Journal of the Formosan Medical Association (2019) 118, 1055e1061

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journal homepage: www.jfma-online.com

Original Article

Outcome assessment of apical surgery:

A study of 234 teeth
Wan-Chuen Liao a, Yuan-Ling Lee a,g, Yi-Ling Tsai a,g,
Hseuh-Jen Lin b, Mei-Chi Chang c,d,***, Shu-Fang Chang e,
Shu-Hui Chang f,**, Jiiang-Huei Jeng a,*

a
Department of Dentistry and School of Dentistry, National Taiwan University Hospital and National
Taiwan University Medical College, Taipei, Taiwan
b
Department of Dentistry, Show Chwan Memorial Hospital, Chang Hua, Taiwan
c
Chang Gung University of Science and Technology, Kwei-Shan, Taoyuan City, Taiwan
d
Department of Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan
e
Department of Dentistry, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
f
Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei,
Taiwan

Received 5 October 2018; received in revised form 24 October 2018; accepted 26 October 2018

KEYWORDS Background/Purpose: Apical surgery is an option for management of endodontically-treated

Apical surgery; tooth with persistent periapical lesions or symptom and sign. The objective of this study
Healed rate; was to investigate the correlation between the demography, preoperative, postoperative fac-
Clinical tors and healed rate of apical surgery.
characteristics; Methods: Subjects were retrospectively collected from patients who received apical surgery/
Lesion size; apicoectomy at the Endodontic Department, National Taiwan University Hospital from January
Follow-up period 2013 to June 2015. The standard apical surgery procedures were performed. The demography,
preoperative clinical and radiographic examination data as well as postoperative variables
were collected. The outcome assessment was carried out after surgery. Statistical analysis
was performed by chi square test to evaluate the potential outcome predictors.
Results: Total 187 patients and 234 teeth receiving apical surgery were included. 53 male and
134 female patients were collected. The age was ranged between 17 and 89 years old and the
mean age was 43.64 years old. Better healed rate with significant differences were observed in
female patient (p < 0.05), age 60 years old (p < 0.01), preoperative root canal filling
material >2 mm short of apex (p < 0.01), lesion size from 2 mm to 12 mm (p < 0.05)
and follow-up period S12 months (p < 0.01) groups.

* Corresponding author. School of Dentistry and Department of Dentistry, National Taiwan University Medical College, Taipei, Taiwan.
** Corresponding author. College of Public Health, National Taiwan University Hospital, No. 1, Chang-Te Street, Taipei 100, Taiwan.
*** Corresponding author. Chang-Gung University of Science and Technology, 261, Wen-Hua 1st Road, Kwei-Shan, Taoyuan City, Taiwan.
E-mail addresses: mcchang@mail.cgust.edu.tw (M.-C. Chang), jhjeng@ntu.edu.tw (J.-H. Jeng).
g
This author makes an equal contribution to the first author.

https://doi.org/10.1016/j.jfma.2018.10.019
0929-6646/Copyright ª 2018, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1056 W.-C. Liao et al.

Conclusion: Gender, age, preoperative root canal filling material extent, lesion size and
follow-up period may affect the outcome of apical surgery. Tooth type, post, prosthesis,
and lesion area showed no marked effect on apical healing. These results provide more
detailed information for the clinical practitioners to make treatment plans and are important
for clinical endodontic practices.
Copyright ª 2018, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction and cases with absence or size 5 mm of periapical lesion

