Review Article
Outcome of Endodontic Surgery: A Meta-analysis
of the Literature—Part 3: Comparison of
Endodontic Microsurgical Techniques with
2 Different Root-end Filling Materials
Meetu R. Kohli, BDS, DMD, Homayon Berenji, DDS, DMD, Frank C. Setzer, DMD, PhD, MS,
Su-Min Lee, DDS, MS, DScD, and Bekir Karabucak, DMD, MS
Abstract
Introduction: The aim of the present study was to
investigate the influence of root-end preparation and
filling material on endodontic surgery outcome. A
systematic review and meta-analysis was conducted to
determine the outcome of resin-based endodontic
surgery (RES, the use of high-magnification preparation
of a shallow and concave root-end cavity and bonded
resin-based root-end filling material) versus endodontic
microsurgery (EMS, the use of high-magnification
ultrasonic root-end preparation and root-end filling
with SuperEBA [Keystone Industries, Gibbstown, NJ],
IRM [Dentsply Sirona, York, PA], mineral trioxide
aggregate [MTA], or other calcium silicate cements).
Methods: An exhaustive literature search was
conducted to identify prognostic studies on the outcome
of root-end surgery. Human studies conducted from
1966 to the end of December 2016 in 5 different
languages (ie, English, French, German, Italian, and
Spanish) were searched in 4 electronic databases
(ie, Medline, Embase, PubMed, and Cochrane Library).
Relevant review articles on the subject were scrutinized
for cross-references. In addition, 5 dental and medical
journals (Journal of Endodontics; International
Endodontic Journal; Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology,
and Endodontics; Journal of Oral and
Maxillofacial Surgery; and International
Journal of Oral and Maxillofacial Surgery)
were hand checked dating back to 1975. All abstracts
were screened by 3 independent reviewers (H.B.,
M.K., and F.S.). Strict inclusion-exclusion criteria were
defined to identify relevant articles. Raw data were
extracted from the full-text review of these selected
articles independently by each of the 3 reviewers. In
case of disagreement, an agreement was reached by
discussion, and qualifying articles were assigned to
From the Department of Endodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.
Address requests for reprints to Dr. Meetu R Kohli, Department of Endodontics, University of Pennsylvania, 240 S 40th Street, Philadelphia, PA 19104. E-mail address:
mkohli@upenn.edu
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.02.021
JOE — Volume -, Number -, - 2018
group RES. For EMS, the same search strategy was performed for the time frame
October 2009 to December 2016, whereas up to October 2009 the data were obtained
from a previous systematic review with identical criteria and search strategy. Weighted
pooled success rates and a relative risk assessment between RES and EMS were
calculated. To make a comparison between groups, a random effects model was
used. Results: Sixty-eight articles were eligible for full-text review. Of these, per strict
inclusion exclusion criteria, 14 studies qualified, 3 for RES (n = 862) and 11 for EMS
(n = 915). Weighted pooled success rates for RES were 82.20% (95% confidence
interval [CI], 0.7965–0.8476) and 94.42% for EMS (95% CI, 0.9295–0.9590). This
difference was statistically significant (P < .0005). Conclusions: The probability for
success for EMS proved to be significantly greater than the probability for success for
RES, providing best available evidence on the influence of cavity preparation with
ultrasonic tips and/or SuperEBA (Keystone Industries, Gibbstown, NJ), IRM (Dentsply
Sirona, York, PA), MTA, or silicate cements as root-end filling material instead of a
shallow cavity preparation and placement of a resin-based material. Additional
large-scale randomized clinical trials are needed to assess other predictors of outcome.
(J Endod 2018;-:1–9)
Key Words
Apicoectomy, calcium silicate cements, endodontic microsurgery, IRM, meta-analysis,
mineral trioxide aggregate, outcome, resin, Retroplast, root-end filling, root-end
surgery, success, SuperEBA, systematic review
E ndodontic root-end
surgery is a procedure
indicated for the treatment
Significance
Endodontic microsurgery with the use of high-
magnification ultrasonic root-end preparation and
of nonhealing apical peri-
root-end filling with SuperEBA, IRM, or MTA (sili-
odontitis after nonsurgical
cate cements) has a higher probability of success
retreatment or, in certain
than resin-based endodontic surgery with the use
situations, primary end-
of high-magnification preparation of a shallow
odontic therapy (1). The
concave root-end cavity filled with bonded resin-
procedure can address
based materials.
both intracanal and extra-
radicular infections that
may have contributed to the negative outcome of the previous treatment. Over the
course of time, there have been remarkable variations in the execution of endodontic
Outcome of Endodontic Surgery 1
Review Article
surgery. Apicoectomy was the classic term applied to the procedure,
which may or may not have included the preparation and filling of
the root-end cavity. Root-end surgery is the current terminology
used in the American Association of Endodontics Glossary of
Endodontic Terms that addresses endodontic surgery using
contemporary techniques, involving root-end preparation and
