ORIGINAL ARTICLE

Traditional Endodontic Surgery Versus Modern

Technique: A 5-Year Controlled Clinical Trial
Silvia Tortorici, MD,* Paolo Difalco, DDS, PhD,* Luigi Caradonna, MD,* and Stefano Tete`, MD
Abstract: In this study, we compared outcomes of traditional
apicoectomy versus modern apicoectomy, by means of a controlled
clinical trial with a 5-year follow-up. The study investigated 938
teeth in 843 patients. On the basis of the procedure performed, the
teeth were grouped in 3 groups. Differences between the groups were
the method of osteotomy (type of instruments used), type of preparation of retrograde cavity (different apicoectomy angles and instruments used for root-end preparation), and root-end filling
material used (gray mineral trioxide aggregate or silver amalgam).
Outcome (tooth healing) was estimated after 1 and 5 years,
postoperatively. Clinical success rates after 1 year were 67% (306
teeth), 90% (186 teeth), and 94% (256 teeth) according to traditional
apicoectomy (group 1), modern microsurgical apicoectomy using
burns for osteotomy (group 2) or using piezo-osteotomy (group 3),
respectively. After 1 year, group comparison results were statistically
significant (P G 0.0001). Linear trend test was also statistically
significant (P G 0.0001), pointing out larger healing from group 1 to
group 3. After 5 years, teeth were classified into 2 groups on the basis
of root-end filling material used. Clinical success was 90.8% (197
teeth) in the silver amalgam group versus 96% (309 teeth) in the
mineral trioxide aggregate group (P G 0.00214). Multiple logistic
regression analysis found that surgical technique was independently
associated to tooth healing. In conclusion, modern apicoectomy
resulted in a probability of success more than 5 times higher (odds
ratio, 5.20 [95% confidence interval, 3.94Y6.92]; P G 0.001) compared with the traditional technique.
Key Words: Endodontic surgery, MTA, amalgam, prognosis,
statistics
(J Craniofac Surg 2014;25: 804Y807)

eriapical surgery, endodontic surgery, or apicoectomy is indicated when conservative endodontic treatment proves to be unsuccessful, nonsurgical endodontic retreatment is impractical, or
when a biopsy is to be obtained.1Y3 Apicoectomy involves resection

From the *Department of Stomatological Science, University of Palermo,

Palermo; and Department of Medical, Oral and Biotecnological Sciences, University of Chieti-Pescara, Chieti, Italy.
Received April 30, 2013.
Accepted for publication August 26, 2013.
Address correspondence and reprint requests to Paolo Difalco, DDS, PhD,
Department of Stomatological Science, University of Palermo, Palermo,
Via Pergusa,75, 92020, Palma di Montechiaro (Ag), Italy; E-mail:
paolodifalco@tin.it
The authors report no conflicts of interest.
Copyright * 2014 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000000398

804

of the root end (apex), followed by removal of the diseased periapical

tissues and then sealing of the pulp canal system to remove any
communication between the oral cavity and the periapical tissues.4
Periapical surgery is carried out using 2 surgical procedures: traditional and modern. The traditional endodontic surgical procedure
involved the use of burs and a slow-speed, straight handpiece with
sterile coolant for osteotomy and periapical amputation.3,5 Although
the hope is always to preserve as much tooth substance as possible, a
steep angle of resection (45 degrees to the long axis of the root on
average) is often necessitated to allow access for root-end cavity
preparation and filling with silver amalgam (SA).5 Regarding the
amount of apical resection, the literature consulted recommends an
apical resection of 3 mm in length with respect to the long axis of the
root.5 By contrast, modern endodontic surgery allows a more precise
procedure with no or minimal bevel of root-end resection, as well as a
biocompatible root-end filling material (such as ethoxybenzoate
cement or mineral trioxide aggregate [MTA]).5 It is a microsurgical
technique that uses magnification devices (loupes, surgical microscope, or endoscope), microinstruments for osteotomy, and root-end
preparation (microburs or tips). The goal of endodontic surgery is to
facilitate the regeneration of hard and soft tissues, including the
formation of a new attachment apparatus.6 Unfortunately, both traditional and modern surgical endodontic techniques have a different
model of healing. According to previously reported models for
healing after periapical surgery, we adopted the following classifications: complete healing, partial healing (incomplete healing),
uncertain healing, and no healing (or failure).7Y9 Several factors
influenced the type of healing, but surgical technique and root-end
filling material used are the most important. In the current study,
we performed endodontic surgery, using both traditional and modern
techniques. The study also compared 2 different materials used as
root-end filling: SA and MTA. In addition, we studied the outcomes
of 2 different methods for osteotomy used with modern technique:
osteotomy carried out with burs and a slow-speed, straight handpiece
and osteotomy performed with piezoelectric devices.

