Clinical Research
Periapical Bone Healing after Apicectomy with and without
Retrograde Root Filling with Mineral Trioxide Aggregate:
A 6-year Follow-up of a Randomized Controlled Trial
Casper Kruse, DDS,* Rubens Spin-Neto, DDS, PhD,* Ren
e Christiansen, DDS, PhD,†
Ann Wenzel, DDS, PhD, Dr odont,* and Lise-Lotte Kirkevang, DDS, PhD*‡
Abstract
Introduction: In cases of post-treatment periapical dis-
ease, retreatment may be necessary. To choose the most
appropriate retreatment method, knowledge of the
long-term prognosis is important. Surgical endodontic
retreatment (SER) is a relevant treatment method. This
study assessed changes in outcome from 1 to 6 years af-
ter surgery. Methods: SER was performed on teeth
randomly allocated to have a MTA root-end filling
(MTA group) or smoothing of the orthograde gutta-
percha filling after apicectomy (GP group). Patients
participating in the 1-year follow-up were reinvited for
a 6-year clinical and radiographic examination. Three
observers assessed treatment outcome both clinically
and radiographically from the 1-year and 6-year
follow-up examination. Results: At the 6-year follow-
up, 39 of 52 teeth were available and examined (75%
participation rate). In the MTA group, 16 of 19 teeth
(86%) and in the GP group 11 of 20 teeth (55%) were
assessed as successful (P = .04). In the MTA group
and the GP group, 80% and 90%, respectively, of teeth
assessed as successful at the 1-year follow-up remained
successful. All unsuccessful teeth in the MTA group (3
teeth) were lost because of vertical root fracture. Con-
clusions: The proportion of healed cases was larger in
the MTA group than in the GP group at both the 1-year
and 6-year follow-up. Findings indicate that a 1-year
follow-up may not be sufficient in assessing the long-
term outcome of surgical endodontic retreatment. With
a longer follow-up, other factors not directly related to
the endodontic treatment may be relevant for a success-
ful outcome. This needs further investigation in larger pa-
tient samples. (J Endod 2016;42:533–537)
Key Words
Mineral trioxide aggregate, periapical surgery, radio-
graphic, surgical endodontic retreatment, trioxide
aggregate
From the *Section of Oral Radiology, Department of Dentistry, Aarhus University, Aarhus, Denmark; †Private Practice, Højbjerg, Denmark; and ‡Department of End-
odontics, Institute of Clinical Dentistry, Faculty of Dentistry, Oslo University, Oslo, Norway.
Address requests for reprints to Dr Casper Kruse, Section of Oral Radiology, Department of Dentistry, Aarhus University, Vennelyst Boulevard 9, 8000 Aarhus,
Denmark. E-mail address: casper.kruse@odont.au.dk
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.01.011
JOE — Volume 42, Number 4, April 2016
T he main goal of root canal treatment is either to prevent or treat apical periodon-
titis (1). If a periapical lesion develops or fails to heal after primary root canal
treatment, the primary treatment is regarded as unsuccessful, and retreatment may
be performed. Unsuccessful cases can be treated either by nonsurgical endodontic
retreatment (NSER) or surgical endodontic retreatment (SER). NSER and SER of un-
successful primary endodontic cases have been shown to be equally successful treat-
ment strategies, but if NSER is expected to be technically challenging, the most
appropriate treatment approach can be SER (2, 3).
In the clinical situation, diagnosis, treatment planning, and evaluation of the treat-
ment outcome are based on subjective symptoms reported by the patient as well as clin-
ical and radiographic findings. Since Rud et al (4) and Molven et al (5) introduced
criteria for evaluation of the treatment outcome of SER, these criteria have been widely
accepted and used in several studies (6–28).
