DOI 10.20398/jscr.v12i1.

24054

ENDODONTIC SURGERY: A REVIEW OF POSTOPERATIVE AND HEALING

OUTCOME

Laís Carolina Landim Gomes1,2, Jafar César Dutra3

1. DDS, MSc, PhD student - Department of Restorative Dentistry, Endodontic Division,

São Paulo State University (Unesp), Institute of Science and Technology, São José dos
Campos, SP, Brazil. E-mail: [email protected]
2. Department of Dental Materials and Prosthodontics, São Paulo State University
(Unesp), Institute of Science and Technology, São José dos Campos, SP, Brazil
3. DDS, Specialty in Endodontics - Department of Endodontics, Sao Paulo University,
School of Dentistry, Bauru, SP, Brazil. E-mail: [email protected]

Study performed at Department of Dental Materials and Prosthodontics, São Paulo State
University (Unesp). Brazil.
Financial Support: None.
Conflict of interest: None.
Corresponding author: José Antonio de Oliveira Street. 72. Cidade Morumbi. São José dos
Campos, SP – Brazil. Postal code: 12236-690 [email protected]/
[email protected].
Submitted: feb 14; accepted after revision, sep 16, 2021.

ABSTRACT
The purpose of this review was to give the reader an update about the postoperative
period and healing outcome after surgical endodontic retreatment. Endodontic surgery
has become a standard of care for dental maintenance if conventional endodontic
retreatment is not able to eliminate the infection, it is important to know how to manage
the post-surgical care, due it might directly interfere in the healing outcome after the
surgical procedure. An electronic search of the relevant English-language literature was
conducted in the MEDLINE/ PubMed database using the following key-words
combinations: Postoperative care; apical surgery; apicoectomy; wound healing. Articles
from 1980 to 2011 were included. Based on the results of this present review, the
postoperative period after the surgery treatment is very mild, without any
complications, being similar to any dental surgical discomfort, as swelling, bleeding and
pain, which could be easily controlled with simple medicine. Regarding the repair after
endodontic surgery, the length of follow-up time and the healing evaluation criteria
affect the outcome, and 1-year follow-up periods might be insufficient to predict a long-
term healing.
Key words: Apicoectomy. Endodontics. Postoperative Care. Postoperative Period.
Wound Healing.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 24

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

INTRODUCTION

In medical imaging, conventional radiographs, such as panoramic, use

techniques based on two-dimensional (2D) representation of bone structures 1.
However, to obtain a volumetric evaluation of bone tissue, it is necessary to use imaging
tests that provide visualization in three-dimensional format (3D), in this context,
computed tomography has been used in order to reconstruct the information collected
by the equipment, through the analysis of cuts in different planes of the human body.
This technology allows 3D reconstruction and image manipulation to take place using
computerized software at full scale (1:1)2.
Initial root canal therapy has been shown to be a predictable procedure with a
high degree of success 1–4, although, failures can occur after treatment. Some
publications reported failure rates of 14%–16% for initial root canal treatment 1,5. Lack
of healing is attributed to persistent intraradicular infection residing in previously
uninstrumented canals, dentinal tubules, or in the complex irregularities of the root
canal system 6–9.
Typically, when conventional root canal treatment fails in clinical situations, the
preferred subsequent option in most cases is non-surgical retreatment. However, in
some instances, other factors, such as a complex root canal system or previous
accidents, may interfere with the success of non-surgical retreatment. In such cases,
periradicular surgery is the treatment of choice in order to save the tooth 10.
Periradicular belongs to the field of endodontic surgery, and its aims to solve a
periapical inflammatory process by surgical access followed by lesion enucleation and
root filling. In order to preserve the dental element, in this cases, apicectomy is
considered one of the best options 11. Futhermore, the main objective of an endodontic
surgery is to surgically maintain a tooth that has an endodontic lesion which cannot be
resolved by non-surgical retreatment 12.
Regarding the success of endodontic surgery, it depends on the condition of the
tooth. The prognosis of periradicular surgery is directly affected by the existing bone
portion attached to the root framework. It is therefore important to know that the
likelihood of success depends on the condition of the dental element 13.
The postoperative period of an endodontic surgery should occur as optimally as
possible, so that repair of the periapical region could happen. As a surgical procedure,
some discomfort may occur after the surgery, as swelling, pain, discoloration of the soft
tissues and bleeding. The post-surgical management of the patient is important as the
surgical management of the patient. Patients who do not receive adequate post-surgical
instructions or who ignore these instructions are predisposed to untoward sequelae 14.
This literature review aims to give the reader an update about the postoperative
period and healing outcome after a surgical endodontic treatment. The present paper is

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 25

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

divided into three sections: Endodontic surgery definition and its indication,
postoperative management, and healing outcome.

