Endodontic Surgery Prognosis, Treatment Planning, Techniques and Materials 2010

Objectives and Goals

  • Discuss the indications and contra-indications for endodontic surgery.
  • Describe the various endodontic surgical procedures.
  • Describe and discuss the various root end filling materials with regards to their ease of use, biocompatibility, sealing ability, and success.
  • Describe and discuss the advantages and disadvantages of in vitro techniques for measuring leakage of retrograde filling materials.
  • Describe and discuss the various endodontic flap designs with regards  to technique, indications, and contra-indications.
  • Discuss the prognosis of endodontic surgery with regards to
    • Differences between various clinical studies
    • Length of post operative evaluation
    • Radiographic vs clinical success
    • Pre-operative status of the canal space: Obturated vs unobturated
    • Surgical procedure performed
  • Discuss surgical access as it regards to soft and hard tissue management.
  • Discuss periradicular curettage, root- end resection, and root-end preparation with regards to:
    • Need for procedure
    • Various techniques
    • Materials and instruments used
  • Discuss closure of the surgical site with regards to: Suture material, needle types, suturing techniques.
  • Discuss methods for hemostasis during endodontic surgical procedure, as well as the advantages and disadvantages of the various techniques. 

Friedman S.  The prognosis and expected outcome of apical surgery. Endo Topics 2005;11:219-262

Rud J,  Andreasen JO, Moller Jensen   JE.  Radiographic criteria for assessment of healing after endodontic surgery.  Int J Oral Surg 1972;1:195-214

Langer B, Stein SD, Wagenberg B.  An evaluation of root resections, A ten-year study.  J Periodontol 1981;52:719-22

Molven O,  Halse A,  Grung B.  Surgical management of endodontic failures: indications and treatment results.  Int Dent J  1991;41:33-42

Halse A, Molven O,  Grung  B.  Follow-up after periapical surgery : the value of the one-year control.  Endod Dent Traumatol  1991;7:246-250

Rapp EL,  Brown CE,  Newton CW.  An analysis of success and failure of apicoectomies.  J Endodon  1991;17:508-512

Rud J, Rud V, Munksgaard EC.  Effect of root canal contents on healing of teeth with dentin-bonded resin composite retrograde seal.  J Endodon 1997;23:535-541

Rubinstein RA, Kim S.  Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and super-EBA as root-end filling material.  J Endodon 1999;25:43-48

Kvist T, Reit C. Results of endodontic reteatmnt: A randomized clinical study comaring surgical and nonsurgical procedures. J Endodon 1999;25:814-817

Testori T, Capelli M, Milani S, Wienstein RL. Success and failure in periradiccular surgery a longitudinal retrospective analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:493-8

Zuolo ML, Ferreira MOF, Gutmann JL.  Prognosis in periradicular surgery: a clinical prospective study.  Int Endodon J 2000;33:91-98

Rud J, Rud V, Munksgard EC.  Periapical healing of mandibular molars after root-end sealing with dentine-bonded composite.  Int Endodon J 2001;34:285-292

von Arx T, Gerber C, Hardt N.  Periradicular surgery of molars: a prospective clinical study with a one-year follow-ip.  Int Endodon J 2001;34:520-525

Rubinstein RA, Kim S.  Long-term follow-up of cases considered healed one year after apical microsurgery.  J Endodon 2002;28:378-383

Maddalone M, Gagliani M.  Periapical endodontic surgery: a 3-year follow-up study.  Int Endo J 2003;36:193-198

Chong BS, Pitt Ford TR, Hudson MB.  A prospective clinical study of mineral trioxide aggregate and IRM when used as root-end filling materials in endodontic surgery.  Int Endo J 2003;36:520-526

Wang N, Knight K, Dao T, Friedman S.  Treatment outcome in endodontics-The Toronto study.  Phases I and II: Apical surgery.  J Endodon 2004;30:751-761

Gagliani MM, Gorni FGM, Strohmenger L.  Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison.  Int Endo J 2005;38:320-327

Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R.  Endodontic surgery with ultrasonic retrotips: one-year follow-up.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:380-7

