Introduction: In periapical surgery, the absence of standardization between different studies makes it difficult to  compare the outcomes.  Objective: To compare the healing classification of different authors and evaluate the prognostic criteria of periapical  surgery at 12 months.  Material and methods: 278 patients (101 men and 177 women) with a mean age of 38.1 years (range 11 to 77) treated  with periapical surgery using the ultrasound technique and a 2.6x magnifying glass, and silver amalgam as root-end  filling material were included in the study. Evolution was analyzed using the clinical criteria of Mikkonen et al., 1983;  radiographic criteria of Rud et al., 1972; the overall combined clinical and radiographic criteria of von Arx and Kurt,  1999; and the Friedman (2005) concept of functional tooth at 12 months of surgery.  Results: After 12 months, 87.2% clinical success was obtained according to the Mikkonen et al., 1983 criteria; 73.9%  complete radiographic healing using Rud et al. criteria; 62.1% overall success, following the clinical and radiographic  parameters of von Arx and Kurt, and 91.9% of teeth were functional. The von Arx and Kurt criteria was found to  be the most reliable.  Conclusion: Overall evolution according to von Arx and Kurt agreed most closely with the other scales

Arx, Thomas von

García Mira, Berta

Gay Escoda, Cosme

Martí Bowen, Eva

Ortega Sánchez, Bárbara

Peñarrocha Diago, Miguel

Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura

E143Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                         Prognosis in periapical surgery                                                                         Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                                                                           Prognosis in periapical surgeryEvaluation of healing criteria for success after periapical surgeryMiguel Peñarrocha Diago 1, Bárbara Ortega Sánchez 2, Berta García Mira 3, Eva Martí Bowen 4, Thomas von Arx 5, Cosme Gay Escoda 6(1) Professor of Oral Surgery. Director of the Master of Oral Surgery and Implantology. Valencia University Medical and Dental School. Valencia, Spain(2) Student of Master of Oral Surgery and Implantology. Valencia University Medical and Dental School. Valencia, Spain(3) Associate Professor of Oral Surgery. Valencia University Medical and Dental School. Valencia, Spain(4) Doctor in Dental Surgery. Private Practice. Valencia, Spain(5) Departament of Oral Surgery and Stomatology, School of Dental Medicine, University of Berne. Berne, Switzerland(6) Professor and Chairman Oral and Maxillofacial Surgery. University Medical and Dental School. Barcelona, SpainCorrespondence:Dr. Miguel Peñarrocha-DiagoClínicas OdontológicasGascó Oliag 146021 - Valencia. SpainE-mail: Miguel.Penarrocha@uv.esReceived: 28/01/2007Accepted: 17/11/2007Peñarrocha-Diago M, Ortega-Sánchez B, García-Mira B, Martí-Bowen E, von Arx T, Gay-Escoda C. Evaluation of healing criteria for success after periapical surgery. Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.© Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946URL: http://www.medicinaoral.com/medoralfree01/v13i2/medoralv13i2p143.pdfSummaryIntroduction: In periapical surgery, the absence of standardization between different studies makes it difficult to compare the outcomes.Objective: To compare the healing classification of different authors and evaluate the prognostic criteria of periapical surgery at 12 months.Material and methods: 278 patients (101 men and 177 women) with a mean age of 38.1 years (range 11 to 77) treated with periapical surgery using the ultrasound technique and a 2.6x magnifying glass, and silver amalgam as root-end filling material were included in the study. Evolution was analyzed using the clinical criteria of Mikkonen et al., 1983; radiographic criteria of Rud et al., 1972; the overall combined clinical and radiographic criteria of von Arx and Kurt, 1999; and the Friedman (2005) concept of functional tooth at 12 months of surgery.Results: After 12 months, 87.2% clinical success was obtained according to the Mikkonen et al., 1983 criteria; 73.9% complete radiographic healing using Rud et al. criteria; 62.1% overall success, following the clinical and radiographic parameters of von Arx and Kurt, and 91.9% of teeth were functional. The von Arx and Kurt criteria was found to be the most reliable.Conclusion: Overall evolution according to von Arx and Kurt agreed most closely with the other scales.Key words: Periapical surgery, prognosis, endodontic surgery.Indexed in: -Index Medicus / MEDLINE  /  PubMed            -EMBASE, Excerpta Medica-SCOPUS-Indice Médico Español                                                        -IBECSIntroductionThe success rate in periapical surgery (PS) varies between 37% (1) and 91% (2). These differences may be due to the criteria used when selecting the patients for surgery, to the variation in the surgical techniques, the magnification and lighting systems, the root-end filling materials, and/or the healing criteria used to evaluate the outcome of the studies (3).Published studies use different criteria to determine the prognosis of PS (4), with no general agreement between them. There are clinical healing criteria based on patient signs and symptoms (5); while others, such as Rud et al. (6), use only radiographic studies. The von Arx and Kurt scale (7) uses a combination of clinical and radiographic parameters, and in 2005, Friedman (3) established only whether the tooth was functional or not (it remained in the mouth). The healing classification most used in the literature is that of Rud et al. (6).The aim of this study was to compare the success rates given by each of the different criteria used to assess healing in PS after 12 months of follow-up.               