Magnification devices for endodontic therapy

Magnification devices for endodontic therapy

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Magnification devices for endodontic therapyReview information

AuthorsMassimo Del Fabbro1, Silvio Taschieri1, Giovanni Lodi2, Giuseppe Banfi1, Roberto L Weinstein1

1Department of Health Technologies, University of Milan, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy2Unit of Oral Pathology and Oral Medicine, Department of Medicine, Surgery and Dentistry, University of Milan,Milan, ItalyCitation example: Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein RL. Magnification devices forendodontic therapy. Cochrane Database of Systematic Reviews 2006 , Issue 2 . Art. No.: CD005969. DOI:10.1002/14651858.CD005969 .

Contact personMassimo Del FabbroHead of Section of Oral PhysiologyDepartment of Health TechnologiesUniversity of Milan, IRCCS Galeazzi Orthopaedic InstituteVia R Galeazzi 4Milan20161Italy

E-mail: [email protected]

DatesAssessed as Up-to-date:9 April 2009Date of Search: 2 April 2009Next Stage Expected: 8 July 2011Protocol First Published: Issue 2 , 2006Review First Published: Not specifiedLast Citation Issue: Issue 2 , 2006

What's newDate Event Description

HistoryDate Event Description

AbstractBackgroundAfter the introduction of microsurgical principles in endodontics, involving new techniques for root canaltreatment, there has been a continuous search for enhancing the visualisation of the surgical field. It would beinteresting to know if the technical advantages for the operator brought in by magnification devices like surgicalmicroscope, endoscope and magnifying loupes, are also associated with advantages for the patient, in terms ofimprovement of clinical and radiographic outcomes.

ObjectivesThe purpose of this systematic review was to evaluate and compare the effects of endodontic treatmentperformed with the aid of magnification devices versus endodontic treatment without magnification devices. Wealso aimed at comparing among them the different magnification devices used in endodontics (microscope,endoscope, magnifying loupes).

Search strategyThe Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE were searched with appropriatesearch strategies. Handsearching included nine dental journals. The bibliographies of relevant clinical trials andrelevant articles were checked for identifying studies outside the handsearched journals. Seven manufacturers ofinstruments in the field of endodontics and/or endodontic surgery, as well as the authors of the identifiedrandomised controlled trials (RCTs) were contacted in order to identify unpublished or ongoing RCTs. There wereno language restrictions. The last electronic search was conducted on 2nd April 2009, and the lasthandsearching was undertaken on 31st January 2009.


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Selection criteriaAll randomised and quasi-randomised trials comparing endodontic therapy performed with or without using oneor more types of magnification device, as well as randomised and quasi-randomised trials comparing two ormore magnification devices used as an adjunct to endodontic therapy were considered.

Data collection and analysisScreening of studies and data extraction were conducted independently and in duplicate. The CochraneCollaboration statistical guidelines were to be followed for data synthesis.

Main resultsNo trial could be included in the present review. All of the prospective trials that were identified, all dealing withendodontic surgery, had to be excluded for various reasons. Only one RCT was identified comparing threemagnificators (magnifying loupes, surgical microscope, endoscope) in endodontic surgery. No RCT was foundthat compared the outcome of endodontic therapy using or without using a given magnification device.

Authors' conclusionsNo objective conclusion can be drawn from the results of this review as no article was identified in the currentliterature that satisfied the criteria for inclusion. It is unknown if and how the type of magnification device affectsthe treatment outcome, considering the high number of factors that may have a significant impact on the successof endodontic surgical procedure. This should be investigated by further long-term RCTs with large sample size.Technical advantages of magnificators have been widely reported in low evidence level studies, but they shouldbe systematically addressed to know if there can be the clinical indication for using a given magnification devicefor specific clinical situations, such as for molar teeth, or if they can all be used interchangeably.Well-designed RCTs should also be performed to determine the true difference in terms of treatment successrates between using or not using a magnification device in both conventional and surgical endodontic treatment,if any exist.

