Periapical Surgery

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Periapical Surgery
Thomas Dietrich
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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.
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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.
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Study flowchart
Number 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.
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Distribution of teeth per incision technique
Teeth Intrasulcular incision Intrasulcular incision Papilla base incision Papilla base incision Submarginal incision Submarginal incision
Teeth
Teeth 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.
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Distribution of teeth per restoration
Teeth No restoration No restoration Filling Filling Crown Crown
Teeth
Teeth 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
Von Arx et al. Int Endod J 2007 40 959-969.
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Changes (mean  SD) of PD, GM, CAL by incision
technique
Site Incision technique PD GM CAL

Pooled buccal Intrasulcular incision -0.08 (0.50) -0.42 (0.69)x 0.34 (0.68)x?
Pooled buccal        
Pooled buccal Papilla base incision -0.21 (0.38) -0.31 (0.49) 0.10 (0.62)?
Pooled buccal        
Pooled buccal Submarginal incision -0.18 (0.37) 0.05 (0.61)x -0.23 (0.57)x
Von Arx et al. Int Endod J 2007 40 959-969.
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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.
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Marginal incision
Von Arx et al. Int Endod J 2007 40 959-969.
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Papilla-base incision
Von Arx et al. Int Endod J 2007 40 959-969.
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Submarginal incision
Von Arx et al. Int Endod J 2007 40 959-969.
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Criteria for success

• For example (von Arx Kurt 1999)
• Pain score (0-3)
• Clinical Score (0-3)
• Healing classification
• Success/complete healing (gt90 regeneration of
  bone pain/clinical scores 0)
• Improvement/partial healing (50-90 regeneration
  of bone pain/clinical scores 0)
• Failure/incomplete/uncertain healing (lt50
  regeneration of bone OR pain/clinical scores gt0)

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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.
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Study flowchart
N Teeth N Excluded Reason for Exclusion
266 (initial number of treated teeth)
? 21 No 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
? 3 Dropouts (patients did not show up for 1-year control)
191 (final number of evaluated teeth)
Von Arx et al . J Endod 2007 33 123-128.
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Results (example)
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
Von Arx et al . J Endod 2007 33 123-128.
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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.