Lindeboom JAH, Frenken JWFH, Kroon FHM, van den Akker H P.  A comparative prospective randomized clinical study of MTA and IRM as root-end filling materials in single-rooted teeth  in endodontic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:495-500

Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z.  Retrospective evaluation of surgical endodontic treatment: Traditional versus modern technique.  J Endod 2006;32:412-416

von Arx T, Jensen SS, Hanni S.  Clinical and radiographic assessment of various predictors for healing outcome 1 year after periapical surgery.  J Endod 2007;33:123-128

Christiansen R, Kirkevang LL, Horsted-Bindslev P, Wenzel A.  Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling – 1-year follow-up.  Int Endod J 2009;42:105-114

Barone C, Dao TT, Basrani BB, Wang N, Friedman S.  Treatment outcome in endodontics: The Toronto study-Phases 3, 4, and 5: Apical Surgery.  J Endod 2010;36:28-35


Jesslen P, Zetterqvist L, Heimdahl A.  Long-term results of amalgam versus glass ionomer cement as apical sealant after apicectomy.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:101-3

Forssell H,  Tammisalo T,  Forssell K. A follow-up study of apicectomized teeth. Proc Finn Dent Soc  1988;84:85-93

Rud J,  Andreasen JO,  Moller Jensen JE.  A follow-up study of 1,000 cases treated by endodontic surgery.  Int J Oral Surg  1972;1:215-228

Andreasen JO.  Cementum repair after apicoectomy in humans.  Acta Odont Scand1973;31:211-221

Harty FJ, Parkins BJ, Wengraf AM. The success rate of apicectomy: A retrospective study of 1,016 cases.  Brit Dent J  1970;129:407-413

Rud J,  Andreasen JO,  Moller Jensen JE.  A multivariate analysis of the influence of various factors upon healing after endodontic surgery.  Int J Oral Surg 1972

Rud J,  Andreasen JO.  A study of failures after endodontic surgery byradiographic, histologic and stereomicroscopic methods.  Int J Oral Surg 1972;1:311-328

Finne K,  Nord PG,  Lennartsson B.  Retrograde root filling with amalgam and cavit.  Oral Surg  1977;43:621-626

Reit C,  Hirsch J.  Surgical endodontic retreatment.  Int Endo J 1986;19:107-112

Lustmann J,  Friedman S,  Shaharabany V.  Relation of pre- and intraoperative factors to prognosis of posterior apical surgery.  J Endodon  1991;17:239-241

Friedman S.  Retrograde approaches in endodontic therapy.  Endod Dent Traumatol  1991;7:97-107

Friedman S,  Lustmann J,  Shaharabany V.  Treatment results of apical surgery in premolar and molar teeth.  J Endodon  1991;17:30-33

Andreasen JO, Munksgaard EC, Fredebo L, Rud J.  Periodontal tissue regeneration including cementogenesis adjacent to dentin bondedretrograde composite fillings in humans.  J Endodon 1993;19:151-153

Jansson L, Sandstedt P, Laftman AC, Skoglund A.  Relationship between apical and marginal healing periradicuar surgery. Oral Surg 1996;83:596-601

Mattila K,  Altonen M. A clinical and roentgenological study of apicoectomized teeth. Odont Tids. 1968;76:389-408

Nordenram A, Svardstrom G.  Results of apicoectomy.  Swed Dent J. 1970;63:593-604

Basten CHJ, Ammons WF, Persson R.  Long-term evaluation of root-resected molars: a retrospective study.  Int J Perio Rest Dent 1996;16:207219

Andreasen JO, Rud J.  Modes of healing histologically after endodontic surgery in 70 cases.  Int J Oral Surg  1972;1:148-160

Filipowicz F, UmstottP, england M.  Vital root resection in maxillary molar teeth: a longitudinal study.  J Endodon 1984;10:264-268

Altonen M,  Mattila K.  Follow-up study of apicoectomized molars.  Acta Odont Scand  1976;5:33-40

Danin J, Stromberg T, Forsgren H, Linder LE, Ramskold LO.  Clinical management of nonhealing periradicular pathosis surgery versusendodontic retreatment.  Oral Surg Oral Med Oral Pathol Oral Rdiol Endod   1996;82:213-217

