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t'.iidodUnil fmiimiilol t')')(,: t2: tS^-t t'nilleil III ttnimaik .

Ml righls lesenmt

Muiik.sgaard t 996

Endodontics & Dental Traumatology

tS.SN 01(19-2502

Reasons for apicectomies. A retrospective study

El-Swiali ]M, Walker RT. Reasotis for apicectomies. A retrospective study. Endod Dent Tranmatol 1996; 12: leS.5-191. Mnnksgaard, 1996 Abstract - A retros]3ective study was carried ciut to evaltiate the clitiical factors invohed in deciding to perform apicectomies. Fi\'e hundred and sexenteen teeth from .H92 patients (211 women and leS] men) that had tmdergone apicectoni)' dnring the period from September, 1990 to December, 1992 were assessed using ibe jDatients' clinical records. The information recorded inc hided the sotirce ol referral, the qtialitv of preoperative root canal Ulliiig, the si/e of periradicnlar lesion, the type of the lesicMi (for biopsed lesions), the type of coronal and radictilar restorations, and the different factors that influenced the decision to perfbrtn an apicectomy for each tooth. These factors were classified into technical and biological, and when thev occuried togedier they were classified as combined. The decisions to perform apicectomies most commonly involved combined technical and biological factors. Biological factors alone only amotmted to ?>^-)"/o ofthe total. Technical factors alone amotinted to only ,H% ofthe total. When all factors were considered, biological factors cc:)nstituted 60%, whilst technical factors constituted 40%, ofthe total. The most cotiimou biological factors were persistent symptoms (54%), and contintiing presence c:)f a periradicular lesion (44%). The mc:)st common technical factors were post crown (60%)) and crowned teeth withotit posts (."^1 %). This study emphasised the need for a high standard of conventional root canal treatment in OITUM' \O a\'oid surgical treatment.
J. iVI. El-Swiaii, R. T. Walker
Leeds Dental Institute/Division of Restorative Dentistry, Leeds, UK

Key words: apicectomy: endodontic therapy Jamal Mustafa El-Swiah. Leeds Dental Institute, Division of Restorative Dentistry. Level 6. Wotsley Building, Clarendon Way, Leeds-LS2 9LU, England Accepted October 30. 1995

The general objective of endodontic treattnetit is to retain both the \'ital tooth with irreversible pulpal disease and the non-vital tooth in lunctioti in the dental arch. Endodontic tberapy is often thought to be syncMiymotts with root canal treatmetu, which involves the removal ol ptilp tisstte or pttlp tisstie renmants from tlie root canal system, followed by thorough cleaning, shaping and tbree dimensional baclcriological sealing and obtttrag g tiou of tbe prepared space. Tbe objective of root canal tieatmenl is lo lemove ihe or potential catise of the disease from the pulp space to litnit die effect on the pet iradicular lissttes. Where

these effects are ahead)' established the objecdxe is to remove the causes and encouiage tbe resolution of an established periradictilar lesion (1,2). Non-stirgical eiulodontic treatment can be carried out sticce.ssftilly for most ofthe teeth which require root catial treattnent, provided that the pulp space is adeqtiateh' shaped, cleaned and obttirated. In the past, when periradicnlar patholog)' did not respond to non snrgical treatment, stirgical iutei veution has been ad\'ocated in order io remoxe di.seased periradicnlar ti.ssue and seal any connection between tbe root canal and periodc:)ntium. hi reviewing the literature the success rate of


