Meta-Analysis

Outcome of Endodontic Surgery: A Meta-analysis

of the Literature—Part 2: Comparison of Endodontic
Microsurgical Techniques with and without the Use
of Higher Magnification
Frank C. Setzer, DMD, PhD, MS, Meetu R. Kohli, BDS, DMD, Sweta B. Shah, BDS, DMD,
Bekir Karabucak, DMD, MS, and Syngcuk Kim, DDS, PhD

Abstract
Introduction: The aim of this study was to investigate articles that qualified were assigned to group CRS. Articles belonging to group EMS
the outcome of root-end surgery. It identifies the effect had already been obtained for part 1 of this meta-analysis. Weighted pooled success
of the surgical operating microscope or the endoscope rates and a relative risk assessment between CRS and EMS overall as well as for molars,
on the prognosis of endodontic surgery. The specific premolars, and anteriors were calculated. A random-effects model was used for
outcomes of contemporary root-end surgery techniques a comparison between the groups. Results: One hundred one articles were identified
with microinstruments but only loupes or no visualiza- and obtained for final analysis. In total, 14 studies qualified according to the inclusion
tion aids (contemporary root-end surgery [CRS]) were and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for
compared with endodontic microsurgery using the EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data
same instruments and materials but with high-power showed an 88% positive outcome for CRS (95% confidence interval, 0.8455–0.9164)
magnification as provided by the surgical operating and 94% for EMS (95% confidence interval, 0.8889–0.9816). This difference was statis-
microscope or the endoscope (endodontic microsurgery tically significant (P < .0005). Relative risk ratio analysis showed that the probability of
[EMS]). The probabilities of success for a comparison of success for EMS was 1.07 times the probability of success for CRS. Seven studies
the 2 techniques were determined by means of a meta- provided information on the individual tooth type (4 for CRS [n = 457] and 3 for
analysis and systematic review of the literature. The EMS [n = 222]). The difference in probability of success between the groups was statis-
influence of the tooth type on the outcome was investi- tically significant for molars (n = 193, P = .011). No significant difference was found for
gated. Methods: A comprehensive literature search for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P =
longitudinal studies on the outcome of root-end surgery .715). Conclusions: The probability for success for EMS proved to be significantly
was conducted. Three electronic databases (ie, Medline, greater than the probability for success for CRS, providing best available evidence on
Embase, and PubMed) were searched to identify human the influence of high-power magnification rendered by the dental operating microscope
studies from 1966 up to October 2009 in 5 different or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions
languages (ie, English, French, German, Italian, and for current endodontic questions are needed to make informed decisions for clinical
Spanish). Review articles and relevant articles were practice. (J Endod 2012;38:1–10)
searched for cross-references. In addition, 5 dental
and medical journals (ie, Journal of Endodontics, Key Words
International Endodontic Journal, Oral Apicoectomy, dental operating microscope, endodontic microsurgery, endoscope, IRM,
Surgery Oral Medicine Oral Pathology Oral loupes, meta-analysis, microscope, mineral trioxide aggregate, outcome, root-end
Radiology and Endodontics, Journal of Oral surgery, success, SuperEBA, systematic review
and Maxillofacial Surgery, and International
Journal of Oral and Maxillofacial Surgery)
dating back to 1975 were hand searched. Following pre-
defined inclusion and exclusion criteria, all articles were
T he goal of endodontic therapy is the prevention or elimination of apical periodon-
titis. Root-end surgery may be indicated in cases with persistent or refractory peri-
radicular pathosis that does not heal after nonsurgical retreatment (1). This can be
screened by 3 independent reviewers (S.B.S., M.R.K., caused by both intraradicular or extraradicular infections that cannot be addressed
and F.C.S.). Relevant articles were obtained in full-text by an orthograde treatment approach.
form, and raw data were extracted independently by The first part of this meta-analysis dealt with the question how the outcome of
each reviewer. After agreement among the reviewers, traditionally applied surgical techniques in endodontics compared with endodontic

From the Department of Endodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
One of the authors (S.K.) declares a potential conflict of interest by the development of microsurgical ultrasonic tips.
Address requests for reprints to Dr Frank C. Setzer, Instructor, Department of Endodontics, School of Dental Medicine, University of Pennsylvania, 240 South 40th
Street, Philadelphia, PA 19104. E-mail address: fsetzer@dental.upenn.edu
0099-2399/$ - see front matter
Copyright ª 2012 American Association of Endodontists.
doi:10.1016/j.joen.2011.09.021

JOE — Volume 38, Number 1, January 2012 Outcome of Endodontic Surgery with or without Higher Magnification 1
Meta-Analysis
microsurgery (2). For the purpose of the investigation, 2 groups studies with strictly defined inclusion and exclusion criteria
had been defined. In brief, studies had been grouped either as (outcome)?’’
traditional root-end surgery (TRS) or endodontic microsurgery
(EMS). Studies in group TRS used conventional burs and amalgam
root-end fillings without the application of magnification devices, Identification of Studies
whereas studies in group EMS used the operating microscope or A detailed description of the literature search that identified rele-
an endoscope with high-power magnification together with micro- vant articles can be found in part 1 of this investigation (2). Briefly, 3
surgical instruments, ultrasonic root-end preparation, and more electronic databases (Medline, Embase, and PubMed) were searched
biocompatible filling materials such as IRM, SuperEBA, or MTA. for related articles, regardless of the publication type, using the term
The weighted pooled success rates calculated from the raw data {(apicoectomy OR apicectomy OR root-end filling OR root-end surgery
of 12 studies in TRS and 9 studies in EMS showed a 59% positive OR retro-grade filling OR retro-grade surgery OR periapical surgery OR
outcome for TRS (95% confidence interval [CI], 0.55–0.6308) and periradicular surgery OR surgical endodontic treatment OR apical
94% for EMS (95% CI, 0.8889–0.9816) based on Rud’s and microsurgery) AND (success OR treatment outcome)}. The search
Molven’s success criteria for periapical surgery. This difference was limited to studies on humans in either English, French, German,
was statistically significant (P < .0005). A relative risk analysis Italian, or Spanish from 1966 to the second week of October 2009.
showed that the probability of success for EMS was 1.58 times In addition, 5 relevant journals (Journal of Endodontics, Interna-
the probability of success for TRS. From this study, it was concluded tional Endodontic Journal, Oral Surgery Oral Medicine Oral
that the use of microsurgical techniques is superior in achieving Pathology Oral Radiology and Endodontics, Journal of Oral and
predictably high success rates for root-end surgery than with tradi- Maxillofacial Surgery, and International Journal of Oral and Maxil-
tional techniques as defined earlier. lofacial Surgery) dating back to 1975 were hand searched. Review arti-
The protocol for endodontic microsurgery suggests to use mid- cles and matching publications were searched for cross-references.
range magnification (8–14) for the majority of the surgical proce- Three independent reviewers (S.B.S., M.R.K., and F.C.S.) screened
dures, including hemostasis, the removal of granulation tissue, the the relevant articles, checked for inclusion or exclusion, and extracted
detection of root tips, apicoectomy, root-end preparation, and root- the raw data for analysis. Cohen kappa statistics were applied to check
end filling (3). High magnification (14–26) should be used for the interreviewer agreement. Full articles were obtained either electroni-
inspection and documentation of the resected root surface, the root- cally or as paper versions. Gray literature was identified by consulting
end cavity, and the root-end filling to allow for the observation of fine 3 experts on the subject matter for publications or consensus reports
anatomic details, such as accessory canals, isthmi, fins, microfractures, in the making. Within the timeframe between the submission of parts
or lateral canals (3). Tsesis et al (4) suggested that the identification 1 and 2 of this meta-analysis, the endodontic literature was carefully re-
and treatment of microscopically small anatomic details should result viewed for recent articles on the subject matter.
in a more successful outcome. Besides the studies that strictly use
microsurgical techniques, including high-power magnification
(EMS), there are other investigations on the outcome of endodontic Inclusion and Exclusion Criteria
surgery that also apply microsurgical instruments, ultrasonic root- Studies were selected based on the following inclusion criteria:
end preparation, and the same biocompatible filling materials but do
1. Clinical study was on root-end surgery.
not use any or only low-range magnification. This raises the question
2. Sample size was given.
whether the use of high-power magnification is critical as a single factor
3. There was a minimum follow-up period of 12 months.
if all other microsurgical techniques are applied, but only loupes or no
4. Success and failure were evaluated using Rud’s (5) or Molven’s (6)
magnification device are used.
radiographic parameters and clinical assessment. Radiographically,
Based on the previous systematic review and meta-analysis of
success was defined as either complete or incomplete healing (scar
the literature that had been performed to compare cumulative
tissue formation) and clinically by the absence of pain, swelling,
success rates and relative risk ratios for TRS and EMS, this second
percussion sensitivity, or sinus tracts. Failure included uncertain
part of the investigation presents the comparison of contemporary
healing (reduction or same lesion size) or complete failure
root-end surgery techniques with only loupes or no magnification
(increase in lesion size) as determined from the radiograph. Clinical
devices (contemporary root-end surgery [CRS]) with the previously
failure was defined as the presence of any of the symptoms
reported data on endodontic microsurgery using high-power magni-
mentioned previously.
fication provided by the dental microscope or the endoscope (EMS)
5. Success and failure were evaluated per tooth.
to assess the impact of the microscope or endoscope on the prog-
6. The overall success rate was given for the specific technique or could
nosis of endodontic surgery by the means of cumulative success rates
be calculated from the raw data.
and relative risk ratios. Studies in CRS were defined as the identical
7. The method used in the study followed strictly either the specific
techniques as EMS with the exception of the use of magnifications
techniques for CRS or EMS as follows: CRS: modern microsurgical
10 and above. It also investigates the influence of the tooth type
instruments and filling materials (microinstruments; ultrasonic
on the probability of success.
root-end preparation; and root-end filling with IRM, SuperEba, or
MTA) but with magnification #10 (loupes or no magnification
devices) and EMS: the same microsurgical instruments and filling
Materials and Methods materials but with the surgical operating microscope or endoscope
According to the PICO (Population, Intervention, Comparison, allowing magnification >10.
Outcome) format, the following research question had been formu- 8. Study was limited to humans.
lated before the search for matching publications: Teeth that have 9. Publication was in English, French, German, Italian, or Spanish.
undergone a root-end surgery and root-end filling procedure (pop-
ulation) by EMS (intervention) compared with CRS (comparison) Studies were excluded if the inclusion criteria were not met or
have what expected probability of success according to longitudinal showed any of the following exclusion criteria:

2 Setzer et al. JOE — Volume 38, Number 1, January 2012

 Meta-Analysis
1. Study did not evaluate the outcome of root-end surgery. gories; 2  2 contingency tables were used to derive relative risk ratios
2. No sample size was given. and odds ratios. Chi-square analysis on the frequencies of success and
3. Root-end surgery was performed on lesions >10 mm in diameter. failures was used to investigate statistically significant differences
4. Teeth presented with apicomarginal defects or teeth with peri- between CRS and EMS for the overall comparison, premolars, and ante-
odontal disease (periodontal pockets and/or mobility). riors. The Fisher exact test was used in lieu of chi-square analysis for the
5. Guided tissue regeneration was used. molar subcategory because 1 cell in the contingency table had an ex-
6. Surgery took place after previous endodontic surgery (resurgery pected value of <5.
cases), root resections, and amputations and cases presenting
with root fractures or perforations.
7. There was <12 months of follow-up. Results
8. Outcome was not evaluated according to the success and failure Inclusion and Exclusion of Studies
criteria defined earlier. In total, 1,189 citations were reviewed, 1,088 eliminated, and 101
9. Success rate was not given or it was only reported for roots, or data reviewed. Of the 101 citations obtained after abstract and full-text
extraction or success rate calculation for CRS or EMS from raw review, a total of 14 records were included in this second part of the
data was not possible. meta-analysis (10–23). Data from 2 articles were used for CRS as
10. Root-end surgery was performed with a technique or a combina- well as EMS (12, 15), bringing the total number to 7 datasets for CRS
tion of techniques that did not fit the specific criteria defined for (10–16) and 9 datasets for EMS (12, 15, 17–23). There were 6
CRS or EMS. randomized controlled trials (best) (13, 15, 16, 18, 21, 23), 2
11. It was an in vitro or animal study, case report, review article, or prospective studies with concurrent controls (better) (12, 22), and 6
opinion paper. prospective case studies (average) (10, 11, 14, 17, 19, 20) included
12. The study was based on a population that was part of an earlier into the analysis (Table 1).
publication. The initial kappa value between the 3 reviewers at stage 1 for
13. Publication was in any other language than those mentioned in the keeping or rejecting articles was 97.0%. Discussion among the 3
inclusion criteria. reviewers resolved the question of inclusion or exclusion for the 4
articles when no agreement had been reached. The detailed reasons
for the exclusion of the 87 articles that were not taken into consider-
Data Extraction ation after full-article review were noted (17, 24–106) (Table 2).
In total, the database search resulted in 1,152 citations. Of these, Two articles (17, 77) were excluded because the original data
1,020 were excluded as irrelevant to the subject title review. An addi- from these publications had been already analyzed in 2 earlier
tional 68 studies were eliminated from the remaining 132 studies after studies. None of the 3 articles identified after conduction of the
abstract review. The remaining 64 articles were obtained for full-text full-scale systematic review could be included in the meta-analysis
analysis based on the electronic database search. Cross-referencing for CRS or EMS. One article investigated the differences in outcome
of these publications and 16 review articles as well as the hand search between endodontic microsurgery with MTA and with Retroplast
of the 5 relevant journals revealed additional 34 publications of rele- (7). Within the MTA group, which was complying with the inclusion
vance. Between the publication of part 1 of the meta-analysis and the criteria for microsurgical techniques, primary surgeries as well as re-
preparation of the manuscript for part 2, 3 additional publications surgeries were included and could not be separated for raw data
on the outcome of endodontic surgery were identified (7–9). In extraction. Another article (8) looked into the effect of nonsurgical
total, 101 studies were obtained as full-text copies. The language distri- retreatment before periapical surgery. The success and failure evalu-
bution of these articles is listed in part 1 of this investigation. The articles ation in the cases that underwent surgery for this study combined the
were subjected to a 6-category quality assessment detailed in the first results for incomplete healing (classified as success in this meta-
part of this study. For all relevant studies, the following data were ex- analysis) with uncertain healing (classified as failure) and could
tracted from the articles for statistical analysis: sample size in teeth, not be separated for data extraction from an eligible treatment group.
roots, molars, premolars, and anteriors; follow-up period; the use of The third study (9) only investigated the outcome of resurgery cases.
inclusion and exclusion criteria for surgery; the type of magnification; The initial interreviewer agreement for the selection of the 14 articles
the type of root-end preparation; root-end filling material; statistical in groups CRS and EMS at stage 2 was 94.2%. The issues were dis-
methods; success in teeth, roots, molars, premolars, and anteriors; cussed until a joint agreement was reached.
the reported success rate; success criteria; and the number of cases
with complete, incomplete, uncertain healing, and failure.
Comparison of Contemporary Root-end Surgery
Statistical Analysis with Only Loupes or No Visualization Aids (CRS)
SPSS v15.0 (SPSS Inc, Chicago, IL), Minitab v15.0 (Minitab Inc., versus Endodontic Microsurgery with High-power
State College PA), and Excel 2007 (Microsoft Corporation, Redmond, Magnification (EMS)
WA) were used for all descriptive and inferential analyses. The power Overall Comparison. Success rates at the 12-month examination
of the analyses was estimated using STATA v10 (StataCorp LP, College for CRS and EMS were derived from the dataset. The 7 studies (n =
Station, TX). For the comparison between the weighted pooled success 610) included in CRS resulted in a weighted pooled success rate of
rates of CRS and EMS, including the overall comparison and the 3 88.09% (95% CI, 0.8455–0.9164). As reported in part 1 of the
subcategories (ie, molars, premolars, and anteriors), the following meta-analysis, the 9 studies included in EMS yielded a weighted pooled
statistical analyses were performed: a homogeneity analysis to assess success rate of 93.52% (95% CI, 0.8889–0.9816) (Fig. 1) (2). The
the assumption that all of the effect sizes were estimating the same pop- detailed remedial solution for the incorporation of Christiansen et al
ulation mean. Standardized mean differences between CRS and EMS (23), which had a 100% success rate and thus presented with a statis-
were calculated using probits of individual group success probabilities tical problem as the inverse variance was undefined, was described in
to obtain a z score for group comparison overall and for all 3 other cate- part 1 of this investigation. Briefly, the remedial solution adjusted the

JOE — Volume 38, Number 1, January 2012 Outcome of Endodontic Surgery with or without Higher Magnification 3
Meta-Analysis
individual success rates to 0.99 and computed the inverse variance from

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

the adjustment (107).