MATERIALS AND METHODS

We undertook a retrospective review of surgical records
(clinical charts, biologic tests, and radiologic investigations) held by
the Department of Stomatological Science of the University of
Palermo and identified all patients with periapical lesions of teeth
who had undergone periapical surgery and retrograde endodontic
treatment between 1985 and 2005.
A patient was considered eligible for the study if the records
had included a preoperative imaging of the lesion (intraoral
periapical radiographs, or computed tomography), the date of the
surgical treatment, a careful description of the periapical surgery
method, follow-up records with radiographic examination (intraoral
periapical radiographs), and a follow-up duration of 5 years.
Exclusion criteria were (1) unsatisfactory orthograde root
filling, determined radiographically (short or insufficient condensation); and (2) teeth with advanced periodontal disease (93-mm
pocket depth) or if the marginal bone level was entered as zero.

The Journal of Craniofacial Surgery

& Volume 25, Number 3, May 2014

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 25, Number 3, May 2014

According to these criteria, we included in the study 843

patients who had undergone periapical surgery, comprising 670 teeth
with periapical lesions in the maxillary bone (347 in women and 323
in men) and 268 teeth with radicular lesions in the mandible (48 in
women and 220 in men). The following variables were extracted by
consulting the medical records: the age and sex of the patients and the
number and anatomic location of radicular lesions. The radiological
findings were noted. A single surgical team, including 2 endodontists
and 2 oral surgeons, all with more than 10 years of experience,
performed all the periapical surgery. The technical aspects of curettage and root-end sealing were similar for all the operators. Each
treatment was performed under local anesthesia (mepivacaine, 2%
with epinephrine), after disinfection of the mouth using 0.2%
chlorhexidine. All operators used a trapezoidal flap. We used traditional technique of apicoectomy and retrograde obturation with SA
(without zinc nonYgamma-2) until 1993; after this date, we
performed apicoectomy with modern techniques, using MTA
(ProRoot [gray]; Dentsply Tulsa Dental, Johnson City, TN) as rootend filling material. We grouped the patients on the basis of the
procedure performed. Differences between the groups were the
method of osteotomy, type of preparation of retrograde cavity, and
root-end filling material used. The first group included 393 patients
(205 male and 193 female patients), who were operated on with traditional techniques, performing osteotomy and apicoectomy with a
low-speed dental handpiece (Kavo Dentale Medizinische Instrumente
Vertriebsgesellschaft m.b.h., Biberach, Riss, Germany), root-end resection with a 45-degree bevel, and root-end preparation with traditional burs (Dentsply Maillefer, Ballaigues, Switzerland).
Silver amalgam was the root-end filling material for this
group. The second group comprised 195 patients (116 male and 79
female patients) who were operated on with surgical endodontic
techniques, using a surgical microscope, osteotomy, and apicoectomy
with a low-speed dental handpiece, root-end resection with a 90degree bevel, root-end preparation with an ultrasonic source, and
retroangled, diamond-surfaced tips (EMS Silver Amalgam G.H.,
Nyon, Switzerland); then, the root canals were filled, using MTA. The
255 patients of the third group (142 male and 113 female patients)
were treated like the first group, but using piezoelectric devices for
both osteotomy and apicoectomy. After periapical surgery, each flap
was closed with a 4-0 silk suture, and hemostasis was obtained. The
patients were followed up after 15 days, 4 months, 6 months, 1 year,
and 5 years, with evaluation of certain criteria for success. According
to previously reported models for healing after periapical surgery, we
adopted the following classifications: complete healing, partial
healing (incomplete healing), uncertain healing, and no healing (or
failure). We classified apicoectomy as successful or complete healing
when patients showed a complete root canal filling and had bony
regeneration, as well as the absence of signs and symptoms such as
mobility, pain, and swelling. Intraoral periapical radiographs were
used to evaluate whether a root canal filling was satisfactory. Bony
regeneration was defined as the increase in radiopacity of the bone
around the apex of the root in the postoperative radiographs. By
contrast, apicoectomy was considered to be a failure when subjects
showed postoperative signs and symptoms, such as pain, gingival
swelling, mobility, hypersensitivity, tenderness on percussion, and
tenderness on palpation on the crown and/or in the apical area;
inability to masticate with the tooth; and the presence of fistula. The
radiological parameters of failure were an inadequate retrograde root
filling and no changes or increases of bony rarefaction around
the apex of the root. Consequentially, we classified healing as partial when patients had a complete root canal filling and absence
of symptoms, but their intraoral periapical radiographs showed
periapical radiotransparency smaller than that before the intervention.
By contrast, healing was considered to be uncertain when the tooth
had a complete root canal filling and absence of symptoms, and