Plain language summaryMagnification devices for endodontic therapyThere are no data to draw a sound conclusion on the effect of adopting either a microscope, an endoscope, ormagnifying loupes for better visualisation in endodontic therapy, in terms of clinical outcomes. Though the useof magnification devices has often been associated with technical advantages for the operator and with animproved management of the root canal due to a better visualisation of the operative field, it still has to bedemonstrated that their use may lead to an improved treatment success rate. More long-term well-designedrandomised trials with a large sample size are urgently needed to address the issues of the present review.

Background The objective of successful endodontic therapy is thorough mechanical and chemical cleansing of the entire rootcanal system, followed by its complete obturation with an inert filling material (Vertucci 1984). Creating an idealaccess opening is one of the most important steps to ensure a successful endodontic procedure. At the sametime, the inability to identify and adequately treat all the canals of the endodontic system is a major cause fortreatment failure and persistence of disease (Weine 1969; Sjogren 1990; Wolcott 2002; Dugas 2003).Recent developments within the dental equipment have improved the clinician's ability to treat elusive regionswithin the oral cavity, increasing the efficiency and the quality of root canal treatment. For example, inendodontic surgery the advent of microsurgical instruments has involved technical changes in the approach toroot canal preparation. Along with the diffusion of such instruments, the use of well-focused illumination andmagnification devices has been recommended as a standard of care (Kim 1997).The most common magnification devices that have been introduced in endodontics are loupes, surgicalmicroscope (Pecora 1993; Khayat 1998; Rubinstein 1999; Castellucci 2003) and, more recently, endoscope (Bahcall 1999; Bahcall 2000; von Arx 2002; Bahcall 2003). Working using such devices has become a widelyaccepted practice in conventional and surgical endodontics. Besides increasing the accuracy of the endodonticprocedure, these devices may improve diagnostic capability, due to a better visualisation of the treatment field.As an example, they allow to identify the presence of isthmuses, accessory canals or microfractures of the root,that are otherwise difficult to be recognised and treated in the absence of proper magnification (de Carvalho2000; Schwartze 2002; Slaton 2003; von Arx 2003a; Rampado 2004; von Arx 2005).Furthermore, the use of loupes and microscope has been shown to reduce the occurrences of repetitive stressinjuries related to bad posture by improving working posture (Behle 2001; Perrin 2002).It would be interesting to investigate if the technical advantages for the operator brought in by magnificationdevices are also associated with advantages for the patients, in terms of higher treatment success rate, reducedtreatment time, and lower total costs.

Objectives The purpose of this systematic review was to evaluate and compare the effects of endodontic treatmentperformed with the aid of magnification devices versus endodontic treatment without magnification devices.We also aimed at comparing among them the different magnification devices used in endodontics (microscope,


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endoscope, magnifying loupes).

Methods Criteria for considering studies for this reviewTypes of studiesAll randomised and quasi-randomised clinical studies comparing endodontic therapy performed with or withoutusing one or more types of magnification device. Also randomised and quasi-randomised clinical studiescomparing two or more magnification devices used as an adjunct to endodontic therapy were considered.

Types of participantsPatients who received endodontic therapy and were followed up for at least 1 year after treatment.

Types of interventionsSurgical or non-surgical endodontic treatment performed with the aid of one or more types of magnificationdevices (surgical microscope, endoscope, magnifying loupes), compared with the same kind of interventionperformed without visual enhancers. Outcomes obtained with different magnification devices were to becompared.

Types of outcome measuresPrimary outcomesThe main outcome sought in this systematic review was the success of the treatment at 1 year follow up, asdetermined by clinical assessment of signs and symptoms, combined with examination of periapical radiographsto evaluate radiographical healing.The outcome of endodontic therapy is generally assessed 1 year after treatment and is categorized as follows:(a) 'success' that includes two sub-categories: 'complete healing' (radiographic and clinical normalcy) and'incomplete healing' (clinical normalcy combined with reduced radiolucency and scar formation);(b) 'uncertain healing' (persistence of radiolucency in the absence of clinical signs and symptoms, or presence ofclinical signs/symptoms (clinical questionable) associated with a not complete radiographic healing);(c) 'failure' (presence of clinical signs and symptoms combined with reduced or persistent radiolucency) (Rud1972; Molven 1987; Gutmann 1991). Jesslen 1995 determined that the validity of a 1 year follow up ispredictable in over 95% of the cases. When the 1 year outcome is recorded as 'uncertain healing', the toothshould be re-evaluated yearly up to 4 years after treatment and then recorded as success or failure (Molven 1996).The outcome was recorded when available at the following time points:- 1 year after treatment- between 1 and 4 years after treatment- more than 4 years after treatment.Unexpected events/outcomes were documented if identified in included randomised controlled trials.

