Periradicular surgery

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In the dental specialty of endodontics, periradicular surgery is surgery to the external root surface. Examples of periradicular surgery include apicoectomy, root resection, repair of root perforation or resorption defects, removal of broken fragments of the tooth or a filling material, and exploratory surgery to look for root fractures. [1]

Contents

Symptoms may be due to infection in the periradicular tissue around a root-treated tooth, which can impede healing of the tooth after conventional root canal treatment. [2] After removing the pulp, the aim of endodontic treatment is to seal the pulpal space to prevent further bacterial contamination and allow healing of the periradicular tissue. Success rates for root-canal treatment range from 47 to 97 percent; failures may be due to spaces in the root-canal filling, a root filling which is too short or a preexisting periapical lesion. [3]

Treatment options are nonsurgical root-canal re-treatment or periradicular surgery. Although accessing and cleaning the pulp chamber and canals would be easier with the former, it is contraindicated in some patients. [2]

The stages of periradicular surgery are:

  1. Local anaesthesia
  2. Flap design
  3. Bone removal
  4. Curettage
  5. Apicectomy
  6. Retrograde preparation and filling
  7. Wound closure

Indications

Periradicular surgery should be very considered where previous endodontic treatment has failed, and possible re-root treatment is the preferred option. [4] If re-root treatment is not possible, will not correct the problem or patient factors prevent it, periradicular surgery is indicated. [5] [6] [7]

Anatomical deviations preventing access or preparation of canal, including root-canal calcification, pulp stones, severely curved roots, bifurcations, secondary roots, lateral canals, delta apexes, internal and external resorption resistant to conventional treatment and an incomplete apex, may prevent the complete cleaning and preparation of the canal. [4] [5]

Procedural errors include the formation of ledges, perforation of the root or floor of the pulp chamber, [6] extruded root filling material, [7] file breakages, or underfilled canals. These are only indications for periradicular surgery if they cause persistent periapical radiolucency, swelling and pain. [8] [6] [7] [4] [5]

Exploratory surgery that identifies possible root fractures [7] or perforations [4] [5] indicates periradicular surgery.

A biopsy may be used in suspicious or non-healing lesions, or when a patient has uncharacteristic signs and symptoms in periapical areas. [4] [5]

Contraindications

Several factors are considered before periradicular surgery is performed. [2] [9] [10]

Severe systemic disease poses the risk of poor healing after surgery. The patient's attitude towards surgery should also be taken into account.

A tooth is unsuitable for periradicular surgery if it does not have a good periodontal support or coronal seal. It must have enough structure to support restoration. Filling the root canals of the tooth from the crown (orthograde root canal therapy) should be the first treatment option to resolve inflammation caused by the tooth. Periradicular surgery is only considered if the inflammation persists after conventional root canal treatment. A patient's oral hygiene must be considered; poor oral hygiene increases the risk of infection and impairs healing of the surgical site.

The lack of appropriate surgical access to the site contraindicates periradicular surgery; cutting the gum near important anatomical structures, such as neurovascular bundles, risks permanent jaw numbness. Unusual bone structure and root arrangement of the tooth should also be considered.

The surgeon's skill and experience, and the facilities available, should be considered.

Procedure

Assessment

Assessment before periradicular surgery involves a thorough history and clinical exam, followed by special investigations. Clinical assessment considers a number of factors. Oral hygiene and overall dental condition indicates the patient's motivation for treatment and the tooth's restorative prognosis. Gum health is important to ensure optimum healing and appearance after surgery. Cortical bone thickness, regional anatomy, and root fracture or resorption indicate possible difficulties. [11]

Special investigations include radiography, vitality testing of adjacent teeth and an occlusal loading assessment. Radiography identifies disease presence, including periradicular pathology. A periapical radiograph is usually the radiograph of choice. When examining the tooth which will receive surgery, the quality of the root treatment and canal anatomy (sclerosed or missed canals) is noted. More than one radiograph may be required to indicate possible treatment success. The root filling should be optimal.

The relationship of the tooth to neighbouring structures (the inferior dental nerve, mental foramen and maxillary sinus) or to adjacent roots must be noted, to anticipate operative complications and inform the patient. At least 3 mm of tissue beyond the apex of the roots should be radiographically assessed.  

Anaesthesia and haemostasis

Haemostasis is imperative during surgery to allow optimum visualisation. It is achieved preoperatively with a local anaesthetic. The anaesthetic's adrenaline targets the smooth muscle of arterioles by acting on the alpha adrenergic receptors.