El-Swiah & Walker

conventional endodc:)iitic treatment ranges between 6(S-93%) (.H-6). One of tbe common surgical scopes of endodontic therapy which in\'olves the surgical lemoval of the tooth root apex, is known as apicectomy, or root end resection, which may be performed alone or in conjunction witb placing a retrograde lilling to seal the apical jxirt ofthe root. Apical ctuettage is the sttrgical removal of periapical pathological material by means of sttrgical ctirettage (7), both procedtires are normally adopted when convenlional endodontic treatment has failed and the sttccess ol cotiventional re-treatment is not predictable. It is now thotiglit that the treatment ofthe |3itlpand periradictilar diseased tissties shotild be rotitinely undertaken by non-stirgical means, and the stirgical intervention should only be adopted as an alternative when conventional therapy is clearly not possible, and as an addition to conventional treatment when a bio|:).sy or corrective or reparative surgery are reqtiired (8),or as an alternative way of placing a root canal filling when conventional endodontic therapy is not possible. The classical indications for apicectomy (with or without retrograde filling) are: 1. Inability to undertake conservative endodontic treatment. This may be dtie to: a. Anatomical, pathological and/or iatrogenic defects in die root canal (9-1!^). b. Blockage of the root canal which makes conventional root canal therapy physically impracticable, like adec]tiate coronal and/or radictilar restoration (9, 11, 12, 14-16). c. Medical and/or lime (expediency) reasons. For example, when the |)atient cannot tolerate routine endodontic therapy atid is likely to be treated tinder general anaesthesia, cjr when the patient or the operator cannot offer more than cjne visit i'ov routine endodontic treatment. (9, 10, 13, 17). 2. Failure to achieve complete conservative endodontic treatment, which may be dtie to persistence of extraradicular infection, symptoms and tmcoiurolled suppuration or exudate throtigh the root canal (9, 1.5, 16). 3. Failure of previotis ccMiventional root canal treatment, and when tbe success of conventicTual re-treatment is not predictable (10, 1.3-15, 18), and is tmlikely to achieve a good restilt witb conventional retreatment or if the teeth fail to respond to conventional endodontic therapy after a long period of follow ii|3 (11, 12). 4. The need for biopsy ol apical patholog)' (18, 19), and the persistence of extraradictilar endodontic inlection by certain types of bacteria (20) indicate the need for stirgical therapy which involves curettage of die infected apical area with re.section ofthe involved rool(s) and the administration of antibiotics e.g. actinomycosis periradicular infection (21). 5. Apicectomy may be indicated in the case ol posterior teeth to avoid the need for posterior fixed c3r removable appliances and becattse roots may be severely cttrved (22). In general terms the indications for apical surgery in posterior teeth are similar to the indications for anterior teeth (2.3). 6. Apicectomy may also be indicated to evaltiate tbe resected root face for any additional canals or fractures, and examitie the quality ol apical seal as part of re-platitation procedtires (19). The criteria for successftil apicectomy are: - The tooth should be symptom free and ftmctional for two or more years; there shotild be no obviotis clinical evidence of infection (absence ol tenderness and flsttila); the radiographic follow-up should sbow satisfactory evidence of bone healing and the periodontal ligament remains normal or returns to uormal (24). fn reviewing the literature, the sticcess rate of apicectomy ranges between 50-90%, which is not higher than the conventional root canal treatment (8, 16, 2.5-27). It is clear that there are different reasons for |3erlormitig an a|Dicectomy. Some of these reasons are invalid in the light of new concepts in endodontic practice. It is crticial that the right decision be taken belbre j^erforming an a|3icectomy to preserve an affected tooth where the i^ractical diflictilties of performing conventional root canal tieatment, or conventional re-treatmenl are recognised. Generally speaking it mttst be recogtiised that few trtie indications exist for surgical euclodontic treatment and these indications shottld be in the best interests ofthe patient and satisfy the basic biological principles ol inodern conventional endodontic therapy. Surgical interventioti shotild be attempted only after it is not possible io achieve conventional re-treatment or when patients cannot be convinced to accejDt endodontic retreatment. Tbe aim ol this sUidy was to identify the clinical factors involved in fleciding to ]:)erform a|)icectomies at the Leeds Dental Instiuite, and investigate ihe extent to wliich the decision making is being inlluenced l)y modern thinking.

iViaterial and methods

The study plan involved samjile selection and data collection, data prc:)cessing and analysis. This retrospective stttdy was based on a sam]3le ol 517 leeth that had undergone apicectomy for 392 patients from September, 1990 to December,