root-end filling, or other methods of retrograde sealing of the apically
resected root surface.
Various studies have described the outcome of endodontic surgery
irrespective of the techniques used (2–4). However, when cumulative
success rates were calculated depending on the surgical technique,
variations in outcomes become obvious. For the modern technique,
Tsesis et al (2009/2013) (3, 5) published 2 meta-analyses on the
outcome of endodontic surgery that used IRM, mineral trioxide
aggregate (MTA), or SuperEBA as root-end filling materials; ultrasonic
root-end preparation; and dental microscopes, endoscopes, or loupes
for visualization and magnification. The cumulative success rates were
91.9% (3) and 89.0% (5), respectively. In a 2-part investigation, Setzer
et al (6, 7) strictly defined endodontic microsurgery (EMS) as a
microsurgical approach to endodontic surgery using ultrasonic
root-end preparation; root-end filling with IRM, SuperEBA, or MTA
(calcium silicate cements); and the application of high-power
magnification >10 with a dental operating microscope or an
endoscope. The first study compared EMS with traditional root-end
surgery (TRS) using conventional burs for root-end preparation and
amalgam root-end fillings without the application of magnification
devices (7). The second meta-analysis (6) compared EMS with
contemporary root-end surgery (CRS), which is identical to EMS,
however, without the use of high-power magnification, relying only
on loupes or no magnification. Weighted pooled success rates from 9
studies for EMS were calculated to be 93.5% (95% confidence interval
[CI], 0.8889–0.9816; n = 699 teeth), 88% for CRS from 7 studies
(95% CI, 0.8455-0.9164, n = 610), and 59% for TRS from 12 studies
(95% CI, 0.55–0.6308, n = 925) from 12 studies. The differences
between EMS and TRS as well as between EMS and CRS were statistically
significant. Relative risk ratio analyses showed that the probability of
success for EMS was 1.58 times the probability of success for TRS
and 1.07 times the probability of success for CRS, the latter providing
the best available evidence for the improvement of outcome in
endodontic surgery using high-power magnification over loupes or
the naked eye.
Another method of the bonded resin-based endodontic surgery
(RES) to seal the root end after root resection was first described in
the literature by Rud et al (1991) (8) and more recently by von Arx
et al (2010) (9). Briefly, while using a microscope or endoscope for
the technical steps of the surgical procedure, the procedure differs
significantly from EMS by using a round bur to create a concave cavity
over the entire resected root surface instead of an ultrasonically pre-
pared axial root-end cavity within the root canal, and after etching
with EDTA, a bonded resin material (eg, Retroplast [Retroplast Trading,
Rorvig, Denmark] or Geristore [Den-Mat, Santa Maria, CA]) is placed
in a domelike fashion over the entire resected root surface instead of
IRM, SuperEBA, or calcium silicate cements. Although this technique
has been repeatedly described in the context of modern endodontic sur-
gery, so far no cumulative success rate or relative risk assessment in
comparison with other techniques has been described in the literature.
The primary aim of this systematic review and meta-analysis was to
assess the cumulative success rate of contemporary RES and to test the
hypothesis that there was no significant difference in the outcome in
comparison with EMS. Considering several recent publications, the
secondary aim of this investigation was to provide an update on the
expected outcome of EMS.
2 Kohli et al.
Materials and Methods
In order to control the methodologic quality and reporting bias,
the AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) tool
was reviewed (10) and the Preferred Reporting Items for Systematic
review and Meta-Analysis (PRISMA) Protocols checklist (11)
addressed. A provision for an a priori design was formulated to reduce
publication bias and create a transparent search process. Using the
PICO (Population, Intervention, Comparison, Outcome) format, the
following research question was formulated: Teeth that have undergone
a root-end surgery and root-end filling procedure (population) by EMS
(intervention) compared with RES (comparison) have what expected
probability of success according to longitudinal studies with strictly
defined inclusion and exclusion criteria (outcome)?
Identification of Studies
The materials and methods for this investigation are detailed in
part 1 and 2 of this publication for EMS (6, 7). To reiterate briefly, 4
electronic databases were searched for surgical prognosis-related
studies. The terms [(apicoectomy OR apicectomy OR root-end filling
OR root-end surgery OR retro-grade filling OR retro-grade surgery
OR periapical surgery OR periradicular surgery OR surgical
endodontic treatment OR apical microsurgery) AND (success OR
treatment outcome)] was applied for the EMS group, and the terms
[(endodontics) AND (retroplast)] was applied for RES to search the
Medline, Embase, PubMed, and Cochrane Library databases. Studies
were limited to human subjects and publication in any of the 5
languages (English, French, German, Italian, and Spanish). The
previous identical search for EMS for the time frame 1966 to the second