Persson G.  Prognosis of reoperation after apicectomy: A clinical-radiological investigation.  Swed Dent J  1973;66:49-67

Hirsch JM,  Ahlstrom U,  Hendrikson PA,  Heyden G,  Peterson LE. Periapical surgery. Int J Oral Surg 1979;8:173-185

Dorn SO,  Gartner AH.  Retrograde filling materials: a retrospective success-failure study of amalgam, EBA, and IRM. J Endodon 1990;16:391-393

Jesslen P, Zetterqvist L, Heimdahl A.  Long-term results of amalgam versus glass ionomer cement as apical sealant after apicectomy.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:101-103

Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K.  Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching hospital: a retrospective study.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:700-9

Jensen SS, Nattestad A, Egdo P, Sewerin I, Minksgaard EC, Schou S.  A prospective, randomized, comparative clinical study of resin composite and glass ionomer cement for retrograde root filling.  Clin Oral Invest 2002;6:236-243




FALL, 2010  

Kramper BJ, Kaminski EJ, Osetek EM, Heuer MA.  A comparative study ofthe wound healing of three types of flap disign used in periapical surgery.   Endodon  1984;10:17-25

Martin MV, Nind D.  Use of chlorhexidine gluconate for pre-operative disinfection of apicectomy sites.  Br Dent J  1987;162:459-461

Selim HA, El Deeb ME, Messer HH.  Blood loss during endodontic surgery. Endod Dent Traumatol  1987;3:33-36

Tidmarsh BG, Arrowsmith MG.  Dentinal tubules at the root ends of apicected teeth: a scanning electron microscopic study.  Int Endodon J  1989;22:184-189

Phillips J, Weller RN, Kulild JC.  The mental foramen:Part I.  Size, orientation and positional relationship to the mandibular second premolar. J Endodon1990;16:221-23

Frankle KT, Seibel W, Dumsha TC.  An anatomical study of the position of the mesial roots of mandibular molars.  J Endodon  1990;16:480-485

Harrison JW. Healing of Surgical wounds in oral mucoperiosteal tissues.  J Endodon 1991;17:401-408

Harrison JW, Jurosky KA. wound healing in the tissues of the periodontium following periapical surgery. I. The incisional wound.  J Endodon 1991;17:425-435

Harrison JW, Jurosky KA. Wound Healing in the tissues of the periodontiumfollowing periradicular surgery. II. The dissectional wound. J Endodon1991;17:544-552

Harrison JW, Jurosky KA.  Wound healing in the tissues of the periodontium following periradicular surgery. III. The osseous exisional wound.  J Endodon 1992;18:76-8

Craig KR, Harrison JW. Wound healing following demineralization of resected roots ends in periradicular surgery.  J Endodon  1993;19:339-347

Molven O, hales A, Grung B.  Incomplete healing (scar tissue) after periapical surgery-radiographic findings 8 to 12 years after treatment.  J Endodon 1996;22:264-268

Mehlhaff DS, Marshall JG, Baumgartner JC.  Comparison of ultrasonic and high-speed-bur root-end perparations using bilaterally matched teeth.  J Endodon  1997;23:448-452

Morgan LA, Marshall JG.  A scanning electron microscopic study of in vivo ultrasonic root-end preparations.  JEndod 1999;25:567-570

Dietrich T, Zunker P, dietrich D, Bernimoulin JP, Periapical and periodontal healing after osseuous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: Results after 12 months.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:474-82

De Bruyne MAA, De Moor RJG.  SEM analysis of the integrity of resected root apices of cadaver and extracted teeth after ultrasonic root-end preparation at different intensities.  Int Endod J 2005;38:310-319

Velvart P, Peters CI, Peters OA.  Soft tissue management :flap design, incision, tissue elevation, and tissue retraction.  Endo Topics 2005;11:78-97

Hoskinson AE.  Hard tissue management : osseous access, curettage, biopsy and root isolation.  Endo Topics 2005;11:98-113

Stropko JJ, Doyson GE, Gutmann JL.  Root-end management: resection, cavity preparation, and material placement.  Endo Topics 2005;11:131-151