Decision to perform apicectomies

Table 1. Distribution of tiie treated patients and teeth according to tbe source ot reterral. Source of referral No. G.D.P' Interdepartmental Selfreferral Others Total 233 152 5

Patient (%) (59.4) (38.8) (1.3) (0.5) (100) No. 299 210 6

Teeth (%) (57.8) (40.6) (1.2) (0.4)




' General dental practitioner (G. D. P)

1992, at tbe Leeds Dental institiUc, in the Depanuicnl of Oral and Maxillo-Facial Surgery. Patient.s were idenlified (patient name, hospital number, date (if operation, looth ntimber) from the day aj)pointment book surgical .sheets in the Departmenl ol Oral and Maxillo-Facial Surgery. Their clinical record cards were located in the main offtce. No search was undertaken for anv missing records (Hve clinical records), and it was not possible to identify those referrals wliich were eilher rejected for or allocated to ahernati\e treatments. A piloi stttdy of 2.5 cases was cai i ied otit to determine the ptacticalities of the stn'vey, and to assist in the design ofthe (inal data collection foim. The facts derived from tlie treatment record sheet were ; 1) Patient's demograpliic data. (Name, date of bii th, sex, hosjiital nttmber) 2) Clinical details. (Referral details, cliiel com])laint, tooth nnmber, date oldj^eration. suspected natitre of the periraflicttlar lesion, biopsy result, wheti taken and recorded in the patient trc-atnient record). 3) Rafliogra|)hic details. The follo\vitig information was collected at the time ol examinitig the jMeoperatixe radiogtapli: Size (maxitiitim diameter) in millimetres o( tlie apical lesion related to alfected tooth if anv; (jtiality of root canal treatment; The material used lor root canal lilling as recorded in jjatient tteatment recotfl; The c]tialit)' of preoperatix'e root (anal fillitig as judged hv close examination ofthe j ^ e o p e t ati\e iadiogra])li (or each tooth; root lillings were classilied itito satisfactory, or ttnsatislactorv wheti the qualitx' of loot eanal lilling <k-m<)nstra(ed lack ol detisitv, voids, tttulet ftlled catials, loss of (ontour, tmlilled canals (in nmlti(analecl teetli). overextensioti, atid tnidetextetision ol' the tcxM catial filling; citiality and material ofst'al; t\pe of coronal testoration; tvpe oT tadicular testoratiou (l.etigth o( post in millimc-tres, diameter of post in millimeires at the apical end ofthe post).

4) Rationale for performitig apicectomy. The reasotis for perfortiiing apicectotiiies were classified in to two main headings for the ptnpose of analysis (technical and biological). The teehnical factors that make conventional root eanal treatment impossible or impractical recorded in this stncK- were; post crown restored teeth; crowned teeth; fractured instrittnents; presence ol old root canal lillings which eould not be temoved; perfotated root c;mals; opeti apices; sclet (ised root catials; others. The biological factors, which teflected contituiitig infection recorded in this study were; pei.sistent sytiiptoms; ditnensioual change iti radiogra]5hic appearatue (R.A) of ])eriradicular lesions; catial tiot dtv (uticotitroUed root catial exudate). \A'here technical and biological factors were oc(itrtitig together atid were both invohed in the decision tiiaking process they weie cotisidered to be combined. Sample selection; 'fhe samples were selected as follow: Itiitial .sample selectioti. i. Patients who had undergone apicectomv during tbe period from January, 1988 to February, 199S wete idetitified. ii. The cases selected for the study weie those cases selectc-d for surgical endodontic treatment onh, from September, 1990 to Decembet, 1992. The total number of teeth which had undergone an apicectomv dtning this period wete 538 teeth for -110 i^atietits. Final samjjle selections. i. All the selected cases clitiical record cards wete collected chronologically itito grotips. starting from September, 1990 to December. 1992 ii. The details of each tooth were tecorded sei)atateh- tising the data collection form. If a tooth had more than one ajiicectomv details of each werc^ reeorded separately. iii. Fighteen patietits' records (21 leeth) wete excluded from the study because there were no preojietative radiographs, atid two ofthetu h;ul no treatment record sheets. The final nnmber of teeth investigated was .517 lor 392 patietits (Table 1). Data collectioti. .\ fortii was designed as a meatis ol d a t a coUec tion. The inlotiuatioti tecotded lor the ftti;tl satiiple o( (ases were tiansreirecl to a coinptiter .system. A comptttitig lotiii Avas designed to facilitate the collection, transcription, and transference oC the inlortiiation lrotii each patient's tecord card to the computer = (tising a Micrcxsoft work spread sheet ' piogtamtiie lor an;tl\sis).


