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 Tetè, MDÞ
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 prep-
aration of retrograde cavity (different apicoectomy angles and in-
struments 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) com-
pared with the traditional technique.
Key Words: Endodontic surgery, MTA, amalgam, prognosis,
statistics
(J Craniofac Surg 2014;25: 804Y807)
P eriapical surgery, endodontic surgery, or apicoectomy is indi-
cated when conservative endodontic treatment proves to be un-
successful, 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 Sci-
ences, 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 The Journal of Craniofacial Surgery
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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: tradi-
tional 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 micro-
scope, 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 tra-
ditional 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 classifi-
cations: 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 conden-
sation); and (2) teeth with advanced periodontal disease (93-mm
pocket depth) or if the marginal bone level was entered as zero.
& Volume 25, Number 3, May 2014
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 cu-
rettage 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 tra-
ditional 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 root-
end 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 tra-
ditional techniques, performing osteotomy and apicoectomy with a
low-speed dental handpiece (Kavo Dentale Medizinische Instrumente
Vertriebsgesellschaft m.b.h., Biberach, Riss, Germany), root-end re-
section with a 45-degree bevel, and root-end preparation with tradi-
tional 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 90-
degree 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 par-
tial 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
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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 Fisher-
Freeman-Halton statistics. The W2 for linear trend was also com-
puted. 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 min-
imal 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 signifi-
cant (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 clin-
ical 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
Group 1 Group 2 Group 3
Tooth Type n = 510 n = 206 n = 273
Upper anterior teeth* 188 74 128
Upper premolars 75 36 41
Upper molars 72 28 27
Lower anterior teeth 19 10 8
Lower premolars 36 23 37
Lower molars 120 35 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.
805
Tortorici et al The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014

TABLE 2. One-Year Distribution of Outcomes According to Tooth Location TABLE 3. Five Years’ Distribution of Outcomes According to Tooth Location
and Surgical Treatment Groups and Type of Material for Root-End Cavity Filling

Type of Healing Tooth Type per Group Clinical Success Relapse of Lesions

Clinical Success Clinical Failure SA group

Tooth Type per
Upper anterior teeth 74 9
Group Complete Partial Uncertain Unsatisfactory
Upper premolars 35 3
Group 1* Upper molars 38 2
Upper anterior teeth 112 8 53 15 Lower anterior teeth 9 1
Upper premolars 45 7 21 2 Lower premolars 16 2
Upper molars 43 5 20 4 Lower molars 25 3
Lower anterior teeth 12 2 5 0 Total teeth healed (% of healing) 197 (90.8%) 20 (9.2%)
Lower premolars 21 5 8 2 MTA group
Lower molars 40 6 18 4 Upper anterior teeth 118 6
Total teeth healed 273 (60%) 33 (7%) 125 (27%) 27 (6%) Upper premolars 58 1
(% of healing) Upper molars 31 4
Group 2† Lower anterior teeth 10 0
Upper anterior teeth 54 15 5 0 Lower premolars 47 0
Upper premolars 26 7 3 0 Lower molars 45 2
Upper molars 20 5 2 1 Total teeth healed (% of healing) 309 (96%) 13 (4%)
Lower anterior teeth 5 1 1 3
Group comparison was statistically significant (P G 0.00214).
Lower premolars 16 5 2 0
Lower molars 25 7 1 2
Total teeth healed 146 (71%) 40 (19%) 14 (7%) 6 (3%)
(% of healing) and clinical or radiographic signs. The size of the marginal bone level
Group 3‡ (the distance in millimeters of the surgical cavity from the alveolar
Upper anterior teeth 93 27 5 1 crest before closure of the mucosal flap) has been discussed in the
Upper premolars 31 9 1 0 literature.12,13 We treated 203 teeth with a marginal bone level less
Upper molars 18 6 2 1 than 3 mm; in these cases, we applied a splint to immobilize the teeth
Lower anterior teeth 5 1 2 0 with poor stability. After 1 year, 115 (57%) teeth showed clinical
Lower premolars 28 7 1 1 success, 80 (39%) were clinically unsuccessful, and 8 (4%) were not
Lower molars 24 7 2 1 followed up. More recently, endodontic surgery has seen various
Total teeth healed 199 (73%) 57 (21%) 13 (5%) 4 (1%) innovations including the use of magnification devices and new
(% of healing) apical cements. These innovations have suggested that a conservative
Group comparison was statistically significant (P G 0.0001). Linear trend test was microsurgical procedure and an adequate apical seal are important
statistically significant (P G 0.0001) as well, pointing out larger healing from group 1 to factors that influence success rates in periapical surgery.2,11,13,15 A
group 3. systematic review performed by del Fabbro and Taschieri16 found no
*Group 1: teeth treated with traditional apicoectomy.
†Group 2: teeth treated with modern apicoectomy using traditional burns for
significant difference in outcomes among patients treated using
osteotomy and MTA as root-end filling material. magnifying loupes, surgical microscopes, or endoscopes. Magnifi-
‡Group 3: teeth treated with modern apicoectomy using piezo-osteotomy and MTA cation devices offer advantages such as minor surgical trauma for
as root-end filling material. 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
group and MTA group, respectively. The corresponding rates of teeth that cause the persistence of pathosis, such as accessory canals that
with relapse of lesions were 9.2% (20 teeth) and 4% (13 teeth) are not detectable by the naked eye. We used no magnification
(Table 3). Group comparison was statistically significant (P G systems for the treatment of the first group, whereas we treated the
0.00214). Multiple logistic regression analysis found out that sur- second and third groups with operative microscope. In both first and
gical technique was independently associated to tooth healing. In second groups, we performed osteotomy with traditional burs,
fact, modern surgical technique resulted with a probability of success whereas in the third group we used a piezoelectric surgical device for
more than 5 times higher (odds ratio, 5.2 [95% confidence interval, osteotomy. Piezo-osteotomy is a minimally invasive technique that
3.5Y7.8]; P G 0.001) compared with traditional technique (Table 4). allows bone to be cut while preserving soft tissues, including nerves

DISCUSSION
Previous studies have reported success rates of apicoectomy TABLE 4. Multiple Logistic Regression Analysis Results
ranging from 43.5% to 92%.1,10,11 These differences may be the Variable Odds Ratio (95% Confidence Intervals) P
result of variations in the surgical procedure performed, the mag-
nification and lighting systems used, the root-end filling materials Sex 0.95 (0.62Y1,45) 0.818
applied, the evaluation period adopted, and/or the healing criteria Age* 1,00 (0.99Y1,01) 0.906
used to evaluate outcomes. There is a consensus that factors such as Modern apicoectomy 5,20 (3,94Y6,92) G0.001
age, sex, smoking, and tooth type do not significantly influence Tooth type 0.99 (0.88Y1,12) 0.921
postsurgical outcomes.12,13 The same authors reported that patients Only the modern apicoectomy with MTA as root and filling material is indepen-
with preoperative signs and symptoms have significantly lower dently associated to the outcome variable (tooth healing after 5 years) even when
corrected for sex, age, and tooth type.
healing rates compared with patients without signs or symptoms.13,14 *Age was transformed by fractional polynomial to find the best fit power (in our
We have not considered the prognosis in the presence of case 3).
clinical signs or symptoms, because all our patients had symptoms

806 * 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 incom-
plete 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 end-
odontic 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.
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