Velvart P, Peters CI, Peters OA.  Soft tissue management: suturing and wound closure.  Endo Topics 2005;11:179-195

Kim S, Kratchman S.  Modern endodontic surgery concepts and practice: a review.  J Endodon 2006;32:601-623

von Arx T, Vinzens-Majaniemi T, Burgin W, Jensen SS, changes of periodontal parameters following apical surgery: a prospective clinical study of three incision techniques.  Int Endod J 2007;40:959-969

Roy R, Chandler NP, Lin J.  Peripheral dentin thickness after root-end cavity preparation.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:263-6

Lin L, Chen MYH, Ricucci D, Rosenberg PA. Guided tissue regeneration in periapical surgery.  J Endod 2010;36:618-625


Lyons CJ.  Surgical technic of apicoectomy.  JADA 1920; 7:700-704 

Tebo HG.  Variations in the position of the mental foramen.  Dent Items nterest.  1951;52-53

Omnell KA.  Electrolytic precipitation of zinc carbonate in the jaw.  Oral Surg 1959;12:846-852

Luebke RG, Glick DH, Ingle JI.  Indications and contraindications for endodontic surgery.  Oral Surg  1964;18:97-113

Costich ER, Youngblood PJ, Walden JM.  A study of the effects of high-speed rotary instruments on  bone repair in dogs.  Oral Surg  1964;17:563-571

Grung B.  Healing of gingival mucoperiosteal flaps after marginal incision in apicoectomy procedures.  Int J Oral Surg  1973;2:20-25         

Marcotte LR, Dowson J, Rowe NH.  Apical healing with retrofilling materials amalgam and gutta-percha.  J Endodon  1975;1:63-65

Vreeland DL, Tidwell E.  Flap design for surgical endodontics.  Oral Surg 1982;54:461-465

Sieraski SM, Cororan JF.  Osseous healing kinetics after apicoectomy in monkeys: I. An isodensitometric interpretation of radiographic images.  J Endodon  1984;10:233-239

Filipowicz F, Umstott P, England M.  Vital root resection in maxillary molar teeth: A longitudinal study.  J Endodon  1984;10:264-268

Nedderman TA, Hartwell GR, Portell FR.  A Comparison of root surfacesfollowing apical root resection with various burs: Scanning electron microscopic evaluation.  J Endodon  1988;14:423-427

Fox NA.  The position of the inferior dental canal and its relation to the mandibular second molar.  Br Dent J  1989;167:19-21

Baker PS, Oguntebi BR.  Effect of apical resection and reverse fillings on thermafil root canal obturations.  J Endodon 1990;16:227-229

Lemon RR, Steele PJ, Jeansonne BG. Ferric sulfate hemostasis: Effect on osseous wound healing. I. Left in situ for maximum exposure.  J Endodon 1993;19:170-173

Gutmann JL, Saunders WP, Nguyen L, Guo IY, Saunders EM.  Ultrasonic root-end preparation Part I.  SEM analysis.  Int Endodon J 1994;27:318-324

Saunders WP, Saunders EM, Gutmann JL.  Ultrasonic root-end preparation Part 2. Microleakage of EBA root-end fillings.  Int Endodon J 1994;27:325-  329.

Pecora G, Kim S, Celletti R, Davarpanah M.  The guided tissue regeneration principle in endodontic surgery: one-year postoperative results of large periapical lesions.  Int Endodon J 1995;28:41-46.

Lin L, Skribner J, Shovlin F, Langeland, K.  Periapical surgery of mandibular posterior teeth: Anatomical and surgical considerations.  J Endodon  1983;9:496-501

Ibarrola JL, Bjorenson JE, Austin BP, Gerstein H.  Osseous reactions to three hemostatic agents.  J Endodon  1985;11:75-83

Lloyd A, Jaunberzins A, Dummer PMH, Bryant S.  Root-end cavitypreparation using the MicroMega Sonic retro-prep tip. SEM analysis.  IntEndod J 1996;29:295-301

Layton CA, Marshall JG, Morgan LA, Baumgartner JC.  Evaluation of cracks associated with ultrasonic root-end preparation.  J Endodon  1996;22:157-160