Secondary outcomesSecondary outcomes were related to advantages brought in by the use of a given magnification device in theclinical procedure, that may lead to a preference of the operator for one versus another device, or to thefeasibility of treating with greater accuracy a given clinical situation:(a) the possibility and easiness of removing broken instruments from the canal;(b) the quality of visualisation of root canal anatomy and morphology (detection of dentinal cracks oridentification of peculiar anatomical features, such as the presence of isthmuses, that may affect the clinicalprocedure);(c) the quality of root-end filling (only for the retrograde treatment);(d) the possibility of perforation repair;(e) the total time required for completing the clinical procedure.

Search methods for identification of studiesThe search strategy aimed at identifying all published randomised and quasi-randomised clinical trials dealingwith the subject of this review. For the identification of studies to be considered for this review, detailed searchstrategies were developed for each database searched. These were based on the search strategy developed forMEDLINE (OVID), detailed in Appendix 1. This subject strategy was revised appropriately for each database, totake account of differences in controlled vocabulary and syntax rules. The MEDLINE search strategy combined thesubject search with the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials inMEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions, version 5.0.1 (updated September2008) (Higgins 2008). The subject search used a combination of controlled vocabulary and free text terms.

Searched databasesThe following electronic databases were searched:


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Cochrane Oral Health Group Trials Register (to 2nd April 2009) (see search strategy in Appendix 2)Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4) (see Appendix3)MEDLINE (1966 to April 2009) (see Appendix 1)EMBASE (1980 to 20 December 2008) (see Appendix 4).

The last electronic search was performed on 2nd April 2009.

LanguageNo language restriction was placed. In case of need for translations, these were provided by appropriateDepartments of University of Milan. The authors of identified articles written in languages other than Englishwere contacted for clarification.

Unpublished studiesSeven manufacturers of instruments for either orthograde therapy and/or endodontic surgery, and the authors ofthe identified randomised controlled trials were contacted in order to identify unpublished or ongoingrandomised controlled trials.

HandsearchingAll issues of the following journals were handsearched as being of particular importance to this review:International Endodontic JournalJournal of EndodonticsDental Traumatology (formerly Dental Traumatology and Endodontics)Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and EndodontologyInternational Journal of Oral and Maxillofacial SurgeryJournal of Oral and Maxillofacial SurgeryBritish Journal of Oral and Maxillofacial SurgeryBritish Dental JournalEndodontic Topics.Where these journals had not already been searched as part of the Cochrane Journal Handsearching Programme,the journals were handsearched by two review authors (Massimo Del Fabbro and Silvio Taschieri). The lasthandsearching was undertaken on 31st January 2009.The bibliographies of all identified randomised controlled trials and relevant review articles were searched foridentification of studies outside the handsearched journals.

Data collection and analysisSelection of studiesThe titles and abstracts of all reports identified through the searches were scanned independently by two reviewauthors. Full reports were obtained for trials appearing to meet the inclusion criteria or for which there wasinsufficient information in the title and abstract to make a clear decision. The full reports obtained from all theelectronic and other methods of searching were assessed independently, in duplicate, by two review authors toestablish whether the trials met the inclusion criteria or not. Disagreements were resolved by discussion. Allstudies meeting the inclusion criteria underwent validity assessment and data extraction. All studies rejected atthis or subsequent stages were recorded in the Characteristics of excluded studies table and reasons forexclusion were recorded.

