Clinical Research

A 10-year Follow-up Study of 119 Teeth Treated

with Apical Surgery and Root-end Filling with
Mineral Trioxide Aggregate
Thomas von Arx, Prof, DMD,* Simon S. Jensen, DDS, Dr Odont,† Simone F.M. Janner, DMD,*
anni, DMD,ठand Michael M. Bornstein, Prof, DMDk
Stefan H€

Abstract
Introduction: The objective of this clinical study was to
assess the long-term outcome (clinical signs/symptoms
and radiographic healing) of teeth treated with apical
surgery and mineral trioxide aggregate (MTA) for root-
end filling. Methods: One hundred ninety-five patients
were recalled 1, 5, and 10 years after apical surgery for
A pical surgery is an
clinical and radiographic examinations. Three calibrated
observers evaluated the periapical radiographs indepen-
dently. The evolution of the cases over time was
analyzed. Healing classification of teeth was divided
into “healed” versus “not healed” teeth using well-
established clinical and radiographic healing criteria.
The potential influence of sex, age, type of treated
tooth, type of MTA, and first-time versus repeat surgery
on healing outcome was statistically analyzed. Results:
The inception cohort included 195 teeth. The dropout
rate after 10 years amounted to 39% (n = 76). Of the
119 teeth available for the 10-year analysis, 97 teeth
were classified as healed (81.5%). No significant differ-
ences were found with regard to the rate of healed cases
for the subcategories of the parameters of age, sex, type
of MTA, and first-time or repeat surgery. Concerning the
type of treated tooth, the rate of healed maxillary molars
(95.2%) differed significantly (P = .035) from the rate of
healed maxillary premolars (66.7%). The predictive
value of the cases classified as healed at 1 year and re-
maining so over the 10-year observation period was
86.8%. Conclusions: This 10-year follow-up study of
teeth treated with apical surgery and MTA as root-end
filling material showed an acceptable rate of healed
cases. Many of the lost teeth had been extracted
because of longitudinal root fractures during the obser-
vation period. (J Endod 2019;45:394–401)
Key Words:
10-year follow-up, apical surgery, clinical study, mineral trioxide aggregate
important treatment
option in endodontics.
Significance
This clinical long-term study of apical surgery using
MTA for root-end filling showed a rate of healed
Root canal treatment may
cases of 81.5% after 10 years. The predictive value
fail because of the complexity
of healed cases at 1 year to remain so after 10 years
of the root canal system or
was 86.8%.
procedural errors. If con-
ventional orthograde re-
treatment is not feasible, is associated with risks, or is declined by the patient, apical
surgery with retrograde obturation is a treatment alternative for tooth preservation.
Because bacterial reinfection from the root canal system is a major cause of failure after
root canal treatment and microbes might persist in the root canal system after apical
surgery, the placement of a bacteria/toxin-tight root-end filling is considered para-
mount for the success of apical surgery (1).
Historically, filling materials developed for restorative dentistry have often also
been introduced as root-end filling materials in apical surgery. The list of physical,
chemical, and biologic requirements for a root-end filling material is long and complex,
including biocompatibility (no toxicity), bioactivity (cementogenesis), no mutagenicity,
dimensional stability (marginal adaptation), insolubility, easy handling (mixing and
application), and cost-effectiveness.
Preclinical studies showed that mineral trioxide aggregate (MTA) had high sealing
capability, good material stability, and excellent biocompatibility (2, 3). Experimental
studies in animals showed only mild tissue reactions adjacent to this material (4, 5).
Furthermore, histologic analysis of periapical regions showed deposition of new
cementum, not only onto the resection plane (cut dentinal surface) but also directly
onto MTA (6). For these reasons, MTA is considered a bioactive material. In 1997,
MTA was cleared for clinical use in patients. Multiple prospective studies as well as ran-
domized clinical trials have reported high success rates of MTA-treated teeth in apical
surgery. However, the majority of outcome studies on apical surgery have a follow-up
period limited to 1 year. Only a few clinical studies have reported 5-year data, and 10-
year data are very sparse (7).