Haemostasis is continued throughout the procedure. The main methods are:

  1. Topical epinephrine pellets
  2. Ferric sulphate, which forms a plug by agglutinating the blood proteins; however, it is cytotoxic and can cause necrosis of the oral tissues.
  3. Calcium sulphate mechanically blocks open vessels and aids bone regeneration.

Bleeding in the bone is also affected by the local anaesthetic's vasoconstriction and topically-applied agents. These topical agents should be removed before closing the surgical site. [12] When the flap has been sutured in position, haemostasis is maintained postoperatively. Digital pressure on a damp gauze controls bleeding and stabilises the flap. An ice pack is recommended (15 minutes on, 30 minutes off) for the first six hours.

Flap design

Two main flap designs used in endodontic surgery are full and limited mucoperiosteal flaps. Full mucoperiosteal flaps involve an intrasulcular horizontal incision with reflection of the marginal and interdental gingival tissue. [13] They can be two- or three-sided or envelope-shaped. A two-sided (triangular) flap is made with a horizontal, intrasulcular incision and a vertical relieving incision. The first horizontal incision follows the contours of the tooth, cutting the gingival sulcus (including the mesial or distal papilla. The relieving incision begins at the gingival margin and extends to the attached gingiva. For posterior teeth, the horizontal incision is always mesial. [13] A three-sided (rectangular) flap is made with a horizontal, intrasulcular incision and two vertical relieving incisions. Although this flap increases surgical access, it is difficult to re-approximate the tissue. [13] An envelope (horizontal) incision is a horizontal, intrasulcular incision with no vertical relieving incision. This design provides little surgical access to the root surface. [13]

Limited mucoperiosteal flaps have a submarginal horizontal or horizontally-oriented incision, and do not include marginal or interdental tissues. A submarginal curved (semilunar) incision begins in the alveolar mucosa, dips down into the attached gingiva and extends back into the alveolar mucosa. Semilunar flaps have poor healing potential, and often lead to scarring. [13] A submarginal scalloped (Ochsenbein-Luebke) flap is similar to the rectangular flap, but the horizontal incision is in the attached gingiva. It is scalloped, following the contour of the gingival margins below. This flap is also prone to delayed healing and scarring. [13]

Wound closure

Before closing the wound, it should be well-irrigated (to prevent infection) and the flap compressed to reduce the risk of haematoma. The flap is re-approximated, and the first suture should be placed in the interdental papilla. [2] After suturing the flap, a sterile damp gauze should be compressed on the wound for several minutes; an ice pack can be used (15 minutes on, 30 minutes off) by the patient. Sutures should be removed two to four days after surgery, depending on type. [2]

Complications and management

Periradicular surgery has a risk of complications, which can be minimised by the surgeon. By identifying and managing any complications, long-term damage is usually prevented.

Pain and swelling are common, and can be managed with prescription analgesics. A long-acting local anaesthetic may provide relief immediately after surgery. [14] Swelling can be minimised by applying pressure with an ice pack for four to six hours after surgery. Ecchymosis (bruising) may occur, but it is self-limiting and usually resolves within two weeks after surgery.

Damage to blood vessels during surgery can lead to haemorrhage; severe haemorrhage is rare but serious. [15] Although mild haemorrhage is relatively common and not life-threatening, it may affect treatment outcome. Haemorrhaging may be prevented with adequate haemostasis, essential to improve visualisation of the site (minimising operating time and providing an optimal environment for placing filling materials. Local anaesthetic, with an appropriate vasoconstrictor, is used during endodontic surgery to achieve anaesthesia and haemostasis. [15] Assuming no contraindications, the anaesthetic of choice is two-percent lidocaine with 1:100,000 adrenaline. Mild bleeding is common, and can be controlled by digital compression or ligation of the vessel. [16]

Infection of the surgical site, which may cause secondary haemorrhaging, cellulitis or abscess, can result from poor surgical technique, poor oral hygiene, or smoking. [17] Prevention of infection is promoted by advising the patient to maintain oral hygiene and the use of an antiseptic mouthwash, such as chlorhexidine, immediately before and after surgery. [14] In the event of systemic involvement or with immunocompromised patients, systemic antibiotics can be prescribed. [2]

Outcomes

Since a range of benchmarks has been used to assess the outcome of periradicular surgery, [18] comparisons are challenging; the classification most published papers adopt is by Rud et al, [19] which evaluates success radiographically. Clinical criteria have also been considered, as outlined by the Royal College of Surgeons of England.