Data extractionData were extracted by two review authors independently using properly designed data extraction forms. Thedata extraction forms were piloted on several papers and modified as needed before use. Any disagreement wasresolved by discussion and a third review author was consulted where necessary. If agreement could not bereached data were excluded until further clarification was provided.For each trial the following data were to be recorded:- Date of the study, year of publication, country of origin and source of study funding.- Details of the participants including demographic characteristics, criteria for inclusion, type and location ofteeth, type of materials and instruments used for root canal system management.- Details on the type of intervention.- Details on the type of magnification device(s) adopted.- Details of the outcomes reported, including method of assessment and time intervals after intervention.- Any kind of advantage or disadvantage reported in relation to the use of a given magnification device. Inparticular we considered the possibility of detection and treatment of peculiar anatomic features of importancefor proper canal treatment, otherwise not identifiable.

Assessment of risk of bias in included studiesAn assessment of the risk of bias in included studies was planned to be undertaken independently and induplicate by two review authors following the recommendations as described in Chapter 8 of the CochraneHandbook for Systematic Reviews of Interventions 5.0.1 (Higgins 2008). In future updates, any inconsistenciesbetween the review authors will be discussed and resolved and if necessary a third review author will be


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consulted. Where uncertainty cannot be resolved, effort will be made to contact authors directly for clarification.A specific tool for assessing risk of bias in each included study was adopted. This comprises a description and ajudgement for each entry in a risk of bias table, where each entry addresses a specific feature of the study:(1) Adequate sequence generation(2) Concealment of allocation(3) Blinding of evaluator(s)(4) Incomplete outcome data addressed(5) Free of selective reporting(6) Free of other bias.The judgement for each entry involves answering a question, with answers 'Yes' indicating low risk of bias, 'No'indicating high risk of bias, and 'Unclear' indicating either lack of information or uncertainty over the potentialfor bias. We planned to summarise an assessment of the overall risk of bias involving the consideration of therelative importance of different domains.

Data synthesisThe following procedures will be conducted if eligible trials are found in future updates. In order to standardizestatistical calculations using Review Manager (RevMan) software, we will dichotomize the outcomes, similar to aprevious Cochrane Review (Del Fabbro 2007). All cases classified as complete or incomplete healing plus casesclassified as uncertain healing in the absence of clinical signs and symptoms will be considered as 'successful'.Those cases classified as failures plus those classified as uncertain healing in the presence of signs andsymptoms will be considered as 'unsuccessful'. The patient will be considered as the unit of analysis. Thosepatients that had multiple teeth treated will be classified as unsuccessful if they experience at least oneunsuccessful case.Statistical analyses outlined in the Cochrane Handbook for Systematic Reviews of Interventions will be followed (Higgins 2008) and, for each trial, risk ratios along with 95% confidence intervals will be calculated to estimate theeffect of interventions.Clinical heterogeneity will be assessed by examining the types of participants, teeth, interventions and outcomesin each study. Only if studies of similar comparisons reporting the same outcome measures are found a meta-analysis will be attempted. Risk ratios will be combined for dichotomous data using a random-effects model.An intention-to-treat analysis was also planned, considering as unsuccessful all patients that have receivedtreatment but in the trial have been excluded from the analysis at any time for any reason.

Results Description of studiesThe electronic search strategy provided 410 studies. The last electronic search was conducted on 2nd April 2009.No further trial was identified by handsearching (the last handsearch was performed on 31st January 2009). Fromthe analysis of the abstracts of these studies, only three trials (von Arx 2003; Tsesis 2005; Taschieri 2008) wereidentified as eligible for inclusion in this review. There was perfect agreement among the review authors.After reviewing the full text of the three eligible trials, none of them could be included for further analysis.Summary details are given in the Characteristics of excluded studies table.One study was excluded (Tsesis 2005) because the two groups were treated not only using or non using amagnification device but also with different instrumentation and techniques. Furthermore patients were notrandomised to the treatment but all patients belonging to the control group were treated consecutively by usingnaked eyes before a dental operating microscope was purchased. After that, all patients belonging to the testgroup were treated consecutively using the microscope.In another study (von Arx 2003) patient allocation to the two groups was not randomised (information providedby the authors), and, consequently, this study had to be excluded too.In Taschieri 2008 three magnificators were adopted (information provided by the authors): endoscope,magnification loupes and microscope. The study was excluded because sample size calculation prior to thebeginning of the study was undertaken on a tooth basis while group allocation occurred on a patient basis.Another reason for exclusion was the presence of patients with multiple teeth treated that had a greater chanceof experiencing a negative outcome with respect to those that had a single tooth involved. Finally, molar teethwere not included in the first 2 years of the enrolment period while they were included only during the third year.