Prospective study with

Prospective study with

Prospective study with

Prospective case study
Prospective case study

Prospective case study

Prospective case study

Prospective case study

Prospective case study
concurrent controls

concurrent controls

concurrent controls
Study design Homogeneity analysis showed that within-group homogeneity was
achieved (Q[14] = 15.68, P = .333) with variance comprised from
EMS (Q[8] = 6.57, P = .584) and CRS (Q[6] = 9.11 , P = .167).
Between the groups, homogeneity was not achieved (Q[1] = 8.03,
P = .005). Therefore, a random-effects model was used for adjustment.
The standardized mean difference between the CRS and EMS was statis-
tically significant (z = 53.60, standard error = .0171, P < .0005). The
relative risk ratio indicated that the probability of success for EMS was
328.8693

579.1190
375.7457
716.4323

547.2289

424.5051

805.8018

252.5253
1729.7298

1021.4505

3034.6074

1179.0908

1625.2209

1221.0012

3238.7955
1270.933
Weight

1.07 times the probability of success for CRS. The odds ratio indicated
that EMS had 2.09 times the odds of success as did CRS (odds ratio =
2.09, 95% CI, 1.43–3.04). Chi-square analysis on the frequencies of
success and failures between the 2 groups indicated a significant differ-
Reported

rate (%)
success

91.2
92.5
75.4

89.0
91.3
90.6
80.5
96.8

88.9

89.8
92.9
93.2
94.9
91.0

95.2

100.0
ence (c21 = 15.19, P < .0005). The statistical power of the overall
investigation was estimated at 0.922 based on the 95% level of signifi-
cance.
Molars. A total of 6 records were included in the meta-analysis of
Failure
9
9
15

11
4
3
29
3

11
2
7
2
9

0 molar treatment success (Table 3). Success rates at the 12-month

examination for CRS and EMS were derived from the dataset. CRS
included 4 studies (n = 146) with a weighted pooled success rate of
Success
93
111
46

89
42
29
120
91

48

97
26
96
37
91

141

25

90.24% (95% CI, 0.8340–09709). EMS included 2 studies (n = 47)

with a weighted pooled success rate of 97.95% (95% CI, 0.8958–
1.0). Each of the 2 study groups had 1 study that included a success
MTA/IRM
Super EBA/
Root-end

Super EBA
Super EBA

Super EBA
Super EBA

Super EBA

Super EBA

Super EBA
Super EBA
Super EBA
Super EBA

rate of 100% (EMS: Taschieri, 2008 [21]; CRS: Taschieri, 2005

MTA/IRM

MTA/IRM
filling

[14]). The standard error for these 2 individual studies was zero.
MTA
IRM

IRM

Weights were calculated as the inverse variance; therefore, weights

for these studies were undefined. The situation was adjusted analog
to the solution that had been made to include Christiansen et al (23)
preparation
Ultrasonic
Ultrasonic
Ultrasonic

Ultrasonic
Ultrasonic
Ultrasonic
Ultrasonic
Ultrasonic

Ultrasonic

Ultrasonic
Ultrasonic

Ultrasonic
Ultrasonic
Ultrasonic
Ultrasonic

Ultrasonic
Root-end

in the overall comparison (107).

Within-group homogeneity was achieved (Q[4] = 6.69, P = .153)
with variance comprised from EMS (Q[1] = .07, P = .795) and CRS (Q
[3] = 6.62 , P = .085). Between-group homogeneity was also achieved
Magnification

(Q[1] = 1.95, P = .162). The standardized mean difference between

Loupes 4.0

Loupes 3.5
Loupes 4.3
Loupes 4.3

microscope
Microscope

Microscope

Endoscope/

Microscope

Microscope
Endoscope

Endoscope
Endoscope
Endoscope

the groups was statistically significant (z = 29.74, standard error =

.0313, P < .0005). The relative risk ratio indicated that the probability
None

None

None

of success for EMS was 1.09 times the probability of success for CRS.
The odds ratio indicated that EMS had 9.04 times the odds of success
as CRS (odds ratio = 9.04, 95% CI, 1.19–68.83). The Fisher exact
Follow-up
(months)
12–48

12–60

test showed that the differences in success and failure between the 2
36
12

12
12
12
14
14

12

24
12
12
12
24

12

groups were statistically significant (z = 3.85, P = .011). The statis-

tical power was estimated at 0.497 based on the 95% level of signifi-
cance.
Sample
size
102
120
61

100
46
32
149
94

54

108
28
103
39
100

148

25

Premolars. A total of 7 records were included in the meta-analysis of

premolar treatment success, and success rates were derived from the
dataset (Table 3). CRS included 4 studies (n = 110) with a weighted
Language

German

German
English
English
English

English
English
English
English
English

English
English

English
English

English

English

pooled success rate of 90.37% (95% CI, 0.8488–0.9586) and EMS 3

studies (n = 59) with a weighted pooled success rate of 94.6% (95%
TABLE 1. Studies Included in the Meta-analysis

CI, 0.8878–1.0).
Within-group homogeneity was validated (Q[5] = 6.5, P = .256)
Group

EMS

EMS

EMS
EMS
EMS
EMS
EMS

EMS

EMS

with variance comprised from EMS (Q[2] = 2.23, P = .329) and CRS
CRS
CRS
CRS

CRS
CRS
CRS
CRS

(Q[3] = 4.32, P = .229). Between-group homogeneity was not

achieved (Q[1] = 1.07, P = .301), and a random-effects model was
Christiansen et al, 2009 (23)
Maddalone et al, 2003 (11)

Lindeboom et al, 2005 (13)

used to assess the data. The standardized mean difference between

Taschlerl et al, 2005 (14)
Taschieri et al, 2006 (15)

Taschieri et al, 2005 (19)

Taschieri et al, 2008 (21)

Taschieri et al, 2006(15)
von Arx et al, 2003 (12)

the groups was statistically significant (z = 36.93, standard error =

MTA, mineral trioxide aggregate.
von Arxet al, 2003 (12)

Filippi et al, 2006 (20)

Lange et al, 2003 (16)

Chong et al, 2003(18)

Zuolo et al, 2000 (10)

Rubinstein and Kim,

.0248, P < .0005). The relative risk ratio indicated that the probability
Kim et al, 2008 (22)
Study

of success for EMS was 1.05 times the probability of success for CRS.
The odds ratio indicated that EMS had 1.57 times the odds as did
1999 (17)

CRS of success (1.57, 95% CI, 0.538–4.611). However, the CI for

the odds ratio included zero; therefore, it was determined that the
odds ratio result was not significant. Chi-square analysis on the