Article Number: 10489901              © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946               eMail:  medicina@medicinaoral.com E144Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                         Prognosis in periapical surgery                                                                         Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                                                                           Prognosis in periapical surgeryMaterial and MethodPatient selectionA clinical follow-up study was carried out between May 1999 and June 2004. Three hundred sixteen patients with chronic periapical lesions were treated with PS using the ul-trasound technique and a 2.6x magnifying glass to prepare the root-end cavity, and filling with silver amalgam.The inclusion criteria for patients in the study were: 1) apicoectomies on teeth with canals treated by ultrasound techniques to create the root-end cavity, filling with sil-ver amalgam; and 2) at least 12 months follow-up after treatment (8). All patients provided informed consent; 38 patients were excluded for lack of follow-up.Data were collected using a protocol for each patient and stored in an automated database. The data were coded for later statistical processing.- Surgical TechniqueAll operations were carried out by the same surgeon (MPD). Infiltrative loco-regional anesthesia was accomplished with 4% articaine and 1:100.000 adrenaline (Inibsa, Lliça de Vall, Barcelona, Spain). Complete or partial Newman flaps were raised; ostectomy was carried out using round 0.27mm tungsten-carbide drills (Jota, Switzerland) mounted in a handpiece, and abundant irrigation with sterile physiological serum. The minimum apical resection necessary to access the apex was made, with subsequent apical curettage. The cavity for root-end filling was pre-pared with ultrasound, Piezon Master® (EMS, Electro Medical Systems S.A, Switzerland). Magnifying glasses of 2.6 magnification Orascoptic® (Acuity™ System. Kerr Corporation, Middleton, USA) were used to facilitate the procedure, and root-end filling with non gamma 2 silver amalgam (Tytin®, Kerr, USA). Sutures were placed using 4/0 silk thread ( Lorca Marin®, TB15, 3/8, Murcia, Spain).- Radiographic studyPanoramic radiographs were taken using a digital or-thopantomograph OP100® (Instrumentarium Imaging, Tuusula, Finland). The resulting image was placed in an image analyzer, previously calibrated with the Cliniview® Version 5.1 program (Instrumentarium Imaging, Tuusula, Finland).- Prognostic assessment healing classificationThe following criteria were used to evaluate the success of the PS.The clinical criteria of Mikkonen et al. (5), considering: 1) success: when there is no pain, swelling or fistula, 2) uncertain healing: radiographic evidence of  bone des-truction  and presence or not of symptomatology; and 3) failure: when there is bone destruction, root resorption and symptomatology.The radiographic criteria of Rud et al. (6): 1) complete healing: complete bone regeneration, normal or slight increase in width of periodontal periapical space, but less than double the width of the unaffected radicular areas; 2) Incomplete healing: reduced radiolucency, characteri-zed by signs of bone healing around the periphery of the rarefaction; 3) Doubtful healing: reduced radiolucency with one or more of  the following characteristics: the radiolucency was greater than twice the width of  the periodontal space, it was bordered by a structure such as hard lamina, it had a circular or semi-circular periphery, or was located symmetrically ‘cone-like’ around the apex as an extension of the periodontal space;4) Radiographic failure: there were no changes, or there was an increase in radiolucency.The clinic and radiographic criteria of von Arx and Kurt (9) to determine overall evolution: 1) success: when bone regeneration was ≥90% and the pain and clinical scales were 0 (on a scale of 0 to 3); 2) improvement:  when bone regeneration was between 50% and 90% and the pain and clinical scales were 0; and 3) failure: when bone regenera-tion was less than 50% or there were clinical symptoms.Finally, it was evaluated if  the tooth was functional (re-mained in place) or not (3).- Statistical analysisThe data were coded for later statistical processing using the SPSS version 12 for Windows. Pearson’s correlation coefficients and spread graphs were used to establish the relationship between the different scales. ResultsIn total 278 patients were studied (177 female and 101 male) with a mean age of  36.9 years (range 11 to 77 years). The success rate of PS with ultrasound and silver amalgam was 82.7% at 12 months according to the clinical evolution of Mikkonen et al. (5); and 73.9%when using the radiographic healing classification of Rud et al. (6). According to the overall evolution of von Arx and Kurt (9) the success rate was 62.1%; and 91.9% of teeth were functional (Table 1).The dispersion coefficients table (Table 2) verifies the re-lationship between the different prognostic criteria. The higher the values of rho for a healing classification, the better the correlation with the remainder at 12 months. The von Arx and Kurt (7) overall evolution agreed most closely with the other criteria used.DiscussionFrom the results obtained in this study, we find the success rate in PS with ultrasound and silver amalgam root-end filling was about 62.1% at 12 months according to the von Arx and Kurt (9) healing criteria. Using the same technique and criteria, Martí et al. (10) found 84.2% suc-cess. With respect to Rud et al. (6) and carrying out PS with ultrasound and Super-EBA