Accepted Manuscript

Long-term survival of teeth in the posterior region after apical surgery

Benedicta Elisabeth Beck-Broichsitter, University Professor, Helene Schmid, DMD,

Hans-Peter Busch, MD, DMD, Jörg Wiltfang, University Professor, Stephan Thomas
Becker, University Professor

PII: S1010-5182(18)30184-7
DOI: 10.1016/j.jcms.2018.08.005
Reference: YJCMS 3077

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 3 May 2018

Revised Date: 8 July 2018
Accepted Date: 8 August 2018

Please cite this article as: Beck-Broichsitter BE, Schmid H, Busch H-P, Wiltfang J, Becker ST, Long-
term survival of teeth in the posterior region after apical surgery, Journal of Cranio-Maxillofacial Surgery
(2018), doi: 10.1016/j.jcms.2018.08.005.

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Long-term survival of teeth in the posterior region after apical surgery

Benedicta Elisabeth Beck-Broichsitter1, University Professor; Helene Schmid2, DMD;

Hans-Peter Busch3, MD, DMD; Jörg Wiltfang2, University Professor; Stephan

Thomas Becker2, University Professor

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Charité - University Medical Center Berlin, Department of Oral and Maxillofacial Surgery,

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Augustenburger Platz 1, 13353 Berlin, Germany
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Department of Oral and Maxillofacial Surgery, Schleswig-Holstein University

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Hospital Arnold-Heller-Straße 3, Haus 26, 24105 Kiel, Germany
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Private Practice for Oral and Maxillofacial Surgery, Sophienblatt 12, 24103 Kiel, Germany
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This work is attributed to:

Department of Oral and Maxillofacial Surgery, Schleswig-Holstein University Hospital

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Head: Jörg Wiltfang, University Professor

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Arnold-Heller-Straße 3, Haus 26,

24105 Kiel, Germany

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Corresponding Author:
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Benedicta E. Beck-Broichsitter
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Charité - University Medical Center Berlin

Augustenburger Platz 1

13353 Berlin, Germany

Telephone: 0049-30-555-022

Fax: 0049-30-555-901

Email: [email protected]
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Sources of Support (Grants)

This study was not financially supported by any institution.

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SUMMARY

Oftentimes the discussion of long-term success rates and treatment modalities

becomes a central issue in consultations with patients. The aim of this study was to

retrospectively evaluate survival rates of teeth after apicoectomy in an established

private practice for Oral and Maxillofacial Surgery in Kiel, Germany.

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All teeth treated with apicoectomy between 2001 and 2006 were included. Treatment

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success was previously defined as preservation of the tooth. Putative influence

factors on success as kind and quality of endodontic treatment, additional

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intraoperative endodontic filling, inflammatory status, tooth mobility, and pre- and

postoperative X-rays were further evaluated.

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A total of 149 teeth could be included. The mean observation period was 6.3 (SD:
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4.4) years. In all, 48.3% of these teeth could be retained after a 10-year period. Teeth
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that received an additional retrograde root canal filling during surgery resulted in a

significantly higher success rate (p=0.0237) compared to those with orthograde root
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canal fillings or without additional endodontic treatment. The quality of endodontic

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treatment had no impact (p=0.125).

Our results suggest that apical surgery is a reliable procedure to treat and ensure the
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survival of symptomatic teeth in the posterior region for several years. A significant

improvement was further determined for a retrograde filling.

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KEYWORDS

Apicoectomy; endodontics; operative dentistry; periodontal diseases; tooth survival

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INTRODUCTION

In everyday clinical routine it is a common problem to decide about the best

treatment option for patients with symptomatic, endodontically treated teeth and

radiologically detected apical lesions (Imura et al., 2007; Torabinejad et al., 2009;

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Kang et al., 2015).

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Although primary endodontic treatment modalities have improved over the last

decades, a large portion (14% to 58%) of endodontically treated teeth continue

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causing problems (Chercoles-Ruiz et al., 2017). In some cases, pain relief during

treatment is missing, mainly in cases of preoperative pain, hindering root filling; in

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other cases, problems occur days to years after treatment as a feeling of pressure or
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apical lesions without pain detected radiologically (Siqueira et al., 2002).
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To definitively reduce bacteria, the removal of the tooth is a suitable option.

Afterwards implants or prosthetic restorations can replace the missing tooth. For
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these options, long-term results are well documented in the literature (Krebs et al.,
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2013; Becker et al., 2016).

