volume of 0.06 mL (median lesion
size) or less, and teeth with a lesion volume
of more than 0.06 mL. The presence of pre-
operative clinical symptoms (pain, tender-
ness to percussion, tenderness to palpation
on the buccal mucosa, swelling of the buc-
cal mucosa, presence of a stula, and
abscess) were considered. Cases under-
going rst-time surgery and resurgery were
differentiated.
a b
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Fig 2 Surgical approach: Anatomical connection between the periapical osteolysis and furcation area in
molars.
Clinical and radiographic measures
were used for a dichotomous outcome: suc-
cess or failure (clinical or/and radiographic
failure). In multirooted teeth, the worst radio-
graphic nding was recorded to decide
whether the healing was successful. The
Fisher exact test was applied for each pre-
dictor to determine if a nonrandom associa-
tion between the outcome and predictor
could be demonstrated. Differences were
considered to be signicant when P < .05.
The statistical analysis was performed with
a spreadsheet (Microsoft Excel 2003) and
statistics software (SPSS for Windows 17.0
|BM]).
RESULTS
A total of 281 teeth (65 anterior teeth, 86
premolars, and 130 molars) in 255 patients
(170 woman and 85 men; mean age,
46.6 14.3 years [median, 46 years]) who
presented for follow-up 6 to 12 months
(mean, 7.7 2.6 months) after surgery were
enrolled.
Table 1 shows the distribution of the
teeth investigated. Fifty-ve patients (21.6%)
were smokers. The mean attachment loss at
baseline amounted to 4.0 1.7 mm. In 13
cases, postoperative complications were
recorded (wound dehiscence [n = 4],
wound infection [n = 4], and temporary
nerve injury [n = 5]).
Thirty-ve cases (teeth) were deemed a
failure (Table 2). Five teeth were extracted
before the 6-month follow-up appointment
because of recurring clinical symptoms.
The overall success rate after 6 to 12
months was 88.0%.
Sex was a signicant (P = .024) predic-
tor. There was a success rate of 89.8% in
women and 84.0% in men.
The median age (46 years) was used to
divide the patients into a younger and older
oatogory. No signihoant dioronoos oould
be found between patients aged 46 years or
less (success rate, 88.7%) and patients
aged more than 46 years (success rate,
87.1 %). The best results, however, were
achieved in patients aged between 31 and
40 years of age with a signicant difference
when compared with the total patient popu-
lation in the remaining groups (P < .001).
There were no signicant differences
between smokers (success rate, 90.9%) and
nonsmokers (success rate, 87.0%) (Table 3).
No signihoant dioronoos woro oalou-
lated between maxillary (success rate,
87.8%) and mandibular teeth (success rate,
88.1%) when pooling anterior teeth, premo-
lars, and molars. The outcome, however,
was signicantly better in premolars (suc-
cess rate, 91.9%) than in molars (success
rate, 86.4%; P = .026) and anterior teeth
(success rate, 86.1%; P = .042).
CAL was not a signicant predictor.
Teeth with a CAL of less than 4 mm at base-
line had a success rate of 86.8%, and teeth
with a CAL of 4 mm or more at baseline had
a success rate of 88.7%. Teeth without buc-
cal bone on the apicoectomized root
(n = 37) had a considerably lower success
rate (81.1%) than teeth in which the buccal
a b
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Table 1 Distribution of the treated
teeth according to tooth type
Maxilla n (total) Mandible n (total)
Central incisor 21 Central incisor 5
Lateral incisor 19 Lateral incisor 6
Canine 9 Canine 5
First premolar 18 First premolar 11
Second premolar 36 Second premolar 21
First molar 61 First molar 54
Second molar 9 Second molar 6
Total 173 108
Table 2 Distribution of the failed
cases
Failure n (total)
Clinical and radiographic 7
Padiograpnio 17
Clinical 11
Total 35
Table 3 Patient-related factors
n (%) Success rate (%) P value
Sex
Male 32.3 84.0 .024
Female 67.7 89.8
Age (y)
46 54.6 88.7 .498
> 46 45.6 87.1
30 14.1 85.4 .113*
3140 20.6 95.0 < .001*
4150 25.8 86.7 .472*
5160 21.6 85.7 .360*
> 60 17.9 86.5 .586*
Smoking habits
Smoker 21.6 90.9 .15
Nonsmokor 78.4 87.0
*As compared with the total patient population without
the respective age group.
bone was present (88.8%). The differences,
however, were not signicant (P = .05).
