Surgical endodontics: quo vadis?JAMES L. GUTMANN
Surgical endodontic intervention has emerged over the
last 100 years as a significant treatment modality in the
retention of sound teeth (1). While the evolution of this
treatment modality and the refinement of its principles
have had a long and tumultuous history, biologically
based directives are emerging and are integrated with
significant advances in clinical modalities. No longer
does the endodontic literature support a litany of
indications for surgical applications, but rather, well-
thought, evidenced-based principles are guiding the
selection of this treatment modality (2–7). Coupled
with the introduction of magnification through the use
of the surgical operating microscope, refined principles
of soft and hard tissue management, use of tissue
regenerative root-end fill materials, and enhanced
principles of wound closure and postoperative manage-
ment, surgical endodontics has emerged as a highly
predictable and relatively painless procedure (8–13).
Ironically, the impetus for the evolution of con-
temporary surgical endodontic principles came from a
better understanding of the challenges faced in the
cleaning, shaping, disinfecting and obturating the
complex and unpredictable anatomy of the root canal
system. While technology in the non-surgical provision
of treatment has advanced significantly (14), there still
remains the challenge of eradicating microbial species
and their biofilms from the root canal system, primarily
in the apical third of the root (15–18). Even with this
dictate, it is still imperative to consider the choice of
non-surgical root canal treatment (19) or the revision
of previous less-than-ideal treatment (20) before
surgical intervention, as outcomes of non-surgical
intervention would support this choice.
Surgical intervention is not a substitute for failure to
manage properly the root canal system non-surgically,
to assess thoroughly the periodontal status, and to
ignore the shortcomings of the coronal restoration(s)
(21, 22). Knowing when to choose surgical interven-
tion is just as important as the expertise to be exercised
in the surgical procedure and the judgment to be
exercised in the assessment of what has been done (23).
In essence treatment planning the choice of surgery
may actually be more difficult and challenging than the
surgical procedure itself (24). This is especially true
with the massive and sometimes irrational movement
to replace every endodontically treated tooth with or
with symptoms with an intraosseous implant (25–30).
Retention of the natural tooth structure is still the goal
of quality dental care and many previously root-treated
teeth that appear to be done quite well, yet exhibit
adverse signs or symptoms, are viable candidates for
non-surgical treatment revision or surgical revision of
treatment (31–33).
With each patient that presents for treatment, the
clinician is challenged to make choices that result in the
best treatment possible for the patient. These choices
are based on a number of factors that influence the
clinician in the decision-making, problem-solving
process (24, 34, 35). These factors include the
following:
� Axioms that are commonly held in endodontics and
supportive disciplines.
� Formative knowledge to support the choices.
� Clinical skill.
� Clinical experience.
� Problem solving skills.
� Patient preference after being informed fully of
treatment options and their rationale.
� Economic factors.
� Evidence-based concepts.
� Integrity.
Failure to take all factors into account may lead to
treatment plans that are ill advised or not in the best
interest of the patient. While many teeth can be
maintained with a surgical endodontic procedure, it
may not be in the best interest of the patient to retain a
tooth that has restorative or periodontal compromises
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Endodontic Topics 2005, 11, 1–3All rights reserved
Copyright r Blackwell Munksgaard
ENDODONTIC TOPICS 20051601-1538
(24). Furthermore, if a tooth cannot be returned to
symptom-free function following surgical intervention
removal may be indicated. Moreover, while tooth
retention is ideal for function and aesthetics, at times
tooth resection or removal and replacement with a fixed
partial prosthesis, a removable partial prosthesis,
implant, or no replacement may be in the best interest
of the patient (24).
This volume of endodontic topics focuses on multiple
issues that deal with surgical endodontics, with a
primary focus on apical surgery – a ‘first’ for this
publication. Furthermore, other than textbook chap-
ters, this is the first comprehensive literature-scientific,
evidence-based publication on surgical endodontics in
15 years. This publication and its focus on the
principles of apical surgery are supported by a multi-
tude of general concepts that apply to treatment
planning choices both prior to and following surgery,
pain prevention and management, postsurgical man-
agement and outcomes. As the availability of true
evidence-based information in surgical endodontics is
sparse, there is in some topics presented by the author
more of a best evidence approach to this treatment
modality. The fact that this topic is presented by a cross
section of clinicians, academicians and researchers,
lends great credibility and reality to contemporary
principles discussed. Hopefully this approach will
encourage more evidence-based research and long-
term outcomes studies to solidify or alter the concepts
delineated herein.
References
1. Gutmann JL, Harrison JW. Surgical Endodontics.Boston: Blackwell Scientific Publications, 1991.
2. Rubinstein RA, Kim S. Short-term observation of theresults of endodontic surgery with the use of a surgicaloperation microscope and Super-EBA as root-endfilling material. J Endod 1999: 25: 43–48.
3. Rubinstein RA, Kim S. Long-term follow-up of casesconsidered healed on year after apical microsurgery. JEndod 1999: 28: 378–383.
4. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis inperiradicular surgery: a clinical prospective study. IntEndod J 2000: 33: 91–98.
5. Testori T, Capelli M, Milani S, Weinstein RL. Successand failure in periradicular surgery: a longitudinal
retrospective analysis. Oral Surg Oral Med Oral PatholOral Radiol Endod 1999: 87: 493–498.