Traditional vs Modern Endodontic Surgery

intraoral periapical radiographs showed periapical radiotransparency

smaller than that before the intervention, but there were cystic images
(radiotransparency surrounded by hard lamina) or root resorption.
When a multirooted tooth presented 1 healed root and 1 or 2 roots that
were not healed, we classified it as not healed.

Statistical Analysis
Data are shown as mean T SD for continuous variables and
as absolute frequency and percentage for discrete or categorical
variables. Contingency table analyses were performed by the FisherFreeman-Halton statistics. The W2 for linear trend was also computed. Multiple logistic regression analysis was performed to study
relationships between the outcome variable (healing at 5 year) and
covariates. Fractional polynomial analysis was performed to study
the best fit between age and the outcome. A 2-sided value of P G 0.05
was intended as statistically significant. STATAversion 11.2 (StataCorp
LP, College Station, TX) for Windows was used for all the analyses.

RESULTS
The initial sample comprised 937 teeth in 843 patients (463
men and 385 women), and patients ages ranged from 20 to 56 years
(35.1 T 8.6 years). The majority of individuals was white (92%); the
rest were of African descent. Distribution of the teeth according to
location and surgical treatment group is presented in Table 1. The
most common outcome in all groups at the first control (15 days after
the intervention) was clinical uncertainty. Complete healing was not
observed until 6 months after intervention, except in 10 anterior teeth
(3 lower and 7 upper incisors), belonging to group 3, which showed
complete healing after only 4 months. We observed this improved
prognosis among the younger patients who were treated with minimal osteotomy. The clinical success (absence of clinical symptoms
or signs) rates after 1 year were 67% (306 teeth), 90% (186 teeth),
and 94% (256 teeth) in groups 1, 2, and 3, respectively, whereas
complete healing was recorded in 60% (273 teeth), 71% (146 teeth),
and 73% (199 teeth). There were 27 teeth with unsatisfactory healing
(6%) in group 1, 6 (3%) in group 2, and 4 (1%) in group 3. Uncertain
healing was observed in 125 teeth (27%) in group 1, 14 teeth (7%) in
group 2, and 199 teeth (73%) in group 3 (Table 2). After 1 year,
group comparison indicated that there were statistically significant
differences (P G 0.0001). Linear trend test was statistically significant (P G 0.0001), pointing out larger healing from group 1 to group
3. At the follow-up after 5 years, the teeth were classified in 2 groups
(SA group and MTA group) only on the basis of the root-end filling
material used. Two hundred eight teeth were lost at follow-up
(dropout rate of 27.8%). After 5 years, the rates of teeth with clinical success were 90.8% (197 teeth) and 96% (309 teeth), in the SA
TABLE 1. Distribution of Teeth According to Location and Surgical
Treatment Groups