Dean Jw, Lenox RA, Lucas FL, Culley, WL, Himel VT.  Evaluation of a combined surgical repair and guided tissue regeneration technique to treat     recent root canal perforations.  J Endodon. 1997;23:525-532

Sawyer D, Kiely M, Pyle M.  The frequency of accesory mental foramina in four ethnic groups.  ArchOralBio  1998;43:419

Bahcall JK, DiFiore PM, Poulakidas TK.  An endoscopic technique for endodontic surgery.  J Endodon 1999;25:132-135

Jeansonne BG, Boggs WS, Lemon RR. Ferric sulfate hemostasis: Effect on osseous wound healing. II. With curettage and irrigation.  J Endodon 1993;19:174-176

Vickers FJ, Baumgartner JC, Marshall G.  Hemostatic efficay and cardiovascular effects of agents used during endodontic surgery.  J Endodon 2002;28:322-323

Calzonetti KJ, Iwanowski T, Komorowski R, Friedman S.  Ultrasonic root end cavity preparation assessed by an in situ impression technique.  Oral Surg 1998;85:210-215

Abedi HR, Van Mierlo BL, Wilder-Smith P, Torabinejad M.  Effects of ultrasonic root-end cavity preparation on the root apex.  Oral Surg 1995;80:207-213

Cambruzzi JV, Marshall FJ, Pappin JB.  Methylene blue dye: An aid to endodontic surgery.  J Endodon  1985;11:311-314

Peters CI, Peters OA, Barbakow F.  An in vitro study comparing root-end cavities prepared by diamond-coated and stainless steel ultrasonic retrotips.  Int Endodon J 2001;43:142-148

Back SH, Kin S.  Bone repair of experimentally induced through-and-through defects by Gore-Tex, Guidor, and Vicryl in ferrets:A pilot study.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:710-4

Kleier DJ.  The continuous locking suture technique.  J Endodon 2001;27:624-626

Yoshikawa G, Murashima Y, Wadachi R, Sawada N, suda H.  Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy:a comparative histomorphometrical study.  Int Endod J 2002;35:255-263

Velvart P.  Papilla base incision: a new approach to recession-free healing of the inderdental papilla after endodontic surgery.  Int Endod J 2002;35:453-460

Gutmann JL, Harrison JW.  Surgical Endodontics. 1994. pp123-299.

Clark MA, Bueltmann KW.  Anatomical considerations in periodontal surgery.  J Periodon 1971;42:625

Denio D, Torabinejad M, Bakland LK.  Anatomical relationship of the mandibular canal to its surrounding structures in mature mandibles.  J Endodon 1992;18:161-165

Selvig KA, Torabinejad M.  Wound healing after mucoperiosteal surgery in the cat.  J Endodon 1996;22:507-515

Eastman JR, Backmeyer J.  A review of the periodontal, endodontic, and prosthetic considerations in odontogenous resection procedures.  Int J Perio Rest Dent 1986;2:35-51

Corcoran JF, Sieraski SM, Ellison RL.  Osseous healing kinetics after apicoectomy in monkeys:II. A quantitative histological Appraisal.  J Endodon  1985;11:269-274

Lin LM, Gaengler P, Langeland K.  Periradicular curettage.  Int Endodon J 1996;29:220-227

Kleier DJ.  The continuous locking suture technique.  J Endodon 2001;27:624-626

Morgan LA, Marshall JG.  The topography of root ends resected with fissure burs and refined with two types of finishing burs.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod  1998;85:585-91

Gagliani M, Taschieri S, Molinari R.  Ultrasonic root-end preparation: influence of cutting angle on the apical seal.  J Endodon 1998;24:726-730

Bergenholtz G, wikesjo UME, Sorensen RG, Xiropaidis V, Wozney JM. Observations on healing following endodontic surgery in nonhuman primates (Macaca fascicularis): Effects of rhBMP-2.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod  2006;101:116-125

von Arx T, Hanni S, Jensen SS.  Correlation of bone defect dimensions with healing outcome one year after apical surgery.  J Endodon 2007;33:1044-1048