4 Setzer et al. JOE — Volume 38, Number 1, January 2012

 Meta-Analysis
TABLE 2. Excluded Studies with Reasons for Exclusion from the Meta-analysis TABLE 2. (Continued )
Exclusion Exclusion
Study Language criteria Study Language criteria
Saunders, 2008 (24) English 7, 8 Bumberger-Niesslbeck et al, German 1
Finne et al, 1979 (25) English 10 1987 (88)
von Arx et al, 2007 (26) English 6 Becker et al, 1987 (89) German 1
Hirsch et al, 1979 (27) English 10 Kopp et al, 1987 (90) German 1
Wesson and Gale, 2003 (28) English 4, 10 Lindemann et al, 1987 (91) German 1
Malmstro € m et al, 1983 (29) English 10 Cordes et al, 1987 (92) German 10
Oginni and Olusile, 2002 (30) English 2, 9 Geiger and Peuten, 1987 (93) German 1
von Arx et al, 2001 (31) English 8 Mohr et al, 1987 (94) German 10
Testori et al, 1999 (32) English 2, 9 Haas et al, 1995 (95) German 1
Sumi et al, 1996 (33) English 7, 8, 10 Ortega-Sanchez et al, 2009 (96) English 8, 10
Reinhart et al, 1995 (34) German 9, 10 Penarrocha et al, 2007 (97) English 8, 10
Cheung and Lam, 1993 (35) English 9, 10 Marti-Bowen et al, 2005 (98) Spanish, 8, 10
Lustmann et al, 1991 (36) English 2, 7, 9 English
Grung et al, 1990 (37) English 4, 10 Garcia et al, 2008 (99) English 8, 10
Berrone and Aimetti, 1989 (38) Italian 9, 10 Penarrocha et al, 2008 (100) English 10
Palattella et al, 1987 (39) Italian 1, 11 Rapp et al, 1991 (101) English 7, 10
loannides and Borstlap, 1983 (40) English 2, 7, 9, 10 Zetterqvist et al, 1991 (102) English 10
Harty et al, 1970 (41) English 2, 8–10 Pantschev et al, 1994 (103) English 10
Gagliani et al, 2005 (42) English 8 Jesslen et al, 1995 (104) English 10
Wang et al, 2004 (43) English 4, 8–10 August, 1996 (105) English 10
von Arx and Kurt, 1999 (44) English 8 Schwartz-Arad et al, 2003 (106) English 7, 10
Pecora and Adreana, 1993 (45) English 7, 10 von Arx et al, 2010 (7) English 6, 9
Ilgenstein and Ja € ger, 2006 (46) French, 1, 7, 11 Taschieri et al, 2010 (8) English 9
German Song et al, (9) English 6
Danin et al, 1996 (47) English 10
Rud et al, 1996 (48) English 10
Frank et al, 1992 (49) English 8, 9
Wang et al, 2004 (50) English 4, 9, 10 frequencies of success and failures between the 2 groups were not
Halse et al, 1991 (51) English 9, 10 significant (c21 = 0.70, P = .404). The statistical power was estimated
Rahbaran et al, 2001 (52) English 9, 10 to be at 0.08 based on the 95% level of significance.
Molven et al, 1996 (53) English 1, 12
Mikkonen et al, 1983 (54) English 10 Anteriors. A total of 7 records were included in the meta-analysis of
Carrillo et al, 2008 (55) English 2, 3, 9, 10 anterior treatment success (Table 3). Success rates were derived from
Kvist and Reit, 1999 (56) English 9, 10 the dataset, with CRS including 4 studies (n = 161) with a weighted
Allen et al, 1989 (57) English 7, 9, 10 pooled success rate of 92.41% (95% CI, 0.8833–0.9649) and EMS
Beckett and Briggs, 1995 (58) English 11
Pen~ arrocha et al, 2001 (59) English 10 including 3 studies (n = 116) with a weighted pooled success rate of
Marti et al, 2008 (60) English 10 94.52% (95% CI, 0.9041–0.9863).
Friedman et al, 1991 (61) English 7, 9, 10 Within-group homogeneity was achieved (Q[5] = 2.79, P = .732)
Lyons et al, 1995 (62) English 1, 2, 8, 10 with variance comprised from EMS (Q[2] = 1.884, P = .390) and CRS
Shearer and McManners, English 7, 8
2008 (63)
(Q[3] = 0.907, P = .824). Between-group homogeneity was also
Forssell et al, 1988 (64) English 7, 10 achieved (Q[1] = 0.509, P = .476). The standardized mean difference
Reit and Hirsch, 1986 (65) English 10 was statistically significant (z = 63.3, standard error =.0148, P <
Rubinstein and Kim, 2002 (17) English 12 .0005). The relative risk ratio indicated that the probability of success
Molven et al, 1991 (66) English 9, 10 for EMS was 1.01 times the probability of success for CRS. The odds
Vallecillo Capilla et al, 2002 (67) Spanish, 7, 8
English ratio showed that EMS had 1.19 times the odds of success as CRS
Dorn and Gartner, 1990 (68) English 7, 10 (odds ratio = 1.19, 95% CI, 0.48–2.96). Chi-square analysis showed
Wa €livaara et al, 2007 (69) English 3, 4 no statistically significant difference between EMS and CRS (c21 =
Luebke, 1974 (70) English 11 0.13, P = .715). The statistical power was estimated to be at 0.062
Andreasen et al, 1972 (71) English 8
Burke, 1979 (72) English 11
based on the 95% level of significance.
Jansson et al, 1997 (73) English 7, 8, 10
Block et al, 1976 (74) English 7–10
von Arx et al, 2007 (75)
Kimura, 1982 (76)
English
English
10
11
Discussion
Tay et al, 1978 (77) English 10, 12 Over the past decade, endodontic surgery has evolved into
Edmunds, 1979 (78) English 1, 11 endodontic microsurgery by the introduction of the surgical micro-
Altonen and Mattila, 1976 (79) English 9, 10 scope (45, 108–110) and/or the endoscope (111, 112). Although
Waikakul and Punwutikorn, English 7, 8, 10 the use of the surgical microscope in general dentistry is still
1991 (80)
Bader and Lejeune, 1998 (81) English 6
debated, its use for nonsurgical and surgical endodontics has
Nordenram and Sva € rdstrom, English 10 become a routine procedure for endodontists since the 1990s and
1970 (82) has been made a requirement for postgraduate education in the
Block et al, 1979 (83) English 8, 10 United States in 1998 (113). Based on a survey among active members
Andreasen and Rud, 1972 (84) English 8, 10 of the American Association of Endodontists in the United States, 52% of
Arwill et al, 1974 (85) English 8
Herzog et al, 1995 (86) German 8, 10 the endodontists who had been surveyed had had access to a dental
el-Swiah and Walker, 1996 (87) English 1, 11 operating microscope in 1999 (114). In 2008, a web-based survey
(Continued ) of these active members revealed that access and use of the microscope

JOE — Volume 38, Number 1, January 2012 Outcome of Endodontic Surgery with or without Higher Magnification 5
Meta-Analysis
TABLE 3. Studies Included in the Meta-analysis of Molar, Premolar, and Anterior Groups
Sample Molars Molars Premolars Premolars Anteriors Anteriors
Study Group size n/success success (%) n/success success (%) n/success success (%)
de Lange et al, 2003 (16) CRS 149 73/56 76.7* 48/39 81.3* 28/25 89.3*
Taschieri et al, 2005 (14) CRS 46 6/6 100.0* 8/7 87.5* 32/29 90.6*
Maddalone et al, 2003 (11) CRS 120 28/27 96.4* 30/27 90.0* 62/57 91.9*
Zuolo et al, 2000 (10) CRS 102 39/33 84.6* 24/23 95.8* 39/37 94.9*
Total 417 146/122 90.24* 110/96 90.37* 161/148 92.41*
Taschieri et al, 2008 (21) EMS 100 16/16 100.0* 22/19 86.4* 62/56 90.3*
Taschieri et al, 2005 (14) EMS 28 0/0 NA 6/5 83.3* 22/21 95.5*
Rubinstein and Kim, EMS 94 31/30 96.8* 31/30 96.8* 32/31 96.7*
1999 (17)
Total 222 47/46 97.95* 59/54 94.60* 116/108 94.52*
NA, not applicable.
*Weighted pooled success rate.