El-Swiah & Walker

Table 2. Distribution of the study sample according to the number of patients and teeth by gender Women No. Number of patients Number of teeth 211 291 (%) (53.8) (56.3) No. 181 226 (46.2) (43.7) Table 6. Distribution of the number of treated teeth according to the size of the radiographic periradicular lesion in the two arches Size ot lesion in millimetres." (100) (100) 1-4 Maxilla No. 119 143 62 40 364 (32.7) (39.3) (17) (11) (100) Mandible

No. 392 517



28 34 17 3 82 (34.1) (41.5) (20.7) (3.7) (100)

147 177 79 43 446

(33) (39.7) (17.7) (9.6) (100)

Note: Percentages given in parenthesis are included in the table to assist comparison.

5-8 9-12
13 and over Total

Table 3. Distribution of treated patients according to age and gender Age ranges Women No. Under 20 20-29 30-39 40-49 50-59 60 and over Total 8 61 62 41 22 17 211 (%) (3.8) (28.9) (29.4) (19.4) (10.4) (8.1) (100) No. 5 42 63 31 29 11 181

'Out of 517 cases, 71 cases had no periradicular lesions.

(%) (2.8) (23.2) (34.8) (17.1) (16) (6.1) (100) No. 13 103 125 72 51 28 392

Total (%) (3.3) (26.3) (31.9) (18.4) (13.0) (7.1) (100)

Table 4 Distribution of the number of the treated teeth in tiie two arches by tooth type Tooth type No. Central incisors Lateral incisors Canines 1st. Premolars 2nd. Premolars 1st. Molars Total Maxilla Mandible Total

(37.1) (40.3) (8.4) (7.9) (5.8) (0.5) (100)

No. 52

(59.1) (31.8) (4.6) (1.1) (3.4)

No. 211

(%) (40.B) (38.9) (7.7) (6.8) (5.4) (0.4) (100)

173 36 34 25 2



3 88





Table 5. Distribution ot treated teeth according to the preoperative quality of root canal filling Quality of root canal tilling Root canal treated teeth

Satisfactory Unsatisfactory Total 138 370 508

(%) (27.2) (72.8) (100)

*l\line teeth out of 517 teeth had calcified root canals.

The distribution of the sttidy sample according k) numbci- of paticnt.s and teeth are presented in Table 2. The majoiity of cases were referred by general dental practilionens a.s presented in Table 1. The age grotips were classified in to six gioti]3 langes as pie.sented in Table 3, and each range is completely inchisive. Apicectomy procedtn es were tindertaken moie often in maxillary teeth as presented in Table 4 (8.^% of total ntnnber of cases were in the maxilla). Tbe difierciice between the teeili involved in the two arches was statistically significant (%'= 1(3.89, df?>; p< 0.0008 ). There was no statistically significant difference between maxilla and mandible according to the size ol periradictilar lesions as presented in Table 6 ()(= 4.37, df"?>\ n.s). The total number of biopsied teeth was 180 from total of 446 cases with periradiciihu' lesions as found in the patient trealment lecords. These were classified according to (he results of the biops)' as presented in Table 7. Analysis of factors involved in the decision to perform apicectomies: The clinical factors involved in deciding to perform apicectomy procedures in this sttidy (Table 8) were classified into technical, biological, and combined (where the decision was inlluenced by both biological and technical factors). The relative proportion of all the technical factors, i.e. inchiding those combined with other factors, and all the biological factors, i.e. inchiding those combined with other factors is shown in Fig. 1 The relative proportion of the different ]:)iological factors for performing apicectomy in this retrospective sttidy is shown in Fig. 2, and the relative proportion of the different technical factors is shown in Fig. ?>. The peicentages have been rcjtinded by the computer.