week of October 2009 was performed and combined with a new search
starting the second week of October 2009 to the end of December 2016.
The electronic database search for RES covered the time frame from
1966 to the end of December 2016. Five relevant scientific journals
(Journal of Endodontics; International Endodontic Journal; Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and
Endodontics; Journal of Oral and Maxillofacial Surgery; and
International Journal of Oral and Maxillofacial Surgery) were
hand searched back to 1975. Three independent reviewers (H.B.,
M.K., and F.S.) screened the identified titles and abstracts for inclusion
or exclusion from the study. In situations of disagreement or uncertainty
about the relevance of the article, a consensus was reached by
discussion. Full articles were obtained for titles wherein the abstract
did not provide adequate information to help make a decision. The
references of all these articles were searched for cross-references,
and the additional abstracts were subjected to the same reviewing
process. Three experts in the field were contacted to reveal possible
gray literature in the form of ongoing studies or consensus reports
by major endodontic societies.
Inclusion and Exclusion Criteria
The selection of studies was based on the following inclusion
criteria, which were modified from and defined in part 2 of the
meta-analysis (6):
1. Clinical study on root-end surgery
2. Sample size given
3. A minimum follow-up period of 1 year
4. Success and failure were evaluated using Rud et al’s (12) or Molven
et al’s (13) radiographic parameters and clinical assessment.
Radiographically, success was defined as either complete or
incomplete healing (scar tissue formation) and clinically by the
absence of pain, swelling, percussion sensitivity, or sinus tracts.
JOE — Volume -, Number -, - 2018
 Review Article
Failure included uncertain healing (reduction or same lesion size) 9. The success rate was not given, it was only reported for roots and
or complete failure (increase in lesion size) as determined from the data extraction, or success rate calculation for EMS or RES from
radiograph. Clinical failure was defined as the presence of any signs raw data was not possible.
and symptoms mentioned previously. 10. Root-end surgery performed with a technique or a combination of
5. Success and failure were evaluated per tooth. techniques that does not fit the specific criteria defined for EMS or
6. The overall success rate was given for the technique or could be RES
calculated from the raw data. 11. In vitro or animal study, case report, review article, or opinion
7. The method used in the study follow either EMS (modern article
microsurgical instruments and filling materials [microinstruments; 12. Studies based on a population that was part of an earlier
ultrasonic root-end preparation; or root-end filling with IRM, publication
SuperEBA, MTA, or similar calcium silicate cements] and use of 13. Publication in any other language than those mentioned in the
high-power magnification >10 with a dental operating microscope inclusion criteria
or endoscope) or RES (identical to EMS with the exception of
root-end preparation and root-end filling being placed in a concave
cavity preparation and resin-based materials). Data Extraction
8. Study limited to humans For RES, a total of 23 studies were included in full-text review.
9. Publication in English, French, German, Italian, or Spanish Nineteen articles were decided upon after excluding 169 irrelevant
The exclusion criteria and studies that did not meet the inclusion citations from the 188 citations obtained from the electronic database
criteria were excluded as follows as defined in part 2 of the search. Cross-referencing these publications and 6 other review articles
meta-analysis (6): and the hand search of the 5 relevant journals revealed an additional 4
publications of relevance, resulting in a total of 23 studies obtained for
1. Study did not evaluate the outcome of root-end surgery. full-text review (Fig. 1) (8, 9, 12, 14–33).
2. No sample size given For EMS, the original search up to the second week of October
3. Periapical lesions more than 10 mm in diameter 2009 returned a total of 1189 citations; 1088 were eliminated after title
4. Teeth presenting with periodontal involvement or apicomarginal and abstract review, and 101 were subjected to full-text analysis (6). A
defects or mobility total of 9 studies (34–42) fulfilled the inclusion criteria and allowed for
5. Use of guided tissue regeneration data extraction and calculation of weighted pooled success rates (6).
6. Surgery after previous endodontic surgery (resurgery cases), root The additional database search for EMS for the time period from
resections, amputations, and cases presenting with root fractures the second week of October 2009 to the end of December 2016 resulted
or perforations in 518 citations. Of these, 483 were excluded as irrelevant to the subject
7. Less than 1 year of follow-up after title or abstract review. The remaining 35 articles were obtained for
8. The outcome was not evaluated according to the success and full-text analysis. Cross-referencing of these publications and 9 review
failure criteria defined earlier. articles as well as the hand search of the 5 relevant journals revealed