had increased to 90% (115). No data exist on the general distribution of study, von Arx et al (122) documented a significant difference between
the endoscope in dentistry or the specialty of endodontics. cases undergoing surgery with the use of the endoscope and without.
High magnification allows for better identification of isthmi or However, in this investigation, the results from studies that made use
accessory canals (116, 117) and enhances the visualization as well of the dental operating microscope, which allows for a similar magni-
as improves the management of anatomic aberrations, prior fication range as the endoscope, were not combined with the endo-
iatrogenic complications, fractures, or canal obstructions, such as scopic procedures nor were these studies separated from
separated instruments or calcifications (3). It was recommended to investigations that used no or only low-magnification devices, such as
help with the identification of dentinal cracks when the resected root loupes (122). Similarly, when prognostic data for endodontic surgery
surface is stained by dyes such as methyleneblue (3). It has been shown were reviewed in the past, results from cases treated by traditional tech-
in in vitro studies that the accuracy of identifying dentinal cracks on niques were frequently combined with results from studies in which
resected root surfaces was not significantly different between unaided patients underwent modern surgical procedures (123). This approach
observation and high magnification (35) without the use of dyes or is disregarding the effects that modern surgical techniques have on
transillumination (118). Von Arx et al (119) compared the observa- prognosis. Often, differences in techniques could not be or were not
tions of structures on resected root surfaces between an endoscope identified (4, 120, 124).
with an impression of the surface taken at the time of the procedure Based on the data presented in this meta-analysis, the suggestion
and observed under the scanning electron microscope. They concluded that magnification aides have no effect on the prognosis of endodontic
that the observation of a stained resected roots surface with high magni- surgery could be considered premature in the absence of large-scale
fications accurately identified isthmi, accessory canals, obturation gaps, randomized controlled trials. There is a high acceptance of the dental
and chipping of cavity margins but that there was a difference in operating microscope and endoscope in the endodontic community.
correctly identified intradentinal cracks. Besides a microscope and Nevertheless, based on the fact that no data were available in the liter-
endoscope, the use of ultrasonic tips and microinstruments as well ature, del Fabbro et al (125) could not find scientific evidence of
as more biologically acceptable root-end filling materials have changed a benefit using a microscope for endodontic treatment in general at
the technical approach significantly (3). that point in time. The authors of the review correctly stated that no
The weighted pooled success rates for TRS (59.0%) from the first objective conclusions could be drawn from the results of the review
part of this meta-analysis and EMS (93.5%) can be considered as a very because no articles were identified in the current literature that satisfied
low and a very high outcome for endodontic surgery, respectively. These their inclusion criteria, which pointed out the absence of and the need
cumulative success rates lie on 2 ends of the spectrum and do not reflect for well-controlled trials.
the outcome of surgical procedures in which microsurgical instruments The data obtained from this meta-analysis showed a weighted
and biocompatible filling materials were used, but no high-power pooled success rate of 88.09% after a 1-year follow-up for endodontic
magnification was applied. The influence of high-power magnification surgery with microsurgical instruments and biocompatible filling mate-
can be isolated by comparing EMS with CRS. EMS and CRS are defined rials with only loupes or no visualization aids (CRS) with a statistically
here as identical approaches to endodontic surgery, except that EMS significant difference to the weighted pooled success rate for
uses high-power magnification but CRS does not. Tsesis et al (4) pub- endodontic microsurgery with high-power magnification (EMS) of
lished a meta-analysis and systematic review on modern endodontic 93.52% after 1 year of follow-up. This is in contrast to a study by von
surgery that included studies that used modern techniques, such as Arx et al (12) who did not find statistically significant differences in
ultrasonic root-end preparation and modern filling materials, but did the outcome after 1-year follow-up for cases treated with the aid of
not identify significant differences in outcome between studies that the endoscope (94.5%) compared with control cases treated with the
made use of the microscope, endoscope, or loupes (4). Del Fabbro naked eye and micro-mirrors (88.5%). Similarly, del Fabbro and Ta-
et al (120) concluded that, based on 3 prospective studies on schieri (120) did not find that magnification affects the surgical prog-
endodontic surgery, no significant differences in outcome could be nosis positively. Their conclusion was based on 3 prospective studies on
found between surgery performed with loupes, microscope, or endo- endodontic surgery treated with loupes, microscope, or endoscope.
scope. Furthermore, although describing the benefits of the dental One of the 3 included studies (15) was an outcome comparison
operating microscope based on individual studies on endodontic between surgical cases treated with loupes and cases treated with the
surgery with high success rates (15, 17, 18), a review by Torabinejad endoscope, with nearly similar results for both groups. Both groups
et al (121) did not address cumulative success rates for endodontic were executed by the same surgeons. From a methodological point of
surgical procedures with or without high magnification. In a prospective view, it could be argued that the groups should have been treated by

6 Setzer et al. JOE — Volume 38, Number 1, January 2012

 Meta-Analysis

Figure 1. Weighted pooled success rates and individual study weights for groups CRS and EMS.

different practitioners. There may have been an adaptation phase after (127). The conclusive evaluation of the differences between EMS,
the treatment of cases with high magnification, for instance the antici- CRS, and TRS in this meta-analysis was based on contingency tables
pation of isthmi in typical clinical situations although not visible by and chi-square tests. Although statistically significant differences existed
loupes but suspected after the experience with the high-magnification for every group of teeth (ie, molars, premolars, and anteriors) over all
device. In contrast to the present meta-analysis, del Fabbro and Ta- groups (ie, EMS, CRS, and TRS) between the standardized means by
schieri (120) chose to include only randomized clinical trials. This is applying probits of probabilities and z scores, these were not used as
a methodological sound approach, yet it also shows the impact of they only apply for continuous data. A z score significance is based
sample size on statistical outcome. The sample sizes of the only studies on effect sizes differences only, which are based on successes percent-
that could be included in their systematic review and meta-analysis ac- ages, whereas contingency tables and chi-square tests take the percent-
cording to the inclusion and exclusion criteria were, as is the case for ages of failures into account as well because they relate more to
many clinical trials in dentistry, rather low. In the first of the included frequencies and proportions.
articles, the statistical evaluation was based on a sample size of 29 for The statistical power of the analyses according to individual tooth
the endoscope and 24 for loupes-aided surgery (15). The second groups in this part II of the study was low. Power is defined as the ability
article (21) was a comparison between the endoscope and microscope; of an analysis to indicate statistically significance that is truly in the data.
both seeing aids can provide greater than 10 magnification and hence Hulley and Cummings (128) discussed the importance of statistical
are comparable. Statistical calculations were run with 31 patients in the power to reach valid statistically significant conclusions. Therefore,
endoscope and 35 in the microscope group. The third study was by von for this investigation preference was given to a larger sample size
Arx et al (12) with 45 patients treated with the endoscope and 41 with even if the data were not derived from randomized clinical trials, in
the naked eye. With only limited available data at hand, the systematic lieu of an approach that uses only randomized clinical trials and neces-
review and meta-analysis had to conclude, that for endodontic surgery sarily relies on a smaller sample size (120, 125). In part I of
no significant difference in outcomes could be found between loupes, this meta-analysis, the overall statistical power was 1.0, the highest
microscope, or endoscope and that the type of magnification device per power achievable (100% power). The sample size for the study
se could only minimally affect the outcome of endodontic treatment (n = 1,624) and the difference between the weighted pooled success
(120). rates of TRS versus EMS (34.52%) were both large enough to achieve
The sample size being too small is a probable reason for data to be good power. The analysis of the overall comparison of the CRS versus
not statistically significantly different. The relative absence of large-scale EMS groups (n = 1,309, a difference in weighted pooled success rates
randomized controlled trials in endodontics is one difficulty in identi- of 5.43%), achieved an adequate power of 0.922. However, power was
fying ‘‘true’’ outcomes. Mead et al (126) investigated the quality of clin- considerably lower for the analyses on the 3 subgroupings of molars (n
ical investigations on the outcome of endodontic surgery and found no = 193, a difference in weighted pooled success rates of 7.71% with
level of evidence 1 randomized clinical trials and only 2 level of evidence a power of 0.497), premolars (n = 169, a difference in weighted
2 randomized clinical trials comparing the outcomes of surgical treat- pooled success rates of 4.23% with a power of 0.08), and anteriors
ment with that of nonsurgical retreatment. The remainder being level of (n = 277, a difference in weighted pooled success rates of 2.11%
evidence 3 case control studies and a majority of level of evidence 4 low- with a power of 0.06). Although the power for the molars only analysis
quality cohort or case series investigations (126). According to the was considerably lower than for the overall comparison, the larger
methodology of part 1 of this meta-analysis (2), the aim of this investi- difference in the pooled success rates of CRS versus EMS for molars
gation was to provide the best available evidence in the absence of large- (7.71%) could still be detected as statistically significant. The premolar
scale randomized controlled trials by calculation from extracted raw and anterior differences in weighted pooled success rates were less
data from all available publications that fit the inclusion and exclusion than 5%, and, therefore, the sample size was not adequate to power
criteria of this systematic review, following the example of Ng et al these 2 analyses.