Departments of *Oral Surgery and Stomatology and ‡Preventive, Pediatric, and Restorative Dentistry, School of Dental Medicine, University of Bern, Bern,
Switzerland; †Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark;
§
Private Practice Limited to Endodontology, Bern, Switzerland: and kOral and Maxillofacial Radiology, Applied Oral Sciences, Faculty of Dentistry, The University of Hong
Kong, Prince Philip Dental Hospital, Sai Ying Pun, Hong Kong SAR, China.
Address requests for reprints to Prof Thomas von Arx, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Freiburgstrasse 7,
CH-3010 Bern, Switzerland. E-mail address: thomas.vonarx@zmk.unibe.ch
0099-2399/$ - see front matter
Copyright ª 2019 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.12.015

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So far, only 1 study has prospectively evaluated MTA-treated cases
with all teeth having a follow-up longer than 5 years (8). The authors
assessed 19 MTA-treated teeth with a mean follow-up of 6 years 3
months (range, 5 years 7 months–7 years). The initial sample included
26 teeth, resulting in a dropout rate of 27% at the long-term reexami-
nation. The reported success rate amounted to 84%. At the long-term
follow-up, 80% of the teeth rated as successful after 1 year remained
successful.
The aim of this long-term study was to reexamine teeth treated with
apical surgery and MTA as root-end filling after 1, 5, and 10 years using
clinical parameters and periapical radiographs. Rates of healed cases
were calculated (primary objective). Furthermore, the effects of sex,
age, type of tooth, type of MTA, and first-time or repeat surgery on
the outcome were statistically evaluated (secondary objectives).
Materials and Methods
Patients were referred for apical surgery to a specialty clinic of a
university dental school by their general dental practitioners or from
other departments within the school. Patients were fully instructed
Clinical Research
TABLE 1. Healing Categories and Definitions
Clinical signs
or symptoms Radiographic healing
Healed None AND Complete or incomplete
Not healed Yes OR Uncertain or unsatisfactory
about treatment alternatives and the surgical procedure according to
the Declaration of Helsinki (2013) (www.wma.net). Indications were
based on the European Society of Endodontology guidelines (9); how-
ever, many patients declined conventional retreatment, particularly of
teeth with crown/core buildups or for financial reasons. From a general
medical perspective, patients were only included if they were American
Society of Anesthesiologists class I or II (10).
The clinical examination of the tooth to be treated as well as its
neighboring teeth followed a strict protocol including visual inspection,
periodontal probing, and mobility testing. Teeth presenting probing
depths >5 mm were not considered candidates for apical surgery. Pre-
operative and follow-up periapical radiographs were taken with a

Fig. 1. Apical surgery of the right maxillary central incisor in a 53-year-old woman. Follow-up radiographs after 1, 5, and 10 years all show complete healing.

Fig. 2. Apical surgery of the right maxillary first premolar in a 51-year-old man. Follow-up radiographs after 1, 5, and 10 years all show complete healing. Note that
a new single crown and post had been inserted between the 1- and 5-year controls.

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Clinical Research

Fig. 3. Apical surgery of both buccal roots of the left maxillary first molar in a 53-year-old woman. Periapical healing was judged complete after 1, 5, and 10 years,
with the density of the periapical bone improving over the observation period.

