Meta-Analysis
Outcome of Endodontic Surgery: A Meta-analysis of the Literature—Part 2: Comparison of Endodontic Microsurgical Techniques with and without the Use of Higher Magnification

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Abstract

Introduction

The aim of this study was to investigate the outcome of root-end surgery. It identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids (contemporary root-end surgery [CRS]) were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the 2 techniques were determined by means of a meta-analysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated.

Methods

A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (ie, Medline, Embase, and PubMed) were searched to identify human studies from 1966 up to October 2009 in 5 different languages (ie, English, French, German, Italian, and Spanish). Review articles and relevant articles were searched for cross-references. In addition, 5 dental and medical journals (ie, Journal of Endodontics, International Endodontic Journal, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral and Maxillofacial Surgery, and International Journal of Oral and Maxillofacial Surgery) dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by 3 independent reviewers (S.B.S., M.R.K., and F.C.S.). Relevant articles were obtained in full-text form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall as well as for molars, premolars, and anteriors were calculated. A random-effects model was used for a comparison between the groups.

Results

One hundred one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455–0.9164) and 94% for EMS (95% confidence interval, 0.8889–0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715).

Conclusions

The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice.

Section snippets

Materials and Methods

According to the PICO (Population, Intervention, Comparison, Outcome) format, the following research question had been formulated before the search for matching publications: Teeth that have undergone a root-end surgery and root-end filling procedure (population) by EMS (intervention) compared with CRS (comparison) have what expected probability of success according to longitudinal studies with strictly defined inclusion and exclusion criteria (outcome)?”

Inclusion and Exclusion of Studies

In total, 1,189 citations were reviewed, 1,088 eliminated, and 101 reviewed. Of the 101 citations obtained after abstract and full-text review, a total of 14 records were included in this second part of the meta-analysis 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23. Data from 2 articles were used for CRS as well as EMS 12, 15, bringing the total number to 7 datasets for CRS 10, 11, 12, 13, 14, 15, 16 and 9 datasets for EMS 12, 15, 17, 18, 19, 20, 21, 22, 23. There were 6 randomized

Discussion

Over the past decade, endodontic surgery has evolved into endodontic microsurgery by the introduction of the surgical microscope 45, 108, 109, 110 and/or the endoscope 111, 112. Although the use of the surgical microscope in general dentistry is still debated, its use for nonsurgical and surgical endodontics has become a routine procedure for endodontists since the 1990s and has been made a requirement for postgraduate education in the United States in 1998 (113). Based on a survey among active

Acknowledgment

The authors would like to thank Elaine Bellucci, Statistician, Murrieta, California, for the conduction of the statistical analyses presented in this review.

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  • Cited by (0)

    One of the authors (S.K.) declares a potential conflict of interest by the development of microsurgical ultrasonic tips.

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