Randomized controlled trials (RCTs) have proven SER to be a reliable and suc-
cessful treatment approach in cases of chronic apical periodontitis on root-filled teeth
with success rates of up to 89%–94% 1 to 2 years after treatment (29–31). SER has
been found to be more successful than NSER after 1 year, but after 3 years of
observation, studies have reported equal healing rates (32–35). This has partly been
explained by the development of ‘‘late failures’’ in 5%–25% of SER cases (36). When
patients have to choose between treatment modalities, knowledge of the long-term
prognosis is important. Previous clinical cohort studies have assessed the outcome
of SER 3 to 10 years after treatment (6, 10, 11, 13, 15, 18, 20, 21, 23, 25, 28), but
differences in the techniques used, materials, and follow-up periods may complicate
direct comparison and pooling of data for meta-analyses (23). Nevertheless, a recent
meta-analysis of the outcome of SER using a microsurgical technique reported an esti-
mated overall pooled success rate of 92% (37). The importance of a retrograde root-
end filling to the outcome of SER has been shown previously (8, 38).
The aim of this study was to assess treatment outcome changes from 1 to 6 years
after periapical surgery in teeth randomized to SER with and without placement of a
mineral trioxide aggregate (MTA) root-end filling.
Materials and Methods
The present study reports the results of a 6-year follow-up of a previously per-
formed RCT of the 1-year outcome of SER using a microsurgical technique (8). The
study in 2005 to 2006 was approved by the regional committee of ethics and registered
in a public clinical trials registry (ClinicalTrials.gov ID: NCT00228280) and was con-
ducted in accordance with the World Medical Association Declaration of Helsinki.
Periapical Surgery: Outcome Changes from 1–6 Years 533
Clinical Research
The regional committee of ethics independently approved the repeated
recall for the 6-year follow-up study.
Briefly, from June 2005 to October 2006, 44 patients (52 teeth)
with chronic periapical infection on a root-filled single-rooted tooth
participated in an RCT comparing treatment outcome of SER with
root-end filling with MTA (ProRoot MTA White; Dentsply Tulsa Dental,
Tulsa, OK) and SER with no root-end filling. A comparison was made
between 2 treatment modalities in which 1 group of patients (MTA
group) received a retrograde root-end filling of MTA, and the patients
in the other group (GP group) had a smoothing of the orthograde gutta-
percha filling after the apicectomy. All treatments were performed by 1
operator (R.C.) using a dental operating microscope (OPMI Pico; Zeiss,
Oberkochen, Germany). For a detailed description of the surgical pro-
cedure, see Christiansen et al (8). During surgery, teeth were randomly
allocated into 1 of 2 treatment groups, MTA or GP, by drawing a lot.
Eight patients contributed with 2 teeth; the first tooth was randomized
to 1 treatment group, and the second tooth was then allocated to the
other treatment group. Treatment outcome was evaluated 1 year after
treatment. A total of 39 patients (46 teeth) were available for the 1-
year follow-up.
All patients participating in the 1-year follow-up were contacted
and reinvited for a 6-year postoperative clinical and radiologic exami-
nation. The follow-ups were performed March to October 2012. The
flow of participants and reasons for loss to follow-up can be seen in
Figure 1. Six patients (7 teeth; 6 MTA and 1 GP) did not participate
in the 6-year follow-up; 3 patients (3 teeth) had died, 2 patients (3
teeth) refused to participate because of impaired general health, and
1 patient (1 tooth) did not respond to the invitation. Furthermore, 3 pa-
tients (3 teeth) had had all teeth extracted during the follow-up period
and were not seen for clinical and radiologic examination but were
included and counted as failures in the final analysis. A total of 30 pa-
tients (36 teeth), 16 women and 14 men, participated in the 6-year
follow-up examination. A total of 33 participants, 17 women and 16
men, (39 teeth) were included in the final analysis. The MTA group
included 10 maxillary premolars, 6 maxillary incisors, and 3 mandib-
ular premolars; the GP group included 9 maxillary premolars, 1 maxil-
Figure 1. A flow diagram of the number of teeth included in the study.
534 Kruse et al.
lary canine, 7 maxillary incisors, 2 mandibular premolars, and 1
mandibular canine. In cases in which the tooth had been extracted,
dental records from the dental school or private practice were exam-
ined to find the reason for extraction.
A periapical radiograph was obtained using a Gendex 1,000 DC X-
ray unit (Gendex Corporation, Milwaukee, WI) using a paralleling tech-
nique, 65 kV, 10 mA, and a film focus distance of 28 cm. The exposure
time was adjusted according to the individual patient and region. A stor-
age phosphor plate system was used with a spatial resolution of 755 
1025 pixels (D€urr Dental VistaScan Plus; D€urr Dental AG, Bietigheim-
Bissingen, Germany). All radiographic images were exported from
the used system as a tagged image file format to Adobe Photoshop
(Adobe Systems Inc, San Jose, CA) and blinded for treatment method
by an individually fitted gray area in the apical third of the root.