Apical surgery is an option for the management of
endodontically-treated tooth with persistent periapical le-
sions or symptom/sign. Several epidemiological studies
have suggested that 33e60% of endodontically-treated
teeth still presented the pictures of apical periodontitis.1
The possible causes may be persistent primary infection,
secondary infection after endodontic therapy,2 vertical
root fracture or cemental tears.3,4 Nonsurgical retreatment
is preferable as the first choice for management of teeth
with symptoms/signs, apical lesions and prior root canal
treatment.5,6 However, there were some limitations
restricting the possibility of nonsurgical root canal
retreatment, e.g., obstructed canal pathway, irretrievable
materials within the root canal and persistent symptoms,
which could not be resolved even after the meticulous
performance of nonsurgical treatment, persistent pain or
swelling/sinus tract even after endodontic treatment and
re-treatment.7 For above reasons, apical surgery can be
conducted to preserve the affected teeth.6
The success rate of apical surgery was reported to range
from 37% to 91%.8 Complete apical healing had been
observed in 37%e96% of the endodontically-treated teeth
after apical surgery.9 The wide range and inconsistency of
the results may be attributed to the variation in treatment
planning, surgical technique, methodology, and follow-up
period.10 Endodontic microsurgery was introduced and
recommended in the 1990s with advanced equipment and
material. The healed rate of apical lesion was improved to
80e90% of cases after surgery.11 In addition to the advances
of surgical instruments and techniques, appropriate case
selection is also important for success. The type of root-end
filling material was the most commonly studied issue.
However, there are still many other potential prognostic
factors that would affect the outcome of apical surgery and
await further investigation.
Several prognostic factors of apical surgery have been
proposed. A retrospective study examined 491 teeth and
evaluated the outcome of the endodontic microsurgery at
least 1 year after the operation. The authors suggest that
the potential prognostic factors are gender, tooth position,
lesion type, and root-end filling material.6 A prior meta-
analysis study has evaluated the prognosis of apical sur-
gery with root-end filling. The prognostic factors are
further divided into patient-related, tooth-related, or
treatment-related categories. The results concluded that
within tooth-related factors, cases without preoperative
pain or signs, cases with good density of root canal filling,
showed significantly higher healed rates. As for the
treatment-related factors, cases treated with the use of an
endoscope presented higher healed rates.11 In a prospec-
tive cohort study, the 4- to 10-years follow-up of treatment
outcome of apical surgery was assessed. Total 134 teeth
with 85% recall rate were further examined. The results
showed that in subjects >45 years old, teeth with inade-
quate root-filling length, and crypt size 10 mm presented
better clinical outcome.10 The other 5-year longitudinal
study evaluated the prognosis of 170e194 teeth 5 years
after apical microsurgery. The predictors were also grouped
into patient-, tooth-, and treatment-related variables for
analysis. The study suggested that outcome of apical sur-
gery was significantly impacted by the interproximal bone
levels and the materials used for root-end filling.12 With
regard to the previous study, the prognostic factors of the
apical surgery still did not meet a consensus. Further
studies related to the analysis of prognostic factors are
needed for clinician’s reference and to assist the treatment
considerations during clinical practice.
The objectives of this study were to investigate the
correlation between the demography, preoperative, post-
operative factors and the healed rate of apical surgery.
Patients receiving apical surgery were collected and used
for further outcome assessment evaluation and statistical
analysis. The outcome-predicting value may provide the
clinicians with better evaluation and treatment planning
before apical surgery in the future.
Material and methods
Case selection
By the approval of Ethics Committee, National Taiwan Uni-
versity Hospital, subjects in this study were retrospectively
collected from patients who received apical surgery with
apicoectomy at the Endodontic Department, National Taiwan
University Hospital from January 2013 to June 2015. Teeth
with crack or fracture detected during surgical procedures,
teeth receiving other endodontic surgery (auto-trans-
plantation, hemi-section, root amputation and intentional
replantation . etc.), and re-surgery cases were all excluded.
Treatment protocol
The standard apical surgery procedures operated at the
Endodontic Department, National Taiwan University
Factors for the outcome of apical surgery 1057

