Endoscopic periradicular surgery: A prospective clinical study

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British Journal of Oral and Maxillofacial Surgery 45 (2007) 242–244

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Endoscopic periradicular surgery: A prospective clinical study S. Taschieri, M. Del Fabbro ∗ , T. Testori, R. Weinstein Istituto Ortopedico Galeazzi, Department of Odontology, University of Milan, Via R. Galeazzi 4, 20161 Milano, Italy Accepted 14 September 2005 Available online 17 October 2005

Abstract We did apicectomies of 30 teeth with periradicular lesions in 23 patients, using a 3 mm endoscope. Two patients failed to attend for postoperative assessment and of the remaining 21 patients who had 28 teeth treated the operation was judged after 1 year to be a success in 26 (93%). © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Periradicular surgery; Retro-tip; Endoscope


Patients and methods

The introduction of microsurgical instruments and ultrasonic retro-tips has brought many advantages in the management of root ends.1 A small bony crypt is all that is needed, which reduces the morbidity of the classic surgical approach to root ends. The cutting bevel at the resected root end can be perpendicular to the long axis of the canal, and this reduces the number of exposed dentinal tubules and minimises apical leakage.1 Ultrasonic retro-tips also enable the long axis of the tooth to be followed, while preserving the morphology of the canal. Apical cavities can be shaped more easily, more safely, and with greater precision than those achieved by conventional hand-pieces.2 It is, however, essential to have adequate illumination and magnification and this has been provided by microscopes and loupes. Recently, there has been growing interest in endoscopy as an alternative tool for optimising visualisation in surgical endodontics.3,4 Our objective in this prospective clinical study was to assess the outcome of periradicular surgery using an endoscope for illumination and magnification.

Patient selection and inclusion criteria

Corresponding author. Tel.: +39 02 50319950; fax: +39 02 66214770. E-mail address: [email protected] (M. Del Fabbro).

The following criteria were adopted: (1) a periradicular lesion of strictly endodontic origin was present and nonsurgical retreatment was considered not to be feasible or had previously failed; (2) the teeth had an adequate final restoration with no clinical evidence of coronal leakage; (3) the apical root canal was more than 6 mm away from a post; (4) no acute symptoms were present; and (5) no general medical contraindications to oral operations were present (patients were American Society of Anesthesiology (ASA)-1 or ASA-2). The following groups of patients were excluded: (1) patients who had lesions associated with vertical fractures of a root; (2) those who had perforation of the furcation area or lateral walls of the canal; (3) those who had injuries; (4) molars; (5) those who had severe periodontal bony loss detected with a periodontal probe (more than 5 mm probing depth); and (6) those who had bony defects involving both buccal and lingual cortical bone. Based on the above criteria 30 teeth (22 anterior and 8 premolars) in 23 patients were selected for periradicular surgery.

0266-4356/$ – see front matter © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.


S. Taschieri et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 242–244



Table 1 Outcome of apicectomy with endoscopic vision

Full mucoperiosteal tissue flaps were raised. Access to the root was through the cortical bone using a round bur at low rotary speed, in a brush stroke manner. The periradicular lesion was removed with sharp bone curettes and angled periodontal curettes. After exposure of the end of the root we inserted a straight fissure bur in a hand-piece perpendicular to the long axis of the root, and shaved away 2.5–3 mm of the root-end. Local haemostasis was achieved with bone wax. An endoscope 6 cm long and 3 mm wide (Karl Storz GmbH, Tuttlingen, Germany) was then used as the magnification device to improve visualisation for preparation of the root-end cavity. The viewing angle was 70◦ . Images obtained through the endoscope were inspected on a monitor placed opposite the surgeon at the level of the patient’s feet. This allowed the surgeon and the whole surgical team to view the preparation of the root-end. Cavities 2.5–3 mm deep were prepared under constant copious irrigation with sterile water using zirconium nitrate retro-tips (Dentsply, Maillefer Instruments, Ballaigues, Switzerland), driven by an ultrasonic device (Piezon master 400, EMS, Nyon Switzerland) set at no more than half power. Root-end cavities were then dried using paper cones, and carefully examined with the endoscope to detect morphological alterations of the rootface such as marginal chipping. Root-ends were sealed with a zinc oxide-eugenol (EBA) cement (Super Seal, Ogna Pharmaceuticals, Milan, Italy). The excess of filling material was removed and soft tissues were sutured.