paralleling technique using an X-ray film holder (Rinn XCP; Dentsply,
Elgin, IL). No individualized film holders were used.
All patients signed a consent form. Surgeries were performed be-
tween May 2001 and December 2007, and they were all performed by
the same surgeon. Cases with apicomarginal defects, tunneling lesions,
or iatrogenic root perforations were excluded from the present evalu-
ation. In patients with multiple treated teeth, only 1 tooth was randomly
included for the follow-up analysis (QuickCalc; GraphPad Software Inc,
La Jolla, CA).
Surgical Treatment
Apical surgery was performed in a dedicated operating room
using a surgical microscope (M€oller Denta 300; M€oller-Wedel/
Haag-Streit International, K€oniz, Switzerland). The surgical site was
swabbed with chlorhexidine 0.2%. Local anesthesia was administered
with articaine 4%/epinephrine 1:100,000 (Ultracain DS forte; Sanofi-
Aventis GmbH, Frankfurt, Germany). A full mucoperiosteal flap was
raised, either triangular or trapezoidal depending on the clinical sit-
uation. Osteotomy was performed with round burs. Root-end resec-
tion was accomplished with a fluted fissure bur at 3 mm from the
apex as perpendicular as possible to the long axis of the root. The
periapical pathologic tissue was curetted out using surgical spoons
and excavators. Occasionally, periodontal curettes were used to re-
move the remaining soft tissue on the palatal aspect of the root. He-
mostatic agents (Expasyl [Produits Dentaires Pierre Roland,
Merignac, France] and Stasis [Gingi-Pak, Camarillo, CA]) were
placed and removed, and the cut root face was stained with methy-
lene blue. A rigid endoscope (Hopkins Tele Otoscope 70 ; Karl Storz
GmbH, Tuttlingen, Germany) was used for root-end inspection. A
class I root-end cavity was prepared with diamond-coated ultrasonic
microtips to a depth of 3 mm (Endo Success Apical Surgery Kit; Sat-
elec Acteon, Merignac, France). After endoscopic inspection, the cav-
ity was filled with MTA (ProRoot; Dentsply Tulsa Dental, Tulsa, OK).
Gray MTA was used until February 2003; thereafter, white MTA was
used. The root-end filling was finished and checked with the endo-
scope. After cleaning the bony crypt, the flap was repositioned, and
wound margins were reapproximated with single interrupted sutures

Fig. 4. Apical surgery of the mesial root of the left mandibular first molar in a 41-year-old woman. Follow-up radiographs after 1, 5, and 10 years all exhibit
complete periapical healing.

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 Clinical Research

Fig. 5. Apical surgery of both roots of the left mandibular first molar in a 63-year-old woman. Follow-up radiographs after 1, 5, and 10 years all show complete
healing.

(Seralon 5-0 and 6-0; Serag-Wiessner GmbH, Naila, Germany). Pre-
scriptions included a nonsteroidal analgesic and an antiseptic mouth
rinse with chlorhexidine 0.2%. Sutures were removed 4–7 days after
surgery.
Follow-up
All patients were invited by letter 1 year after surgery for the first
clinical and radiographic follow-up examination. The patients attending
the 1-year follow-up were contacted later for a 5-year follow-up. Pa-
tients who were present at the 5-year reexamination were invited for
a 10-year follow-up. No travel reimbursement or payment was offered,
but the 5- and 10-year reexaminations were free of charge. The reasons
for not attending an appointment were recorded, and the dropout rates
were calculated accordingly.
Outcome Assessment
Healing (= outcome) was determined clinically and radiograph-
ically as healed versus not healed (Table 1). Patients were clinically as-
sessed for the presence of clinical signs (fistula, swelling, and
apicomarginal communication) and symptoms (pain, sensitivity to
percussion, and/or palpation). Cases with clinical signs or symptoms
were categorized as not healed irrespective of the radiographic healing
category. Radiographic healing around the operated root(s) was cate-
gorized into 4 groups according to the criteria by Rud et al (11) and
Molven et al (12):
1. Complete healing
2. Incomplete healing (scar tissue formation)
3. Uncertain healing
4. Unsatisfactory healing
In teeth with multiple roots treated with apical surgery, the worst
healing category was used for categorizing the radiographic healing per
tooth. The periapical radiographs were assessed independently by 3
calibrated observers (Figs. 1–8). In case of disagreement, the
following rules were applied: when 2 of the 3 observers agreed on
the same healing category, their rating was considered irrespective of

Fig. 6. Apical surgery of both roots of the left mandibular first molar in a 67-year-old woman. Follow-up radiographs after 1 year showed complete healing. The
case was classified as not healed after 5 years (uncertain radiographic healing) and after 10 years (clearly new radiolucency and clinical symptoms).