6. Chong BS, Pitt Ford TR, Hudson MB. A prospectiveclinical study of mineral trioxide aggregate and IRM
when used as root-end filling materials in endodonticsurgery. Int Endod J 2003: 36: 520–526.
7. Maddalone M, Gagliani M. Periapical endodonticsurgery: a 3-year follow-up study. Int Endod J 2003:
36: 193–198.8. Arens DE, Torabinejad M, Chivian N, Rubenstein RA.
Practical Lessons in Endodontic Surgery. Chicago:Quintessence, 1998: 79–87.
9. Pitt Ford TR. Surgical treatment of apical periodontitis.In: Ørstavik D, Pitt Ford RT, eds. Essential Endodon-tology: Prevention and Treatment of Apical Periodontitis.Oxford: Blackwell Science, 1998: 278–307.
10. Velvart P. Das operationsmikroskop in der wurzelspit-zenresektion. teil 1: die Resektion. Schw MonatsschrZahnmed 1997: 107: 507–521.
11. Velvart P. Das operationsmikroskop in der wurzelspit-zenresektion. teil 2: die retrograde Versorgung. SchwMonatsschr Zahnmed 1997: 107: 969–983.
12. Velvart P, Peters CI. Soft tissue management inendodontic surgery. J Endod 2005: 31: 4.
13. Kim S, Pecora G, Rubinstein R. Color Atlas ofMicrosurgery in Endodontics. Philadelphia: WB Saun-ders, 2001.
14. Peters OA, Dummer PMH Infection control throughroot canal preparation: a review of cleaning and shaping
procedures. Endod Topics 2005: 10: 1–190.15. Friedman S. Considerations and concepts of case
selection in the management of post-treatment endo-dontic disease (treatment failure). Endod Topics 2002: 1:54–78.
16. Friedman S Etiological factors in endodontic post-treatment disease: apical Periodontitis Associated with
Root-filled Teeth. Endod Topics 2003: 6: 170.17. Dahlen G, Bergenholtz G Advances in the study of
endodontic infections. Endod Topics 2004: 9: 1–96.18. Nair PNR. Pathogenesis of apical periodontitis and the
causes of endodontic failures. Crit Rev Oral Biol Med2004: 15: 348–381.
19. Lazarski MP, Walker WA, Flores CM, Schindler WG,Hargreaves KM. Epidemiological evaluation of theoutcomes of nonsurgical root canal treatment in a largecohort of insured dental patients. J Endod 2001: 27:791–796.
20. Aqrabawi J. Management of endodontic failures: caseselection and treatment modalities. Gen Dent 2005: 53:63–65.
21. Saunders WP, Saunders EM. Coronal microleakage as acause of failure in root canal therapy: a review. EndodDent Traumatol 1994: 10: 105–108.
22. Ray HA, Trope M. Periapical status of endodonticallytreated teeth in relation to technical quality of the rootfilling and the coronal restoration. Int Endod J 1995: 28:12–18.
23. Mead C, Javidan-Nejad S, Mego ME, Nash B,Torabinejad M. Levels of evidence for the outcome ofendodontic surgery. J Endod 2005: 31: 19–24.
24. von Arx T. Failed root canals: the case for apicoectomy
(periradicular surgery). J Oral Maxillofac Surg 2005:
63: 832–837.
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25. Rose LF, Weisgold AS. Teeth or implants: a 1990’s dilem-
ma. Compend Contin Educ Dent 1996: 17: 1151–1159.26. Trope M. Implant or root canal therapy-an endodon-
tist’s view. J Esthet Restor Dent 2005: 17: 139–140.27. Ruskin JD, Morton D, Karayazgan B, Amir J. Failed root
canals: the case for extraction and immediate implant
placement. J Oral Maxillofac Surg 2005: 63: 829–831.28. Moiseiwitsch J. Do dental implants tool the end of
endodontics? Oral Surg Oral Med Oral Pathol OralRadiol Endod 2002: 93: 633–634.
29. Heffernan M, Martin W, Morton D. Prognosis ofendodontically treated teeth? Quintessence Int 2003: 7:558–561.
30. O’Neal RB, Butler BL. Restoration or implant place-ment: a growing treatment planning quandary. Period-ontol 2000 2002: 30: 111–122.
31. Danin J, Stromberg T, Forzgren H, Linder LE,Ramskold LO. Clinical management of nonhealingperiradicular pathosis: surgery versus endodontic re-
treatment. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1996: 8: 213–217.
32. Kvist T, Reit C. Results of endodontic re-treatment: arandomized clinical study comparing surgical and non-
surgical procedures. J Endod 1999: 25: 814–817.33. Siqueira JF Jr. Aetiology of root canal failure: why well-
treated can fail. Int Endod J 2001: 34: 1–10.34. Bader HI. Treatment planning for implants versus root
canal therapy: a contemporary dilemma. Implant Dent2002: 11: 217–222.
35. Gutmann JL, Dumsha TC, Lovdahl PE. ProblemSolving in Endodontics, 4th edn. St. Louis: Elsevier-Mosby, 2006.
Surgical endodontics
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