Tooth Type
Upper anterior teeth*
Upper premolars
Upper molars
Lower anterior teeth
Lower premolars
Lower molars

Group 1

Group 2

Group 3

n = 510

n = 206

n = 273

188
75
72
19
36
120

74
36
28
10
23
35

128
41
27
8
37
32

Teeth treated with traditional apicoectomy (group 1), teeth treated with modern
apicoectomy using traditional burns for osteotomy and MTA as root-end filling material
(group 2), teeth treated with modern apicoectomy using piezo-osteotomy and MTA as
root-end filling material (group 3).
*Anterior teeth = incisors and canines.

* 2014 Mutaz B. Habal, MD

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

805

The Journal of Craniofacial Surgery

Tortorici et al

TABLE 2. One-Year Distribution of Outcomes According to Tooth Location

and Surgical Treatment Groups

Group 1*
Upper anterior teeth
Upper premolars
Upper molars
Lower anterior teeth
Lower premolars
Lower molars
Total teeth healed
(% of healing)
Group 2
Upper anterior teeth
Upper premolars
Upper molars
Lower anterior teeth
Lower premolars
Lower molars
Total teeth healed
(% of healing)
Group 3
Upper anterior teeth
Upper premolars
Upper molars
Lower anterior teeth
Lower premolars
Lower molars
Total teeth healed
(% of healing)

Clinical Success

Clinical Failure

Complete

Partial

Uncertain

Unsatisfactory

112
45
43
12
21
40
273 (60%)

8
7
5
2
5
6
33 (7%)

53
21
20
5
8
18
125 (27%)

15
2
4
0
2
4
27 (6%)

54
26
20
5
16
25
146 (71%)

15
7
5
1
5
7
40 (19%)

5
3
2
1
2
1
14 (7%)

0
0
1
3
0
2
6 (3%)

93
31
18
5
28
24
199 (73%)

27
9
6
1
7
7
57 (21%)

5
1
2
2
1
2
13 (5%)

1
0
1
0
1
1
4 (1%)

Group comparison was statistically significant (P G 0.0001). Linear trend test was
statistically significant (P G 0.0001) as well, pointing out larger healing from group 1 to
group 3.
*Group 1: teeth treated with traditional apicoectomy.
Group 2: teeth treated with modern apicoectomy using traditional burns for
osteotomy and MTA as root-end filling material.
Group 3: teeth treated with modern apicoectomy using piezo-osteotomy and MTA
as root-end filling material.

group and MTA group, respectively. The corresponding rates of teeth

with relapse of lesions were 9.2% (20 teeth) and 4% (13 teeth)
(Table 3). Group comparison was statistically significant (P G
0.00214). Multiple logistic regression analysis found out that surgical technique was independently associated to tooth healing. In
fact, modern surgical technique resulted with a probability of success
more than 5 times higher (odds ratio, 5.2 [95% confidence interval,
3.5Y7.8]; P G 0.001) compared with traditional technique (Table 4).