However, many people tend to keep the tooth in function and prefer endodontic
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revisions or apical root resections. Within the last years, an increasing number of

papers from endodontists have appeared demonstrating impressive radiological

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images of large lesions healed after endodontic revisions; but the statistical results
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remain less impressive (Naito, 2010; Chercoles-Ruiz et al., 2017). These papers

often focus on anterior teeth and mostly neglect the occurrence of cysts that

obviously cannot be treated sufficiently with endodontic revisions alone. This remains

crucial, considering the incidences of radicular cysts (6% to 55%) (Ramachandran

Nair et al., 1996) granulomas (9.3% to 87.1%) and periapical abscesses (28.7%

to 70.1%) (Schulz et al., 2009).

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This deficiency is not even considered in review papers of statistical experts

comparing surgical and endodontic treatment options. Nevertheless these papers

clearly state that the surgical approach leads to significantly better results (Kang et

al., 2015). For longer periods, data are missing (Kang et al., 2015).

For most clinicians, surgical treatment with management of the infection source and

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a hermetic seal of the apical area is the treatment of choice (K.M., 2006). The results

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for outcomes of apical root resection presented in the literature mostly rely on a time

span of 1 or 2 years, and some even up to 5 years (Gagliani et al., 2005; Wang et al.,

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2014). Long-term studies following patients are missing.

Therefore, the aim of this study was to evaluate the long-term survival rate of teeth

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after apical root resection. Potential influencing factors such as fillings, quality of
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previous endodontic treatment, and position of teeth were considered separately.
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MATERIALS AND METHODS

Patient Recruitment

In a private practice for Oral and Maxillofacial Surgery in Kiel, Germany, medical

records of patients who underwent apicoectomy in the years 2001 to 2005 were

collected in a retrospective manner. These patients had been sent from their dentists

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for further treatment, either tooth removal or surgical endodontic revisions.

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Endodontic revisions without surgery were regarded as not being reasonable (e.g.

insufficient root canal filling and cyst or osteolytic zone), or multiple treatment

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sessions were not accepted by the patient in these cases; otherwise they would have

been treated by their dentist alone. Only teeth where no surgery had been done

before were included.

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To ease data collection, the patients’ records were screened for the nine dentists that
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had sent the most patients. Therefore, only their records had to be reviewed. A total

of 149 teeth, mostly in the posterior region, could finally be included in this follow-up
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evaluation with complete data.

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The study was conducted in accordance with the WMA Declaration of Helsinki -

Ethical Principles for Medical Research Involving Human Subjects, after approval of
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the local ethics committee (Permit No.: D 578/15).

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Assessment of medical records

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Medical records and surgical reports with pre- and postoperative radiographs were

screened. The treated tooth was identified as well as the number of treated roots, the

date of endodontic treatment, the date of the apicoectomy, following antibiotic

treatment, and in special cases the date of tooth removal.

The existence of pain, tooth mobility, fistula, periodontitis, and the kind of

prosthodontic treatment were further noted.

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Assessment of radiographs

The teeth treated underwent dental X-ray in bisecting technique pre- and

postoperatively. Endondontic treatment was screened for kind and quality of

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additional treatment during apicoectomy (orthograde, retrograde, no additional root

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filling). The size of the apical lesion was measured, as well as signs of reossification.

Radiographs were further assessed according to the criteria established by Molven et

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al. and Rud et al. as follows:

I. Complete healing

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Extension of periodontal gap is less than twice its normal size. Former
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apical lesion is completely filled with new bone.
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II. Incomplete healing

New bone or soft tissue formation in the apical region of former lesion,
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which is still apparent but constant over time, corresponding with the
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presence of scar tissue.

III. Uncertain healing

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Periodontal gap is more than twice its normal size, apical lesion is still

determinable, sometimes regredient. If lesion is still persistent after 4 years,

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healing may not be expected and should be declared as failure.

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IV. Failure

Apical lesion is persistent or enlarged over time.

Surgical protocol
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A single surgeon performed all procedures in his own private practice in the city of

Kiel, Germany. After patients gave written and informed consent in a first visit,

apicoectomies were appointed for a second visit.

The teeth were anesthetized with 2-4 ml Articaine with adrenaline (Ultracain D-S

1:200.000, Sanofi-Aventis, Frankfurt/Main, Germany). In the anterior region, a curved

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cut according to Partsch was chosen, whereas a paramarginal approach was

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preferred in the posterior region in order to access the apical region. A

mucoperiosteal flap was raised, the adjacent bone was removed with a round burr,

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and 3 mm of the root´s apex was resected. If, due to the previous clinical and

radiographic findings, it was considered necessary, root fillings were applied either

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orthogradely or retrogradely. In the former case, the root channel was prepared for a
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new filling after removal of old root canal filling material or completely prepared after
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initial trepanation of the tooth. The channel was rinsed with hydrogen peroxide, dried

with papertips and filled with gutta-percha tips, which were cut and condensed after
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application of sealer with heated instruments. In the latter case, 2-3 mm of the old
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filling material was removed with a micro handpiece. Under dry conditions, the

retrograde filling was applied using Diaket (3M Deutschland GmbH, Neuss,
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Germany), Ketac Bond (3M Deutschland GmbH, Neuss, Germany) or Super-EBA

(SPEIKO-Dr. Speier GmbH, Münster, Germany). The wound was closed with non-
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resorbable 4-0 sutures and a radiograph was taken. Antibiotic treatment was
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recommended in cases with multiple apicoectomies in one session or with an

intraoperative fistula to the maxillary sinus.

