A study of clinical outcome in apicectomies with or without root-end filling

Abstract

Background: To study and compare the clinical outcome in apicectomy with or without root end
filling.

Materials & Methods: Over a span of 1 year, a total of 40 subjects who exhibited clinical and
radiological signs of pulpal and periapical issues exceeding 5mm and necessitating apicectomy
were enrolled into two study groups, namely Group A and Group B. The results were analysed
using SPSS software.

Results: A total of 40 participants were initially enrolled in the study. The ages of the patients
ranged from 20 to 60 years, with the majority falling within the 21-31 years age group. Notably,
19 out of 28 teeth treated without root-end filling showed successful outcomes, whereas 8 out of
12 teeth treated with apicectomy and retrofil demonstrated success.

Conclusion: No substantial disparity was observed when comparing the outcomes of apicectomy
procedures conducted with or without root-end filling.

Keywords: Apicectomy, retrofil, periapical.

Introduction

Endodontic treatment is usually performed in teeth with periapical lesions.1 In some cases, root
canal treatment can result in failure. The main factors of endodontic failure are microbial
infection in the root canal system and/or the periradicular area.2,3 The clinician thinks that the
direct causes of endodontic failures are procedural errors such as broken instruments,
perforations, overfilling, underfilling, and ledges. 3 Nevertheless, there are some cases in which
the treatment has followed the highest technical standards and yet treatment can result in failure. 3
They include microbial factors, comprising extraradicular and/or intraradicular infections, and
intrinsic or extrinsic nonmicrobial factors. 3 In case of failure, one of the treatment choices is
retreatment by an orthograde approach.1 However, when a nonsurgical attempt proves
unsuccessful or is contraindicated, surgical endodontic therapy is indicated to obtain an apical
seal and save the tooth. 1,3,4

Apicoectomy has been recommended as a retreatment procedure after endodontic failure. 5

However, apicoectomy, as the first choice of treatment for non-vital incisors with large
periapical defects has seldom been documented. In our patient, mineral trioxide aggregate
(MTA) was used to obtain the apical seal. It has been known for its outstanding tissue
compatibility, and has been found to promote periradicular healing and the production of
cementum and bone. 6,7 Fluoride treatment was done for the exposed root surface following
apicoectomy, to prevent root resorption owing to loss of predentine or precementum due to
surgical heat liberation, irregular cutting or the presence of micro-organisms.8 When appropriate,
conventional, nonsurgical re-treatment efforts are directed to target deficiencies or repair of
pathogenic and iatrogenic defects. Non-surgical management of endodontic failures have
recorded high success rates and is favored due to less discomfort and morbidity in comparison
with periradicular surgery. 9 However, when periradicular lesions with diameter>5mm are
present, lower success rates have been recorded with non-surgical approach. Surgical endodontic
management of periradicular lesions is resorted to when conventional endodontic therapy is not
indicated, impossible or unsuccessful. 10 Traditionally, apicectomy procedure involves placing a
root-end filling following apical resection which is favored by some authors, while others
support adequate cleaning and obturation of the canal, followed by apical resection without root-
end filling as the treatment of choice. 11,12

Apicoectomy is a surgical procedure that requires incision, root resection, root-end cavity
preparation associated with a retrograde/root-end filling and closure. 13 Apicoectomy is one of
the most used surgical treatments in endodontics, because it can prevent tooth extraction, by
eliminating the pathological tissues around the apical third of the root. 14 Also, there are several
types of dental materials that can be used as a root-end filling, in order to seal the apical surface,
each having its advantages and disadvantages. 13 Hence, this study was conducted to compare the
clinical outcome in apicectomy with or without root end filling.

Materials & Methods:

Over a span of 1 year, a total of 40 subjects who exhibited clinical and radiological signs of
pulpal and periapical issues exceeding 5mm and necessitating apicectomy were enrolled into two
study groups, namely Group A and Group B. In Group A, apicectomy procedures were carried
out without root-end filling, whereas in Group B, apicectomy procedures included root-end
filling. After a year, all subjects were scheduled for a follow-up assessment, involving both
clinical examinations and radiological evaluations. The results were analysed using SPSS
software.