RCS outcome guidelines for surgical endodontics [5]
OutcomeClinicalRadiological
SuccessfulPrevious signs and symptoms resolvedRegular or slightly-wider PDL

Previous periapical radiolucency reduced (or resolved), with normal replacement of bone and lamina dura.

Sound roots, without resorption

IncompletePrevious signs and symptoms resolvedSome bone surrounding root of tooth, with gradual replacement but incomplete healing

Periapical radiolucency still present

UncertainIndefinite symptoms - slight ache (or discomfort) associated with tooth in questionSome bone surrounding root of tooth, with gradual replacement but incomplete healing

Periapical radiolucency still present.

UnsuccessfulUnresolved signs and symptoms associated with tooth in questionNo bony replacement surrounding root of tooth

If periapical surgery is unsuccessful, the cause(s) of failure must be determined before further treatment. [5] [20] Follow-up surgery is usually less successful (35.7 percent) [5] and is not recommended. [20]

Options to repeat periapical surgery are:

Root canal filling

Periraduclar surgery is necessary if root canal treatment fails. Its outcome depends on a number of factors, one of which is the root-canal filling. The filling promotes cementum and bone formation, [21] [22] blocks bacteria, and is a barrier for the root canal. Inflammation of the periradicular site due to bacteria could cause recovery to deteriorate and induce periradicular infection. [22] Careful evaluation of root canal filling material is required to optimise healing after the procedure.

Amalgam filling was the recommended material for root-end fillings until the 1990s, when safety concerns (leakage, toxicity, and corrosion) prompted re-evaluation of its use. [23] Calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA) are considered more suitable, since they enhance periradicular tissue regeneration. [22]

MTA was introduced in 1993. [23] Although it prevents leakage and is biocompatible, it has questionable antibacterial properties, [22] a long setting time (about three hours), manipulates poorly and is expensive. [24] CEM cement is superior to MTA as a root-end filling material; it has greater antibacterial effects, a shorter setting time, less film thickness and a smaller particle size. [22] Compared to other root-end canal filling materials (eg amalgam, zinc oxide eugenol and intermediate restorative material), the long term effectiveness of MTA is inconclusive. [25]

See also

Related Research Articles

<span class="mw-page-title-main">Root canal</span> Hollow part of the root of a tooth

A root canal is the naturally occurring anatomic space within the root of a tooth. It consists of the pulp chamber, the main canal(s), and more intricate anatomical branches that may connect the root canals to each other or to the surface of the root.

<span class="mw-page-title-main">Endodontics</span> Field of dentistry

Endodontics is the dental specialty concerned with the study and treatment of the dental pulp.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Apicoectomy</span> Endodontic root end surgery

A root end surgery, also known as apicoectomy, apicectomy, retrograde root canal treatment or root-end filling, is an endodontic surgical procedure whereby a tooth's root tip is removed and a root end cavity is prepared and filled with a biocompatible material. It is an example of a periradicular surgery.

Dens invaginatus (DI), also known as tooth within a tooth, is a rare dental malformation where there is an infolding of enamel into dentine. The prevalence of condition is 0.3 - 10%, affecting more males than females. The condition is presented in two forms, coronal and radicular, with the coronal form being more common.

<span class="mw-page-title-main">Dentin dysplasia</span> Medical condition

Dentin dysplasia (DD) is a rare genetic developmental disorder affecting dentine production of the teeth, commonly exhibiting an autosomal dominant inheritance that causes malformation of the root. It affects both primary and permanent dentitions in approximately 1 in every 100,000 patients. It is characterized by presence of normal enamel but atypical dentin with abnormal pulpal morphology. Witkop in 1972 classified DD into two types which are Type I (DD-1) is the radicular type, and type II (DD-2) is the coronal type. DD-1 has been further divided into 4 different subtypes (DD-1a,1b,1c,1d) based on the radiographic features.

<span class="mw-page-title-main">Dental abscess</span> Medical condition

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

<span class="mw-page-title-main">Dental radiography</span> X-ray imaging in dentistry

Dental radiographs, commonly known as X-rays, are radiographs used to diagnose hidden dental structures, malignant or benign masses, bone loss, and cavities.

