Endodontic microsurgery: outcomes and prognostic factors

  • Euiseong KimEmail author
  • Yaelim Kim
Modern Approaches to Endodontics (S Kim and B Karabucak, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Modern Approaches to Endodontics


Purpose of Review

This review addresses endodontic microsurgery procedures compared with traditional surgery and aims to review factors related to the success and failure of endodontic microsurgery from the existing literature.

Recent Findings

Periodontal involvement and tooth position are patient- and tooth-related factors known to have an effect on the outcome of apical surgery. Factors related to successful outcome have been reported and include whether the mineral trioxide aggregate used to obturate the apical portion of the root after surgery was fast or slow setting. Although not statistically significant, larger difference in the success rate between slow- and fast-setting MTA groups was observed in teeth with endodontic-periodontal lesions than in teeth with isolated endodontic lesions suggesting that the faster setting root-end filling material is most advantageous, particularly when endodontic lesions have periodontal involvement.


Endodontic microsurgery has witnessed major advances and is currently regarded as an integral part of standard endodontic treatment. Improved visibility and illumination because of the operating microscope, advances in ultrasonic instrument technology, and the development of more biocompatible root-end filling materials have contributed to the technical advances that have led to higher success rates in endodontic microsurgery compared with traditional surgery.


Endodontic microsurgery Apical surgery Apicoectomy Microsurgery outcome Microsurgery prognostic factors 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endod Top. 2002;1:54–78.CrossRefGoogle Scholar
  2. 2.
    • Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature--part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2010;36:1757–65 This manuscript reported improved success rate of endodontic microsurgery compared with traditional root-end surgery. PubMedCrossRefGoogle Scholar
  3. 3.
    Creasy JE, Mines P, Sweet M. Surgical trends among endodontists: the results of a web-based survey. J Endod. 2009;35:30–4.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Yang Y, Rossi FMV, Putnins EE. Periodontal regeneration using engineered bone marrow mesenchymal stromal cells. Biomaterials. 2010;31:8574–82.PubMedCrossRefGoogle Scholar
  5. 5.
    • Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32:601–23 This manuscript established the concept of endodontic microsurgery. PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and apical ramifications in response to pathologic conditions and treatment procedures. J Endod. 2010;36:1–15.PubMedCrossRefGoogle Scholar
  7. 7.
    Kim E, Fallahrastegar A, Hur YY, Jung IY, Kim S, Lee SJ. Difference in root canal length between Asians and Caucasians. Int Endod J. 2005;38:149–51.PubMedCrossRefGoogle Scholar
  8. 8.
    • Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. J Endod. 2008;34:546–51 This manuscript compared the success rate of isolated endodontic lesion and combined periodontal-endodontic lesion.PubMedCrossRefGoogle Scholar
  9. 9.
    Song M, Kim H, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodntic treatment by microscopic inspection during endodontic microsurgery. J Endod. 2011; In press.Google Scholar
  10. 10.
    • Song M, Shin S-J, Kim E. Outcomes of endodontic micro-resurgery: a prospective clinical study. J Endod. 2011;37:316–20 This manuscript studied the outcome of micro-resurgery and showed that the success rate of re-surgery is comparable with that of initial surgery in cases which the cause of failure could be identified. PubMedCrossRefGoogle Scholar
  11. 11.
    Saunders WP, Saunders EM, Gutmann JL. Ultrasonic root-end preparation, part 2. Microleakage of EBA root-end fillings. Int Endod J. 1994;27:325–9.PubMedCrossRefGoogle Scholar
  12. 12.
    De Bruyne MA, De Moor RJ. Influence of cracks on leakage and obturation efficiency of root-end filling materials after ultrasonic preparation: an in vitro evaluation. Quintessence Int. 2008;39:685–92.PubMedGoogle Scholar
  13. 13.