JOE — Volume 38, Number 1, January 2012 Outcome of Endodontic Surgery with or without Higher Magnification 7
Meta-Analysis
From a clinical point of view, the increasing difficulty in anatomy 13. Lindeboom JA, Frenken JW, Kroon FH, van den Akker HP. A comparative prospec-
with molars over premolars and anteriors could be a logical explana- tive 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
tion for a statistically significant difference between the use of micro- Radiol Endod 2005;100:495–500.
scope or endoscope versus the naked eye or loupes. Although certain 14. Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery
premolars or anteriors may present with complex anatomy, such as with ultrasonic retrotips: one-year follow-up. Oral Surg Oral Med Oral Pathol Oral
canal isthmi or additional canals, the proportions of these findings Radiol Endod 2005;100:380–7.
are much higher in molars. Therefore, the majority of cases with 15. Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery
using 2 different magnification devices: preliminary results of a randomized
simpler anatomy may mask any significant effects of higher magnifica- controlled study. J Oral Maxillofac Surg 2006;64:235–42.
tion on the treatment of the respective groups at large. To show a statis- 16. de Lange J, Putters T, Bass EM, van Ingen JM. Ultrasonic root-end preparation in
tically significant difference at a 90% statistical power confidence level apical surgery: a prospective randomized study. Oral Surg Oral Med Oral Pathol
between 2 groups with a difference in outcome of 10%, comparable to Oral Radiol Endod 2007;104:841–5.
17. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year
the premolar group, a sample size of 266 cases per group would be after apical microsurgery. J Endod 2002;28:378–83.
necessary (128). The raw data extraction across different studies for 18. Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of Mineral
the purpose of a meta-analysis allowed for a sample size large enough Trioxide Aggregate and IRM when used as root-end filling materials in endodontic
to show statistically significant differences between cumulative success surgery. Int Endod J 2003;36:520–6.
rates as close as the difference between EMS and CRS with statistical 19. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Endoscopic periradicular
surgery: a prospective clinical study. Br J Oral Maxillofac Surg 2007;45:242–4.
validity. 20. Filippi A, Meier ML, Lambrecht JT. Periradicular surgery with endoscopy—a clin-
In conclusion, based on the data presented in this meta-analysis, ical prospective study. Schweiz Monatsschr Zahnmed 2006;116:12–7.
the probability for success for EMS was significantly greater than the 21. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Microscope versus endoscope
probability for success for CRS (P < .0005). The treatment of molars in root-end management: a randomized controlled study. Int J Oral Maxillofac Surg
2008;37:1022–6.
with the microscope or the endoscope seems to be of advantage over 22. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating
treatments without higher magnification. This provided the best avail- endodontic microsurgery outcomes for cases with lesions of endodontic origin
able evidence on the influence of high-power magnification provided compared with cases with lesions of combined periodontal-endodontic origin.
by the dental operating microscope or the endoscope and the superi- J Endod 2008;34:546–51.
ority of endodontic microsurgery over contemporary endodontic 23. Christiansen R, Kirkevang LL, Hørsted-Bindslev P, Wenzel A. Randomized clinical
trial of root-end resection followed by root-end filling with mineral trioxide aggre-
surgery with no or low magnification. The results from this study also gate or smoothing of the orthograde gutta-percha root filling—1-year follow-up.
showed the necessity for large-scale randomized clinical trials for statis- Int Endod J 2009;42:105–14.
tically valid conclusions for current endodontic questions to make an 24. Saunders WP. A prospective clinical study of periradicular surgery using mineral
informed decision for clinical practice. trioxide aggregate as a root-end filling. J Endod 2008;34:660–5.
25. Finne, Nord, Persson, Lennartsson. Retrograde root filling with amalgam and cavit.
Oral Surg Oral Med Oral Pathol 1977;43:621–6.
Acknowledgment 26. von Arx T, Jensen SS, H€anni S. Clinical and radiographic assessment of various
predictors for healing outcome 1 year after periapical surgery. J Endod 2007;
The authors would like to thank Elaine Bellucci, Statistician, 33:123–8.
Murrieta, California, for the conduction of the statistical analyses 27. Hirsch JM, Ahlstr€om U, Henrikson PA, Heyden G, Peterson LE. Periapical surgery.
presented in this review. Int J Oral Surg 1979;8:173–85.
28. Wesson CM, Gale TM. Molar apicectomy with amalgam root-end filling: results of
a prospective study in two district general hospitals. Br Dent J 2003;195:
References 707–14.
1. Karabucak B, Setzer F. Criteria for the ideal treatment option for failed endodon- 29. Malmstr€om M, Perkki K, Lindquist K. Apicectomy: a retrospective study. Proc Finn
tics: surgical or nonsurgical? Compend Contin Educ Dent 2007;28:391–7. Dent Soc 1982;78:26–31.
2. Setzer FC, Shah S, Kohli M, Karabucak B, Kim S. Outcome of endodontic surgery: 30. Oginni AO, Olusile AO. Follow-up study of apicectomised anterior teeth. SADJ
a meta-analysis of the literature—part 1: comparison of traditional root-end 2002;57:136–40.
surgery and endodontic microsurgery. J Endod 2010;36:1757–65. 31. von Arx T, Gerber C, Hardt N. Periradicular surgery of molars: a prospective clin-
3. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. ical study with a one-year follow-up. Int Endod J 2001;34:520–5.
J Endod 2006;32:601–23. 32. Testori T, Capelli M, Milani S, Weinstein RL. Success and failure in periradicular
4. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment surgery: a longitudinal retrospective analysis. Oral Surg Oral Med Oral Pathol Oral
performed by a modern technique: a meta-analysis of literature. J Endod 2009;35: Radiol Endod 1999;87:493–8.
1505–11. 33. Sumi Y, Hattori H, Hayashi K, Ueda M. Ultrasonic root-end preparation: clinical
5. Rud J, Andreasen JO, Jensen JE. Radiographic criteria for the assessment of heal- and radiographic evaluation of results. J Oral Maxillofac Surg 1996;54:590–3.
ing after endodontic surgery. Int J Oral Surg 1972;1:195–214. 34. Reinhart E, Reuther J, Bleym€uller W, Ordung R, K€ubler N, Pistner H. Comparative
6. Molven O, Halse A, Grung B. Observer strategy and the radiographic classification studies with apicoectomy using various surgical techniques and filling materials.
of healing after endodontic surgery. Int J Oral Maxillofac Surg 1987;16:432–9. Fortschr Kiefer Gesichtschir 1995;40:152–6.
7. von Arx T, H€anni S, Jensen SS. Clinical results with two different methods of root- 35. Cheung LK, Lam J. Apicectomy of posterior teeth: a clinical study. Aust Dent J 1993;
end preparation and filling in apical surgery: mineral trioxide aggregate and adhe- 38:17–21.
sive resin composite. J Endod 2010;36:1122–9. 36. Lustmann J, Friedman S, Shaharabany V. Relation of pre- and intraoperative factors
8. Taschieri S, Machtou P, Rosano G, Weinstein T, Del Fabbro M. The influence of to prognosis of posterior apical surgery. J Endod 1991;17:239–41.
previous non-surgical re-treatment on the outcome of endodontic surgery. 37. Grung B, Molven O, Halse A. Periapical surgery in a Norwegian county hospital:
Minerva Stomatol 2010;59:625–32. follow-up findings of 477 teeth. J Endod 1990;16:411–7.
9. Song M, Shin SJ, Kim E. Outcomes of endodontic micro-resurgery: a prospective 38. Berrone S, Aimetti M. Apicoectomy: comparison between 2 case series. Minerva
clinical study. J Endod 2011;37:316–20. Stomatol 1989;38:291–4.
10. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical 39. Palattella G, Carnesecchi R, Mangani F, Palattella P, De Luca M. 3-dimensional
prospective study. Int Endod J 2000;33:91–8. closure of the root canal as a prerequisite for success in periapical surgery.
11. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year follow-up study. Dent Cadmos 1987;55:75–80. 83–9.
Int Endod J 2003;36:193–8. 40. Ioannides C, Borstlap WA. Apicoectomy on molar: a clinical and radiographical
12. von Arx T, Frei C, Bornstein MM. Periradicular surgery with and without endos- study. Int J Oral Surg 1983;12:73–9.
copy: a prospective clinical comparative study. Schweiz Monatsschr Zahnmed 41. Harty FJ, Parkins BJ, Wengraf AM. The success rate of apicectomy. A retrospective
2003;113:860–5. study of 1,016 cases. Br Dent J 1970;129:407–13.