Results The processed data and restilts for the retrospective sttidy are presented using tables and/orgraphs. 188 In order to .satisfy the endodontic needs of teeth with periradictilar lesions the surgical removal of

Decision to perform apicectomies

Table 7. Distribution of fhe histopathological results by tooth type Tooth fype

Abscess No. (50) (50)

Granuloma No.
(44) (35.3) (6.9) (9.5) (4.3) 15 28 3 1 47

Cyst No. (31.9) (59.6) (6.4) (2.1)

(100) 8 4 1


Total No. ot teeth No (61.5) (30.8) (7.7) 76 75 12

11 6

(42.2) (41.7) (6.7)

Cenfral incisors Lateral incisors Canines 1st.Premolars 2nd.Premolars Total No. of lesion

2 2

51 41 8 11 5

(6.1) (3.3) (100)







1st molars excluded trom the sample in this table as there were no biopsies recorded. Twelve cases were diagnosed as scar tissue. Two were scar tissue with a foreign body. One case was diagnosed as chronically inflamed antral mucosa.

Table 8. Distribution of the study sample number according fo fechnical and biological factors The factors Technical only Biological only Combined Total Number of feefh 17 182 318 517 Relafive proportion (%) (3.3) (35.2) (61.5) (100)

diseased periradiettlar ti.ssne and the placetnent of an ajiical seal does not etadicate the sonrce ol infection. This can only be successfully achieved by a non surgical approach, performed in a thorough tiiatinet. Petiapieal sttrgety performed alone is not a total ctne Ibr periradicnlar indannnation. The i)rimary t)bjectives of sutgical endodontics ate to teniove the inllamed periradiettlar tissne. and place an apical seal. Snrgical intervention shonld lje considered as ati altetnative ainpioach when non snrgical tteattitetit is tiot feasible. It tnay also sitpplement non smgical tieatment when it has failed. This opitiioti is based oti atiahsis of tteatmetit results in tioti sittgical ;nid sntgical etidodontic cases atid emjjhasises the importance (if ij stndies (8). With the mattnation of

etidodontics as a speciality, re-treattnent of root catials after treatment failtne has become a clinical teality. Non sttrgical re-treattnent, in eases of previousl)' failed t oot canal treatment provides the best prognosis. Man\- appat etit indications for surgei7 ate no longer relevant (15). The resvtlts of the present stttdy at e discussed and where possible refetence is made to previous stitdies which have dealt largely with the prognosis, success and lailme of apicectotiiy procedures, atid the tnatetials and techniques used. There has been litde investigatioti itito the relative itnportance of the different lactot s considered wheti decisions are tnade in the pt escription of endodcnitic surgeiy. The quality ofthe recorded information in a patient's clitiical tecotd ate of utmost importance in a retrospective study. In the presetit study most of the clinical lecords did not give complete details regarding the factors which influeneed treatment seleetioti or the reasotis for performing apicectomies. The tnajotity of cases (59.4%) were referred by genetal dental practitioners, i.e. 233 patients (299 teeth) of the whole satiiple. Most of the patients recei\ed tteatmetit in the 30-39 years, followed by 20-29 years age groups. Stockdale & Chatidler : (28) also lound that the tiiost common age group


D Total biological factors

54% 2%

Total technical lactots

I. RrUuiw proponion of Ici hnical and liiologit al tanor.s spc"! tive ol each oilier.


Pesistant symptoms Catial tiot dry R.A. of periradicular lesion

/)>. 2. Relative piojiortion.s olbilotiical laclors.