Statistical assessment
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GraphPad Prism software version 6.0 (GraphPad Software, La Jolla, California, USA)

was applied for statistical evaluation of all data. Descriptive statistics are reported for

single factors. The overall tooth survival and the tooth survival under consideration of

influence factors was displayed in Kaplan-Meier plots. The endpoint was defined as

removal of the tooth or the last visit at the dentist. The level of statistical significance

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was set at p<0.05. Chi-square tests were applied to determine influential factors pre-

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and postoperatively. Differences between groups were evaluated using Mann-

Whitney U testing.

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We explicitly concentrated our evaluation on survival and not success, to facilitate

comparisons and reviews with our data. Success criteria differ a lot from study to

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study, and therefore comparisons are often difficult.
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RESULTS

Descriptive statistical assessment

A total of 124 patients (73 female and 51) with existing follow-up data could be

included in this evaluation with a mean follow-up interval of 6.3 years (± 4.4 years).

Patients were referred by their dentist after having discussed treatment alternatives

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(e.g. root canal retreatment). All patients underwent apicoectomy.

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Collective description

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Of a total of 149 teeth undergoing apicoectomy, the first molar in the mandible (n=37,

24.83%) and the second premolar (n=27, 18.12%) in the maxilla represented the

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main proportion in this collective. Table 1 depicts the distribution of treated teeth. The
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spectrum of indication for the surgery was mainly driven by clinical symptoms:
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80 (53.7%) out of 149 teeth were documented to be painful before surgery, and 17

(11.41%) out of 149 teeth were sensitive to a knocking touch. Tooth mobility was
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slightly elevated in 8 teeth (5.55%), further clinical evaluation revealed a painful

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palpation of the alveolar ridge in 31 teeth (20.81%), and fistula could be detected in

14 teeth (9.4%).
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Kaplan-Meier analyses
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Including all resected teeth, the survival rate after 1 year was calculated 90.41%.
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After 5 years 60.4% and after 10 years 48.3% of these teeth remained in situ (Figure

1).

Differentiation between filling procedures revealed significantly superior (p=0.0273)

results for retrograde filling compared to orthograde ones or procedures without

additional endodontic treatment (Figure 2 and Table 2), while there were no
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significant differences between radiologically sufficient endodontic treatment prior to

surgery compared to insufficiently filled root canals (p=0.125, Figure 3).

Postoperative dental treatment did not yield statistically significant differences. The

best results were obtained for fillings, and slightly worse ones for crowns and bridges.

To evaluate the influence of the surgical procedure on preoperatively determined

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presumptive influential factors on treatment success, such as painful teeth, painful

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palpation, painful response to knocking touch, tooth mobility or fistula, the Fisher test

was applied. A statistically significant influence could be found regarding the

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presence of fistula (p=0.0462), painful palpation (p=0.014) and tooth mobility

(p=0.0152) in correlation with the surgical procedure. There was no statistically

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significant correlation regarding painful teeth or response to knocking touch
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(p=0.0676 each).
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DISCUSSION

Nowadays patients want to be informed about different treatment options. Statistical

data should support the patients in deciding about their individual treatment option

preferences. This is the first study, to our knowledge, to report long-term results (10

years plus) after surgical apicoetomy.

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Our data rely on a collective in which classic endodontic revisions were already

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excluded as treatment options by their dentists. Most patients had to decide between

immediate removal of the tooth or surgical revision. Therefore, it is remarkable that

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after 5 years even 60.4% of these teeth could remain functional and after 10 years

still 48.3%. This is considerably in the range of other studies that relied only on data

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until 5 years after surgery (Zuolo et al., 2000; Gagliani et al., 2005; Naito, 2010).
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Another aspect specific to this analysis is the fact that the patients were not treated in
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a clinical environment with many different surgeons of different surgical experience

with varying results, but rather by a specialized surgeon, who had more than 20
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years of experience and a highly standardized surgical protocol. This specialty

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compared to most other reports allows the estimation of these results to be highly

valid.
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A study evaluating the results of general German insurance companies found

survival rates for teeth of 93.0% after 1 year, 88.2% after 2 years and 84.3% after 3
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years (Raedel et al., 2015). These data represent 556,067 primary endodontic
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treatment cases treated in 1 year in all German dental treatment units. The authors

also reported about the results of 93,797 surgical apiectomies. It is remarkable that

the survival rates with 91.4% after 1 year, 85.7% after 2 years and 81.6% after 3

years are rather similar to the ones after primary endodontic treatment. This allows

the conclusion that a surgical intervention is capable of retaining a tooth completely.