8 Setzer et al. JOE — Volume 38, Number 1, January 2012

 Meta-Analysis
42. Gagliani MM, Gorni FG, Strohmenger L. Periapical resurgery versus periapical 74. Block RM, Bushell A, Rodrigues H, Langeland K. A histopathologic, histobacterio-
surgery: a 5-year longitudinal comparison. Int Endod J 2005;38:320–7. logic, and radiographic study of periapical endodontic surgical specimens. Oral
43. Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics: the Tor- Surg Oral Med Oral Pathol 1976;42:656–78.
onto Study -phases I and II: apical surgery. J Endod 2004;30:751–61. 75. von Arx T, H€anni S, Jensen SS. Correlation of bone defect dimensions with healing
44. von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type outcome one year after apical surgery. J Endod 2007;33:1044–8.
of sonic and diamond-surfaced retrotip: a 1-year follow-up study. J Oral Maxillofac 76. Kimura JT. A comparative analysis of zinc and nonzinc alloys used in retrograde
Surg 1999;57:656–61. endodontic surgery. Part 2: optical emission spectrographic analysis for zinc
45. Pecora G, Andreana S. Use of dental operating microscope in endodontic surgery. precipitation. J Endod 1982;8:407–9.
Oral Surg Oral Med Oral Pathol 1993;75:751–8. 77. Tay WM, Gale KM, Harty FJ. The influence of periapical radiolucencies on the
46. Ilgenstein B, J€ager K. Micro Apical Placement System (MAPS): a new instrument for success or failure of apicectomies. J Br Endod Soc 1978;11:3–6.
retrograde root filling. Schweiz Monatsschr Zahnmed 2006;116:1243–56. 78. Edmunds DH. Surgical endodontics. J Br Endod Soc 1979;12:73–81.
47. Danin J, Stromberg T, Forsgren H, Linder LE, Ramskold LO. Clinical management 79. Altonen M, Mattila K. Follow-up study of apicoectomized molars. Int J Oral Surg
of nonhealing periradicular pathosis: surgery versus endodontic retreatment. Oral 1976;5:33–40.
Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:213–7. 80. Waikakul A, Punwutikorn J. Clinical study of retrograde filling with gold leaf:
48. Rud J, Rud V, Munksgaard EC. Long-term evaluation of retrograde root filling with comparison with amalgam. Oral Surg Oral Med Oral Pathol 1991;71:228–31.
dentin-bonded resin composite. J Endod 1996;22:90–3. 81. Bader G, Lejeune S. Prospective study of two retrograde endodontic apical prep-
49. Frank AL, Glick DH, Patterson SS, Weine FS. Long-term evaluation of surgically arations with and without the use of CO2 laser. Endod Dent Traumatol 1998;14:
placed amalgam filling. J Endod 1992;18:391–8. 75–8.
50. Wang Q, Cheung GS, Ng RP. Survival of surgical endodontic treatment performed in 82. Nordenram A, Sv€ardstr€om G. Results of apicectomy. Sven Tandlak Tidskr 1970;63:
a dental teaching hospital: a cohort study. Int Endod J 2004;37:764–75. 593–604.
51. Halse A, Molven O, Grung B. Follow-up after periapical surgery: the value of the 83. Block RM, Bushell A, Grossman LI, Langeland K. Endodontic surgical re-treatment:
one year control. Endod Dent Traumatol 1991;7:246–50. a clinical and histopathologic study. J Endod 1979;5:101–15.
52. Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical 84. Andreasen JO, Rud J. Modes of healing histologically after endodontic surgery in
outcome of periapical surgery in endodontic and oral surgery units of a teaching 70 cases. Int J Oral Surg 1972;1:148–60.
dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 85. Arwill T, Persson G, Thilander H. The microscopic appearance of the periapical
Endod 2001;91:700–9. tissue in cases classified as "uncertain" or "unsuccessful" after apicectomy. Odon-
53. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical tol Revy 1974;25:27–42.
surgery: radiographic findings 8 to 12 years after treatment. J Endod 1996;22: 86. Herzog U, Wilksch A, Haesen Y, Gundlach KK. Results of follow-up after apicoec-
264–8. tomy with 2 different root canal filling materials. Fortschr Kiefer Gesichtschir 1995;
54. Mikkonen M, Kullaa-Mikkonen A, Kotilainen R. Clinical and radiologic re- 40:150–2.
examination of apicoectomized teeth. Oral Surg Oral Med Oral Pathol 1983;55: 87. el-Swiah JM, Walker RT. Reasons for apicectomies: a retrospective study. Endod
302–6. Dent Traumatol 1996;12:185–91.
55. Carrillo C, Pe~narrocha M, Bagan JV, Vera F. Relationship between histological diag- 88. Bumberger-Niesslbeck U, Kunde V, Hoffmeister B. Statistical survey of 9446 api-
nosis and evolution of 70 periapical lesions at 12 months, treated by periapical coectomies. Dtsch Zahnarztl Z 1987;42:224–5.
surgery. J Oral Maxillofac Surg 2008;66:1606–9. 89. Becker S, Tetsch P, Karcher R, Trippler S. Dtsch Zahnarztl Z. Statistical analysis of
56. Kvist T, Reit C. Results of endodontic retreatment: a randomized clinical study 9000 apicoectomies: technical changes in intraoperative root filling. Dtsch Zah-
comparing surgical and nonsurgical procedures. J Endod 1999;25:814–7. narztl Z 1987;42:226–7.
57. Allen RK, Newton CW, Brown CE Jr. A statistical analysis of surgical and nonsurgical 90. Kopp S, Hoffmeister B, Bumberger U. Complications and failures of apicoectomy:
endodontic retreatment cases. J Endod 1989;15:261–6. an analysis of 3281 cases. Dtsch Zahnarztl Z 1987;42:228–30.
58. Beckett H, Briggs P. A 5 year audit of outcome of apicectomies carried out in 91. Lindemann U, Kopp S, Hoffmeister B. The results of preoperative and intraoper-
a district genral hospital. Ann R Coll Surg Engl 1995;77:465. ative root canal filling during apicoectomy in comparison. Dtsch Zahnarztl Z
59. Pe~narrocha Diago M, Sanchis Bielsa JM, Gay Escoda C. Periapical surgery of 31 1987;42:245–7.
lower molars based on the ultrasound technique and retrograde filling with silver 92. Cordes V, Schubert H, Bier J. Apicoectomy of molars with surgical root filling using
amalgam. Med Oral 2001;6:376–82. titanium: techniques, clinical and radiographic results. Dtsch Zahnarztl Z 1987;42:
60. Martı E, Pe~narrocha M, Garcıa B, Martınez JM, Gay-Escoda C. Distance between 262–4.
periapical lesion and mandibular canal as a factor in periapical surgery in mandib- 93. Geiger SA, Peuten M. Apicoectomy in maxillary molar teeth: postoperative findings
ular molars. J Oral Maxillofac Surg 2008;66:2461–6. in the bone and maxillary sinus. Dtsch Zahnarztl Z 1987;42:268–70.
61. Friedman S, Lustmann J, Shaharabany V. Treatment results of apical surgery in 94. Mohr P, Tetsch P, Schaudig D. Long-term results of apicoectomies with intraoper-
premolar and molar teeth. J Endod 1991;17:30–3. ative apical silver cone fillings. Dtsch Zahnarztl Z 1987;42:274–6.
62. Lyons AJ, Hughes CE, Dixon EJ. A 5-year audit of outcome of apicectomies carried 95. Haas R, Mensdorff-Pouilly N, Riegler-Thornton B, Watzek G, Mailath-Pokorny G.
out in a district general hospital. Ann R Coll Surg Engl 1995;77:273–7. Advantages of microsurgical apicoectomy and retro-preparation with ultrasound
63. Shearer J, McManners J. Comparison between the use of an ultrasonic tip and a mi- compared with current apicoectomy. Fortschr Kiefer Gesichtschir 1995;40:
crohead handpiece in periradicular surgery: a prospective randomised trial. Br J 156–9.
Oral Maxillofac Surg 2009;47:386–8. 96. Ortega-Sanchez B, Pe~narrocha-Diago M, Rubio-Martınez LA, Vera-Sempere JF.
64. Forssell H, Tammisalo T, Forssell K. A follow-up study of apicectomized teeth. Proc Radiographic morphometric study of 37 periapical lesions in 30 patients: valida-
Finn Dent Soc 1998;84:85–93. tion of success criteria. J Oral Maxillofac Surg 2009;67:846–9.
65. Reit C, Hirsch J. Surgical endodontic retreatment. Int Endod J 1986;19:107–12. 97. Pe~narrocha M, Martı E, Garcıa B, Gay C. Relationship of periapical lesion radio-
66. Molven O, Halse A, Grung B. Surgical management of endodontic failures: indica- logic size, apical resection, and retrograde filling with the prognosis of periapical
tions and treatment results. Int Dent J 1991;41:33–42. surgery. J Oral Maxillofac Surg 2007;65:1526–9.
67. Vallecillo Capilla M, Munoz Soto E, Reyes Botella C, Prados Sachez E, Olmedo 98. Martı-Bowen E, Pe~narrocha-Diago M, Garcıa-Mira B. Periapical surgery using
Gaya MV. Periapical surgery of 29 teeth: a comparison of conventional technique, the ultrasound technique and silver amalgam retrograde filling: a study of
microsaw and ultrasound. Med Oral 2002;7:46–9. 71 teeth with 100 canals. Med Oral Patol Oral Cir Bucal 2005;10(suppl 1):
68. Dorn SO, Gartner AH. Retrograde filling materials: a retrospective success-failure E67–73.
study of amalgam, EBA, and IRM. J Endod 1990;16:391–3. 99. Garcia B, Penarrocha M, Martı E, Martınez JM, Gay-Escoda C. Periapical
69. W€alivaara DA, Abrahamsson P, Isaksson S, Blomqvist JE, Samfors KA. Prospective surgery in maxillary premolars and molars: analysis in terms of the distance
study of periapically infected teeth treated with periapical surgery including ultra- between the lesion and the maxillary sinus. J Oral Maxillofac Surg 2008;66:
sonic preparation and retrograde intermediate restorative material root-end fill- 1212–7.
ings. J Oral Maxillofac Surg 2007;65:931–5. 100. Pe~narrocha Diago M, Ortega Sanchez B, Garcıa Mira B, Martı-Bowen E, von Arx T,
70. Luebke RG. Surgical endodontics. Dent Clin North Am 1974;18:379–91. Gay Escoda C. Evaluation of healing criteria for success after periapical surgery.
71. Andreasen JO, Rud J. Correlation between histology and radiography in the assess- Med Oral Patol Oral Cir Bucal 2008;13:E143–7.
ment of healing after endodontic surgery. Int J Oral Surg 1972;1:161–73. 101. Rapp EL, Brown CE Jr, Newton CW. An analysis of success and failure of apicoec-
72. Burke IT. Retro root filling. Oral Surg Oral Med Oral Pathol 1979;48:254–5. tomies. J Endod 1991;17:508–12.
73. Jansson L, Sandstedt P, Laftman AC, Skoglund A. Relationship between apical and 102. Zetterqvist L, Hall G, Holmlund A. Apicectomy: a comparative clinical study of
marginal healing in periradicular surgery. Oral Surg Oral Med Oral Pathol Oral amalgam and glass ionomer cement as apical sealants. Oral Surg Oral Med Oral
Radiol Endod 1997;83:596–601. Pathol 1991;71:489–91.