Molars in which the apical osteolysis
expanded to the furcation (n = 24) had a
success rate of 79.2%. Teeth in which a
bone layer separated the furcation area
from the apical osteolysis had a success
rate of 87.9%. The differences, however,
were not signicant (P = .107).
Teeth with lesions of 0.06 mL or less has
a success rate of 89.9%. Teeth with a lesion
volume of more than 0.06 mL had a signi-
cantly (P = .043) lower success rate (85.9%).
Teeth with perforating defects were treated
successfully in only 70.6%. The success
rate was signicantly (P = .001) lower than
in teeth without a perforating lesions. A post-
operative oroantral stula also signicantly
(P = .001) decreased the success rate in
maxillary premolars and molars (Table 4).
Preoperative pain, tenderness to per-
cussion, the presence of a stula, and
resurgery resulted in signicantly lower suc-
cess rates (Table 5). Tenderness to palpa-
tion and swelling of the buccal mucosa
insignicantly lowered the success rate. In
contrast, teeth with a history of an abscess
had an insignicantly higher success rate.
DISCUSSION
The outcome of apical surgery is inuenced
by patient-, tooth-, and treatment-related
factors.
9
To minimize treatment-related fac-
tors, data were collected from ve oral sur-
gery centers, and these factors were not
considered in the present evaluation. This is
particularly true for the surgical techniques
and materials applied. The patient popula-
tion included in the present study consisted
of healthy patients referred to an oral sur-
gery ofce or a university clinic for apicec-
tomios. No sovoro systomio noaltn probloms
were recorded among the participants.
Conventional endodontic retreatment was
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Table 5 Tooth-related factors (II)
Clinical symptom* Yes (%) Success rate (%) No (%) Success rate (%) P value
Pain 47.9 84.6 52.1 90.6 .012
Tenderness to percussion 55.1 85.4 44.9 90.7 .024
Tenderness to palpation 38.0 86.1 62.0 88.0 .303
Swelling of the buccal mucosa 15.3 86.3 84.7 88.1 .529
Fistula 15.3 77.3 84.7 89.7 .002
History of abscess 13.6 92.3 86.4 87.0 .103
Posurgory 11.2 75.0 88.8 89.4 .003
*Prior to surgery. Pain, tenderness to percussion, the presence of a stula and resurgery had a signicantly negative
inuence on the outcome.
Table 4 Tooth-related factors (I)
n (%) Success rate (%) P value
Tooth location
Maxilla 59.5 87.8 .929
Mandible 40.5 88.1
Anterior teeth 22.3 86.1
Premolars 29.6 91.9
Molars 48.1 86.4
Anterior teeth vs premolars .042
Anterior teeth vs molars .885
Premolars vs molars .026
Marginal bone level
CAL < 4 mm 47.6 86.8 .423
CAL 4 mm 52.4 88.7
Buooal bono plato
Present 87.1 88.8 .05
Lost 12.9 81.1
Furcation involvement*
Yos 17.1 79.2 .107
No 82.9 87.9
Lesion size
0.06 mL 50.1 89.9 .043
> 0.06 mL 49.9 85.9
Perforating defect
Present 11.9 70.6 .001
Not prosont 88.1 90.1
Oroantral stula**
Present 19.7 79.1 .001
Not prosont 80.3 92.8
CAL, clinical attachment loss. *In molars only; **in maxillary premolars and molars only.
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considered by the referring dentists but
dismissed for various reasons.
The success rate as evaluated clinically
and radiographically was 88.0% after 6 to
12 months and comparable to results in
previous studies.