Hospital were described as the followings. Preoperative Evaluated factors

periapical radiograph was taken using a parallel tech-
nique. Local anesthesia was administered and followed by The evaluated factors were divided into demographic,
flap elevation. Surgical curette was used to enucleate the preoperative and postoperative factors. Demographic fac-
pathologic tissue and identify the root apex with/without tors included gender and age of the patients. Preoperative
prior osteotomy. The apical 3 mm of the root was resected clinical factors included tooth type and prosthesis status.
perpendicularly to the long axis of the tooth with no or Preoperative radiographic factors included the apical
minimal bevel. The root apex and root surfaces before and extent of root canal filling, lesion size, bony destruction
after root-end resection was carefully inspected and pattern and the presence or absence of post. Postoperative
observed under a surgical microscope (Zeiss OPMI Proergo, factor included follow-up period.
Surgical microscope, Germany). The root-end cavity was
prepared with ultrasonic micro-tips and filled with retro- Follow-up examination and assessment of outcome
grade materials. Flaps were repositioned and sutured.
Periapical radiograph was taken after surgery using the
The patients were usually followed-up at 1, 3, 6, and 12
parallel technique. Antibiotics and analgesics medication
months and every 6 months thereafter. Clinical and radio-
were prescribed. Follow-up appointments were arranged.
graphic examinations were performed at each recall. The
outcome assessment was carried out after the surgery. If
the evaluated tooth presented with subjective discomfort,
Collection of clinical and radiographic examination swelling, sinus tract formation or loss of function, then the
data tooth was classified as clinical failure. The radiographic
healing pattern was categorized according to the classifi-
The collected demography, preoperative clinical examina- cation proposed by Molven and Rud as followed: complete
tion data, preoperative radiographic examination data and healing, incomplete healing, uncertain healing, and un-
postoperative variables were listed as the followings. The satisfactory healing.13,14 The radiographic evaluation of a
rationale of grouping the recorded information was based multirooted tooth was classified according to the worst-
on several published researches.6,10,12 appearing root.12 Teeth were grouped under “healed”
when presenting with complete or incomplete healing
C Demography without clinical failure. Teeth were grouped under “not
- Gender healed” when presenting with uncertain or unsatisfactory
- Age healing or with clinical failure despite the radiographic
C Preoperative clinical examination data evaluation results.
- Tooth type The radiographic interpretation was carried out by 1
A Maxillary anterior tooth endodontic specialist twice with 1 month interval. The
A Maxillary premolar tooth agreement of the intraexaminer reliability in evaluating the
A Maxillary molar tooth apical extent of root canal filling, lesion size and post-
A Mandibular anterior tooth operative radiograph outcome were calculated and pre-
A Mandibular premolar tooth sented. Result conflicts were resolved by discussing and
A Mandibular molar tooth reaching a consensus with another endodontic specialist.
- Prosthesis status
A Present Analyses of data
A Absent
C Preoperative radiographic examination data
The previous described data were listed in tables and pre-
- Apical extent of root canal filling
sented with case numbers and percentage. Statistical
A 0e2 mm short of apex
analysis was performed by the chi square test using the R
A >2 mm short of apex
Studio Version 0.99.902 (The R Foundation for Statistical
A Beyond apex
Computing, Vienna, Austria) to evaluate the potential
- Lesion size
outcome predictors. Significant difference was at the level
A 5 mm
of p < 0.05.
A >5 mm
- Bony destruction pattern
A Apical Results
A Apicomarginal
- Post status Total 187 patients and 234 teeth receiving apical surgery
A Present were included in this study. Most of the patients were fe-
A Absent male (71.66%) and aged between 20 and 59 years old
C Postoperative variable (86.11%).
- Follow-up period Preoperative clinical examinations demonstrated that
A <6 months most of the cases were maxillary teeth (82.91%), maxillary
A 6e11 months anterior teeth (63.68%) and without prosthesis (51.71%)
A 12 months (Table 1).
1058 W.-C. Liao et al.