JOE — Volume 38, Number 1, January 2012 Outcome of Endodontic Surgery with or without Higher Magnification 9
Meta-Analysis
103. Pantschev A, Carlsson AP, Andersson L. Retrograde root filling with EBA cement or 116. Weller RN, Niemczyk SP, Kim S. Incidence and position of the canal isthmus. Part 1.
amalgam: a comparative clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Mesiobuccal root of the maxillary first molar. J Endod 1995;21:380–3.
Endod 1994;78:101–4. 117. von Arx T. Frequency and type of canal isthmuses in first molars detected by
104. Jesslen P, Zetterqvist L, Heimdahl A. Long-term results of amalgam versus glass ion- endoscopic inspection during periradicular surgery. Int Endod J 2005;38:
omer cement as apical sealant after apicectomy. Oral Surg Oral Med Oral Pathol 160–8.
Oral Radiol Endod 1995;79:101–3. 118. Slaton CC, Loushine RJ, Weller RN, Parker MH, Kimbrough WF, Pashley DH. Iden-
105. August DS. Long-term, postsurgical results on teeth with periapical radiolucencies. tification of resected root-end dentinal cracks: a comparative study of visual magni-
J Endod 1996;22:380–3. fication. J Endod 2003;29:519–22.
106. Schwartz-Arad D, Yarom N, Lustig JP, Kaffe I. A retrospective radiographic study of 119. von Arx T, Montagne D, Zwinggi C, Lussi A. Diagnostic accuracy of endoscopy in
root-end surgery with amalgam and intermediate restorative material. Oral Surg periradicular surgery—a comparison with scanning electron microscopy. Int En-
Oral Med Oral Pathol Oral Radiol Endod 2003;96:472–7. dod J 2003;36:691–9.
107. Carter RE, Lipsitz SR, Tilley BS. Quasi-likelihood estimation for relative risk regres- 120. Del Fabbro M, Taschieri S. Endodontic therapy using magnification devices:
sion models. Biostatistics 2005;1:39–44. a systematic review. J Dent 2010;38:269–75.
108. Rubinstein R. The anatomy of the surgical operating microscope and operating 121. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical re-
positions. Dent Clin North Am 1997;41:391–413. treatment and endodontic surgery: a systematic review. J Endod 2009;35:930–7.
109. Kim S. Principles of endodontic microsurgery. Dent Clin North Am 1997;41:481–97. 122. von Arx T, Pe~narrocha M, Jensen S. Prognostic factors in apical surgery with root-
110. Khayat BG. The use of magnification in endodontic therapy: the operating micro- end filling: a meta-analysis. J Endod 2010;36:957–73.
scope. Pract Periodontics Aesthet Dent 1998;10:137–44. 123. Friedman S. The prognosis and expected outcome of apical surgery. Endod Topics
111. Bahcall JK, DiFiore PM, Poulakidas TK. An endoscopic technique for endodontic 2005;11:219–62.
surgery. J Endod 1999;25:132–5. 124. Rud J, Andreasen JO, M€oller Jensen JE. A follow-up study of 1,000 cases treated by
112. von Arx T, Hunenbart S, Buser D. Endoscope- and video-assisted endodontic endodontic surgery. Int J Oral Surg 1972;1:215–28.
surgery. Quintessence Int 2002;33:255–9. 125. Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein RL. Magnification devices for
113. Commission on Dental Accreditation. Accreditation Standards for Advanced endodontic therapy. Cochrane Database Syst Rev 2009;8:CD005969.
Specialty Education Programs in Endodontics. American Dental Association, Chi- 126. Mead C, Javidan-Nejad S, Mego ME, Nash B, Torabinejad M. Levels of evidence for
cago, 2008. Available at http://www.ada.org/sections/educationAndCareers/pdfs/ the outcome of endodontic surgery. J Endod 2005;31:19–24.
endo.pdf. Accessed November 8, 2011. 127. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal
114. Mines P, Loushine RJ, West LA, Liewehr FR, Zadinsky JR. Use of the microscope in treatment: systematic review of the literature—part 1. Effects of study characteris-
endodontics: a report based on a questionnaire. J Endod 1999;25:755–8. tics on probability of success. Int Endod J 2007;40:921–39.
115. Kersten DD, Mines P, Sweet M. Use of the microscope in endodontics: results of 128. Hulley SB, Cummings SR. Designing Clinical Research: An Epidemiologic
a questionnaire. J Endod 2008;34:804–7. Approach. Baltimore, MD: Williams & Wilkins; 1988.

10 Setzer et al. JOE — Volume 38, Number 1, January 2012