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Clinical Research

Fig. 7. Apical surgery of both roots of the right mandibular first molar in a 41-year-old man. Follow-up radiographs after 1 and 5 years exhibited complete healing.
However, a new radiolucency (no clinical symptoms) was noted at the 10-year examination. The case was classified as not healed.

the rating of the third observer. If all observers had different ratings, the
“middle” rating was used, and the best and worst ratings were ignored.
The subcategories for the assessment of the effects on healing
included the following:
1. Sex (male vs female)
2. Age at time of treatment (<45 years vs $45 years; age threshold set
according to von Arx et al [13])
3. Type of treated tooth (maxillary/mandibular incisors/canines, pre-
molars, and molars, respectively)
4. Type of MTA (ProRoot) used (gray vs white)
5. Surgery (first-time vs repeat surgery)
Statistical Analysis
Agreement among observers for radiographic healing classifica-
tion was estimated using the Fleiss kappa (14). A comparison of the
rates of healed cases with regard to sex, age, type of treated tooth,
type of MTA, and first-time or repeat surgery was investigated by chi-
square tests or Fisher exact tests. A comparison of the rates after 1,
5, and 10 years was performed using chi-square tests with Bonferroni
adjustment. The significance level chosen for all statistical tests was
P < 0.05. All statistical analyses were performed by Stata version
11.2 (StataCorp, College Station, TX).
Results
The inception cohort included 195 teeth in 195 patients (Tables 2
and 3). At the 10-year follow-up, 105 teeth could be reexamined clin-
ically and radiographically. The interobserver agreement for the radio-
graphic healing classification was moderate (Fleiss kappa = 0.469, P <
.001). Fourteen teeth that had been extracted because of recurrent in-
fections before the 10-year follow-up were included in the final cohort.
Hence, the 10-year study sample contained 119 teeth (Tables 2 and 3).
The cumulative dropout cases amounted to 76 (39%) at the 10-year
recall (Table 4).
The rate of healed cases after 10 years was 81.5% (Table 5). This
rate of healed cases was significantly lower compared with the rates after

Fig. 8. Apical surgery of the mesial root of the left mandibular first molar in a 47-year-old woman. After 1 year, the case was classified as not healed (uncertain
radiographic healing, no clinical symptoms). However, radiographs after 5 and 10 years showed complete healing, and the patient was asymptomatic. Consequently,
the case was classified as healed.