REVIEW

An electronic literature search of the relevant English-language literature was

conducted in the MEDLINE/ PubMed database using the following key-words
combinations: Postoperative care; apical surgery; apicoectomy; wound healing. Articles
from 1980 to 2011 were included, all of them were clinical trials. The inclusion criteria
were: Postoperative care, symptons and follow-up period after an endondontic surgery.
The exclusion citeria were: Lack of clinical follow up data. Convencional endodontic
treatment. Periodontal disease.
Endodontic surgery: Definition and its indication
If conservative therapy does not lead to healing after a reasonable follow-up,
this failure indicates that the periapical lesion remained unchanged because the canal
was not adequately treated and filled. If periapical pathology persists and / or treatment
through the orthograde route is impracticable or exhausted, the endodontic surgery is
indicated 15.
Endodontic surgery has become a standard of care for dental maintenance if
conventional endodontic retreatment is not feasible or associated with risks. However,
in certain situations, the outcome of endodontic surgery may be compromised or
uncertain due to the extent or location of periapical or periradicular lesions 16.
The first endodontic surgery report was performed by Farrar & Brophy (1880)
17,18 who made the apicectomy (root resection) in the United States. Since then, his

technique has been refined and this procedure has been practiced by both the general
dentist and the specialty one 19,20.
Torabinejad et al. (1995) 15 report that if conservative therapy does not lead to
healing after a reasonable follow-up, this failure indicates that the periapical lesion
remained unchanged because the root canal was not adequately treated and filled. If
periapical pathology persists and / or treatment through the orthograde route is
impracticable or exhausted, endodontic surgery is indicated 15.
The work done by El Swiah and Walter (1996) 21 evaluated the clinical factors
involved in the decision to perform an apicectomy, they concluded that a sum of
technical and biological factors lead to 60% of apicectomies. The most common
biological factors are: persistent symptoms, continuous presence of root lesions and
persistent exudate (2%). Therefore, these factors must be taken into consideration
when indicating the case for surgery 21.
Nishiyama et al. (2002) 22 state that parendodontic surgery (belongs to the field
of endodontic surgery) is indicated when signs and / or symptoms remain after all

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 26

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

possibilities of solution by endodontic treatments have been exhausted. The promotion

of tissue repair through the elimination of the periapical pathological process is the goal
of this surgery.
Von Arx (2011) 16 concluded that the evaluation of a case referred for apical
surgery must always include a careful weighing of the advantages and disadvantages of
surgical and non-surgical intervention. The indication for apical surgery must be based
on a careful and thorough clinical and radiographic examination 16.
The endodontic surgery indications were recently updated by the European
Society of Endodontics (ESE) (2006) 23 and include the following:
1. Radiological findings of apical periodontitis and / or symptoms associated with
an obstructed canal (obstruction proved not to be removable, displacement did not
seem feasible, or the risk of damage was very large).
2. Extruded material with clinical or radiological findings of apical periodontitis
and / or persistent symptoms over a prolonged period.
3. Persistent or emerging disease after root canal treatment when root canal
retreatment is inadequate.
4. Perforation of the root or pulp chamber floor, where treatment by the pulp
cavity is impossible.
Kim and Kratchman (2006) 24 argue that a surgical approach is more conservative
than a non-surgical treatment for certain cases. A common example is a tooth with
acceptable endodontics and a new restoration with root retainer and crown, but a
persistent or enlarged periapical lesion. Breaking or disassembling the crown, removing
the retainer and retracting the channels would be more dramatic, longer, more
expensive and less predictable than a root microsurgical approach. The indications for
endodontic surgery in the articles included in this review are shown (Table 1).

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 27

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

Table 1 – Indications for endodontic surgery present in the articles included in this
review.
Author Indications for Endodontic surgery
Torabinejad et al. Periapical pathology persists and /or treatment through the orthograde
(1995) route is impracticable or exhausted.
El Swiah and Walter The most common biological factors are: persistent symptoms,
(1996) continuous presence of root lesions and persistent exudate (2%).
Nishiyama et al. Indicated when signs and /or symptoms remain after all possibilities of
(2002) solution by endodontic treatments have been exhausted.
Apical surgery must be based on a careful and thorough clinical and
Von Arx (2011)
radiographic examination.
Radiological findings of apical periodontitis and/or symptoms associated
with an obstructed canal;
Extruded material with clinical or radiological findings of apical
European Society of
periodontitis and / or persistent symptoms over a prolonged period;
Endodontics (ESE)
Persistent or emerging disease after, root canal treatment when root
(2006)
canal retreatment is inadequate;
Perforation of the root or pulp chamber floor, where treatment by the
pulp cavity is impossible.
Kim and Kratchman Tooth with acceptable endodontics and a new restoration with root
(2006) retainer and crown, but a persistent or enlarged periapical lesion