Addional records idenfied through other

Records idenfied through database searching resources
(RES=188) (RES= 4)
(EMS= 518 ) (EMS= 10)

Records excluded aer

Records screened reviewing tle and
(RES= 192 ) abstracts
(EMS= 528 ) (RES= 169 )
(EMS=483)

Full-text arcles assessed for eligibility

(RES= 23 )
(EMS= 45)

Full-text arcles excluded,

Included studies with reasons
(RES= 3) (RES= 20 )
(EMS= 11 = 2 new + 9 from part2) (EMS= 43 )

Figure 1. A flowchart of the review search and identification.

JOE — Volume -, Number -, - 2018 Outcome of Endodontic Surgery 3

Review Article
an additional 10 publications of relevance to be reviewed by full-text

Nonrandomized prospective clinical

Prospective study with concurrent

Prospective study with concurrent

analysis (Fig. 1) (9, 14, 26, 27, 43–83).
Iqbal and Kim (84) proposed a criteria to assess the quality of

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

Randomized clinical trial

Retrospective case study
Retrospective case study
Retrospective case study
Retrospective case study
Prospective case study

Prospective case study

Prospective case study
studies included by describing them as best (randomized controlled
trial, double-blind), better (prospective study with concurrent

Study design

controls

controls
controls), good (prospective study with historic controls), average

trial
(prospective case study), fair (retrospective case study), or unknown
(study does not fit any of the previously described criteria or the attempt
of data extraction did not retrieve any information). The included
studies were appraised as per the protocol described previously
(Table 1).
Data extraction was performed for statistical analysis. The data
included the following: the sample size in teeth and roots; the
follow-up period; the use of inclusion and exclusion criteria for surgery;
the type of magnification; the type of root-end preparation; root-end
filling material; statistical methods; success in teeth and roots; the
reported success rate; success criteria; and the number of cases with

Success, n (%)
complete, incomplete, uncertain healing, and failure.