root-end filling material, Taschieri et al. (11) obtained 91.3% complete healing while for Testori et al. (12) the success rate was of 85%. Peñarrocha et al. (13) carried out PS with ultrasound and silver amalgam as a root-end filling material in 31 man-Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                         Prognosis in periapical surgery                                                                         Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                                                                           Prognosis in periapical surgeryE145Table 1. Healing percentages according to the different criteria.E146Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                         Prognosis in periapical surgery                                                                         Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                                                                           Prognosis in periapical surgerydibular molars and obtained 54.8% total healing, 32.3% of incomplete or partial healing and 12.9% failure after one year of follow-up.Rud et al. (6) has been the healing classification most used since its creation, nevertheless the incomplete and doubtful healing criteria are difficult to differentiate and it is common to integrate the two criteria as the concept of a tooth in process of healing. The lowest success rate was was found using the overall criteria of von Arx and Kurt (7), since this covers both clinical and radiographic criteria, that is to say, when con-sidering only the clinical manifestations, the success rate was higher than if the radiographic data was also included. When combining the clinical failures of the Mikkonen et al. (5) criteria, and the radiographic failures of Rut et al. (6), the figures were similar to the overall failures of von Arx and Kurt (7); which is logical, since this healing classification covers both parameters. Similarly, Vallecillo et al. (14) assessed the clinical and radiographic outcomes in PS with different techniques; after 12 months of follow-up, they obtained a success rate of 70% with ultrasound and saw that complete radiographic healing did not occur in any case until 6 months after surgery. Leco et al. (15) evaluated the efficiency of the Erbium:YAG laser in 45 patients with granulomatous periapical lesions, with a clinical and radiographic control; they obtained 95.5 % clinical success and 77.7 % radiographic healing after 24 months of follow-up.On the other hand, the success rate for clinical evolution was similar to the functional tooth concept, since in this case it was only assessed if the tooth remained in the mouth, which is a similar situation to that of a tooth that does not cause pain. The overall evolution of von Ax and Kurt (7) was the healing classification most in agreement with all the others. References1. 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 Jun;91(6):700-9. 2. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular sur-gery: a clinical prospective study. Int Endod J. 2000 Mar;33(2):91-8. 3. Friedman S. The prognosis and expected outcome of apical surgery. Endod Topics 2005;11:219-62.4. Mead C, Javidan-Nejad S, Mego ME, Nash B, Torabinejad M. Le-vels of evidence for the outcome of endodontic surgery. J Endod. 2005 Jan;31(1):19-24. 5. Mikkonen M, Kullaa-Mikkonen A, Kotilainen R. Clinical and radio-logic re-examination of apicoectomized teeth. Oral Surg Oral Med Oral Pathol. 1983 Mar;55(3):302-6. 6. Rud J, Andreasen JO, Jensen JE. A follow-up study of 1,000 cases treated by endodontic surgery. Int J Oral Surg. 1972;1(4):215-28. 7. Von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamond-surfaced retrotip: a 1-year follow-up study. J Oral Maxillofac Surg. 1999 Jun;57(6):656-61. 8. Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion. Int Endod J. 2001 Apr;34(3):189-97. 9. Von Arx T, Kurt B, Ilgenstein B, Hardt N. Preliminary results and analysis of a new set of sonic instruments for root-end cavity preparation. Int Endod J. 1998 Jan;31(1):32-8. Table 2. Correlation between the different scales at 12 months.Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                         Prognosis in periapical surgery                                                                         Med Oral Patol Oral Cir Bucal. 2008 Feb1;13(2):E143-7.                                                                                                                                                                                           Prognosis in periapical surgeryE14710. Martí-Bowen E, Peñarrocha-Diago M, García-Mira B. Periapical surgery using the ultrasound technique and silver amalgam retrograde filling. A study of 71 teeth with 100 canals. Med Oral Patol Oral Cir Bucal. 2005 Apr 1;10 Suppl 1:E67-73. 11. Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. En-dodontic surgery with ultrasonic retrotips: one-year follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Sep;100(3):380-7.12. 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 Apr;87(4):493-8. 13. Penarrocha Diago M, Sanchis Bielsa JM, Gay Escoda C. Periapical surgery of 31 lower molars based on the ultrasound technique and re-trograde filling with silver amalgam. Med Oral. 2001 Nov-Dec;6(5):376-82. 14. Vallecillo Capilla M, Muñoz Soto E, Reyes Botella C, Prados Sáchez E, Olmedo Gaya MV. Periapical surgery of 29 teeth. A comparison of conventional technique, microsaw and ultrasound. Med Oral. 2002 Jan-Feb;7(1):46-9, 50-3. 15. Leco Berrocal MI, Martínez González JM, Donado Rodríguez M. Clinical and radiological course in apicoectomies with the Erbium:YAG laser. Med Oral Patol Oral Cir Bucal. 2007 Jan 1;12(1):E65-9.    