There are not many contraindications for endodontic surgery in the literature,
they were updated by Chong & Rhodes (2014) 25 and divided into general and local
factors as the following:
General
Patient factors including psychological considerations and systemic disease for
example, bleeding dyscrasias
Clinician factors including the training, skill and experience of the operator,
availability of equipment and facilities.
Local
Dental factors including restorability of the tooth, root length, periodontal
support and the patient's oral hygiene status
Anatomical factors including the proximity of neurovascular structures. For
example, the inferior alveolar and mental nerves may be at risk with surgery of
mandibular molars and premolars; similarly, the palatal neurovascular bundle with a
palatal flap
Surgical access factors. For example, the ability of a patient to open their mouth
wide, which will affect the operator's ability to easily see and access the surgical site. In
the posterior region of the mandible the extended width of the external oblique ridge,
when combined with lingually-placed root apices of molar teeth, may complicate

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 28

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

visibility and access. Another example is the presence of a large bony exostosis, which
may make incision and reflection of a flap considerably more difficult.
Postoperative management
The postoperative period of an endodontic surgery should occur as optimally as
possible, so that repair of the periapical region could happen. As a surgical procedure,
some discomfort may occur after the surgery, as swelling, pain, discoloration of the soft
tissues and bleeding.
There are some studies which report the most common symptoms that may
occur after the endodontic surgery and how to deal with them. It is important to
consider, the main role of the patient in the postoperative care, they need to be
informed about the procedure, and follow correctly the surgeon´s instruction for a
postorerative period without any complications.
Swelling is a well-recognised postoperative manifestation and has been
thoroughly investigated with endodontic surgical procedures 26–28. The Royal College of
Surgeons (Eng) dental faculty suggests that application of an ice pack 4-6 hours post-
surgery minimises postoperative swelling 29. Currently, no data exists to study whether
this has any significant impact in postoperative pain, but the findings of Chong & Pitt
Ford (2005) 30 were that non-prescription analgesia provided adequate relief in
symptoms following endodontic surgery in two treatment groups who received different
root-end filling materials 30. This study also concluded that pain was experienced early
in the postoperative period and decreased in intensity with time. A similar outcome is
proposed for swelling: that this is worst 24-48 hours post-surgery, and the autor
suggests the application of an ice pack for 20 minutes in each hour throughout the day
during the day of surgery 31. There is also evidence to suggest that pain and swelling is
more severe in patient with poor oral hygiene and those that smoke 27.
Moreover, the pain following an endodontic surgery is usually minimal. The pain,
if any, is of short duration and reaches its maximum intensity on the day of surgery.
Iqbal et al. (2007) 32 reported data from 199 patients undergoing surgery through
a self-assessment questionnaire. The results showed that pain and edema were
significantly related to females and younger patients (p <0.05). Extreme pain and
swelling were reported on the first day after surgery. Anterior maxillary surgeries were
related to the presence of more pain and swelling. Most patients (67%) rated surgical
endodontics more pleasant than expected with less symptomatology (46%) or the same
(38%) than non-surgical treatment. The results also show that patients generally have
negative feelings and limited knowledge about parendodontic surgery 32.
A significant reduction in pain usually occurs on the first postoperative day,
followed by a steady, progressive decrease in discomfort each succeeding day 33. Some
articles shows that just a few patients experience pain that cannot be contoled it by mild

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 29

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

analgesics 33–36. As it is easier to prevent pain than to eliminate pain, analgesic therapy
should be initiated prior to surgery 14.
The postoperative symptoms after endodontic surgery in the articles included in
this review are shown (Table 2).
Table 2. Postoperative symptoms after endodontic surgery present in the articles
included in this review.
Author Postoperative symptoms

Penarrocha et al
Swelling is a well-recognized postoperative symptom
(2006)

Garcia et al.
Swelling as the first postoperative symptom.
(2007)

Kvist & Reit

Swelling is the main postoperative symptom
(2000)

Chong & Pitt Ford Pain was experienced early in the postoperative period and
(2005) decreased in intensity with time.