Risk of bias in included studiesNo study could be included in the present review.

Effects of interventionsNo randomised clinical trial was found where endodontic treatment (either surgical or non-surgical) performedwith the aid of a magnification device was compared with the same treatment without using magnificators.No trial involving the comparison among different types of magnification devices in endodontic surgery alonecould be included in the present review.Therefore, due to the current absence of evidence, this review is not able to provide a reliable answer to theoriginal question. In other words, it was not possible to find substantial evidence regarding the effect of usingmagnification devices on the outcomes of endodontic therapy.


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Discussion The use of magnification devices in dentistry is becoming more and more common, with the aim of improvingthe quality of treatment. After the introduction of microsurgical principles in endodontics, involving newtechniques for the root canal therapy, there has been a persistent search for enhancing the visualisation of thesurgical field. The use of well-focused illumination and magnification devices was recommended as a standard ofcare in endodontic therapy (Kim 2004; Cohen 2006).In the endodontic literature many in vitro studies have been published, showing that magnification devices likethe microscope or the endoscope allow the identification of microstructures not visible with the naked eye (deCarvalho 2000; Gorduysus 2001; Baldassari-Cruz 2002; Schwartze 2002; Slaton 2003; von Arx 2003a; Zaugg2004). As a natural consequence it has been suggested that such devices can be useful, at least in theory, forimproving clinical outcomes because all phases of the root/root-end management can be performed with greateraccuracy.Conversely, clinical prospective comparative studies evaluating the outcome of endodontic treatment usingdifferent magnification devices are extremely scarce, as it was found in the present review. All of the prospectivetrials that were identified, all dealing with endodontic surgery, had to be excluded from the analysis, for variousreasons.One of the purposes of the present review was also to evaluate secondary outcomes that could be related to thepreference of the operator for a specific type of magnificator during a given clinical situation. Such outcomeswere reported in the Types of outcome measures section and are here briefly resumed: the feasibility of removingbroken instruments from the canal; the quality of visualisation of root canal anatomy and morphology; thequality of root-end filling; the possibility of perforation repair; the total time required for completing the clinicalprocedure. As far as we could be able to find, no study specifically compared these variables, while some of themwere sporadically reported but never statistically assessed. As an example, in one of the eligible articles (Taschieri 2008) it is reported that, based on the operators' experience, the time required for completing thesurgical procedure is on the average 4 to 5 minutes longer for the endoscope as compared to othermagnification devices, due to the need for repeated cleaning of the lens. No systematic evaluation has beenperformed, however, for any of the above mentioned secondary variable, that could suggest a superiority of onemagnification device over the others. In the absence of differences in the clinical outcomes, a precise assessmentof these secondary variables could be important for the choice of a specific magnification device, and should beaddressed in specifically designed trials.Some considerations have to be done in this context. First of all, though the use of magnification devices is awidely emphasized issue in the endodontists community, the overall quality of studies regarding this topic israther poor, confirming what was also pointed out by recent reviews that specifically aimed at assessing the levelof evidence of the endodontic literature (Paik 2004; Mead 2005; Torabinejad 2005). The proportion ofrandomised studies is very low as well as the number of prospective non-randomised studies for both apicalsurgery and endodontic (orthograde) treatment. Another review (Friedman 2004) highlighted that there is a widevariability of successful outcomes for endodontic surgery as reported in the endodontic literature. Such variabilitycould be at least in part explained by the presence of a large number of factors that may affect the result ofapical surgery (e.g. surgical procedures and materials, operator's skill, success criteria adopted, radiographic andclinical evaluators experience, patient demographics and systemic condition, tooth type, location and anatomy,size of the lesion, follow-up duration). Therefore, the use of a specific magnification device per se could be notso critical in determining the success of the treatment. However, many studies report that the adoption ofmagnification devices has several technical advantages for the clinician, because they allow the identification ofmicroscopic anatomical structures otherwise undetectable by the naked eye, that may be important for improvingthe quality of the treatment. Therefore, even though clinical outcomes could not be affected by the type ofmagnification device used, the technical advantages peculiar to any of them may represent a technical 'plus' forthe clinician in specific clinical situations, increasing his/her self-confidence in patients care.Apart from the technical reasons or the individual preferences that may justify the adoption of a givenmagnification device, it should be acknowledged that the disclosure of dentinal cracks or the identification ofpeculiar anatomical features, such as the presence of isthmuses, may affect the clinical procedure allowing amore complete and accurate root canal system management. It can be hypothesized that the latter might beassociated with a decreased recurrence of post-treatment disease, thereby reducing the need for endodontic re-treatment. This point also should be specifically investigated by future studies.