91 (96.8)
48 (88.9)

97 (89.8)
37 (94.9)
96 (93.2)
26 (92.9)

141 (95.2)

105 (91.3)
94 (93.1)

302 (83.4)
119 (79.9)
25 (100)
91 (91)

287 (82)
For the calculation of cumulative success rates, weights for the
individual studies were calculated as the inverse variance. To estimate
‘‘publication bias,’’ funnel plot analyses were performed as required
according to the AMSTAR checklist. Relative risk ratio and odds ratio
calculations for the EMS and RES groups were derived from a 2  2
contingency table.
Follow-up (months)
Statistical Analysis
SPSS v15.0 (SPSS Inc, Chicago, IL), Minitab v15.0 (Minitab Inc,
TABLE 1. The Studies Included in the Meta-analysis for Endodontic Microsurgery (EMS) and the Resin-based Technique

14
12

24
12
12
12
24
12-60

12
48-96
24
12
18
119
State College, PA), and Excel 2007 (Microsoft Corporation, Redmond,
WA) were used for all descriptive and inferential analyses. The power of
the study was estimated by using STATA v10 (StataCorp LP, College
Station, TX).

Results
Of the 45 new citations obtained for full-text review for EMS after
part 2, 2 studies fulfilled the inclusion criteria and allowed for data
Sample size (teeth)

extraction. The reasons for exclusion of the remaining 43 publications

are detailed in Table 2. The extracted data from the 2 selected
studies (47, 48) were combined with the data from the original 9
94
54

39

28

25
108

103

100
148

115
101
351
362
149
studies (34–41, 85) for statistical analysis, resulting in a total of 11
data sets for EMS. To avoid the reporting of redundant information,
the reasons for the exclusion of 92 studies for the search up to the
second week of October 2009 are not repeated and are available for
review in the original publication (6). Of the 23 citations obtained
for full-text review for RES, a total of 3 records (9, 32, 33) fulfilled
the inclusion criteria and allowed for data extraction. All 3 of these
Rubinstein & Kim, 1999 (39)

Christiansen et al, 2009 (38)

articles provided data for data extraction for RES as well as EMS
Taschieri et al, 2006 (36)

Taschieri et al, 2007 (42)

Taschieri et al, 2008 (34)
von Arx et al, 2003 (41)

Chong et al, 2003 (37)

von Arx et al, 2010 (9)

Fllippi et al, 2006 (40)

Song et al, 2014 (47)

(Table 1).
Rud et al, 1996 (32)
Rud et al, 1997 (33)
Kim et al, 2008 (35)

Li et al, 2014 (48)

As reported in part 1 of the meta-analysis (6), a remedial solution

was used for 1 EMS study (38) presenting with a success rate of 100%,
Study

The success rate was adjusted to 0.99 in order to calculate inverse

variance, which would have otherwise been left undefined for this study
(86). The combined sample size of all 11 studies in the EMS group was
n = 915 with a weighted pooled success rate of 94.42% (95% CI,
0.9295–0.9590). The total sample size of the 3 studies included in
RES was n = 862 with a final weighted pooled success rate of
82.20% (95% CI, 0.7965–0.8476). The individual weights and the
pooled success rates are shown in forest plots Figure 2. The funnel plots
for the assessment of publication bias of all studies included in the RES
EMS10
EMS11
Group

and EMS groups are shown in Figure 3.