    • Christiansen R, Kirkevang LL, Horsted-Bindslev P, Wenzel A. Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling--1-year follow-up. Int Endod J. 2009;42:105–14 This manuscript presents the effect of presence of retrofilling material in microsurgery. PubMedCrossRefGoogle Scholar
  14. 14.
    Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end filling materials in endodontic surgery. Int Endod J. 2003;36:520–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Song M, Jung IY, Lee SJ, Lee CY, Kim E. Prognostic factors for clinical outcomes in endodontic microsurgery: a retrospective study. J Endod. 2011;37:927–33.PubMedCrossRefGoogle Scholar
  16. 16.
    Saunders WP. A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling. J Endod. 2008;34:660–5.PubMedCrossRefGoogle Scholar
  17. 17.
    Baek S-H, Lee WC, Setzer FC, Kim S. Periapical bone regeneration after endodontic microsurgery with three different root-end filling materials: Amalgam, SuperEBA, and Mineral Trioxide Aggregate. J Endod. 2010;36:1323–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Kim Y, Kim S, Shin YS, Jung IY, Lee SJ. Failure of setting of mineral trioxide aggregate in the presence of fetal bovine serum and its prevention. J Endod. 2012;38:536–40.PubMedCrossRefGoogle Scholar
  19. 19.
    Kim D, Lee H, Chung M, Kim S, Song M, Kim E. Effect of Fast- and Slow-setting calcium silicate-based root-end filling materials on the outcome of endodontic microsurgery: a retrospective study up to 6 years.Google Scholar
  20. 20.
    Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery using 2 different magnification devices: preliminary results of a randomized controlled study. J Oral Maxillofac Surg. 2006;64:235–42.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Rahbaran S, Gilthorpe MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91:700–9.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod. 2006;32:412–6.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod. 2009;35:930–7.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    • Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature. J Endod. 2009;35:1505–11 This manuscript is a systemic review assessing the outcome of endodontic surgery performed by modern technique, which consists of the use of magnification devices (loupe, endoscope, microscope). PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Wang N, Knight K, Dao T, Friedman S. Treatment outcome in endodontics-The Toronto Study. Phases I and II: apical surgery. J Endod. 2004;30:751–61.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical prospective study. Int Endod J. 2000;33:91–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Lindeboom JA, Frenken JW, Kroon FH, van den Akker HP. A comparative prospective randomized clinical study of MTA and IRM as root-end filling materials in single-rooted teeth in endodontic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:495–500.PubMedCrossRefGoogle Scholar
  28. 28.
    von Arx T, Frei C, Bornstein MM. Periradicular surgery with and without endoscopy: a prospective clinical comparative study. Schweiz Monatsschr Zahnmed. 2003;113:860–5.Google Scholar
  29. 29.
    Caliskan. Nonsurgical retreatment of teeth with periapical lesions previously managed by either endodontic or surgical intervention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:242–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Fava LRG. Calcium hydroxide in endodontic retreatment after two nonsurgical and two surgical failures: report of a case. Int Endod J. 2001;34:72–80.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Schwartz-Arad D, Yarom N, Lustig JP, Kaffe I. A retrospective radiographic study of root-end surgery with amalgam and intermediate restorative material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:472–7.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Peterson J, Gutmann JL. The outcome of endodontic resurgery: a systematic review. Int Endod J. 2001;34:169–75.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Gagliani MM, Gorni FG, Strohmenger L. Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison. Int Endod J. 2005;38:320–7.PubMedCrossRefGoogle Scholar
  34. 34.
    • Kim D, Kim S, Song M, Kang DR, Kohli MR, Kim E. Outcome of endodontic micro-resurgery: a retrospective study based on propensity score-matched survival analysis. J Endod. 2018;44:1632–40 This manuscript evaluated the outcome of endodontic micro re-surgery via the analysis of long-term clinical data and compare the findings with those for primary endodontic microsurgery by using propensity score-matched survival analysis. PubMedCrossRefGoogle Scholar