Rhodes JS
Swelling is worst 24-48 hours post-surgery.
(2005)

Iqbal et al. Extreme pain and swelling were reported on the first day
(2007) after surgery.
Pain usually occurs on the first postoperative day. followed
Seymour et al.
by a steady, progressive decrease in discomfort each
(1986)
succeeding day.
Seymour & Rawlins
Intensive pain, not controlled by mild analgesics.
(1982)

Seymour
Intensive pain, not controlled by mild analgesics.
(1984)

Von Graffenried et al.

Intensive pain, not controlled by mild analgesics.
(1980)

According to Gutmann et al. (2005) 14 the medication therapy recommended are

non-opioid (nonnarcotic) analgesics with the initial dosage timed, so, that the selected
analgesic is approaching peak blood levels before the local anesthesia has worn off. For
example, 500–600 mg of acetaminophen, or 800 mg of ibuprofen are given orally just
prior to injection of lidocaine with vasoconstrictor for periradicular surgery 14. Some

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 30

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

studies indicated the use of both acetaminophen (1000 mg) and ibuprofen (600 mg) in
combination to eliminate or minimize pain 37.
The use of an antibiotic prophylaxis is not recommended for endodontic surgey,
because the post-surgical infections following surgical endodontic procedures are very
rare. When the infection occur it may result from non-oral microorganisms, as a result
of inadequate aseptic surgical techniques, or from bacterial penetration of the surgical
site because of poor re-approximation and stabilization of elevated and reflected
tissues, which can result in a continuous influx of oral microorganisms that overwhelm
the tissues’ defensive mechanisms 14. If an infection should develop, signs and
symptoms of infection are usually present 36–48 h after the procedure and include
increased and progressive swelling and pain, which may or may not be associated with
suppuration, fever, and lymphadenopathy 38. Antibiotic therapy is initiated promptly
and the patient is monitored to ensure the selected antibiotic is effective. There is a
tendency to use penicillinase-resistant drugs, extended spectrum drugs such as
ampicillin and amoxicillin, cephalosporins, azithromycin, clarithromycin or clindamycin,
or some combination of the above. However, there is no scientific evidence available to
support the choice of these drugs for the antibiotic therapy following surgical
endodontic intervention 14.
As a preventative measure, the use of chorhexidine gluconate is indicated not
just for preoperatively, but during the post-surgical care, as a way to reduce the number
of pathogenic microorganisms in the oral cavity.
When discussed in relation to endodontic surgery performed in the modern day,
it is recommended Chorhexidine for use twice daily for one minute, around the surgical
site 39. Its use is recommended particularly at the surgical site, as tooth brushing is often
not possible, and chlorhexidine gluconate mouthwashes do demonstrate evidence to
suppress the formation of dental plaque 40.
The patient restriction of activity is recommended during the 6–8 h following
endodontic surgery, when rest and the intermittent application of ice compresses are
necessary. Patients can usually return to work the day following surgery, but those in
strenuous occupations should limit their activity for 2 days. Medically compromised and
geriatric patients may require longer periods of activity restriction 14.
The removal of sutures in endodontic surgery can carry particular importance as
their prolonged presence has been associated with a 'wicking' effect' 29,41. One animal
study divided rabbits into three groups, raised a mucoperiosteal flap and then
repositioned this. Sutures were removed at three, five and seven days, and the
investigators demonstrated significant differences between the groups to recommend
the removal of sutures after five days 42 This has been strongly refuted by other studies,
which suggest sutures may be removed after 48 hours, but should not be allowed to