<span class="mw-page-title-main">Root canal treatment</span> Dental treatment

Root canal treatment is a treatment sequence for the infected pulp of a tooth which is intended to result in the elimination of infection and the protection of the decontaminated tooth from future microbial invasion. Root canals, and their associated pulp chamber, are the physical hollows within a tooth that are naturally inhabited by nerve tissue, blood vessels and other cellular entities. Together, these items constitute the dental pulp.

Apical periodontitis is typically the body's defense response to the threat of microbial invasion from the root canal. Primary among the members of the host defense mechanism is the polymorphonuclear leukocyte, otherwise known as the neutrophil. The task of the neutrophil is to locate and destroy microbes that intrude into the body – anywhere in the body – and they represent the hallmark of acute inflammation.

<span class="mw-page-title-main">Coronectomy</span>

When extracting lower wisdom teeth, coronectomy is a treatment option involving removing the crown of the lower wisdom tooth, whilst keeping the roots in place in healthy patients. This option is given to patients as an alternative to extraction when the wisdom teeth are in close association with the inferior alveolar nerve, and so used to prevent damage to the nerve which may occur during extraction.

<span class="mw-page-title-main">Pulpotomy</span>

Pulpotomy is a minimally invasive procedure performed in children on a primary tooth with extensive caries but without evidence of root pathology. The minimally invasive endodontic techniques of vital pulp therapy (VPT) are based on improved understanding of the capacity of pulp (nerve) tissues to heal and regenerate plus the availability of advanced endodontic materials. During the caries removal, this results in a carious or mechanical pulp exposure (bleeding) from the cavity. During pulpotomy, the inflamed/diseased pulp tissue is removed from the coronal pulp chamber of the tooth leaving healthy pulp tissue which is dressed with a long-term clinically-successful medicament that maintains the survival of the pulp and promotes repair. There are various types of medicament placed above the vital pulp such as Buckley’s Solution of formocresol, ferric sulfate, calcium hydroxide or mineral trioxide aggregate (MTA). MTA is a more recent material used for pulpotomies with a high rate of success, better than formocresol or ferric sulfate. It is also recommended to be the preferred pulpotomy agent in the future. After the coronal pulp chamber is filled, the tooth is restored with a filling material that seals the tooth from microleakage, such as a stainless steel crown which is the most effective long-term restoration. However, if there is sufficient remaining supporting tooth structure, other filling materials such as amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less. The medium- to long-term treatment outcomes of pulpotomy in symptomatic permanent teeth with caries, especially in young people, indicate that pulpotomy can be a potential alternative to root canal therapy (RCT).

Pulp necrosis is a clinical diagnostic category indicating the death of the pulp and nerves of the pulp chamber and root canal of a tooth which may be due to bacterial sequelae, trauma and chemical or mechanical irritation. It is often the end result of many cases of dental trauma, caries and irreversible pulpitis.

A phoenix abscess is an acute exacerbation of a chronic periapical lesion. It is a dental abscess that can occur immediately following root canal treatment. Another cause is due to untreated necrotic pulp. It is also the result of inadequate debridement during the endodontic procedure. Risk of occurrence of a phoenix abscess is minimised by correct identification and instrumentation of the entire root canal, ensuring no missed anatomy.

<span class="mw-page-title-main">Periapical periodontitis</span> Medical condition

Periapical periodontitis or apical periodontitis (AP) is an acute or chronic inflammatory lesion around the apex of a tooth root, most commonly caused by bacterial invasion of the pulp of the tooth. It is a likely outcome of untreated dental caries, and in such cases it can be considered a sequela in the natural history of tooth decay, irreversible pulpitis and pulpal necrosis. Other causes can include occlusal trauma due to 'high spots' after restoration work, extrusion from the tooth of root filling material, or bacterial invasion and infection from the gums. Periapical periodontitis may develop into a periapical abscess, where a collection of pus forms at the end of the root, the consequence of spread of infection from the tooth pulp, or into a periapical cyst, where an epithelial lined, fluid-filled structure forms.

<span class="mw-page-title-main">Regenerative endodontics</span> Dental specialty

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

<span class="mw-page-title-main">Oroantral fistula</span> Medical condition

Oroantral fistula (OAF) is an epithelialised oroantral communication (OAC). OAC refers to an abnormal connection between the oral cavity and antrum. The creation of an OAC is most commonly due to the extraction of a maxillary (upper) tooth closely related to the antral floor. A small OAC may heal spontaneously but a larger OAC would require surgical closure to prevent the development of persistent OAF and chronic sinusitis.