El-Swiah & Walker


2.6% 2.6% Post crown reslored teeth Fractured itistrutncnt Crowned leetli Pertoratci! root c;inal Fig. 2..1% / "'-(1.3% 1.2% Sclerosed root eattal Presence of old K.C. lilling O])en apex Others

>. R c h t l i v c p i o p o r l i c i t i . s o f U ' ( l t n i ( ; i l l a t l o i . s .

ill whicli cudodoutic surgery was |jcrformcd Icll in to tlie range 31-40 years, in both sexes. Few patieuts fell into the age group of less than 20 years, and from 50 years and over the number of patieuts wa.s low. f hi.s may lx' due to the liigb sticcess rate of eonventional root canal treatment experienced in this age group (29). Eighty-three percent of the treated teeth were maxillary teeth, and this is in agreement with Stockdale & Chandler (28). It appears tbat maxillary teeth receive convfiitional root canal tieatmetit more often than mandibular teeth (3t), 31). Despite the difficulties commonly encountered in treating maxillary lateral incisors endodontieally only 3% more lateral incisors were found to require stirgical treatment. The percentage ol permaiu'iit incisors involved in the maxillary arch was 77.4% in relation to other maxillary tecdi. In the mandible the most common teeth were the central incisors. This highligbtt'd the difficulties encoimterc'd in trcaling these teeth endodontieally. Tbe manchbiilar central incisor frec[uciuly bas two root canals, 41.4% (32). Ninc-ty-one percent ol the treated mandibular teeth were |5crmancnt incisors. This highliglitc'd the need (or tlic clinician to search for the second canal. Failure of conventional root canal tieatment of the mandibular incisors may arise from the uncleancd second < anal. Four bunched and forty six teedi had pcriiadieiilar lesions (3tH iu maxilla and 82 in mandible). The lesions were mosl commonly from 5-8 mm in size, in f)oili arcbes, which may exj^lain tbat the periradicular lesion is lirst discovered radiographically or becomes sym|)loniatic and noticeable by the patient when it reaches this size. Bio|:)sy le]3orts were availabk- for 180 teetb. The predominant lesion was the pcriapical granuloma ((54.4%)). True cysts occurred in only 2(i.l% ol cases. Tbis supported the previous researcli lindings (33). fbrec hundred and seventy teeth were found to have jDrc'-opcrative root lilling which were considered to be unsatisfactory (72%) (Table 5). The ajjparent causes lor faihirt- ciii|3hasiscs the need to improve the slandards of regular conventional

teclinicjtu's in orrlcr lo prevent or reduce the need for rc'-treatmcnt or surgcr). It is |jai tic iilarly significant in those teeth rc-cjuii ing coronal and post-retained restorations. Technical factors alone- only accounted (or 3.3%; of the apicectomy cases. These included 1 perforation repair, 2 separated instrimicnts. 3 retreatment cases, and 1 1 c ascs where teeth were apicected in conjunclion with other apicectomy procedures (because those teeth were endodontieally treated and crownc-d) presumably to exclude- tbe risk of die need (or future- apiece toinics if thc-ir convcnticMial endodontic tie-atmcnt (aile-el. Te-chnical factors we-re- taken into account e-ithe-r alone or in combination with biological (actors in 40%) ofthe cases. Within this group the most common factor was the ]3iese-nce of a |De)st crenvn. )f the total. Crowned which constitnte-d (iO.4 teeth (including bridge- retaine-rs) without posts made- up a (tirther 30.7%) e)( the cases. The need to care-fully c-vahiate die endodontic status of vital and root filled teeth prior to rc-storation is of paramount im]3oi tancc- if suigc-ry is to be- avoided. Biological factors alone constitttte-d 35.2% of tlu- total factors, and in combination with other factors were (it)% o f t h e lotal sample. Within this group the most common factor fotmd was the pcrsisle-nce- of symptoms after conventional root canal therapy (.54.'l%). The most likely catisc of du-se persistent symptoms probably was inadec]uate disin(e-ction and biological se-aling of the ptilj:) sj^ace. The- se-cond common biological factor was the presence ol a pel Iradicular lesion (44.1%). Of the teeth biop.sied (i4% were apical granulomas. When the root canals were accessible, ce)nventional treatment would have bec^n expected to bring about resohition in the great majority of cases. Two percent o( the cases were carried out bccatise the icjot canal could not be dried. The proper use of cleaning, irrigation and intracanal medication ]Drocc-dtire-s would elo mtich lo eliminate the nee-el for surgery in these cases. Tbe combined factors were involved in the decision making process in 62% of the total sample. Technical and biologieal factors most commonly c-xisted together. The pre.sence- of continuing infection, evidenced by the biological factors, associated with a situation in which the pnlp s|3ace is dil(icult to access would appear to be a dominant feature in the decision making process. Conclusions The following conclusions can be- drawn from die data |3rcsc-nted in tins study.