canal filling, lesion size and postoperative radiograph

Table 1 Distribution of demography, preoperative clinical
outcome was ranged from 92% to 96% (Table 2).
and radiographic examination data and postoperative vari-
Table 3 showed the correlation between the demog-
ables in this study.
raphy, preoperative and postoperative features and
Category Case number Percentage the healed outcome after apical surgery. With regard to
Demography the factors examined, female with 49.70% healed rate
Gender (p < 0.05), patients aged 60 years old with 48.79% healed
Male 53 28.34% rate (p < 0.01), preoperative root canal filling material
Female 134 71.66% >2 mm short of apex with 56.10% healed rate (p < 0.01),
Age lesion size from 2 mm to 12 mm (p < 0.05) and follow-up
10e19 3 1.60% period S12 months with 63.83% healed rate (p < 0.01) have
20e29 30 16.04% better outcome after apical surgery, whereas tooth type,
30e39 47 25.14% post, prosthesis, and bony destruction pattern showed little
40e49 40 21.40% association with the healing of apical bone fill.
50e59 44 23.53%
60e69 13 6.95%
70e79 7 3.74% Discussion
80e89 3 1.60%
Preoperative clinical examination The effect of demographic factors on apical surgery was not
Tooth type consistent in previous literature. A meta-analysis study
Maxillary anterior tooth 149 63.68% reported that age and gender of the patient did not present
Maxillary premolar tooth 33 14.10% significant difference in the treatment outcome.11 A
Maxillary molar tooth 12 5.13% retrospective study suggested that younger patients in their
Mandibular anterior tooth 17 7.26% 20s showed the highest success rate (6). Another long-term
Mandibular premolar tooth 8 3.42% study found a higher success rate with significant difference
Mandibular molar tooth 15 6.41% in patient older than 45 years old.10 The cutoff ages of
Prosthesis patients for analysis categories varied in different studies,
Present 113 48.29% such as 40, 41 or 45 years old.11 In this study, patient
Absent 121 51.71% younger than 60 years old presented higher healed rate
Preoperative radiographic examination with statistically significant difference. The actual cause
Apical extent of root canal filling may need further research with biologic basis.10 From the
0e2 mm short of apex 135 57.70% clinical perspective, apical surgery could still be considered
>2 mm short of apex 82 35.04% as a treatment option also in older patients. It seems that
Beyond apex 17 7.26% accomplishing a bacterial-tight apical sealed status during
Lesion size apical surgery was more important than advanced age.11
5 mm 88 37.61% One research proposed that male patient presented
>5 mm 146 62.39% poorer success rate, but the differences may be caused by
Bony destruction pattern the sample discrepancy.6 In this study, female patients also
Apical 229 97.86% showed better healed rate with significant difference in
Apicomarginal 5 2.14% the outcome of apical surgery when comparing to male
Post patients.
Present 95 40.60% For the preoperative clinical factor, maxillary and
Absent 139 59.40% mandibular anterior teeth were reported to present higher
Postoperative evaluation healed rates, which may reach 85%, and the mandibular
Follow-up period molars with a relatively lower healed rate. This results may
<6 months 38 16.24% relate to the access for surgical approach, complexity of
6e11 months 55 23.50% root canal anatomy, presence of isthmus, axis of root canal
12 months 141 60.26% preparation etc.6,11 However, different tooth types did not
present significant difference in this study, which may be
due to the cases were not equally distributed within the
groups and more cases should be analyzed in the future.
Preoperative radiographic examinations showed that
most of the cases with the apical extent of root canal filling
at the position of 0e2 mm short of apex (57.70%), lesion
size >5 mm (62.39%), bony destruction pattern confined Table 2 Intraexaminer reliability in evaluating preoper-
within apical area (97.86%) and without post (59.40%). ative and postoperative radiographs outcome.
Postoperative follow-up period displayed that most of
the patients returned for evaluation after 1 year (12 Factors Agreement (%)
months, 60.26%). Table 1 listed the detailed distribution of Apical extent of root canal filling 92%
demography, preoperative clinical and radiographic exam- Lesion size 96%
ination data and postoperative variables. The intra- Postoperative radiograph outcome 96%
examiner agreement value for the apical extent of root
Factors for the outcome of apical surgery 1059