Root fracture of the tooth is a dentine cementum fracture involving the pulp.

Periapical granuloma, also sometimes referred to as a radicular granuloma or apical granuloma, is an inflammation at the tip of a dead (nonvital) tooth. It is a lesion or mass that typically starts out as an epithelial lined cyst, and undergoes an inward curvature that results in inflammation of granulation tissue at the root tips of a dead tooth. This is usually due to dental caries or a bacterial infection of the dental pulp. Periapical granuloma is an infrequent disorder that has an occurrence rate between 9.3 to 87.1 percent. Periapical granuloma is not a true granuloma due to the fact that it does not contain granulomatous inflammation; however, periapical granuloma is a common term used.

Periodontal surgery is a form of dental surgery that prevents or corrects anatomical, traumatic, developmental, or plaque-induced defects in the bone, gingiva, or alveolar mucosa. The objectives of this surgery include accessibility of instruments to root surface, elimination of inflammation, creation of an oral environment for plaque control, periodontal diseases control, oral hygiene maintenance, maintain proper embrasure space, address gingiva-alveolar mucosa problems, and esthetic improvement. The surgical procedures include crown lengthening, frenectomy, and mucogingival flap surgery.

References

  1. ↑ "Endodontists' Guide to CDT 2017" (PDF). American Association of Endodontists. 2017. p. 13–14. Retrieved 2020-03-14.
  2. 1 2 3 4 5 6 "Guidelines for Surgical Endodontics" (PDF). www.rcseng.ac.uk. Retrieved 2018-12-12.
  3. ↑ Ng, Y.-L.; Mann, V.; Rahbaran, S.; Lewsey, J.; Gulabivala, K. (2007-10-11). "Outcome of primary root canal treatment: systematic review of the literature – Part 2. Influence of clinical factors". International Endodontic Journal. 41 (1): 071011095702005––. doi: 10.1111/j.1365-2591.2007.01323.x . ISSN   0143-2885. PMID   17931388.
  4. 1 2 3 4 5 Pop, I. (28 September 2013). "Oral surgery: part 2. Endodontic surgery". British Dental Journal. 215 (6): 279–286. doi: 10.1038/sj.bdj.2013.876 . ISSN   1476-5373. PMID   24072296.
  5. 1 2 3 4 5 6 7 8 Evans, Glynis E; Bishop, Karl; Renton, Tara (2012). "Guidelines for Surgical Endodontics". RCS Faculty of Dental Surgery. Version 2.
  6. 1 2 3 von Arx, Thomas (January 2011). "Apical surgery: A review of current techniques and outcome". The Saudi Dental Journal. 23 (1): 9–15. doi:10.1016/j.sdentj.2010.10.004. ISSN   1013-9052. PMC   3770245 . PMID   24151412.
  7. 1 2 3 4 Serrano-Giménez, Mireia; Sánchez-Torres, Alba; Gay-Escoda, Cosme (November 2015). "Prognostic factors on periapical surgery: A systematic review". Medicina Oral, Patología Oral y Cirugía Bucal. 20 (6): e715–e722. doi:10.4317/medoral.20613. ISSN   1698-4447. PMC   4670252 . PMID   26449431.
  8. ↑ Murray, Peter (2015), "Periradicular Surgery", A Concise Guide to Endodontic Procedures, Springer, Berlin, Heidelberg, pp. 177–184, doi:10.1007/978-3-662-43730-8_9, ISBN   9783662437292
  9. ↑ Pop, I. (September 2013). "Oral surgery: part 2. Endodontic surgery". British Dental Journal. 215 (6): 279–286. doi: 10.1038/sj.bdj.2013.876 . ISSN   1476-5373. PMID   24072296.
  10. ↑ Dawood, A. (May 2017). "The Dental Practicality Index – assessing the restorability of teeth" (PDF). British Dental Journal. 222 (10): 755–758. doi:10.1038/sj.bdj.2017.447. PMID   28546619. S2CID   4630139.