Results:

A total of 40 participants were initially enrolled in the study. However, for the analysis, data
from 30 patients who attended the recall visit at the 12-month mark and provided complete
radiographs were included. The ages of the patients ranged from 20 to 60 years, with the
majority falling within the 21-31 years age group. Additionally, a significant proportion of the
participants were male. In total, 40 teeth were subjected to treatment, with 12 of them receiving
root-end filling and 28 without such filling. Among the teeth that underwent apicectomy,
maxillary incisors were the most commonly treated. Notably, 19 out of 28 teeth treated without
root-end filling showed successful outcomes, whereas 8 out of 12 teeth treated with apicectomy
and retrofil demonstrated success.

Table 1: Treatment outcome according to gender

 Gender Successful (n) Doubtful (n) Total teeth treated N
Male (22) 19 3 28
Female (8) 8 0 12
Total (30) 27 3 40

Table 2: Treatment outcome at follow up a year

Treatment Number of teeth Successful Doubtful Failure

Apicectomy 28 19 1 0
without
retrograde filling
Apicectomy with 12 8 2 1
retrograde filling
Total 40 27 3 1

Discussion:

Apical surgery belongs to the field of endodontic surgery that also includes incision and
drainage, closure of perforations, and root or tooth resections. The objective of apical surgery is
to surgically maintain a tooth that has an endodontic lesion which cannot be resolved by
conventional endodontic (re-)treatment. 15 This goal should be achieved by root-end resection,
root-end cavity preparation, and a bacteria-tight closure of the root-canal system at the cut root
end with a retrograde filling. In addition, the periapical pathological tissue should be completely
debrided by curettage in order to remove any extraradicular infection, foreign body material, or
cystic tissue. Apical surgery has greatly benefited from continuing development and introduction
of new diagnostic tools, surgical instruments and materials, making this method of tooth
maintenance more predictable. Success rates approaching 90% or above have been documented
in several clinical studies. Hence, this study was conducted to compare the clinical outcome in
apicectomy with or without root end filling.

In the present study, a total of 40 participants were initially enrolled in the study. However, for
the analysis, data from 30 patients who attended the recall visit at the 12-month mark and
provided complete radiographs were included. The ages of the patients ranged from 20 to 60
years, with the majority falling within the 21-31 years age group. Additionally, a significant
proportion of the participants were male. A study by Ajayi JO et al, studied 35 out of 53
recruited patients reported for 12 month re-call visit. Two were excluded because of missing
baseline radiographs. 33 patients that reported at 12months recall visit with complete radiographs
were used for analysis. Patients age ranged from 16 - 66 years, with those in age group 21 - 30
years predominant, Majority (57.6%) were males. Forty teeth were treated, 14 had root - end
filling and 26 without root - end filling. Maxillary incisors were the most frequently
apicectomized teeth. 32 (80%) out of 40 apicectomized teeth were successful, 14 (88.5%) out of
26 teeth treated without root end filling were successful, while 9 (64.3%) out of 14 teeth treated
with apicectomy with retrofil were successful. Though apicectomized teeth without root-end
filling had a higher percentage of success it was not statistically significant (p=0.15). 16