Decision to perform apicectomies

1) Most of the J3atieiits referred for surgical treatment were frotn tbeit general dental jDiactitioner. 2) Maxillary teetb were apicected more ofteti tban mandibtilar teetb. 3) Petniatient iticisors were tbe most cotinnoiily tteated teetb. Maxillaty lateral incisors, and nianclibitlar cetittal iticisois were tbe most common teetb to be treated in tbe respective arches. Tbe difliculties encotititered wben treating tbese teeth sbotild be borne in niitid wben performing conventional endodontics. 4) Utisatisfactory root canal ftlliiigs (72.8%) appeared tbe most common candidates for surgical enclodontic treatment. Mote cate in treatment is required to acbieve tbe objectives and biological ptincijales of cotiventional toot catial tbetapy, atid avoid itnuecessary sut gery. 5) Periradicular gtautilomatotts lesiotis were tbe most commonly biopsied lesion in tbis study. Tbis sup]3orted pie\'ioiis rmcliiigs recorded in tbe literature. 6) Combined biological and tecbnical factors are most commouly involved in tbe decisioti making process. Tbe post retained crowned and crowned teetb proxidecl tbe most common tecbtiical factors, and tbe |3ersistence of symptoms and the jDiesence of petiradicular lesiotis were tbe most (ommon biological factors involved in flie decision making process to pet form ai^icectotiiies. 10. Maisliall I'J. Endodoniic snigcrv: criU'iia. indicalion. and procedures. | Can t^cnl .Vssoe 19(14; :iO: 703-71:5. 1 1. Sniiinicrs L. Oral surgery in general dc-iual praclice. Part \' .Vpicectoniv. .\tist Dent J 197.5; 20: 205-207 12. 1 kill is MIL AiMcoectom)' and retrograde anialgam in mandibtilar niohir leetli. Oral Siiig Oral Med Oral Patliol 1979: 48: 40.5-407. i;V Nehammer CF.Snrgical endodonlics. Br Dem I 1985; 158: 400-409. 14. Litebke RG. Click DH. Ingle ]I. Indications and (-oiitiaindicalions for endodoiuic stiigerv. Oral Snrg Oral Med Oral Patliol 1964; 18:97-113. ' 15. Bloek RM. Lewis t^R. Snrgieal liealnieiil of iatrogenic canal blockage. Oral Surg Oral Med Oral Patliol 1987; (1.3: 722-7:52. 1(1. Mohen O. I lalse A. Crtnig B. Stirgieal nianagemeiit olCndocloiuic failures: indications and treatiiient resnlts. Inl DentJ 1991; 41: :x542. 17. Barnes IE. Surgical luidodoniii s. Cotonr Mitnuat. 2nd ed. Wrigbi: 1991: page 15-18. 18. Gulniann Jt,, Harrison, J\V. Posterior endodoniic siirger\: anatoiiiieal consideration and elinical leehniqties. Int EndodJ 1985: 18: 8-:Vl. 19. Gntnianii jL, Harrison |\V. Pei iriidicnlai- i uretlage, rooiend lesection, rool-end lilling. In: Cntmann ]L and Harrison JW. Stirgical Endodonlics, 1 st ed Blackwell seienlirie publications. 1991: 2():i-2tl:i. 20. IVonslad L, Barnett F. Riso K, SlotsJ. b^xmuadicttlar endodonlii infections Endod Dent Tiatimatol 1987; .''.: 8(i-90. 21. Happonen R-P. Periapical aclinomycosis: A follow-up sludy of 16 stugically treated cases. Endod Dem Trannialol 1986; 2: 20.5-209. 22. La.s:iridis N. Zotilouinisi L. .Vntoniadis R. Bonv lid a]> proaeh lor apicectoni\ of inandihulai molars. .Vnsi Dent | 1991; 36: .3(l(i-.368. 2:V Filz|)atiick B. Endodonlie snvgerv on posievioi leeili. .\nsi Dem I 1974: 19: 2.36-24 1. 24. ]ohns RB. Stirgical EiKlodomics.tiem t'pdale 1977; 4: 223-229.
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1. S a u n d e r s KM. . S a u i u l r i s \ \ P. C o i n i M i l i o n a l iciol e a n a i lliera|)y, I: Pix-paratidn of r o o l l a n a l .s\.sk-in. In; Marly F | , :'nd c d . E n d o d o n t i c s in (.liiiieal P i a i l i ( i ' . L o n d o n : Wrinlit

