Influence of suturing on wound healing

Purpose: To understand the effect of different suture materials and techniques on wound healing.

Most highlighted results:

•The most popular technique for wound closure is the application of sutures.

•As a consequence some clinicians have proposed surgical clamps as an alternative

•Silk sutures are prone to colonization by biofilms, hence should not be applied for prolonged period of time

•Catgut suture material is no longer utilized in periodontal surgery because it loses its consistency owing to enzymatic resorption

•In current periodontal surgical practice synthetic suture materials are predominantly employed because of its stable physical properties and biocompatibility.

•It is evident that prolonged retention time of sutures may have negative effects on the surgical outcome.

•The primary objective of suturing is to position and secure surgical flaps to promote optimal healing, to fulfill this requirement firm anchorage point must be selected in order to maintain stability

•Main anchoring structures: ( Teeth and immobile implants, masticatory mucosa, periosteum, and connective tissue )

•The interrupted simple loop is the most common technique is periodontal plastic surgery.

•Stabilization and  adaptation of the soft tissue covering the wound area with appropriate suturing appears to be a key for achieving optimal surgical outcomes.

•Sutures should be as few as needed to assure stability of the healing wound. ( because of its adverse effect on blood circulation )

Clinical significance:

The knowledge of different types of suture materials and techniques can aid in better wound healing.

Guided tissue regeneration in periapical surgery

Purpose:  To provide a better understanding of basic molecular and cellular biologic concepts when using membrane barriers and bone grafts in periapical surgery with specific reference to GTR in periodontal regenerative therapy.

GTR: is a technique for enhancing and directing cell growth to repopulate specific parts of the peridontium that have been damaged by periodontal disease, tooth disease, or trauma.

Tissue regeneration:  by using membrane barriers and/or bone grafting materials in periapical surgery is an example of tissue engineering technology.

Most highlighted results:

•Regeneration of periapical tissues after periapical surgery requires:

•1) Recruitment of progenitor stem cells to differentiate into committed osteoblasts, PDL cells and cementoblasts

•2) Growth/differentiation factors as necessary signals for attachment, migration, proliferation of stem cells.

•3) Local microenvironmental cues such as adhesion molecules and EMC and associated noncollagenous protein molecules. ( figure 3 )

•In animal studies at 3 to 5 month observation, if membrane barriers were not used to cover the bony defects both buccally and lingually with through-and-through osseous defects, the defects were filled with fibrous connective tissue.

•Clinically, the best application of membrane barriers in periapical surgery appears to be in combined endo-perio or perio-endo lesions or large periapical lesions communicating with the alveolar crest.

•The nature of regenerated periapical tissues after the use of bone grafts in periapical surgery remains unknown.

•All reported outcome studies of periapical wound healing by using bone grafts in periapical surgery are short term (12 month).

•Calcium sulfate can serve as scaffold for new bone formation in periapical surgery.

•Combination of platelet-rich plasma and tri-calcium phosphate placed in a bony defect after periapical surgery was shown to enhance bone regeneration. The host’s blood clot provides an excellent natural scaffold for wound healing.

Effect of guided tissue regeneration on the outcome of surgical endodontic treatment

Purpose:  To evaluate the influence of GTR on the outcome of surgical endodontic treatment.

N= 11 ( n=5 )

Materials and methods:

Inclusion criteria:

RCT study design,  PA lesion, GTR as part of Tx, at least 1 year follow up, outcome evaluation according to Rud et al.

Exclusion criteria:

•Re-surgery, apicomarginal defects, Periodontal disease, root fracture and perforations, retrospective study.

•Articles published in dental journals in English  from 1966 to 2010. •Outcomes were assessed based on radiographic evaluation.

•Complete healing, incomplete healing, and uncertain healing were pooled together as “ success “.

•If sign and symptom was present, the case is considered as “ failure “( regardless of radiograph )

Controlled group: surgical cases done without GTR. 

•Size and type of the lesion was compared between the two groups in means of healing.

Most highlighted results:

•Small lesions showed better healing in both groups than large lesions. ( Lesion size )

•GTR cases overall healed better than controlled cases. ( Lesion size )

•GTR cases achieved better results in through-and-through lesions than controlled cases ( Lesion type )

•No significant advantage for GTR group in four-wall defect cases over controlled group. ( Lesion type )

•The use of a resorbable membrane showed more favorable outcomes over non-resorbable membranes.

Clinical significance:

GTR might be considered when planning surgical endodontic procedure in cases where through-and-through lesions are present.

Comparative Evaluation of Platelet-rich Plasma and Guided Tissue Regeneration Membrane in the Healing of Apicomarginal Defects: A Clinical Study


Purpose:  to  compare the healing response of PRP and collagen membrane used as GTR materials for the treatment of apicomarginal defects.