  35. 35.
    Bahcall JK, Di Fiore PM, Poulakidas TK. An endoscopic technique for endodontic surgery. J Endod. 1999;25:132–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Taschieri S, Del Fabbro M, Testori T, Weinstein R. Endoscopic periradicular surgery: a prospective clinical study. Br J Oral Maxillofac Surg. 2007;45:242–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Taschieri S, Del Fabbro M, Testori T, Weinstein R. Microscope versus endoscope in root-end management: a randomized controlled study. Int J Oral Maxillofac Surg. 2008;37:1022–6.PubMedCrossRefGoogle Scholar
  38. 38.
    von Arx T, Hanni S, Jensen SS. Correlation of bone defect dimensions with healing outcome one year after apical surgery. J Endod. 2007;33:1044–8.CrossRefGoogle Scholar
  39. 39.
    von Arx T, Jensen SS, Hanni S. Clinical and radiographic assessment of various predictors for healing outcome 1 year after periapical surgery. J Endod. 2007;33:123–8.CrossRefGoogle Scholar
  40. 40.
    Lustmann J, Friedman S, Shaharabany V. Relation of pre- and intraoperative factors to prognosis of posterior apical surgery. J Endod. 1991;17:239–41.PubMedCrossRefGoogle Scholar
  41. 41.
    Jensen SS, Nattestad A, Egdo P, Sewerin I, Munksgaard EC, Schou S. A prospective, randomized, comparative clinical study of resin composite and glass ionomer cement for retrograde root filling. Clin Oral Investig. 2002;6:236–43.PubMedCrossRefGoogle Scholar
  42. 42.
    Wang Q, Cheung GSP, Ng RPY. Survival of surgical endodontic treatment performed in a dental teaching hospital: a cohort study. Int Endod J. 2004;37:764–75.PubMedCrossRefGoogle Scholar
  43. 43.
    Barone C, Dao TT, Basrani BB, Wang N, Friedman S. Treatment outcome in endodontics: the Toronto study--phases 3, 4, and 5: apical surgery. J Endod. 2010;36:28–35.PubMedCrossRefGoogle Scholar
  44. 44.
    von Arx T, Penarrocha M, Jensen S. Prognostic factors in apical surgery with root-end filling: a meta-analysis. J Endod. 2010;36:957–73.CrossRefGoogle Scholar
  45. 45.
    Rapp EL, Brown CE Jr, Newton CW. An analysis of success and failure of apicoectomies. J Endod. 1991;17:508–12.PubMedCrossRefGoogle Scholar
  46. 46.
    Duncan HF, Pitt Ford TR. The potential association between smoking and endodontic disease. Int Endod J. 2006;39:843–54.PubMedCrossRefGoogle Scholar
  47. 47.
    Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005;19:151–7.PubMedCrossRefGoogle Scholar
  48. 48.
    W-Dahl A, Toksvig-Larsen S. Cigarette smoking delays bone healing: a prospective study of 200 patients operated on by the hemicallotasis technique. Acta Orthop Scand. 2004;75:347–51.PubMedCrossRefGoogle Scholar
  49. 49.
    Chang LD, Buncke G, Slezak S, Buncke HJ. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996;12:467–74.PubMedCrossRefGoogle Scholar
  50. 50.
    Testori T, Capelli M, Milani S, Weinstein RL. Success and failure in periradicular surgery: a longitudinal retrospective analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87:493–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year follow-up study. Int Endod J. 2003;36:193–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery with ultrasonic retrotips: one-year follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:380–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Friedman S. The prognosis and expected outcome of apical surgery. Endod Top. 2005;11:219–62.CrossRefGoogle Scholar
  54. 54.
    • Kim S, Jung H, Kim S, et al. The influence of an isthmus on the coutcomes of surgically treated molars: a retrospective study. J Endod. 2016;42:1029–34 This manuscript studied the influence of an isthmus on the outcomes of microsurgery in molars. PubMedCrossRefGoogle Scholar
  55. 55.
    Kim S, Park S, Lee Y, Lee C-J, Karabucak B, Kim H-C, et al. Stress analyses of retrograde cavity preparation designs for surgical endodontics in the mesial root of the madibular molar: a finite element anlaysis-part I. J Endod. 2019;45:442–6.PubMedCrossRefGoogle Scholar
  56. 56.
    Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39:249–81.PubMedCrossRefGoogle Scholar
  57. 57.