This may be due to the fact that the complex anatomy hinders a complete filling of
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the nerve cavity by endodontic methods (De Deus, 1975). Ultrasonic devices and

retrograde access allow direct view and at least a hermetic closure of the apex

(Regan et al., 2002; Tsurumachi, 2013), which is supported by our data suggesting a

significantly better outcome if an additional retrograde filling was performed. These

results have to be qualified by another study, which resulted in a slightly better

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outcome for teeth with mainly orthograde filling (Ioannides et al., 1983). However,

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one must consider that the observation period was 6 months to 5 years without a

specification of a mean value or standard deviation. Furthermore, there was no

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Kaplan-Meier analysis performed, and percentages of overall tooth survival were

descriptively compared.

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It should be discussed that we evaluated the survival and success of teeth.
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Assessing solely success might lead to perceived better results than success rates,
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as some patients may have had pain or other problems which might have a negative

impact on the value of the treated tooth for further prosthodontic rehabilitation. In
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addition, no consensus exists about success criteria in studies on retreatment and

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apical surgery, as standardization is absent (Kang et al., 2015). To ease further

studies and reviews, our data are kept clear.

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Some reviews have tried to compare endodontic revisions to surgical ones. These

studies clearly indicate that surgical interventions lead to better results than
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endodontic revisions (Naito, 2010; Kang et al., 2015; Chercoles-Ruiz et al., 2017). A
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main problem of these publications is that they rely on data given in other studies. In

most cases, in these studies, there exists no differentiation between anterior and

posterior teeth. It is well known that it is easier to treat anterior teeth and that the

results are much better (Wang et al., 2014). In our study, we mainly focused on

posterior teeth, as some dentists treat anterior teeth by themselves. This emphasizes

the good results documented in this study.

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Another important aspect is that many teeth resected show cysts in the apical region.

These cysts certainly cannot be treated sufficiently with a simple endodontic revision,

as the epithelium remains, continuing growth. No valid method other than surgical

intervention exists to clearly determine whether a radiological osteolysis is filled with

granulation tissue or a cyst (Chercoles-Ruiz et al., 2017). Patients have to be

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informed about this methodological deficiency of endodontic revisions.

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CONCLUSION

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After a period of 10 years, with apical root resection in this collective of teeth with a

reduced number of treatment options, more than 48% of teeth could remain

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functional. A significant improvement was determined for a retrograde filling.
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CONFLICT OF INTEREST

None.
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De Deus QD: Frequency, location, and direction of the lateral, secondary, and accessory

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Ramachandran Nair PN, Pajarola G, Schroeder HE: Types and incidence of human

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Regan JD, Gutmann JL, Witherspoon DE: Comparison of Diaket and MTA when used as

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Figure 1. Survival curve of all included teeth.

Figure 2. Survival of teeth dependent on additional endodontic treatment was

significantly different (p=0.0273) among the three groups. Three patients had to be

excluded due to a combined treatment of no retrograde and retrograde treatment in

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one tooth with multiple roots.

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Figure 3. Survival of teeth was not significantly different regarding the quality of the

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previous endodontic treatment.

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Table 1. Distribution of teeth in the study collective.

Table 2. Survival fractions after 1, 2, 5, 10 and 12 years after surgery and with or

without additional root canal filling.

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TABLE 1
Position 1 2 3 4 5 6 7
Maxilla absolute 6 2 2 17 27 18 5
relative 4.03 % 1.34 % 1.34 % 11.41 % 18.12 % 12.08 % 3.36 %
Mandible absolute 1 0 0 6 17 37 11
relative 0.67 % 0% 0% 4.03 % 11.41 % 24.83 % 7.38 %

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TABLE 2

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Timepoint Tooth survival: no Tooth survival: Tooth survival:
additional filling orthograde root filling retrograde root filling
(N=80) (N=47) (N=17)

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12 months absolute 67 46 16
relative 83.25 % 97.87 % 94.11 %
24 months absolute 65 43 16
relative 81.25 %

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60 months absolute 52 25 16
relative 65.00 % 53.19 % 94.11 %
120 absolute 47 7 11
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months relative 58.75 % 14.89% 64.71 %

144 absolute 40 0 11
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months relative 50.00 % 0% 64.71 %

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