•30  patients  participated in this study

Inclusion criteria :  recurrent episodes of purulent discharge, apicomarginal communication having a pocket depth (PD) of >6 mm confined to buccal aspect, a negative response to vitality tests with radiographic evidence of periapical radiolucency, failed previous RCT , failed previous surgery with persistent bony lesion, and adequate final restoration with no clinical evidence of coronal leakage.

•Exclusion criteria :  clinical or radiographic evidence of vertical root fracture, resorptive processes involving more than the apical third of the root, chronic generalized periodontitis, and systemic disease contraindicating oral surgery

Patients  were divided  into 3 groups :  collagen membrane group, PRP group, and PRP + collagen sponge group

•The clinical and radiographic examination were performed every 3 months up to 12 months

•The criteria for a successful outcome included the absence of clinical signs and/or symptoms ,complete or incomplete healing,  and criteria for failure included any clinical signs and/or symptoms and uncertain or unsatisfactory healing

• Most highlighted Results: 

-The success rate after 12 months in collagen membrane group 80% , PRP group 83.33% , and PRP + collagen sponge group 88.89%

-No significant differences between the three groups

•Clinical significance:   

• Application of PRP to apicomarginal defects has higher success rate ( No statistically significant  difference  ) than collagen membrane 

The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion


Purpose:  to demonstrate the clinical effectiveness of calcium sulphate to act as a barrier and filling material for the treatment of ‘through and through’ bony lesions.


•20 patients  participated in this study

•Inclusion criteria : previous RCT and retreatment ( except 2 cases ) with persistent bony lesion , bone defect wider than 10 mm with lack of both buccal and lingual plates, fistula tracts and recurrent episodes of purulent discharge

•All the cases received conventional root canal retreatment (except two). After a minimum follow-up of 3 months, if the lesion had remained unchanged, the patient was scheduled for the periradicular surgery and included in the present study

•The 20 cases were randomly assigned  , 10 to the test group and 10 to the control group prior to surgery (the two without retreatment were assigned one to each group).

•The treatment consisted of conventional apicectomy and root-end filling, with Super EBA cement  for both groups

•Radiographic healing was classified as complete healing, incomplete healing (scar tissue), uncertain healing, or unsatisfactory healing

•Most highlighted Results: 

-Control group: The six-month control showed that three teeth were completely healed, five incompletely healed, and two had unsatisfactory healing , At 12 months postoperatively the outcome remained the same. vTest group: At 6 months seven sites showed complete healing and two  cases (incomplete healing , At 12 months no changes were detected compared to the previous screening.

•Clinical significance:   

• Using calcium sulphate should be considered especially  in  treatment of through and through  bony lesion

A Randomized Controlled Study of Mineral Trioxide Aggregate and Super Ethoxybenzoic Acid as Root-end Filling


Purpose: to evaluate the long-term clinical outcomes of endodontic microsurgery when MTA and Super EBA are used as the root-end filling material and to compare the clinical outcome of endodontic microsurgery at 1-year and 4-year follow-ups.


•260 Teeth were included in this randomized controlled trial and randomly assiegnd either MTA or  Super EBA groups         ( 130 teeth each group ) •Inclusion criteria : all root-filled cases with symptomatic or asymptomatic apical periodontitis were included.

•Exclusion criteria : teeth with a through-and-through lesion and/or a lesion of combined periodontal endodontic origin, class II mobility , horizontal and vertical root fractures, and perforations

•The patients were recalled periodically at 3, 6, and 12 months and every year after the treatment up to 4 years

•Radiographic healing was classified as complete healing, incomplete healing (scar tissue), uncertain healing, or unsatisfactory healing

Most highlighted Results:

-Among the 260 teeth included in this randomized controlled trial, 182 were examined at the 4-year follow-up

-In the MTA group, 83 of 130 cases were recalled, and the success rate was 91.6% (76/83 cases).

-In the Super EBA group, 99 of 130 cases were recalled, and the success rate was 89.9% (89/99 cases)

-Statistical analysis of the success rate at 4 years after endodontic microsurgery did not show any significant difference between the 2 materials (P = .8).

•Clinical significance:   

• There is no  significant difference in the 4-year success rates of MTA and Super EBA as root-end filling materials in endodontic microsurgery

The Influence of an Isthmus on the Outcomes of Surgically Treated Molars: A Retrospective Study

Purpose: To investigate the effects of an isthmus on the outcomes of surgically treated molars.

N= 106 Maxillary and mandibular 1st molars (72 with isthmus, 34 without)  with endodontic lesion limited to periapical area.