Authors' conclusions Implications for practiceThis review could not find evidence concerning the effect of using a specific type of magnification device as anaid for better visualisation in endodontic therapy. There are no data supporting a systematic difference (orequivalence) in terms of clinical outcomes when either a microscope, an endoscope, or surgical loupes areadopted.A lot of indications deriving from in vitro studies or studies with low evidence level present in the endodonticliterature suggest that the use of a device for visual enhancement may have many technical and clinicaladvantages in most endodontic procedures. On the other hand, no evidence has been found that the use of a

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magnification device in any endodontic procedure is related to a better clinical outcome as compared to the sameprocedures performed without magnification devices.

Implications for researchNo randomised controlled trial was identified in the current literature that satisfied the criteria for inclusion inthis review. In order to understand if there is a significant advantage in using or not a magnification device inendodontics, or to quantify the superiority of a given magnification device over the others in specific clinicalsituations, if any exist, more long-term well-designed randomised trials have to be performed.Given the total absence of randomised trials comparing the clinical outcome of endodontic treatment (bothsurgical and non-surgical) using or not using a magnificator, this type of studies should have the priority.Randomised trials comparing different magnificators in orthograde endodontic treatment are also urgentlyneeded.It is also necessary that such trials investigate the effect that a given magnification device may have in thetreatment of molar teeth. It seems important to explore this item because endodontic treatment for molar teethis typically more challenging than for other tooth types, and therefore it might represent a specific indication forthe adoption of visual enhancers.Ideally, such studies should attempt to standardize all parameters potentially affecting the outcome. Inparticular, factors such as the patient's clinical and demographic characteristics, tooth type and location, theoperator's skill, clinical procedures, instrumentation and materials, radiographic techniques and success criteriashould be standardized. In these studies not only the treatment success should be evaluated, but also any type ofoutcome that could make a difference in the choice between different magnification devices like the possibility ofdetecting important anatomical structures, the quality of visualisation, the learning curve, the total time requiredfor completing the procedure. The patient's preference should eventually be taken into account. Such trialsshould also be reported in a standardized way, according to the Consolidated Standards of Reporting Trials(CONSORT) guidelines (Altman 2001) (www.consort-statement.org/).

Acknowledgements The review authors wish to thank Anne Littlewood, Trials Search Co-ordinator, and Luisa Fernandez Mauleffinch,Co-ordinator of the Cochrane Oral Health Group, for their help in the preparation of this review, and Dr Thomasvon Arx for providing us with information on his study.

Contributions of authors Conceiving the review (Silvio Taschieri (ST) and Massimo Del Fabbro (MDF)).Designing and co-ordinating the review (MDF).Developing search strategies and undertaking searches (MDF).Screening search results and retrieved papers against inclusion criteria (ST, MDF).Writing to authors for additional information (MDF).Appraising quality of papers (Giovanni Lodi (GL) and Giuseppe Banfi (GB)).Extracting data from papers (GL, GB).Providing additional data about papers (MDF, ST).Screening data on unpublished studies (MDF, ST).Analysis and interpretation of data (MDF, ST).Writing the review (MDF).Providing general advice on the review (GL, Roberto L Weinstein (RLW)).

Declarations of interest Massimo Del Fabbro, Silvio Taschieri and Roberto Weinstein are among the authors of some eligible studies.However, none of them was involved in the assessment of eligibility and data extraction of these trials.