DISCUSSION
Previous studies have reported success rates of apicoectomy
ranging from 43.5% to 92%.1,10,11 These differences may be the
result of variations in the surgical procedure performed, the magnification and lighting systems used, the root-end filling materials
applied, the evaluation period adopted, and/or the healing criteria
used to evaluate outcomes. There is a consensus that factors such as
age, sex, smoking, and tooth type do not significantly influence
postsurgical outcomes.12,13 The same authors reported that patients
with preoperative signs and symptoms have significantly lower
healing rates compared with patients without signs or symptoms.13,14
We have not considered the prognosis in the presence of
clinical signs or symptoms, because all our patients had symptoms

806

TABLE 3. Five Years Distribution of Outcomes According to Tooth Location

and Type of Material for Root-End Cavity Filling
Tooth Type per Group

Type of Healing
Tooth Type per
Group

& Volume 25, Number 3, May 2014

SA group
Upper anterior teeth
Upper premolars
Upper molars
Lower anterior teeth
Lower premolars
Lower molars
Total teeth healed (% of healing)
MTA group
Upper anterior teeth
Upper premolars
Upper molars
Lower anterior teeth
Lower premolars
Lower molars
Total teeth healed (% of healing)

Clinical Success

Relapse of Lesions

74
35
38
9
16
25
197 (90.8%)

9
3
2
1
2
3
20 (9.2%)

118
58
31
10
47
45
309 (96%)

6
1
4
0
0
2
13 (4%)

Group comparison was statistically significant (P G 0.00214).

and clinical or radiographic signs. The size of the marginal bone level
(the distance in millimeters of the surgical cavity from the alveolar
crest before closure of the mucosal flap) has been discussed in the
literature.12,13 We treated 203 teeth with a marginal bone level less
than 3 mm; in these cases, we applied a splint to immobilize the teeth
with poor stability. After 1 year, 115 (57%) teeth showed clinical
success, 80 (39%) were clinically unsuccessful, and 8 (4%) were not
followed up. More recently, endodontic surgery has seen various
innovations including the use of magnification devices and new
apical cements. These innovations have suggested that a conservative
microsurgical procedure and an adequate apical seal are important
factors that influence success rates in periapical surgery.2,11,13,15 A
systematic review performed by del Fabbro and Taschieri16 found no
significant difference in outcomes among patients treated using
magnifying loupes, surgical microscopes, or endoscopes. Magnification devices offer advantages such as minor surgical trauma for
both soft and hard tissues (minimal size of either the flap and
osteotomy), accuracy in the curettage of the periapical area, and a
detailed view of the root end with visualization of possible factors
that cause the persistence of pathosis, such as accessory canals that
are not detectable by the naked eye. We used no magnification
systems for the treatment of the first group, whereas we treated the
second and third groups with operative microscope. In both first and
second groups, we performed osteotomy with traditional burs,
whereas in the third group we used a piezoelectric surgical device for
osteotomy. Piezo-osteotomy is a minimally invasive technique that
allows bone to be cut while preserving soft tissues, including nerves
TABLE 4. Multiple Logistic Regression Analysis Results
Variable
Sex
Age*
Modern apicoectomy
Tooth type

Odds Ratio (95% Confidence Intervals)

0.95
1,00
5,20
0.99

(0.62Y1,45)
(0.99Y1,01)
(3,94Y6,92)
(0.88Y1,12)

P
0.818
0.906
G0.001
0.921

Only the modern apicoectomy with MTA as root and filling material is independently associated to the outcome variable (tooth healing after 5 years) even when
corrected for sex, age, and tooth type.
*Age was transformed by fractional polynomial to find the best fit power (in our
case 3).

* 2014 Mutaz B. Habal, MD

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 25, Number 3, May 2014

and the Schneiderian membrane.17,18 This technique revealed its

utility when we treated teeth that presented technical difficulties,
such as the close proximity of the apices to the mandibular canal or
the Schneiderian membrane. The success of apicoectomy depends
both on the technique for preparation of the root-end cavity and the
filling material used. There were no relevant differences in the
outcomes between the second and third group at 1 year. On the basis
of the current literature, we classified healing as complete, partial
healing (incomplete), uncertain, and no healing (or failure).7Y9
For the purposes of our study, complete healing and incomplete healing were considered as clinical success, whereas either
uncertain or no healing was considered as clinically unsuccessful.
We reported the evaluation of success and failure following endodontic surgery at 1 and 5 years, according to criteria suggested by
Rud et al. in 1972.9 Some studies have actually confirmed these
observations and reported that clinical and radiographic criteria
established for the prognosis possess a high degree of reliability after
a 1-year follow-up.9,19,20 Unfortunately, today only few studies
consider all these criteria to assess the prognosis. Our study showed
that at the 5-year follow-up the use of a modern microsurgical
endodontic technique and MTA as a root-end filling resulted in a
clinical success rate more than 5 times higher compared with the
traditional surgical technique.