EMS1
EMS2

EMS3
EMS4
EMS5
EMS6
EMS7
EMS8

EMS9

RES1
RES2
RES3

The relative risk ratio calculation indicated that the probability of

success for EMS was 2.55 times the probability of success for RES

4 Kohli et al. JOE — Volume -, Number -, - 2018

 Review Article
TABLE 2. The Excluded Studies with the Reason for Exclusion from the Meta- Discussion
analysis Based on the results of this study, the original hypothesis that the
Study Exclusion criteria contemporary RES showed no significant difference in outcome in
RES Rud and Andreasen, 1972 (20) 1 comparison with EMS was rejected. Although the RES group contained
RES Andreasen and Rud, 1972 (22) 1, 2 only 3 studies in comparison with 11 investigations in the EMS group,
RES Andreasen and Rud, 1972 (28) 1 the sample size and quality of the studies were comparable with each
RES Rud et al, 1972 (29) 1, 9, 10, 12 other (Table 1). The distinct differences in the 2 techniques may explain
RES Rud et al, 1972 (31) 10
RES Rud et al, 1972 (12) 10
the difference in outcome. The treatment objectives of endodontic
RES Rud et al, 1991 (21) 10 surgery are the excision of the periapical pathology, resection of the
RES Rud et al, 1991 (8) 1 root tip, and sealing of the root canal system. In standard situations,
RES Rud et al, 1996 (18) 12 EMS calls for a 3-mm root resection; a minimum 3-mm-deep
RES Rud and Rud, 1998 (23) 1 ultrasonically prepared class I root-end cavity; and a seal with
RES Rud et al, 2001 (17) 10
RES Jensen et al, 2002 (16) 3, 4, 10 root-end filling such as IRM, SuperEBA, MTA, or newer calcium silicate
RES Platt and Wannfors, 2004 (30) 10 cements (87, 88). These materials have similar reported success rates
RES Cantelmi et al, 2005 (19) 10 (37, 39, 89, 90). However, a meta-analysis to evaluate the difference in
RES Yazdi et al, 2007 (15) 3, 4 the success rates of these materials in relation to each other is needed to
RES von Arx et al, 2007 (24) 6
RES von Arx et al, 2007 (25) 10
make an informed decision to select the root-end filling material that is
EMS Christiansen et al, 2009 (49) 1 most effective.
EMS Moshonov et al, 2009 (50) 1 For RES, sealing of the resected root with bonded resin materials
EMS Pirani et al, 2009 (51) 1 has a different rationale. Here, the material is applied over the entire
EMS Walivaara et al, 2009 (52) 10 resected root surface, with the intent to seal it completely. This includes
EMS Taschieri and del Fabbro, 2009 12
(53) all patent dentinal tubules, potential isthmus or accessory canals, and
EMS Pantchev et al, 2009 (54) 10 the main canal (8, 9, 32, 33). The technique further differs from
EMS Penarrocha et al, 2009 (55) 8,10 EMS by the preparation of a shallow concavity on the resected root
EMS de Lange et al, 2009 (82) 10 surface by using a round bur rather than a class I cavity into the root
EMS Kahler, 2010 (56) 11
EMS von Arx et al, 2010 (9) 6
canal with an ultrasonic tip. The objective of the concave preparation
EMS Barone et al, 2010 (57) 10 is to increase the surface area for bonding and to provide bulk for
EMS Angiero et al, 2011 (58) 10 the resin material to compensate for shrinkage during setting and
EMS Taschieri et al, 2011 (59) 1, 11 polymerization (9, 16). To allow for proper bonding, the prepared
EMS Goyal et al, 2011 (81) 4 cavity is first etched and primed before the placement of the material
EMS Song et al, 2011 (80) 12