The blinded 1- and 6-year postoperative periapical radiographic
images were assessed individually in random order by 3 experienced
observers, 1 radiologist (R.S.N.), and 2 endodontists (C.K. and
L.L.K.). Periapical images taken 1 week postoperatively were used for
comparison. All periapical images were scored according to the criteria
described by Rud et al (4) and Molven et al (5, 39):
1. Complete healing
2. Incomplete healing (scar tissue)
3. Uncertain healing
4. Unsatisfactory healing
Extracted teeth were registered as a separate outcome category.
Both written scoring criteria and ‘‘atlas drawings’’ by Molven et al
(5) were available to observers during scoring of the images. The peri-
apical scores for the 3 observers were converted to a consensus score
by selecting the most frequent score. In 6 cases of disagreement, the
observers discussed until a consensus was reached. The clinical exam-
inations were performed by 1 experienced examiner (C.K.). Recorded
clinical variables and categories are shown in Table 1.
Data were described and analyzed with the tooth as the unit of
analysis. Treatments were compared by computing the difference be-
tween the proportions of success. The difference was assessed with
JOE — Volume 42, Number 4, April 2016
 Clinical Research
TABLE 1. Clinical Variables Recorded during Clinical Examination TABLE 2. Rud and Molven Periapical Scores and Extractions for Teeth
Available at Both the 1-year and 6-year Follow-up by Number of Teeth
No. of teeth
No. of teeth 6 years post surgery
Clinical variable Category MTA GP
Tooth retained Yes 16 16 1 year post surgery 1 2 3 4 EX Total
No 3 4* GP
Soft tissue swelling Yes 0 0 1 6 0 1 0 0 7
No 16 16 2 2 1 0 0 0 3
Pain Yes 0 0 3 2 0 1 3 4 10
No 16 16 4 0 0 0 0 0 0
Tenderness on chewing Yes 1 0 Total 10 1 2 3 4 20
No 15 16 MTA
Tenderness to percussion Yes 2 4 1 10 0 0 0 2 12
No 14 12 2 2 0 0 0 1 3
Fistula Yes 0 0 3 3 0 0 0 0 3
No 16 16 4 1 0 0 0 0 1
Periodontal pocket <4 mm 11 14 Total 16 0 0 0 3 19
depth (deepest of MTA + GP
6 per tooth) 1 16 0 1 0 2 19
4–5 mm 5 2 2 4 1 0 0 1 6
>5 mm 0 0 3 5 0 1 3 4 13
Tooth mobility (degree) 0 13 9 4 1 0 0 0 0 1
1 3 6 Total 26 1 2 3 7 39
2 0 1
3 0 0 EX, tooth extracted; GP, gutta-percha smoothing technique; MTA, mineral trioxide aggregate.
Pulpal post Yes 8 11
No 8 5
Coronal restoration Amalgam 1 0
At the 6-year follow-up, 90% of the teeth in the GP group that were
Composite resin 10 9 scored as successfully healed 1 year postoperatively remained success-
Crown 5 7 ful. In the MTA group, 80% of the teeth assessed as successfully healed
Quality of coronal Sufficient 13 16 after 1 year remained successful.
restoration None of the previously successful teeth in the GP group had been
Insufficient 3 0
or caries extracted during the 6-year follow-up, whereas 3 teeth in the MTA
group previously scored as successfully healed had been extracted
GP, gutta-percha smoothing technique; MTA, mineral trioxide aggregate. because of vertical root fracture. Of 10 teeth in the GP group with a
*Including 3 teeth not seen for clinical evaluation because of known extraction during the
score of 3 (uncertain healing) after 1 year, 2 were scored as success-
follow-up period.
ful at the 6-year follow-up. In the MTA group, 4 teeth had a score 3 or
4 at the 1-year follow-up, and they were all assessed as successful at
adjustment for a potential correlation between outcomes in teeth from the 6-year follow-up.
the same patient. Stata release 13 (StataCorp LP, Statistical Software,
College Station, TX) was used for all statistical calculations (40).