13,9,1317
With regard to sex as a prognostic fac-
tor, this is the second study in which signi-
cant difference could be calculated
between sexes, revealing a better progno-
sis in women. Some studies
7,8,1719
could not
demonstrate any signicant differences
between sexes. von Arx et al calculated a
considerably better success rate in women
(86.8%) than in men (80.0%).
8
The differ-
ence, however, was not statistically signi-
cant. In a retrospective study, Song et al
reported a signicantly better prognosis in
women.
20
The authors of the present study
are not able to explain this phenomenon.
Patient age did not inuence the healing
outcome in the present study, conrming
data published in several studies
7,8,17,18,21,22
investigating age as a predictor. The cutting
age was slightly higher than in former stud-
ies (40 to 45 years). Forming ve age cate-
gories, however, revealed that the healing
outcome was considerably better in people
31 to 40 years of age.
Only one study investigated smoking as
a predictor, showing no signicant differ-
ences between smokers and nonsmokers.
9

This corresponds to the data retrieved from
the present study.
The patient-related factors of age and
sex may not directly inuence the healing
outcome, but the different groups could
contain different distributions of tooth-relat-
ed factors that might inuence the progno-
sis. The authors, however, were not able to
nd specic differences between the
groups, with regard to the percentage of
cases undergoing resurgery, preoperative
pain, or other clinical signs.
In the present study, the healing out-
come was comparable in both arches.
Available data presenting success rates for
the individual tooth group regardless of the
arch was analyzed by von Arx et al.
9
The
cumulative success rates derived from 16
clinical studies were 76.7% (range, 27.9%
to 94.9%) for anterior teeth, 74.2% (range,
21.2% to 96.2%) for premolars, and 76.6%
(range, 40.0% to 100.0%) for molars.
Premolars showed higher success rates
than anterior teeth in 5 out of 14 studies and
higher success rates than molars in 9 out of
15 studies. Despite certain tendencies, the
results were not uniform and might result
from different aspects than the anatomical
localization and inherent degree of surgical
difculty. Different patient populations, the
ratio of surgical revisions to rst time sur-
gery, and individual treatment skills surely
contribute to the inhomogeneous success
rates. To avoid these problems, data were
collected from different treatment centers
and pooled. The percentage of molars in
the present study was 44.7%. The consider-
able number of molars treated in the par-
ticipating centers may have contributed to a
relatively high success rate (86.4%) when
compared with published data. The suc-
cess rates presented in this study were
calculated after a follow-up period of 7.7
months which must be regarded as the
minimal time period for statistical relevance.
Further follow-up investigations are needed
to calculate long-term results.
The fact that preoperative clinical symp-
toms may adversely inuence the treatment
success of endodontic surgery has been
described before.
6,19
The reasons, however,
are not fully understood. Preoperative clini-
cal symptoms may be associated with an
acute or subacute phase of infection that
may compromise the healing potential of
the surgical wound.
9
The marginal bone level as a prognostic
factor was investigated in only one previous
study,
8
revealing no signicant inuence on
the healing outcome of the apicectomy. This
nding was conrmed by the present study.
The total loss of the buccal bone plate
entailed a considerably higher failure rate in
this study. With P = .05, however, the dened
level of signicance was not reached. The
same was true for teeth in which the apical
osteolysis expanded to the furcation
(P = .06). These problems might impede
periapical healing by facilitating a marginal
roinootion. Booauso o a laok o availablo
data, a thorough comparison with literature
was not possible. Lesion size and the pres-
ence of complicated defects (perforating
defect, oroantral stula) may also have an
adverse effect on the treatment success and
should be seen as potential risk factors.
60 VOLUME 44 NUMBEP 1 JANUAPY 2013
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CONCLUSION
The following factors negatively inuence
the success rate of apical surgery: preop-
erative clinical symptoms (pain, tenderness
to percussion, presence of a stula), lesion
size, the presence of a perforating defect or
oroantral stula, and resurgery. More over,
sex (better prognosis in women) and tooth
location (better prognosis in premolars than
in molars and anterior teeth) have a signi-
cant effect on treatment outcome. The nd-
ings presented should be taken into account
when considering apical surgery as a treat-
ment alternative.
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