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 31

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

remain post-96 hours 43–46. In microsurgical procedures, Eliyas et al. (2014) 47 advise the
removal of surgical sutures after only three days 47.
Healing outcome
Repair is the absence of bone defect and symptomatology after the endodontic
surgery, and should be assessed clinically and radiographically, with follow up at least of
one year.
Clinical healing is based on the absence of signs and symptoms such as pain, sinus
tract, swelling, apico-marginal communication, and tenderness to palpation or
percussion. Standard radiographic healing classes include complete healing, incomplete
healing (“scar tissue formation”), uncertain healing (partial resolution of postsurgical
radiolucency), and unsatisfactory healing (no change or an increase in postsurgical
radiolucency). This classification is based on landmark studies that have compared
radiographic findings with histopathologic results of periapical tissues of teeth that had
to be extracted after apical surgery 48,49.
Regarding to healing outcome, the classification of healing should be based on
defined clinical and radiographic healing criteria. Cases should be monitored at yearly
intervals until a final diagnosis (success or failure) can be established. It has been shown
that 95–97% of cases classified as successful at the 1-year control remain so over the
long term (5 years). Generally, lower success rates have been reported for re-surgery
cases, and for teeth with combined endodontic–periodontal lesions. For both problems,
the indication to perform apical surgery must be carefully weighed against extraction
and implant/prosthodontic rehabilitation.16
Torabinejad et al. (2009) 50 showed in his systematic review a statistically
significant decrease in success with each increasing follow-up interval for endodontics
surgery studies. The endodontic surgery weighted success for 2–4 years was 77.8%,
which declined at 4–6 years to 71.8% and further declined at 6+ years to 62.9%. With
respect to the nonsurgical retreatment success rates, a statistically significant increase
in weighted success was observed from 2–4 years (70.9%) to 4–6 years (83.0%) 50 . Frank
et al (1992) 51 reported surgical outcomes from a population that showed healing at an
early recall but found that 43% failed when the recall was extended beyond 10 years 51.
Mead et al. (2005) 52 published a literature review for clinical studies related to
endodontic surgery. They reported that the search found 79 clinical studies. Among
these studies, there was no one at the highest level of evidence and that the vast
majority of literature are low-level case series 52.
Several articles analyzed the healing outcome after endodontic surgery and
reported their success rates below, as Rapp et al. (1991) 53 performed a radiographic
analysis of apicectomies in 424 patients after five years of surgery and found success in
65% of cases 53.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 32

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

Molven et al. (1996) 54, in his study with 24 cases, showed that 1 case was
completely repaired, 1 failed and 22 remained in the same repair group and
characterized by a reduction in bone defect 54 . Also, Kim et al. (2008) 55 reported a
successful outcome of 77.5% in apicoectomized teeth with combined endodontic–
periodontal lesions, compared to a successful outcome of 95.2% in teeth with isolated
endodontic lesions 55.
The correlation between follow-up period and endodontic surgery success rates
in the articles included in this review are shown (Table 3).
Table 3 – Correlation between follow-up period and endodontic surgery success rates
presents in the articles included in this review.
Heling outcome after
Author Follow-up time (year) endodontic surgery.
Success rate (%)

Penarrocha et al. (2007) 1 year 73.9%

Kim et al. (2008) 2 years 77.5%

Torabinejad et al. (2009) 2- 4 years 77.8%

Penarrocha et al. (2007) 2-4 years 71.77%

Torabinejad et al. (2009) 4-6 years 71.8%

Rapp et al. (1991) 5 years 65%

Wesson & Gale (2003) 5 years 57%

Torabinejad et al. (2009) +6 years 62.9%.

All these studies indicates that the length of follow-up time and the healing
evaluation criteria affect the outcome, and 1-year follow-up periods might be
insufficient to predict a long-term healing.

CONCLUSION

Endodontic surgery has become a standard of care for dental maintenance if

conventional endodontic retreatment is not feasible or associated with risks. However,
in certain situations, the outcome of endodontic surgery may be compromised or
uncertain due to the extent or location of periapical or periradicular lesions [16]. This
literature review aimed to update the reader about the surgery endodontic treatment
with scienticfic evidences about the postoperative management and the healing
outcome, after the procedure.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 33

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

The postoperative period after an endodontic surgery, is very mild, without any
complications, being similar to any dental surgical discomfort, as swelling, bleeding, and
pain, which could be easily controlled with simple medicine. It is also important to
consider, the main role of the patient in the postoperative care, they need to be
informed about the procedure, and follow correctly the surgeon´s instruction, for a
better outcome.
Some articles report the symptoms, and the swelling is a well-recognised
postoperative manifestation and has been thoroughly investigated with endodontic
surgical procedures 26–28. They suggests the application of an ice pack 4-6 hours post-
surgery, to minimize the swelling 29. Rhodes et al. (2005) 31 states that swelling is worst
24-48 hours post-surgery, and the autor suggests the application of an ice pack for 20
minutes in each hour throughout the day during the day of surgery 31. There is also
evidence to suggest that pain and swelling is more severe in patient with poor oral
hygiene and those that smoke 27.
Futhermore, the pain following an endodontic surgery is usually minimal. The
pain, if any, is of short duration and reaches its maximum intensity on the day of surgery.
Chong & Pitt Ford (2005) 30 concluded that pain was experienced early in the
postoperative period and decreased in intensity with time 30. Some articles shows that
just a few patients experience pain that cannot be contoled it by mild analgesics 33–36.
As it is easier to prevent pain than to eliminate pain, analgesic therapy should be
initiated prior to surgery 14.
Regarding the use of an antibiotic prophylaxis for endodontic surgey, is not
recommended, because the post-surgical infections following surgical endodontic
procedures are very rare. It will only be used in case of microbial infection, as drug
therapy.
Concerning about the healing outcome, there are many factors that can directly
and indirectly interfere in the process of bone defect repair, futhermore, the analysis of
the results of this search shows that very few high-level studies proved the success and
failure rates after an endodontic surgery with relevant clinical and radiography criteria,
due several studies had various variables, and different follow-up times, that might
reflect in the successful cases rates.
Torabinejad et al. (2009) 50 showed in his systematic review a statistically
significant decrease in success with each increasing follow-up interval for endodontics
surgery studies. The endodontic surgery weighted success for 2–4 years was 77.8%,
which declined at 4–6 years to 71.8% and further declined at 6+ years to 62.9% 50.
Penarrocha et al. (2007) 56 reported a success rate of 73.9% after 12 months of follow-
up, and 71,77% success rate after 2-4 years of follow-up 56. Also, Wesson & Gale (2003)
57 reported a 'complete healing' rate at 5 years of 57% 57.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 34