Differences between protocol and review Published notes Characteristics of studiesCharacteristics of included studies FootnotesCharacteristics of excluded studies Taschieri 2008

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Reason for exclusion Several methodological flaws. Sample size calculation prior to the beginning ofthe study was undertaken on a tooth basis while group allocation occurred ona patient basis. A further concern is due to the presence of patients withmultiple teeth treated that had a greater chance of experiencing a negativeoutcome with respect to those that had a single tooth involved. Finally, molarteeth were not included in the first 2 years of the enrolment period while theywere included only during the third year.

Tsesis 2005Reason for exclusion This was a prospective but not a randomised study. The first 33 patients were

treated by the traditional technique without using the microscope.Subsequently, the other 33 patients were consecutively treated with the aid ofthe surgical microscope, after the latter was purchased. The two groups werealso treated with different techniques and instrumentation.

von Arx 2003Reason for exclusion In this study there was no randomisation. Cases were allocated to groups

according to the surgical protocol if the surgeon had or had not used anendoscope for intraoperative diagnostics.

FootnotesCharacteristics of studies awaiting classification FootnotesCharacteristics of ongoing studies Footnotes

Summary of findings tablesAdditional tables References to studiesIncluded studies Excluded studies Taschieri 2008Unpublished data onlyTaschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R. Endodontic surgery using 2 different magnificationdevices: preliminary results of a randomized controlled study. Journal of Oral & Maxillofacial Surgery2006;64(2):235-42.* Taschieri S, Del Fabbro M, Testori T, Weinstein R. Microscope versus endoscope in root-end management: arandomized controlled study. The International Journal of Oral and Maxillofacial Surgery 2008;37(11):1022-6.

Tsesis 2005Tsesis I, Shoshani Y, Givol N, Yahalom R, Fuss Z, Taicher S. Comparison of quality of life after surgical endodontictreatment using two techniques: a prospective study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiologyand Endodontology 2005;99(3):367-71.

von Arx 2003von Arx T, Frei C, Bornstein MM. Periradicular surgery with and without endoscopy: a prospective clinical study[Periradikuläre Chirurgie mit und ohne Endoskopie: eine klinisch-prospektive Vergleichsstudie]. SchweizerMonatsschrift für Zahnmedizin 2003;113(8):860-5.

Studies awaiting classification Ongoing studies

Other referencesAdditional references Altman 2001Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D et al. The revised CONSORT statement for


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reporting randomized trials: explanation and elaboration. Annals of Internal Medicine 2001;134(8):663-94.

Bahcall 1999Bahcall JK, Di Fiore PM, Poulakidas TK. An endoscopic technique for endodontic surgery. Journal of Endodontics1999;25(2):132-5. [ MEDLINE: 10204473]

Bahcall 2000Bahcall JK, Barss JT. Orascopic endodontics: changing the way we "think" about endodontics in the 21st century.Dentistry Today 2000;19(5):50-5. [ MEDLINE: 12524760]

Bahcall 2003Bahcall JK, Barss J. Orascopic visualization technique for conventional and surgical endodontics. InternationalEndodontic Journal 2003;36(6):441-7. [ MEDLINE: 12870474]

Baldassari-Cruz 2002Baldassari-Cruz LA, Lilly JP, Rivera EM. The influence of dental operating microscope in locating the mesiolingualcanal orifice. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology 2002;93(2):190-4.

Behle 2001Behle C. Photography and the operating microscope in dentistry. Journal of the Californian Dental Association2001;29(10):765-71. [ MEDLINE: 11799672]

Castellucci 2003Castellucci A. Magnification in endodontics: the use of the operating microscope. Practice Periodontics &Aesthetic Dentistry 2003;15(5):377-84. [ MEDLINE: 12901065]

Cohen 2006Cohen S, Hargreaves KM. Pathways of the Pulp. 9th edition. St Louis, MO: Mosby, 2006.

de Carvalho 2000Coelho de Carvalho MC, Zuolo ML. Orifice locating with a microscope. Journal of Endodontics 2000;26(9):532-4. [MEDLINE: 11199796]

Del Fabbro 2007Del Fabbro M, Taschieri S, Testori T, Francetti L, Weinstein RL. Surgical versus non-surgical endodontic re-treatment for periradicular lesions. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005511DOI: 10.1002/14651858.CD005511.pub2.

