The School of Dentistry

Periapical Surgery

Thomas Dietrich

Changes of periodontal parameters following apical surgery: a prospective clinical study of three incision techniques

T. von Arx, T. Vinzens-Majaniemi, W. Bürgin & S. S. Jensen

Int Endod J 2007; 40: 959-969.

Study design

• Longitudinal

• Prospective

• Observational

• Cohort study

• Patients with 238 teeth undergoing apical surgery from 2000 – 2004

Von Arx et al. Int Endod J 2007; 40: 959-969.

Study flowchartNumber of teeth

Numbers excluded Reason for exclusion

238 Initial number of treated teeth

⇓  7 Palatal access

231

⇓ 19 Apico-marginal lesions

212

⇓ 27 Multiple (adjacent) teeth treated in same patient

185

⇓  1 Drop-outs (patients did not show up for 1-year control)

184 Final number of evaluated teeth

Von Arx et al. Int Endod J 2007; 40: 959-969.

Distribution of teeth per incision technique

Teeth

Intrasulcular incision

Papilla base incision

Submarginal incision

n % n % n %

Maxillary anterior 21 17.8 3 9.1 26 78.8

Maxillary premolars 25 21.2 9 27.3 4 12.1

Maxillary molars 15 12.7 8 24.2 1 3.0

Mandibular anterior 1 0.8 1 3.0 2 6.0

Mandibular premolars 12 10.2 1 3.0 0 0

Mandibular molars 44 37.3 11 33.3 0 0

Total 118 100 33 100 33 100

Von Arx et al. Int Endod J 2007; 40: 959-969.

Distribution of teeth per restoration

Von Arx et al. Int Endod J 2007; 40: 959-969.

Teeth

No restoration Filling Crown

n % n % n %

Maxillary anterior 3 21.4 13 36.1 34 25.4

Maxillary premolars 3 21.4 5 13.9 30 22.4

Maxillary molars 6 42.9 8 22.2 10 7.5

Mandibular anterior 0 0 2 5.6 2 1.5

Mandibular premolars 0 0 2 5.6 11 8.2

Mandibular molars 2 14.3 6 16.7 47 35.1

Total 14 100 36 100 134 100

Changes (mean ± SD) of PD, GM, CAL by incision technique

Von Arx et al. Int Endod J 2007; 40: 959-969.

Site Incision technique PD GM CAL*

Pooled buccal Intrasulcular incision

−0.08 (±0.50) −0.42 (±0.69)x 0.34 (±0.68)xΔ

       

Papilla base incision −0.21 (±0.38) −0.31 (±0.49) 0.10 (±0.62)Δ

       

Submarginal incision

−0.18 (±0.37) 0.05 (±0.61)x −0.23 (±0.57)x

Conclusions

• The intrasulcular incision demonstrated greater changes in the levels of the GM and the clinical attachment than the other incision techniques, meaning more recession of the GM and greater loss of attachment.

Von Arx et al. Int Endod J 2007; 40: 959-969.

Marginal incision

Von Arx et al. Int Endod J 2007; 40: 959-969.

Papilla-base incision

Von Arx et al. Int Endod J 2007; 40: 959-969.

Submarginal incision

Von Arx et al. Int Endod J 2007; 40: 959-969.

Criteria for success

• For example (von Arx & Kurt 1999):– Pain score (0-3)– Clinical Score (0-3)– Healing classification:

• Success/complete healing (>90% regeneration of bone & pain/clinical scores = 0)

• Improvement/partial healing (50-90% regeneration of bone & pain/clinical scores = 0)

• Failure/incomplete/uncertain healing (<50% regeneration of bone OR pain/clinical scores >0)

Clinical and Radiographic Assessment of Various Predictors for Healing Outcome 1 Year After Periapical Surgery

T. von Arx, S.S. Jensen, S. Hänni

J Endod 2007; 33: 123-128.

Study flowchart

Von Arx et al . J Endod 2007; 33: 123-128.

N Teeth N Excluded Reason for Exclusion

266 (initial number of treated teeth)

↓ 21No retrofilling (6 orthograde filling, 15

resection only)

245

↓ 33

Lesion not limited to periapical area (10 tunnel lesions, 18 apicomarginal lesions, 8 lateral lesions)

212

↓ 18 Multiple teeth treated in same patient

194

↓ 3Dropouts (patients did not show up

for 1-year control)

191 (final number of evaluated teeth)

Results (example)

Von Arx et al . J Endod 2007; 33: 123-128.

Variable OR 90% CI

Surgery First vs. resurgery 2.8 0.9, 9.1

Retrofilling material

MTA vs. SuperEBA 3.8 1.4, 10.9

“Conclusions”

• In conclusion, case selection for periapical surgery should consider the clinical significance of prognostic variables

• more studies are needed to evaluate the effect of multiple predictors on healing outcome after periapical surgery

Von Arx et al . J Endod 2007; 33: 123-128.