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 Clinical Research
TABLE 2. Sex and Age Characteristics of Inception (n = 195) and 10-year were that evidence about root canal retreatment before apical surgery
Cohorts (n = 119) was not available, and follow-up periapical radiographs were not taken
Inception, n (%) 10-year follow-up, n (%) in a standardized manner.
Although the rate of healed cases was similar after 1 year (91.6%)
Males 90 (46.2) 51 (42.9) and 5 years (91.4%), this rate dropped by about 10% to 81.5% after 10
Females 105 (53.8) 68 (57.1)
years. Judgment of healing was based on clinical findings and periapical
Age (y)* Age (y)* radiographs. It might have been different if cone-beam computed tomo-
Mean 49.5  14.3 48.3  14.0 graphic scans had been taken (15–17). Using novel low-dose cone-
Median 49.5 50 beam computed tomographic protocols could be a future option to
Minimum 11 11 assess long-term healing of apical surgeries in 3 dimensions in clinical
Maximum 83 78
practice and for research purposes (18).
*Age at the time of apical surgery. Previous long-term studies on MTA as root-end filling are
scarce. Shortcomings include a retrospective study design (19), a
small number of followed cases (8), and the use of different retro-
1 year (91.6%, P = .026) and after 5 years (91.4%, P = .047). A com- filling materials without analyzing separately the outcomes per mate-
parison of the 1- and 5-year rates of healed cases showed no significant rial (20, 21).
difference (P = 1.000). Von Arx et al (22) reported a success rate of 93% for teeth with
With regard to the study parameters of age, sex, type of MTA, and MTA root-end fillings after 5 years. The dropout rate amounted to
type of surgery, no significant differences were observed in the rates of 25% with a final sample of 134 teeth reexamined after 5 years. Data
healed cases per subcategory (Table 6). The overall analysis of the rates are similar to the 5-year data of the present study.
of healed cases per tooth group did not yield statistically significant dif- Song et al (20, 21) published 2 articles in which they presented data
ferences. However, some differences were seen in pair-wise compari- about the predictive value of the short-term versus long-term results.
sons. Maxillary molars showed a very high rate of healed cases However, their data cannot be compared with the present study because
(95.2%). In contrast, mandibular molars (70.8%) and maxillary pre- they included 3 different root-end filling materials (MTA, IRM [Caulk
molars (66.7%) showed lower rates of healed cases (Fishers exact test Dentsply, Milford, DE], and SuperEBA [Harry J. Bosworth, Skokie,
between maxillary molars and maxillary premolars, P = .035; between IL]), and they did not specify the outcomes per material. Furthermore,
maxillary molars and mandibular molars, P = .051). the time points of the follow-up examinations differed considerably
The evolution of the cases assessed at 10 years from the 1-year to among the studied cases (ie, 6–10 years [20] and 4–8 years [21]).
the 10-year follow-up is shown in Table 7. The predictive value of healed A striking feature of the present study was the significant decrease
cases at 1 year and remaining so at 10 years was 86.8%. in healed cases (roughly 10%) in the observation period from 5–10
years. The distribution of the teeth categorized as not healed after 10
Discussion years is shown in Table 8. Three tooth groups (ie, maxillary incisors
This is the first 10-year follow-up study of teeth treated with apical and premolars and mandibular molars) accounted for nearly all
surgery using MTA as retrofilling material. Although the dropout rate long-term failures. With regard to the 6 maxillary incisors, 4 were
was high (39%), a reasonable number of teeth (n = 119) could be fol- affected by dental trauma in childhood with a possible risk of subse-
lowed and reexamined after 1, 5, and 10 years. Limitations of the study quently developing cracks. Maxillary premolars and mandibular molars

TABLE 3. Initially Treated (n = 195) and 10-year Evaluated (n = 119) Teeth and Roots
Maxilla Mandible
Type of tooth Inception n 10-year n Inception n 10-year n
Central incisors 33 25 2 1
Lateral incisors 25 14 1 0
Canines 4 3 3 2
First premolars 8 (1 mesiobuccal and 4 (1 mesiobuccal and 6 6
distobuccal*, 2 distobuccal, 1 buccal,
buccal, 5 single root) 2 single root)
Second premolars 29 (1 mesiobuccal and 14 (1 buccal and palatal, 8 5
distobuccal*, 1 buccal 13 single root)
and palatal, 27 single
root)
First molars 29 (10 mesiobuccal, 1 20 (5 mesiobuccal, 1 40 (16 mesial, 4 distal, 21 (10 mesial, 1 distal,
distobuccal, 2 palatal, distobuccal, 2 palatal, 20 mesial and distal) 10 mesial and distal)
11 mesiobuccal and 10 mesiobuccal and
distobuccal, 2 distobuccal, 2
mesiobuccal and mesiobuccal and
distobuccal and palatal, palatal)
3 mesiobuccal and
palatal)
Second molars 4 (3 mesiobuccal and 1 (1 mesiobuccal and 3 (1 mesial, 1 distal, 1 3 (1 mesial, 1 distal, 1
distobuccal, 1 palatal) single root) single root)
mesiobuccal and
palatal)
Total 132 81 63 38
*These premolars had 3 roots (mesiobuccal, distobuccal, and palatal).