1990; 12S-1.W.
2. l'.iiiopen Society ot tMulDdonlolos^y. (.onscnsus rr])orl of the Enro]5eaii Society o t EiidodontologA- on qtiality gnidcliin'.s lor cndodoiuii- iri-alinenl. Int Endod | 1994; 27: 1 1 5 121. '5. llaily F|, Parkins lij, Wcni^ral .\Nt. Siu'c<'ss laie in rooi canal tbfiapy. A ri'ti'ospceli\c siiuh ol coin'cniional eases. Hi

DcntJ 1970; 128: (W-7().

4. Keivkes R, Trtjiistad L. Long-icini icsnlls ol cndodoniiiti'calmciu pcrfornu-d willi a siandaidiscd UH lini(|iu-. | Endod 1979; 5: 83-90. C). Swxuiz DB, Skidmore AK. ClriHin )A. Twcntv yoais ol endodontic success and faiUirc- ] Endod 1983: 9: 198-202. (). Molvcn C). llatsc /\. Siicc-e.s.s rak-s lor gnlla-pi-i-clui a n d kloropei-ka.N.0 root Tillini^s nuulc hv niulcrgiadnaU' sindent.s: Radiographic lindings aflci 10-17 \cars. Inl Kiulod J 1988: 21: 2 1.^-2.50. 7. Mowe CL. Minor oral sni\>(M\.:')i-d cd. Krislol :\\'i-it;lu. ] and sons, \98~r, :M."i. 8. Citing tV Molvcn (). liaise A. Periapical snigriv in a Norwegian country bos|)ilal: Folli)\v-np liiiding ol 177 icclli. | Endod 1990; 111: 11 1-117. 9. Hill TR. Rool canal iliciapx l)\ means ol apic-ccloinv Br | Oral Snrg 1'.170: 7: 1118-177.

1970:129:407-413. :ll). Ingle JL Beveridge FE. (ilick DH. Weic bman jA. M. Modern endodomii tlierap). In: Ingle ] IDE and Taimor JF .3rd ed. Endodomii s. PIiiladelpbia:Lea .^- Fi-biger. 1985: 34-:V5. .31. Manogue M. Manin DM. Changes in paliem age and
toolli disliibmion tin r o o l canal I r e a l n i e n t in a leacliing

hospital over a 1.5-\eais period.hit Endod ] 1994; 27: 148153. 32. Benjamiii K.\. D(nvson |. huidence ol two rool canals in nKiiulibiilar ineisor leelb. Oral snrg 1974: :?8: 122126. y^. BliaskarSX. Periiipical lesi()ns-'r\p(-s, imidence. and clinieal leatnies. Oral Snrg 1966; 21: (157-671.