    Farzaneh M, Abitbol S, Lawrence HP, Friedman S. Treatment outcome in endodontics - The Toronto Study. Phase II: Initial treatment. J Endod. 2004;30:302–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Hirsch JM, Ahlstrom U, Henrikson PA, Heyden G, Peterson LE. Periapical surgery. Int J Oral Surg. 1979;8:173–85.PubMedCrossRefGoogle Scholar
  59. 59.
    Skoglund A, Persson G. A follow-up study of apicoectomized teeth with total loss of the buccal bone plate. Oral Surg Oral Med Oral Pathol. 1985;59:78–81.PubMedCrossRefGoogle Scholar
  60. 60.
    Forssell H, Tammisalo T, Forssell K. A follow-up study of apicectomized teeth. Proc Finn Dent Soc. 1988;84:85–93.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Friedman S. Treatment outcome and prognosis of endodontic therapy. 2nd ed. Malden: Blackwell Science.Google Scholar
  62. 62.
    Douthitt JC, Gutmann JL, Witherspoon DE. Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery. J Endod. 2001;27:404–10.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Britain SK, von Arx T, Schenk RK, Buser D, Nummikoski P, Cochran DL. The use of guided tissue regeneration principles in endodontic surgery for induced chronic periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation. J Periodontol. 2005;76:450–60.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:474–82.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Marin-Botero ML, Dominguez-Mejia JS, Arismendi-Echavarria JA, Mesa-Jaramillo AL, Florez-Moreno GA, Tobon-Arroyave SI. Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: a double-blind, randomized-clinical trial. Int Endod J. 2006;39:368–77.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Song M, Kim SG, Shin S-J, Kim H-C, Kim E. The influence of bone tissue deficiency on the outcome of endodontic microsurgery: a prospective study. J Endod. 2013;39:1341–5.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Kim D, Ku H, Nam T, Yoon T-C, Lee C-Y, Kim E. Influence of size and volume of periapical lesions on the outcome of endodontic microsurgery: 3-dimensional analysis using cone-beam computed tomography. J Endod. 2016;42:1196–201.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19:591–5.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral trioxide aggregate as a root-end filling material. J Endod. 1995;21:109–12.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of marginal adaptation of mineral trioxide aggregate and other commonly used root-end filling materials. J Endod. 1995;21:295–9.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Bates CF, Carnes DL, del Rio CE. Longitudinal sealing ability of mineral trioxide aggregate as a root-end filling material. J Endod. 1996;22:575–8.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Pichardo MR, George SW, Bergeron BE, Jeansonne BG, Rutledge R. Apical leakage of root-end placed SuperEBA, MTA, and Geristore restorations in human teeth previously stored in 10% formalin. J Endod. 2006;32:956–9.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Dorn SO, Gartner AH. Retrograde filling materials: a retrospective success-failure study of amalgam, EBA, and IRM. J Endod. 1990;16:391–3.PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    von Arx T, Hanni S, Jensen SS. Clinical results with two different methods of root-end preparation and filling in apical surgery: mineral trioxide aggregate and adhesive.Google Scholar
  75. 75.
    Andreasen JO, Munksgaard EC, Fredebo L, Rud J. Periodontal tissue regeneration including cementogenesis adjacent to dentin-bonded retrograde composite fillings in humans. J Endod. 1993;19:151–3.PubMedCrossRefPubMedCentralGoogle Scholar
  76. 76.
    Rud J, Munksgaard EC, Andreasen JO, Rud V. Retrograde root filling with composite and a dentin-bonding agent. 2. Endod Dent Traumatol. 1991;7:126–31.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Gillen BM, Looney SW, Gu LS, Loushine BA, Weller RN, Loushine RJ, et al. Impact of the quality of coronal restoration versus the quality of root canal fillings on success of root canal treatment: a systematic review and meta-analysis. J Endod. 2011;37:895–902.PubMedCrossRefPubMedCentralGoogle Scholar

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Authors and Affiliations

  1. 1.Microscope Center, Department of Conservative Dentistry and Oral Science Research CenterYonsei University College of DentistrySeoulRepublic of Korea

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