EMS/RES von Arx et al, 2011 (26) 12, 10 such as Retroplast or Geristore. An additional procedural step
EMS Taschieri et al, 2011 (83) 5 recommended by Rud et al (17) that should be repeated twice involves
EMS Waliavaara et al, 2011 (60) 10 a 2-minute waiting period after mixing the dentin bonding material on a
EMS Alister et al, 2011 (79) 9 mixing pad followed by using 96% ethanol on a miniature brush
EMS Dominiak et al, 2009 (61) 10
EMS von Arx, 2011 (62) 11
followed by a saline rinse to remove the air-inhibited, unpolymerized
EMS Song et al, 2012 (63) 12 layer on top of the material. The material is only then applied on the
EMS Song and Kim, 2012 (64) 6 resected root surface.
EMS/RES von Arx et al, 2012 (14) 12 Rud et al (17) reported a high success rate of 92% with this
EMS Penarrocha et al, 2012 (65) 10 procedure when evaluating 834 roots of molars over 6 months to
EMS Leiblich, 2012 (66) 1, 11
EMS Kreisler et al, 2013 (67) 10 12.5 years. However, a publication by Jensen et al in 2002 (16) using
EMS Penarrocha et al, 2013 (68) 8 Retroplast described a success rate of 73%. A possible explanation given
EMS Taschieri et al, 2013 (69) 8 by the authors is the technical complexity of the procedure that may allow
EMS Bryce et al, 2013 (70) 3 potential for iatrogenic mistakes if the procedure is not executed
EMS Gutmann et al, 2013 (71) 1, 11
EMS Villa-Machado et al, 2013 (72) 3, 5, 8, 10
correctly. Rud et al (17) also stressed that contamination with blood,
EMS Song et al, 2013 (73) 4, 6 tissue fluids, or saliva during the management of the resected root surface
EMS Kurt et al, 2014 (74) 10 step will require recontouring with the bur to remove contaminants and
EMS/RES von Arx et al, 2014 (27) 12 repetition of the etch/prime/bond procedure. Hence, like other dental
EMS Lui et al, 2014 (75) 5 bonding procedures in restorative dentistry, a completely dry field is
EMS Dhiman et al, 2015 (76) 4, 6
EMS Tawil et al, 2015 (77) 8 paramount, making hemorrhage control a critical step for success.
EMS Shinbori et al, 2015 (78) 5, 4, 8 Jensen et al in 2002 (16) partly attributed the 73% success rate to
EMS Caliskan et al, 2016 (45) 3, 6 inexperienced surgeons because the surgical procedures in this
EMS Kim et al, 2016 (43) 8 investigation were performed by residents with no prior experience.
EMS Kim et al, 2016 (44) 12
The majority of the failed cases showed a loosened or detached
EMS, endodontic microsurgery; RES, resin-based endodontic surgery root-end filling radiographically, leading the authors to conclude that
this was a result of either insufficient bonding between dentin and the
material and/or contamination during the etch/prime/bond process.
(relative risk = 2.5542; 95% CI, 1.9377–3.3669). The odds ratio However, in a nonrandomized prospective clinical trial by von Arx
showed that EMS had 2.89 times the odds of success than RES et al (9), a single experienced operator performed all the 353 surgeries,
(odds ratio = 2.892; 95% CI, 2.10753–4.00034). Chi-square analysis and even then, with a 1-year follow-up, EMS procedures with MTA as the
on the frequencies of success and failures between the 2 groups also root filling material performed statistically significantly better with a
indicated a significant difference (c21 = 47.73, P < .0001). 91.3% positive outcome than RES using Retroplast (only 79.5% were