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

These datas shows a decrease in success rate with each increasing follow-up
interval for endodontics surgery, futhermore, the shortcoming is that they determine
success or failure strictly on the basis of radiographic findings. Different observers may
not agree with what they see on a radiograph, and the same observer may disagree with
himself or herself if asked to reassess the same radiograph later 58. In addition,
radiographic studies can be considered of limited use when radiographic images are not
evaluated using standardized angles (custom jigs) along with standardized evaluation
criteria 52.
Therefore, based on the results of the present review, the endodontic surgery
has become a standard of care for dental maintenance if conventional endodontic
retreatment is not able to eliminate the infection. The postoperative period after the
surgery treatment is very mild, without any complications, being similar to any dental
surgical discomfort, which could be easily controlled with simple medicine. Regarding
the repair after endodontic surgery, the length of follow-up time and the healing
evaluation criteria affect the outcome, and 1-year follow-up periods might be
insufficient to predict a long-term healing.

REFERENCES

1. Torabinejad M, Anderson P, Bader J, Brown LJ, Chen LH, Goodacre CJ, et al.
Outcomes of root canal treatment and restoration, implant-supported single
crowns, fixed partial dentures, and extraction without replacement: A systematic
review. Journal of Prosthetic Dentistry. 2007; 98(4):285–311.
2. 2de Chevigny C, Dao TT, Basrani BR, Marquis V, Farzaneh M, Abitbol S, et al.
Treatment Outcome in Endodontics: The Toronto Study-Phase 4: Initial Treatment.
Journal of Endodontics. 2008; 34(3):258–63.
3. Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results
of endodontic treatment. Journal of Endodontics. 1990; 16(10):498–504.
4. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient
population in the USA: An epidemiological study. Journal of Endodontics. 2004;
30(12):846–50.
5. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal
treatment: Systematic review of the literature - Part 2. Influence of clinical factors.
International Endodontic Journal. 2008; 41: 6–31.
6. Nair PNR. On the causes of persistent apical periodontitis: A review. International
Endodontic Journal. 2006; 39: 249–81.
7. Davis SR, Brayton SM, Goldman M. The morphology of the prepared root canal: A
study utilizing injectable silicone. Oral Surgery, Oral Medicine, Oral Pathology. 1972;
34(4):642–8.
8. Peters OA, Barbakow F, Peters CI. An analysis of endodontic treatment with three
nickel-titanium rotary root canal preparation techniques. International Endodontic

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 35

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

Journal. 2004 [cited 2020 Jun 12]; 37(12):849–59. Available from:

http://doi.wiley.com/10.1111/j.1365-2591.2004.00882.x
9. Stropko JJ. Canal morphology of maxillary molars: Clinical observations of canal
configurations. Journal of Endodontics. 1999; 25(6):446–50.
10. Torabinejad M, Walton RE. Endodontics : principles and practice Saunders/Elsevier.
2009: 474
11. Siqueira JF. Aetiology of root canal treatment failure: Why well-treated teeth can
fail. International Endodontic Journal. 2001; 34 : 1–10.
12. Von Arx T. Failed root canals: The case for apicoectomy (periradicular surgery)
Journal of Oral and Maxillofacial Surgery. 2005; 63(6):832–7.
13. Kim S KS. Modern Endodontic Surgery Concepts and Practice: A Review. Journal of
Endodontics. 2006; 32(7):601–23.
14. Gutmann JL. Surgical endodontics: post-surgical care. Endodontic Topics. 2005;
11(1):196–205.
15. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Cytotoxicity of four root end
filling materials. Journal of endodontics. 1995 [cited 2018 Dec 28]; 21(10):489–92.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/8596067
16. von Arx T. Apical surgery: A review of current techniques and outcome. Saudi Dental
Journal. 2011; 23: 9–15.
17. Farrar JN. Radical and heroic treatment of alveolar abscess by amputation of roots
of teeth. Dental Cosmos. 1884; 26(79).
18. W BT. Caries of superior maxilla. Chicago M.j & Exam. 1880; 41(582).
19. Robbins SL, Cotran RS, Kumar V, Collins T. Fundamentos de Robbins: patologia
estrutural e funcional 2001.
20. Grossman JL. Endodontic Practice. 9 th ed. Philadelphia: Lea & Febiger; 1978.
21. El-Swiah JM, Walker RT. Reasons for apicectomies. A retrospective study.
Endodontics and Dental Traumatology. 1996; 12(4):185–91.
22. Nishiyama C. Tratamento cirúrgico das infecções periapicais: quando indicar. In:
Cardoso RJA, Gonçalves EAN. 2 nd ed. São Paulo: Artes Médicas; 2002.
23. Löst C. Quality guidelines for endodontic treatment: Consensus report of the
European Society of Endodontology. International Endodontic Journal. 2006; 39:
921–30.
24. Kim S, Kratchman S. Modern Endodontic Surgery Concepts and Practice: A Review.
Journal of Endodontics. 2006; 32(7):601–23.
25. Chong BS, Rhodes JS. Endodontic surgery. British Dental Journal. 2014; 216(6):281–
90.
26. Penarrocha M, Garcia B, Marti E, Balaguer J. Pain and inflammation after periapical
surgery in 60 patients. Journal of Oral and Maxillofacial Surgery. 2006; 64(3):429–
33.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 36

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

27. García B, Penarrocha M, Martí E, Gay-Escodad C, von Arx T. Pain and swelling after
periapical surgery related to oral hygiene and smoking. Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology and Endodontology. 2007;104(2):271–6.
28. Kvist T, Reit C. Postoperative discomfort associated with surgical and nonsurgical
endodontic retreatment. Dental Traumatology. 2000; 16(2):71–4.
29. Evans GE, Bishop K, Renton T. Update of guidelines for surgical endodontics - The
position after ten years. British Dental Journal. 2012; 212(10):497–8.
30. Chong BS, Pitt Ford TR. Postoperative pain after root-end resection and filling. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology. 2005;
100(6):762–6.
31. Rhodes JS. Advanced endodontics: clinical retreatment and surgery. 1st ed.
Oxfordshire: Taylor & Francis; 2005.
32. Iqbal MK, Kratchman SI, Guess GM, Karabucak B, Kim S. Microscopic Periradicular
Surgery: Perioperative Predictors for Postoperative Clinical Outcomes and Quality
of Life Assessment. Journal of Endodontics. 2007; 33(3):239–44.
33. Seymour RA, Meechan JG, Blair GS. Postoperative pain after apicectomy. A clinical
investigation. International Endodontic Journal. 1986 [cited 2020 Jun 20];
19(5):242–7. Available from: https://pubmed.ncbi.nlm.nih.gov/3473044/
34. Seymour RA, Rawlins MD. Efficacy and pharmacokinetics of aspirin in post-operative
dental pain. British journal of clinical pharmacology. 1982; 13(6):807—810.
Available from: https://europepmc.org/articles/PMC1402030
35. Seymour R, Williams F, Ward A, Rawlins M. Aspirin metabolism and efficacy in
postoperative dental pain. British Journal of Clinical Pharmacology. 1984 [cited 2020
Jun 20]; 17(6):697–701. Available from:
https://pubmed.ncbi.nlm.nih.gov/6378231/
36. von Graffenried B, Nüesch E, Maeglin B, Hägler W, Kuhn M. Assessment of
analgesics in dental surgery outpatients. European Journal of Clinical Pharmacology.
1980 [cited 2020 Jun 20];18(6):479–82. Available from:
https://link.springer.com/article/10.1007/BF00874659
37. Menhinick KA, Gutmann JL, Regan JD, Taylor SE, Buschang PH. The efficacy of pain
control following nonsurgical root canal treatment using ibuprofen or a
combination of ibuprofen and acetaminophen in a randomized, double-blind,
placebo-controlled study. International Endodontic Journal. 2004 [cited 2020 Jun
21]; 37(8):531–41. Available from: https://pubmed.ncbi.nlm.nih.gov/15230906/
38. Pack PD, Haber J. The Incidence of Clinical Infection After Periodontal Surgery: A
Retrospective Study. Journal of Periodontology. 1983 [cited 2020 Jun 23];
54(7):441–3. Available from: https://pubmed.ncbi.nlm.nih.gov/6577181/
39. Martin M V., Nind D. Use of chlorhexidine gluconate for pre-operative disinfection
of apicectomy sites. British Dental Journal. 1987; 162(12):459–61.
40. Löe H, Rindom Schiøtt C. The effect of mouthrinses and topical application of
chlorhexidine on the development of dental plaque and gingivitis in man. Journal of
Periodontal Research. 1970; 5(2):79–83.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 37