  11. ↑ Pop, I (28 September 2013). "Oral surgery: part 2. Endodontic surgery". British Dental Journal. 215 (6): 279–86. doi: 10.1038/sj.bdj.2013.876 . PMID   24072296. S2CID   23143099.
  12. ↑ Faculty of Dental Surgery - Guidelines for Surgical Endodontics 2012
  13. 1 2 3 4 5 6 Ankita Taltia, A.; Pradeep, S. "Flap Designs in Endodontic Surgery" (PDF). www.ijrti.org. Retrieved 2018-12-15.
  14. 1 2 Tsesis, Igor; Beitlitum, Ilan; Rosen, Eyal (2014), "Prevention and Management of Soft Tissue Complications in Endodontic Surgery", Complications in Endodontic Surgery, Springer Berlin Heidelberg, pp. 61–71, doi:10.1007/978-3-642-54218-3_6, ISBN   9783642542176
  15. 1 2 Witherspoon, D. E.; Gutmann, J. L. (May 1996). "Haemostasis in periradicular surgery". International Endodontic Journal. 29 (3): 135–149. doi:10.1111/j.1365-2591.1996.tb01360.x. ISSN   0143-2885. PMID   9206418.
  16. ↑ Penarrocha-Diago, M.; Maestre-Ferrin, L.; Penarrocha-Oltra, D.; von Arx, T.; Penarrocha-Diago, M. (2013). "Influence of hemostatic agents upon the outcome of periapical surgery: Dressings with anesthetic and vasoconstrictor or aluminum chloride". Medicina Oral Patología Oral y Cirugia Bucal. 18 (2): e272–e278. doi:10.4317/medoral.18002. ISSN   1698-6946. PMC   3613880 . PMID   23229242.
  17. ↑ García, Berta; Penarrocha, Miguel; Martí, Eva; Gay-Escodad, Cosme; von Arx, Thomas (August 2007). "Pain and swelling after periapical surgery related to oral hygiene and smoking". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 104 (2): 271–276. doi:10.1016/j.tripleo.2007.01.025. ISSN   1079-2104. PMID   17507266.
  18. ↑ Torabinejad, Mahmoud; Nash, Brandon; Mego, Miguel E.; Javidan-Nejad, Salvia; Mead, Cary (2005-01-01). "Levels of Evidence for the Outcome of Endodontic Surgery". Journal of Endodontics. 31 (1): 19–24. doi:10.1097/01.DON.0000133158.35394.8A. ISSN   1878-3554. PMID   15614000.
  19. ↑ Serrano-Giménez, Mireia; Sánchez-Torres, Alba; Gay-Escoda, Cosme (2015-11-01). "Prognostic factors on periapical surgery: A systematic review". Medicina Oral, Patologia Oral y Cirugia Bucal. 20 (6): e715–722. doi:10.4317/medoral.20613. ISSN   1698-6946. PMC   4670252 . PMID   26449431.
  20. 1 2 Saunders, William P. (2005-07-01). "Considerations in the revision of previous surgical procedures". Endodontic Topics. 11 (1): 206–218. doi:10.1111/j.1601-1546.2005.00155.x. ISSN   1601-1546.
  21. ↑ Asgary, Saeed (2011). "Management of a hopeless mandibular molar: a case report". Iranian Endodontic Journal. 6 (1): 34–37. PMC   3471588 . PMID   23130053.
  22. 1 2 3 4 5 Asgary, Saeed; Ehsani, Sara (2013). "Periradicular Surgery of Human Permanent Teeth with Calcium-Enriched Mixture Cement". Iranian Endodontic Journal. 8 (3): 140–144. PMC   3734518 . PMID   23922577.
  23. 1 2 Tsurumachi, Tamotsu (2013). "Current strategy for successful periradicular surgery". Journal of Oral Science. 55 (4): 267–273. doi: 10.2334/josnusd.55.267 . ISSN   1880-4926. PMID   24351913.
  24. ↑ von Arx, Thomas (2005). "Failed root canals: the case for apicoectomy (periradicular surgery)". Journal of Oral and Maxillofacial Surgery. 63 (6): 832–837. doi:10.1016/j.joms.2005.02.019. ISSN   0278-2391. PMID   15944982.
  25. ↑ Li, Honglin; Guo, Zhiyong; Li, Chunjie; Ma, Xiangyu; Wang, Yan; Zhou, Xuedong; Johnson, Trevor M.; Huang, Dingming (2021-10-14). "Materials for retrograde filling in root canal therapy". The Cochrane Database of Systematic Reviews. 10: CD005517. doi:10.1002/14651858.CD005517.pub3. ISSN   1469-493X. PMC   8515509 . PMID   34647617.
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