JOE — Volume -, Number -, - 2018 Outcome of Endodontic Surgery 5

Review Article
Figure 2. Weighted pooled success rates and individual study weights for groups RES and EMS.
successful). It is worth considering that RES might be the only
promising solution in clinically compromised situations (eg, large posts
with little remaining apical tooth structure that does not allow for
adequate root resection and root-end filling).
The highest levels of evidence are routinely sought in evidence-
based medicine or dentistry to compare established procedures and
outcomes with new procedures or variations. Adequately powered
randomized controlled trials with minimal loss to follow-up are
considered the highest level of evidence for individual studies. However,
these studies remain a challenge because of the recruitment of a high
number of subjects or the inability to follow the entire sample
population over the long period prescribed for the investigation. The
6 Kohli et al.
costs to conduct such studies can be prohibitory too. To overcome
the lack of randomized controlled trials, systematic reviews and
meta-analyses have been used to provide the highest level of available
evidence. This meta-analysis reported weighted pooled success rates
for RES of 82.2%. However, evidence-based dentistry is not only
scientific data but also is defined by the American Dental Association
as an amalgamation of scientific data, patient’s preferences, and the
operator’s skill (91). Hence, from an evidence-based point of view, a
technique that is highly susceptible to iatrogenic errors or requires
more than average clinical skills to allow for successful outcomes
should be critically reevaluated for clinical recommendation.
Moreover, considering the great differences in the procedural steps
JOE — Volume -, Number -, - 2018
 Review Article
if periodontally, endodontically, or restoratively compromised,
demonstrate higher survival rates than dental implants (93). Based
on this and other information, a new consensus exists that natural teeth,
if restorable, should preferably be used as abutment units rather than
replaced by dental implants.
This meta-analysis provided the best available evidence on the
probability of success for RES (82.20%) and an update on the
probability of success for EMS (94.42%). The difference in outcome
was statistically significant, including large combined sample sizes for
each group. The systematic review of the literature also showed that
there is a higher sensitivity in the technical execution of RES. It has to
be remarked that other factors such as periodontal defects or
restorative issues also influence the outcome of endodontic surgery
(35). All studies included in this meta-analysis based their outcome
evaluation of surgery of teeth with true endodontic lesions and not
combined endodontic and periodontal defects. Kim et al (35)
showed that in teeth undergoing surgery with combined endodontic-
periodontal lesions (microsurgical classification D–F [87, 88]) the
outcome was significantly lower (77.5%) than for teeth with true
endodontic lesions (95.2%) (microsurgical classification A–C).

Conclusion
The summation of these data and the results of the current
meta-analysis suggest that the 2 techniques are not just different in
execution but also yield different results. The probability for success
for EMS proved to be significantly greater than the probability for
success for RES, providing best available evidence on the influence of
cavity preparation with ultrasonic tips and/or IRM/MTA/Super EBA as
root end filling material instead of a shallow cavity preparation and
placement of a resin composite. Large-scale randomized clinical trials
for statistically valid conclusions for current endodontic questions are
needed to make informed decisions for clinical practice.

Ms. Minjee L Cho in data assimilation and crosschecking values
for accuracy.
Figure 3. A funnel plot for the assessment of publication bias.
between RES and EMS, these entirely different procedures should not be
combined for the purpose of calculation of weighted pooled success
rates.
By example, in a recent systematic review and meta-analysis, a
comparison of treatment outcomes was made between tooth retention
through EMS and tooth replacement with single implants (92). The
study addressed short-term (2–4 years) and long-term follow-up
periods (6+ years) (tooth replacement with single implants). It was
reported in the results that single implant restorations had higher
long-term survival rates than teeth treated by endodontic surgery.
This statement was based on 1 clinical investigation of endodontic
surgery in the 6+-year group, which included both EMS with
ultrasonically prepared MTA root-end fillings (86.4%) as well as RES
using the Retroplast technique (75.3%) (14). The conclusion that
the long-term outcome of microsurgical endodontics was significantly
lower than the short-term outcome after 1 year or that of
single-implant restoration may have largely resulted from an outcome
bias related to the lower outcome rates of RES. It has also
become evident by long-term data >15 years that natural teeth, even
Acknowledgments
The authors appreciate the support of Ms. Anya Kohli and
The authors deny any conflicts of interest.
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