Maxilla Anterior Premolar

12 2

1 0

0 0

13 2





9 3

0 0

0 1

9 4





26 93.0

1 3.5

1 3.5


Criteria for assessment of healing


The radiographs taken at 1 year postoperatively were used to assess healing according to the classification introduced by Molven et al.: complete healing, incomplete healing, uncertain healing, or unsatisfactory outcome.5 Signs and symptoms was also recorded and classified into clinical success, clinical questionable, and clinical failure. The final classification was:

Many clinical studies have been published on periradicular surgery using microsurgical retro-tips. While the reported success rates are generally high, many criteria and radiographic classifications of healing have been proposed. Rud et al. standardised and validated a radiographic classification system that was integrated with histological findings.6 Subsequent studies have supported the use of the classification of Rud et al. in assessments at 1- to 4-year follow-up visits. Some authors have reported that radiographic criteria for the complete healing group and the unsatisfactory (failure) group are reliable after 1-year follow-up.5–7 Jesslen et al. reported that the result of a 1-year follow-up was valid in more than 95% of the cases.8 The long-term outcome is unpredictable in cases classified as uncertain after 1 year.5 In the present study we followed the indications of Molven et al.5 that, in agreement with other authors6 scheduled the cases classified as “uncertain” for a further examination 3 years later, and then classified them as success or failure. Rubinstein and Kim concluded that the use of a magnification device is a decisive factor in improving success rates of periradicular surgery compared with traditional techniques.9 While the surgical microscope has long been adopted by endodontists to improve visualisation of the surgical field,

(1) Successful: radiographic complete or incomplete healing and clinical success. (2) Uncertain: radiographic uncertain healing or clinical questionable associated with incomplete radiographic healing. (3) Failure: radiographic unsatisfactory healing and clinical failure. All cases classified as uncertain healing were scheduled for a further follow-up 3 years later.5

Results Two patients (two teeth) did not attend for follow-up and were withdrawn from the study. Twenty-eight teeth in 12 women and 9 men (mean age 37 and 49 years, respectively) were assessed at 1-year follow-up. The outcome of surgical

Subtotal Mandible Anterior Premolar Subtotal Total Percentage

Table 2 Distribution of cases according to the presence or absence of a post Type of healing

With post

Without post

Successful Uncertain Failure

14 1 1

12 0 0

Total no.



treatment according to type and location of the teeth is showed in Table 1. One tooth (uncertain outcome) was scheduled for re-evaluation after three more years. Table 2 shows the distribution of outcomes according to the presence or absence of a post.


S. Taschieri et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 242–244

the introduction of fiberoptic endoscopy in endodontics is recent.3,4 Few prospective clinical studies on endoscopy have been published. von Arx et al. reported a better (but not significantly better) outcome of operations with endoscopy compared with those in which micromirrors were used.4 The success rate of their cases was similar to the one that we report. The relatively small sample size and the absence of a control group are the main limits of the present study. The main clinical advantages of endoscopy over surgical microscopy are that the endoscope is readily transportable, is versatile, has excellent illumination and good magnification, and the learning curve is short. von Arx showed that with the exception of intradentine cracks, the endoscope allowed the accurate identification of microstructures such as marginal chipping on the surface of root-ends.10 They used an endoscope to inspect the frequency and types of isthmuses between multiple canals in molar teeth following resection of apical root-ends, which emphasises a further advantage of endoscopy in periradicular surgery.10 Bahcall et al. reported that the rod-lens endoscope allows clinicians to obtain a kind of visualisation that the microscope cannot provide.3 With microscopy the field of vision is fixed and cannot be adjusted readily to view the site of operation from various angles. Endoscopy on the other hand has a non-fixed field of vision and therefore allows observation of the surgical field from various angles and distances without losing the depth of field and the focus. In our clinical experience we appreciated most of the above advantages and verified that the perception of the field depth is similar to the one a surgeon would have with the

naked eye. On the other hand it was necessary to clean the lens repeatedly when there was bleeding, which may increase by a few minutes the time required for completing the operation. References 1. von Arx T, Walker WA. Microsurgical instruments for root-end cavity preparation following apicoectomy: a literature review. Endod Dent Traumatol 2000;16:47–62. 2. Wuchenich L, Meadows D, Torabinejad M. A comparison between two root-end preparation techniques in human cadavers. J Endod 1994;20:279–82. 3. Bahcall JK, Di Fiore PM, Poulakidas K. An endoscopic technique for endodontic surgery. J Endod 1999;25:132–5. 4. von Arx T, Frei C, Bornstein M. Periradicular surgery with and without endoscopy: a clinical and prospective study. Schweiz Monatsschr Zahnmed 2003;113:860–5. 5. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery. Radiographic findings 8–12 years after treatment. J Endod 1996;22:264–8. 6. Rud J, Andreasen JO, M¨oller Jensen JE. A follow-up study of 1000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:215– 28. 7. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod 2002;28:378–83. 8. 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. 9. 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 Endod 1999;25: 43–8. [10]. von Arx T, Montagne D, Zwinggi C, Lussi A. Diagnostic accuracy of endoscopy in periradicular surgery — a comparison with scanning electron microscopy. Int Endod J 2003;36:691–9.

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