In the present study, in total, 40 teeth were subjected to treatment, with 12 of them receiving
root-end filling and 28 without such filling. Among the teeth that underwent apicectomy,
maxillary incisors were the most commonly treated. Notably, 19 out of 28 teeth treated without
root-end filling showed successful outcomes, whereas 8 out of 12 teeth treated with apicectomy
and retrofil demonstrated success. Another study by Nagase M et al, one hundred nineteen teeth
were apicoectomized with orthograde filling, 196 teeth with retrograde gutta-percha root filling
and 42 teeth with sponge gold filling. There was no significant correlation between the treatment
results and the sex or age of the patients, kinds of teeth, preoperative radiolucent areas, the
number of operations or histopathological diagnosis of apical lesion. The success rate of
apicoectomy with orthograde filling or apicoectomy with retrograde gutta-percha root filling was
significantly higher than that with retrograde sponge gold filling. The filling materials and the
operation method were considered to be the most important factors for a successful outcome.
Bone reconstruction was found to start from the periphery of the bone cavity and the bone defect
became gradually reduced in a star-like pattern. At 4 months after operation, in the successful
cases, the area of bone cavity decreased 46-64% compared with before operation, but in the
unsuccessful cases, the area did not change or increased 75-120%. Thus at 4 months after
operation, it is possible to determine whether or not apicoectomy is successful. 17 Chalakkal P et
al, evaluated treatment outcomes after apicoectomy and apexification in adjacent non-vital
maxillary central incisors with large periapical radiolucencies, in a 10-year-old boy. The patient
had complained of tenderness in the upper central incisors on mastication and gave a history of
trauma to those teeth three years ago. On examination, there were found to be non-vital.
Apexification (using Metapex) and apicoectomy (obturation with gutta percha) were performed
on 11 and 21, respectively. Radiographical observations were made six months, one year and
two years, post-operatively. Apical repair was found to be more favorable after apicoectomy than
apexification, for a non-vital maxillary central incisor with an open apex and large periapical
radiolucency. 18 Hirsch V et al, two case reports describing a new technique of creating a
repositionable piezoelectric bony window osteotomy during apicoectomy in order to preserve
bone and act as an autologous graft for the surgical site are described. Endodontic microsurgery
of anterior teeth with an intact cortical plate and large periapical lesion generally involves
removal of a significant amount of healthy bone in order to enucleate the diseased tissue and
manage root ends. In the reported cases, apicoectomy was performed on the lateral incisors of
two patients. A piezoelectric device was used to create and elevate a bony window at the surgical
site, instead of drilling and destroying bone while making an osteotomy with conventional burs.
Routine microsurgical procedures - lesion enucleation, root-end resection, and filling - were
carried out through this window preparation. The bony window was repositioned to the original
site and the soft tissue sutured. The cases were re-evaluated clinically and radiographically after
a period of 12 - 24 months. At follow-up, radiographic healing was observed. No additional
grafting material was needed despite the extent of the lesions. The indication for this procedure is
when teeth present with an intact or near-intact buccal cortical plate and a large apical lesion to
preserve the bone and use it as an autologous graft. 19 The dentist must take into account a
number of factors, such as the clinical and radiological aspect of the lesion, treatment
possibilities in the dental office and the patient’s preference. It is highly probable that an
endodontist or an oral surgeon will take into account the recommendations of the guidelines
specific for each specialization. S/he will also take into account personal experience and
recommendations mentioned in the literature. An important aspect of the therapeutic decision for
an apical periodontitis is the radiological aspect that allows a subjective interpretation by the
dentist. When considering all of these aspects, the dentist must recommend a certain treatment
plan for a tooth affected by apical periodontitis. 20 The treatment outcome of apical surgery
should be assessed clinically and radiographically. Reporting the survival rates of
apicoectomized teeth without periodic radiographic re-examination is of no clinical value. Only
the combination of clinical and radiographic healing criteria is accepted today to determine the
outcome of apical surgery. 21 From a practical point of view, healing is normally evaluated 1-year
postsurgery, although small (<5 mm) periapical defects might heal within a few months. 22
Clinical healing is based on the absence of signs and symptoms such as pain, sinus tract,
swelling, apico-marginal communication, and tenderness to palpation or percussion. Standard
radiographic healing classes include complete healing, incomplete healing (“scar tissue
formation”), uncertain healing (partial resolution of postsurgical radiolucency), and
unsatisfactory healing (no change or an increase in postsurgical radiolucency). This classification
is based on landmark studies that have compared radiographic findings with histopathologic
results of periapical tissues of teeth that had to be extracted after apical surgery. 23

Conclusion:

No substantial disparity was observed when comparing the outcomes of apicectomy procedures
conducted with or without root-end filling.

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