Evaluation of healing criteria for success after periapical surgery

INTRODUCTION: In periapical surgery, the absence of standardization between different studies makes it difficult to compare the outcomes. OBJECTIVE: To compare the healing classification of different authors and evaluate the prognostic criteria of periapical surgery at 12 months. MATERIAL AND METHODS: 278 patients (101 men and 177 women) with a mean age of 38.1 years (range 11 to 77) treated with periapical surgery using the ultrasound technique and a 2.6x magnifying glass, and silver amalgam as root-end filling material were included in the study. Evolution was analyzed using the clinical criteria of Mikkonen et al., 1983; radiographic criteria of Rud et al., 1972; the overall combined clinical and radiographic criteria of von Arx and Kurt, 1999; and the Friedman (2005) concept of functional tooth at 12 months of surgery. RESULTS: After 12 months, 87.2% clinical success was obtained according to the Mikkonen et al., 1983 criteria; 73.9% complete radiographic healing using Rud et al. criteria; 62.1% overall success, following the clinical and radiographic parameters of von Arx and Kurt, and 91.9% of teeth were functional. The von Arx and Kurt criteria was found to be the most reliable. CONCLUSION: Overall evolution according to von Arx and Kurt agreed most closely with the other scales

Evaluation of healing criteria for success after periapical surgery

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