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Clinical Research
TABLE 4. The Reasons for Dropout Cases during the 10-year Observation

P Value

.838*

.606*

.579*
Period (n = 76)

.143†

.694†
NA
0–1 1–5 5–10 0–10
year years years years
Reason n n n n %
Extraction or root 2 12 2 16 20.8
amputation because of
root fracture (8

18.5
17.6
19.1
20.9
17.1
14.3
33.3

18.2
29.2
17.8
25.0
15.9
20.0
4.8
%

0
maxillary premolars, 4

Not healed
mandibular molars, 1
maxillary incisor, 1
maxillary molar, 1
mandibular incisor, 1
mandibular premolar)
Extraction or root 1 7 5 13 16.9

22

13

13

19

15
9

6
6
1
0

2
7

3
7
n
amputation for
unknown reason (4
maxillary molars, 4
mandibular molars, 3
maxillary incisors, 2
maxillary premolars)

81.5
82.4
80.9
79.1
82.9
85.7
66.7
95.2

81.8
70.8
82.2
75.0
84.1
80.0
Patient could no longer 1 10 16 27 35.1

100
be contacted/located
Patient did not want to 1 6 6 13 16.9

Healed
attend
Patient died 0 2 1 3 3.9
Patient too old or ill to 0 1 2 3 3.9
attend
Patient chart not available 0 0 1 1 1.3

97
42
55

36
34
63

12
20

17
88

37
60
3

9
Total 5 38 33 76 100 n

are characterized with complex root canal anatomy that may raise the
difficulty level of apical surgery. Furthermore, surgical access to
35.3
42.9
57.1
36.1
63.9

15.1
17.6

20.2
89.1
10.9
37.0
63.0
2.5

9.2
mandibular molars is often compromised. In addition, maxillary pre-
%
100

molars and mandibular molars are also often affected by longitudinal

root fractures. However, it is currently unknown if and how apical sur-
gery may contribute to the development of vertical root fractures. How-
TABLE 6. The Rates of Healed and Not Healed Cases after 10 Years per Subcategory (n = 119)

ever, several authors have observed vertical root fractures in dropout or

failure cases after apical surgery (8, 20, 23, 24). Also, the work of Tawil
119

107
42

3
51
68
43
76

18
21

11
24

12
44
75
et al (25) highlighted the possibly negative effect of the presence of
n

cracks (they called it “dentinal defects”) on the outcome of apical

Subcategories

surgery.

Conclusion
Maxillary incisors/canines

Mandibular premolars

This clinical long-term study of apical surgery using MTA as root-

Mandibular incisors/
Maxillary premolars

Mandibular molars
First-time surgery
Maxillary molars

end filling material showed a rate of healed cases of 81.5% after 10

Repeat surgery

years. This was significantly lower than the rates after 1 and 5 years
$45 years

canines
<45 years
Female

White
Male

Gray

(91.6% and 91.4%). No significant differences were observed for the

—

effects of age, sex, type of MTA, or first-time versus repeat surgery on

TABLE 5. Outcome Assessment after 1, 5, and 10 Years (n = 195)

1-year 5-year 10-year
P values estimated from the Fisher exact test.
*P values estimated from the chi-square test.

follow-up follow-up follow-up

Outcome n % n % n %
Healed 174 91.6 139 91.4 97 81.5
13† 22‡
Study parameter

Not healed 16* 8.4 8.6 18.5

Subtotal 190 100 152 100 119 100
Drop-outs 5 2.6 43 28.3 76 39.0
NA, not applicable

Total 195 195 195

Surgery
Overall

Tooth

MTA‡

*Including 3 cases extracted because of failure before 1-year assessment.

ProRoot.
Age
Sex

†
Including 7 cases extracted because of failure before 5-year assessment.
‡
Including 14 cases extracted because of failure before 10-year assessment.
†

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 Clinical Research
TABLE 7. The Evolution of Cases Assessed at 10 Years from 1–10 Years (n = 5. Baek SH, Plenk H, Kim S. Periapical tissue responses and cementum regeneration
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The authors thank Ms Kar Yan Li, Centralized Research Lab, of bilateral maxillary sinuses in patients referred for cone beam computed to-
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and Dr Kuofeng Hung, Oral and Maxillofacial Radiology, Applied 38:699–710.
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