•Surgical procedures were performed by the same operator

•Isthmus was included in the retrograde preparation design when observed and filled with either ProRoot MTA or Super EBA

. •Patients were followed up once a year after treatment (for 4 years).

Success was defined as: the absence of clinical signs and symptoms and radiographic evidence of complete or incomplete healing (2 blinded examiners evaluated the periapical radiographs).

Most highlighted Results:

 – The cumulative survival rate after surgery was 61.5% for 4 years when an isthmus was present and prepared. The survival rate after 4 years was 87.4% when an isthmus was absent and unprepared.

Clinical significance:

•Success rate for endodontic microsurgery on isthmus-absent teeth was higher than that for isthmus-present teeth.

•The technique of isthmus retrograde-preparation needs to be improved and carried out carefully.

Two- and tridimensional analysis of periapical repair after endodontic surgery.

Purpose: to evaluate the periapical repair of teeth after endodontic surgery using two- (conventional and digital radiography) and tridimensional (CBCT) imaging methods.

N = 11 patients


•Maxillary anterior single-rooted teeth, with the presence of radiographically visible periapical bone rarefaction and indication for endodontic surgical treatment. •Conventional and digital periapical radiographs and CBCT of the region of interest were taken before endodontic surgery.

•The i-CAT classic unit was used. Recent guidelines state that for the diagnosis of periapical pathology, the smallest available field of view should be used.

•Endodontic surgery was performed.

•Computerized tomography performed and conventional and digital radiographs were taken after periods of 48 h, 4 months and 8 months. •Conventional radiographs were digitized and calibrated. The ImageJ software was used to delimit the outline of the periapical lesions on a computer monitor and 3 evaluators took the measurements. 

•For the CBCT image analysis the values of volume (cubic millimeters) and area (square millimeters), measured in the different time intervals of evaluation, were converted into percentage values, which allowed the comparison of bone repair progression. 

Most highlighted Results: 

•Baseline ( 48 h) showed a larger lesion volume (192.54 mm3) than 4-month (79.79 mm3) and   8-month (47.51 mm3) periods.

•No differences were found in the percentage of repair in the first 4 months and after 8 months.

•The volumetric analysis showed a higher percentage of repair when the first and last 4 months were compared.

•No differences were found in the percentage of repair by area in the CBCTs.

•Repair of 73 % was obtained after 8 months. Similar results were observed by the Bland-Altman agreement analyses.

Clinical significance:

CBCT is more accurate than PA in determining bone healing. Could be used in cases with slow PA healing for follow up.

Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. 

Purpose: The aim of this study was to evaluate the outcomes of endodontic microsurgery and compare the healing success of the isolated endodontic lesion with the endo-perio combined lesions

N = 263 teeth


•227 patients requiring periradicular surgery were included in this study.  •Excluded cases with G > 2 mobility, HRF, VRF, perforations

•All patients were placed on an AB and analgesic regimen preoperatively  •Surgery performed under microscope, 3 root-end filling used randomly: IRM, SuperEBA, and MTA.

•Patients were recalled every 6 months for 2 years and every year thereafter to assess clinical and radiographic signs of healing. 

•A recall rate of 73% (192 of 263 patients) was obtained.

Most highlighted Results:

  •The successful outcome for isolated endodontic lesions was 95.2%.

•In endodontic-periodontal combined lesions, successful outcome was 77.5%, suggesting that lesion type (ABC vs DEF) had a strong effect on tissue and bone healing.

•Successful outcomes were seen with all 3 filling materials: 88.9% with IRM, 91.7% with SuperEBA and 91.5% with MTA.

Five-year changes in periodontal parameters after apical surgery.


Purpose:  (1) to document changes in periodontal parameters in teeth with apical surgery over a long-term period of 5 years.     

   (2) to correlate the documented changes with patient, tooth, and treatment-related co-variables.

N= 186 teeth.


•242 patients who underwent apical surgery from 2000 to 2004.

•After the Surgical procedure All patients were given nonsteroidal analgesics and were instructed to rinse their mouth twice daily with 0.1% chlorohexidine-digluconate for 10 days. Antibiotics was administered mainly for medical reasons if needed.

•Recalled 1-5 years after apical surgery for follow-up examinations. •Periodontal parameters (PD, GM, and CAL)were collected at baseline and1-5 years after surgery. •Secondary study variables: (1) age  (2) sex  (3) smoking  (4) type of treated tooth and restoration (6) type of incision technique and

Most highlighted Results: 

•GM recession and CA loss  during the first year after surgery were more significant at the facial sites. However, between 1-5 years after surgery no significant changes in PD, GM, CAL were observed for all teeth.

Clinical significance:

The surgery itself appears to account for changes observed during the first year, whereas patient- and healing-related factors seem to affect periodontal changes seen thereafter