Discussion
Overall, the 6-year participation rate of the study was (39/52 teeth)
Results 75%. This is comparable with previous clinical cohort studies with a
Thirty-three (including 3 patients with known extraction of the follow-up period of more than 12 months (18 months–10 years),
tooth) of 44 patients (39/52 treated teeth) participated in the 6-year which have obtained participation rates ranging from 59%–100% (6,
follow-up, representing a 75% participation rate of both teeth and pa- 7, 10, 11, 13, 14, 17, 18, 20, 21, 23, 25, 28). Other authors have
tients (Fig. 1). The mean follow-up period was 6 years 3 months (range, used different principles of excluding patients from follow-up. Some
5 years 7 months–7 years 0 months). have excluded teeth that have been lost because of a root fracture in
The 33 participants in the 6-year final analysis had a mean age of the follow-up period (9, 26, 27). In 1 study, teeth extracted because
62 years (range, 40–85 years). The mean age for men (n = 16) was of periodontal problems were excluded (21), and in 2 studies teeth
65 years (range, 41–77 years), and for women (n = 17) it was 61 years not accounted for because of patient death, impaired health, or non-
(range, 40–85 years). No patient reported pain from the treated tooth; reachable patients were excluded (41, 42). The difference in
however, 1 patient reported reactions on chewing. Other clinical find- exclusion criteria may impair the comparison of participation rates.
ings are shown in Table 1. Registrations of periapical radiographic If the criteria from previous studies described previously were used
scores and extractions for teeth available at both the 1-year and 6- in the present study, both the participation rate and the success rate
year follow-up are shown in Table 2. at the 6-year follow-up would have been higher.
At the 1-year follow-up, the combined proportion of successful In the present study, the 4 scores, as originally described by Rud
cases (scores 1 + 2) for MTA and GP was 64% (25/39). The proportion et al (4), were dichotomized as success (scores 1 + 2) and failure
of successful cases for MTA and GP was 79% (15/19) and 50% (10/20), (scores 3 + 4 + extracted teeth). A similar approach has been used
respectively (P = .07). The treatment difference was estimated to be by authors in other long-term follow-up studies (16, 28) in which
29% (95% confidence interval, 3% to 61%). teeth remaining asymptomatic in the ‘‘uncertain healing’’ group
After 6 years, the combined proportion of successful cases (scores were further observed for up to 4 years before characterized as
1 + 2) for MTA and GP was 69% (27/39). The proportion of successful failures. Because the follow-up period in the present study is longer
cases for MTA and GP was 84% (16/19) and 55% (11/20), respectively than the 4 years suggested by Rud et al (4) and Molven et al
(P = .04). The treatment difference was estimated to be 29% (95% con- (5, 39), both scores 3 and 4 were classified as failures at the 6-year
fidence interval, 2%–56%). follow-up assessment.

JOE — Volume 42, Number 4, April 2016 Periapical Surgery: Outcome Changes from 1–6 Years 535
Clinical Research
The aim of the present study was to assess the changes in outcome
of SER from 1 to 6 years after surgery. Therefore, 1-year images of teeth
participating in both follow-ups were re-evaluated by the current ob-
servers. Hence, the 1-year follow-up scores of the present study are
not identical to the previously reported figures because the present
scores only relate to patients participating in the 6-year follow-up and
these patients are merely a part of the total patient group treated in
the RCT in 2005 to 2006 (8).
The current proportion of successful cases of 79% in the MTA
group at the 1-year follow-up is lower than in other studies of MTA
in which frequency of successful healing has been reported to be
90.2%–95.6% 1 year after surgery (12, 19, 22, 24). However, in the
present study, the proportion of successful cases 6 years
postoperatively increased to 84%, which is comparable with similar
studies with a follow-up period of more than 1 year (18 months–
6 years) reporting 80.8%–92.2% of successful cases (6, 7, 17, 23, 25).