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

41. Harrison JW, Jurosky KA. Wound healing in the tissues of the periodontium
following periradicular surgery. I. The incisional wound. Journal of Endodontics.
1991; 17(9):425–35.
42. M Parirokh SAME. The effect of different suture removal time intervals on surgical
wound healing. Iran Endod J. 2006;1:81–6.
43. Gutmann J, Harrison W. Flap designs and incisions. Endodontic Topics.1994:162–75.
44. Selvig KA, Torabinejad M. Wound healing after mucoperiosteal surgery in the cat.
Journal of Endodontics. 1996; 22(10):507–15.
45. Wirthlin MR, Hancock EB, Gaugler RW. The Healing of Atraumatic and Traumatic
Incisions in the Gingivae of Monkeys. Journal of Periodontology. 1984; 55(2):103–
13.
46. Grung B. Healing of gingival mucoperiosteal flaps after marginal incision in
apicoectomy procedures. International Journal of Oral Surgery. 1973; 2(1):20–5.
47. Eliyas S, Vere J, Ali Z, Harris I. Micro-surgical endodontics. British Dental Journal.
2014; 216(4):169–77.
48. Andreasen JO, Möller Jensen JE. Radiographic criteria for the assessment of healing
after endodontic surgery. International Journal of Oral Surgery. 1972; 1(4):195–214.
49. Molven O, Halse A, Grung B. Observer strategy and the radiographic classification
of healing after endodontic surgery. International Journal of Oral and Maxillofacial
Surgery. 1987 [cited 2020 Jul 11];16(4):432–9. Available from:
https://pubmed.ncbi.nlm.nih.gov/3117915/
50. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of Nonsurgical
Retreatment and Endodontic Surgery: A Systematic Review. Journal of Endodontics.
2009; 35: 930–7.
51. A L Frank. Long-term evaluation of surgically placed amalgam fillings. Journal of
Endodontics. 1992 [cited 2020 Jul 11]; 18(8):391–8. Available from:
https://pubmed.ncbi.nlm.nih.gov/1431695/
52. Mead C, Javidan-Nejad S, Mego ME, Nash B, Torabinejad M. Levels of evidence for
the outcome of endodontic surgery. Journal of Endodontics. 2005 [cited 2020 Jul
11]; 31(1):19–24. Available from: https://pubmed.ncbi.nlm.nih.gov/15614000/
53. Rapp EL, Brown CE NC. An analysis of succes and failure of apicetomies. Journal of
Endodontics. 1991;17(10):508–12.
54. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery
- Radiographic findings 8 to 12 years after treatment. Journal of Endodontics. 1996
[cited 2020 Jul 11]; 22(5):264–8. Available from:
https://pubmed.ncbi.nlm.nih.gov/8632141/
55. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective Clinical Study Evaluating
Endodontic Microsurgery Outcomes for Cases with Lesions of Endodontic Origin
Compared with Cases with Lesions of Combined Periodontal-Endodontic Origin.
Journal of Endodontics. 2008; 34(5):546–51.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 38

Endodontic surgery: A review of postoperative and healing outcome
Gomes LCL, Dutra JC

56. Peñarrocha M, Martí E, García B, Gay C. Relationship of Periapical Lesion Radiologic

Size, Apical Resection, and Retrograde Filling With the Prognosis of Periapical
Surgery. Journal of Oral and Maxillofacial Surgery. 2007 [cited 2020 Jul 12];
65(8):1526–9. Available from: https://pubmed.ncbi.nlm.nih.gov/17656278/
57. Wesson CM, Gale TM. Molar apicectomy with amalgam root-end filling: Results of
a prospective study in two district general hospitals. British Dental Journal. 2003
[cited 2020 Jul 12]; 195:707–14. Available from:
https://pubmed.ncbi.nlm.nih.gov/14718966/
58. Goldman M, Pearson AH, Darzenta N. Endodontic success-Who’s reading the
radiograph? Oral Surgery, Oral Medicine, Oral Pathology. 1972; 33(3):432–7.

J Surg Cl Res – Vol. 12 (1) 2021: 24-39 39