ACKNOWLEDGMENTS
The authors thank the whole surgical team of the Department
of Stomatological Science of University of Palermo for collecting
and abstracting data.

REFERENCES
1. Vallecillo M, Munoz E, Reyes C, et al. Ciruga periapical de 29 dientes.
Comparacion entre tecnica convencional, microsierra y uso de ultrasonidos.
Med Oral 2002;7:46Y53
2. Saunders WP. A prospective clinical study of periradicular surgery using
mineral trioxide aggregate as a root-end filling. J Endod 2008;34:
660Y665
3. Tsesis I, Faivishevsky V, Kfir A, et al. Outcome of surgical endodontic
treatment performed by a modern technique: a meta-analysis of
literature. J Endod 2009;35:1505Y1511
4. Simhofer H, Stoian C, Zetner K. A long-term study of apicectomy
and endodontic treatment of apically infected cheek teeth in 12 horses.
Vet J 2008;178:411Y418

Traditional vs Modern Endodontic Surgery

5. Tsesis I, Rosen E, Schwartz-Arad D, et al. Retrospective evaluation

of surgical endodontic treatment: traditional versus modern technique.
J Endod 2006;32:412Y416
6. Karabucak B, Setzer FC. Conventional and surgical retreatment of
complex periradicular lesions with periodontal involvement. J Endod
2009;35:1310Y1315
7. Molven O, Halse A, Grung B. Observer strategy and the radiographic
classification of healing after endodontic surgery. Int J Oral Maxillofac
Surg 1987;16:432Y439
8. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after
periapical surgery radiographic findings 8 to 12 years after treatment.
J Endod 1996;22:264Y268
9. Rud J, Andreasen JO, Jensen JE. Radiographic criteria for the assessment
of healing after endodontic surgery. Int J Oral Surg 1972;1:195Y214
10. Schwartz-Arad D, Yarom N, Lustig JP, et al. A retrospective radiographic
study of rootend surgery with amalgam and intermediate restorative
material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2003;96:472Y477
11. Shearer J, McManners J. Comparison between the use of an ultrasonic tip
and a microhead handpiece in periradicular surgery: a prospective
randomised trial. Br J Oral Maxillofac Surg 2009;47:386Y388
12. 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;195:707Y714
13. von Arx T, Kurt B, Ilgenstein B, et al. Preliminary results and analysis of
a new set of sonic instruments for root-end cavity preparation. Int Endod
J 1998;31:32Y38
14. Lustmann J, Friedman S, Shaharabany V. Relation of pre- and
intraoperative factors to prognosis of posterior apical surgery. J Endod
1991;17:239Y241
15. Rahbaran S, Gilthorpe MS, Harrison SD, et al. Comparison of clinical
outcome of periapical surgery in endodontic and oral surgery units of a
teaching dental hospital: a retrospective study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2001;91:700Y709
16. del Fabbro M, Taschieri S. Endodontic therapy using magnification
devices: a systematic review. J Dent 2010;38:269Y275
17. Labanca M, Azzola F, Vinci R, et al. Piezoelectric surgery: twenty years
of use. Br J Oral Maxillofac Surg 2008;46:265Y269
18. Schlee M. Ultraschallgestutzte ChirurgieYGrundlagen und
Moglichkeiten. Zahnarztl Impl 2005;21:48Y59
19. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed
one year after apical microsurgery. J Endod 2002;28:378Y383
20. 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;79:101Y103

* 2014 Mutaz B. Habal, MD

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

807