The transitions of teeth from success to failure from the 1-year to
the 6-year follow-up at a level of 10%–20% are comparable with the
findings of Kvist and Reit (34) and Torabinejad et al (36), who also re-
ported more failing cases with an increasing observation period
because of the development of recurrent periapical lesions. On the
other hand, all 4 teeth in the MTA group scored as failures (score
3 + 4) at the 1-year follow-up were scored as successfully healed (score
1) at the 6-year follow-up. This indicates that transitions are possible in
both directions. Jessl
en et al (10) reported that 95% of the cases scored
as successful at their 1-year follow-up were still in this category at the 5-
year follow-up. Rud et al (43) reported the same to be true for 97% of
cases 8 to 9 years after surgery, Rubinstein and Kim (15) 91.5% after 5
to 7 years, and Song et al (18) 93.3% after 4 years. Because of this high
frequency of outcome stability, other authors have not performed
further follow-up in cases in which the treatment was scored as either
successful (score 1 + 2) or unsatisfactory (score 4) (6, 16, 17, 28).
Within the limitations of this study, it seems that this approach might
not give the true picture of the long-term prognosis of a single tooth
because transitions in healing can appear in both directions. This
means that cases scored as 4 (without any symptoms) may successfully
heal during further follow-up.
A larger proportion of the MTA group had healed compared with
the GP group both at the 1-year follow-up and the 6-year follow-up
(79% vs 50% and 84% vs 55%, respectively). The longer the
follow-up, the more patients are lost to follow-up, and, consequently,
the power of the study will often be compromised. Because the current
study is a long-term follow-up of a previous RCT, it was not possible to
include more patients to enhance the power. Statistical analysis of
small sample sizes, as in the present study, has a limited power, and
therefore, estimation of outcome is uncertain with large confidence
intervals. At the 6-year follow-up, the difference in the proportion of
successful cases between MTA and GP was borderline statistically sig-
nificant (P = .04).
In the GP group, most unsuccessful cases failed because of a lack of
initial healing after surgery, whereas in the MTA group the cases healed
after surgery, but some were extracted later because of vertical root frac-
tures. It may be speculated that the use of ultrasonic retrograde prepa-
ration could be associated with a higher risk of vertical root fracture. It
has previously been shown that retrograde preparation with ultrasonic
instruments may induce microcracks in the apical dentin (44–46),
which in turn might be the starting point of a vertical root fracture.
An extended observation period could allow microcracks time to
develop into complete fractures. The possible influence of root-end
preparation on the long-term prognosis of SER needs further investiga-
tion, and the strategy of some studies excluding teeth with root fractures
from the analyses might be inappropriate (9, 11, 17, 19, 26, 27).
536 Kruse et al.
Endodontists generally agree that for the outcome of an apicec-
tomy to be predictable, a root-end filling has to be placed (30, 38).
The outcome of this study in the GP group in which only half the
cases were successful also indicates the value of a root-end filling.
The proportion of successfully healed cases was far below the propor-
tion in other clinical studies investigating the outcome of SER using
different types of root-end filling materials, reporting success rates of
68%–97% (6–8, 10–28). Only 1 clinical cohort study using Chelon-
Silver glass ionomer reported a low success rate of 31% (9). Studies
have shown that root fillings are prone to coronal leakage (47). The
high proportion of failing cases in the GP group may reflect that a tight
apical seal was not accomplished without a root-end filling.
The main strength of this study is the randomized controlled trial
design, which facilitates a comparison with other similar studies. This is
important in relation to small sample sizes as often found in clinical
studies with long-term follow-ups. Study design is crucial to allow for
pooling of data for meta-analysis, and the current literature agrees
that we need more and better designed studies regarding the outcome
of SER (23, 31, 36, 38).
Conclusion
The proportion of healed cases was larger in the MTA group than
in the GP group at both the 1-year and 6-year follow-up. Findings indi-
cate that 1-year follow-up may not be sufficient in assessing the long-
term outcome of surgical endodontic retreatment. With longer
follow-ups, other factors not directly related to the endodontic treat-
ment may be relevant for a successful outcome. This needs further
investigation in larger patient samples.
Acknowledgment
The authors acknowledge Prof. Michael Væth, Department of
Biostatistics, Department of Public Health, Health, Aarhus Univer-
sity, Denmark, for help with the statistical analysis and support
during preparation of the manuscript.
The authors deny any conflicts of interest related to this study.
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