healed rate when compared with the other groups. The

Table 3 Demography, preoperative and postoperative
surgical procedures could remove the infected portion of
features and the healed outcome after apical surgery
the root to achieve successful results.6,10 Another study
related to potential outcome predictors.
suggested the length of root canal filling did not show
Variables 1-year follow-up significant difference, but the density of the filling ma-
n Healed % healed p value terial was found as a significant prognostic factor.11 In
this study, the apical extent of root canal filling did
Demography
present significant difference between the groups. One
Gender
study indicated that the preoperative radiographs with
Male 65 22 33.85% 0.0417
lesion size smaller than 5 mm showed a significantly
Female 169 84 49.70%
higher healed rate when compared with lesion larger
Age
than 5 mm. The results may be closely related to the fact
40 years old 107 45 42.06% 0.4336
that healing time for larger lesion usually takes longer
>40 years old 127 61 48.03%
period. Another possible reason may be the smaller
45 years old 128 59 46.09% 0.8915
lesion required surgical enlargement of the bone cavity,
>45 years old 106 47 44.34%
thus thoroughly remove the pathologic tissue with sub-
60 years old 207 101 48.79% 0.0057
sequent better outcome. Also, as the fresh osseous
>60 years old 27 5 18.52%
wound was created during the surgery, the procedure
Preoperative clinical examination
may activate new bone formation.11 In this study, we
Tooth type
found that preoperative lesion size from 2 mm to
Maxillary anterior 149 69 46.31% 0.3947
12 mm showed a higher healed rate with significant
Maxillary premolar 33 14 42.42%
difference. Teeth with apicomarginal defect may have an
Maxillary molar 12 6 50.00%
adverse effect on the outcome of apical surgery and
Mandibular anterior 17 7 41.18%
were usually excluded from the assessment.6 In this
Mandibular premolar 8 1 12.50%
study, only 5 cases presented apicomarginal defect, so
Mandibular molar 15 9 60.00%
the data may not be sufficient to make a conclusion or to
Prosthesis
reach significant difference. The presence or absence of
Present 113 56 49.56% 0.2571
a post did not prove to be a significant prognostic factor
Absent 121 50 41.32%
in a study with total 1273 cases.11,15 In this study,
Preoperative radiographic findings
operated tooth with or without post also did not show
Apical extent of root canal filling
significant difference in the outcome. According to a
0e2 mm short of apex 135 57 42.22% 0.0081
meta-analysis and a review study, the length of the post
>2 mm short of apex 82 46 56.10%
may be more important than the existence of a post. A
Beyond apex 17 3 17.65%
long post would impede the operator to perform standard
Lesion size
root-end resection of 3 mm and root-end filling of 3 mm.
1 mm 10 7 70.00% 0.2008
Thus, the post length would directly impact the proced-
>1 mm 224 99 44.20%
ure of root-end preparation, which was a crucial step to
2 mm 20 15 75.00% 0.0106
remove the infected root portion and to achieve a tight
>2 mm 214 91 42.52%
apical seal.11,15
12 mm 200 97 48.50% 0.0279
Evaluating the outcome of apical surgery at the timing of
>12 mm 34 9 26.47%
1 year after the surgery was commonly adopted in most of
13 mm 214 101 47.20% 0.0945
the studies.16e20 In a prospective clinical study of
>13 mm 20 5 25.00%
comparing the Mineral Trioxide Aggregate and IRM in end-
Bony destruction pattern
odontic surgery, the author suggested that the information
Apical 229 104 45.41% 1
of healing result was revealed 1 year after the surgery
Apicomarginal 5 2 40.00%
which was confirmed by longer follow-up period. Thus, the
Post
outcome after 1 year could be considered as a predictor for
Present 95 45 47.37% 0.6951
treatment prognosis.21 A long-term study of 5 years follow-
Absent 139 61 43.88%
up after apicoectomy reported that assessing the outcome
Postoperative
after 1 year was valid in more than 95% of the cases. Most of
Follow-up period
the 5-year follow-up results could be predicted at the
<6 months 38 2 5.26% <0.01
particular time of 1 year after the surgery.22 The short-term
6e11 months 55 14 25.45%
outcome of apical surgery did not overestimate the success
12 months 141 90 63.83%
rate of the surgery.23
Bold indicate statistically significant difference between groups The exact success rate of different long-term follow-up
(p < 0.05). studies showed conflicting results. In a study of 477 teeth
receiving periapical surgery, the author collected the data
from 1 year up to 8 years after the surgery. The results
For preoperative radiographic factor, root-filling showed that the overall success rate was 87.2%, which was
length prior to surgery is suggested to be an outcome higher than the 80.9% at the 1-year follow-up appointment.
predictor as reported in previous literature. Teeth with Cases with incomplete or uncertain healing 1 year after the
filling length >2 mm short of apex presented higher surgery may end up with complete or unsatisfactory healing
1060
over time.24 However, the success rate of the apical surgery
declined with time in some other studies.22,25e28 The au-
thors concerned that the short follow-up period did not
observe the deteriorating of the treated teeth 1e2 years
after the surgery.10 The disease may recur in 5%e25% of
the healed cases within 4 years after the surgical
treatment.22,26e29 Thus, some concluded that the long-
term success rate was expected to be reduced when
comparing to short-term studies. According to Molven
et al., they proposed that cases classified as uncertain after
1 year follow-up might be unpredictable and needed longer
recall for final outcome assessment.13,30 The authors sug-
gested that for those uncertain healing cases, another
regular follow-up to 3 years was indicated.14,31
In this study, the follow-up period was categorized into
three groups. The low healed rate in the 6 months and
6e11 months categories may be resulted from insufficient
time for healing. Thus, according to the methodology of
other studies and the result of this study, assessing the
outcome of the apical surgery at the point of 1 year after
the operation might be appropriate.16e20 The limit of this
study included that there would be reduced incentive for
the patient to return for recall appointment as the symp-
tom and sign subsided after the surgery.23 Thus, the overall
healed rate in this study might be underestimated. More
cases should be collected and analyzed to know whether
different retrofilling materials or grafting with/without GTR
may affect the treatment outcome. Moreover, long-time
follow-up evaluation results of apical surgery should also
be conducted.
To sum up, female patient, age 60 years old, pre-
operative root canal filling material >2 mm short of
apex, lesion size from 2 mm to 12 mm and follow-up
period S12 months showed a higher healed rate after
apical surgery. Tooth type, post, prosthesis, and lesion
area did not present marked effect on healing of apical
lesion. Although definite conclusions could not be made
arbitrarily, this study still provided important and
valuable information for the endodontic practice.
Additional long-term studies were still important for
comparison and provided more reliable treatment
considerations.
Conflict of interest
The authors denied any conflict of interest for this
submission.
Acknowledgments
This study is supported by grants from the Ministry of Science
and Technology (MOST106-2314-B-002-034-MY2, MOST106-
2314-B-002-033-MY2, MOST 104-2314-B-255-010-MY3,
NSC100-2314-B-002-09, NSC100-2314-B-002-94), Taiwan; Na-
tional Taiwan University Hospital (NTUH 101-S1862, 102-
S2180, 103-S2368, 104-S2658, 106-S3467, 106-UN-001) and
Chang Gung Memorial Hospital, Taipei, Taiwan
(CMRPF1G0101, CMRPF3E0023, CMRPF1F0071, CMRPF3E0021,
CMRPF3E0022, NMRPF3C0093, NMRPF3C0062, NMRPF3C0061,
NMRPF3C0091, NMRPF3E0041, NMRPF3E0042, NMRPF3E0043).
W.-C. Liao et al.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jfma.2018.10.019.
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