Dugas 2003Dugas NN, Lawrence HP, Teplitsky PE, Pharoah MJ, Friedman S. Periapical health and treatment qualityassessment of root-filled teeth in two Canadian populations. International Endodontic Journal 2003;36(3):181-92. [ MEDLINE: 12657144]

Friedman 2004Friedman S, Mor C. The success of endodontic therapy - healing and functionality. Journal of the CalifornianDental Association 2004;32(6):493-503.

Gorduysus 2001Görduysus MO, Görduysus M, Friedman S. Operating microscope improves negotiation of second mesiobuccalcanals in maxillary molars. Journal of Endodontics 2001;27(11):683-6.

Gutmann 1991Gutmann JL, Harrison JW. Surgical Endodontics. Boston, MA, USA: Blackwell Scientific Publications, 1991.

Higgins 2008Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 5.0.1 [updatedSeptember 2008]. The Cochrane Collaboration, 2008. Available from: www.cochrane-handbook.org.

Jesslen 1995Jesslen P, Zetterqvist L, Heimdahl A. Long-term results of amalgam versus glass ionomer cement as apicalsealant after apicectomy. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology1995;79(1):101-3. [ MEDLINE: 7614147]

Khayat 1998Khayat BG. The use of magnification in endodontic therapy: the operating microscope. Practice Periodontics &Aesthetic Dentistry 1998;10(1):137-44. [ MEDLINE: 9582669]

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Kim S. Principles of endodontic microsurgery. Dental Clinics of North America 1997;41(3):481-97. [ MEDLINE:9248686]

Kim 2004Kim S. Modern endodontic practice: instruments and techniques. Dental Clinics of North America 2004;48(1):1-9.

Mead 2005Mead C, Javidan-Nejad S, Mego ME, Nash B, Torabinejad M. Levels of evidence for the outcome of endodonticsurgery. Journal of Endodontics 2005;31(1):19-24.

Molven 1987Molven O, Halse A, Grung B. Observer strategy and the radiographic classification of healing after endodonticsurgery. The International Journal of Oral and Maxillofacial Surgery 1987;16(4):432-9. [ MEDLINE: 3117915]

Molven 1996Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery. Radiographic findings 8-12years after treatment. Journal of Endodontics 1996;22(5):264-8. [ MEDLINE: 8632141]

Paik 2004Paik S, Sechrist C, Torabinejad M. Levels of evidence for the outcome of endodontic retreatment. Journal ofEndodontics 2004;30(11):745-50.

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Other published versions of this review Classification pending references

Data and analyses FiguresSources of support Internal sources

No sources of support provided

External sourcesNo sources of support provided

Feedback Appendices 1 Search strategy for MEDLINE via OVID

ENDODONTICS/1.exp "Root Canal Therapy"/2.Apicoectomy/3.endodontic$.ab,sh,ti.4.(apical and (surgery or surgical$)).mp. [mp=title, original title, abstract, name of substance word, subject5.heading word](apicectom$ or apicoectom$).mp. [mp=title, original title, abstract, name of substance word, subject heading6.word]((orthograd$ adj6 fill$) or (root adj6 therap$) or (root-end adj6 resect$) or (root-end adj6 fill$)).mp. [mp=title,7.original title, abstract, name of substance word, subject heading word](("root canal$" adj (prepar$ or obturat$)) or "dental pulp devitali$").mp. [mp=title, original title, abstract, name8.of substance word, subject heading word](retrograd$ adj6 fill$).mp. [mp=title, original title, abstract, name of substance word, subject heading word]9.or/1-910.(microscop$ or endoscop$ or orascop$ or loupe$).mp. [mp=title, original title, abstract, name of substance11.word, subject heading word](magnification or magnify).mp. [mp=title, original title, abstract, name of substance word, subject heading12.word]exp Microscopy/13.or/11-1314.10 and 1415.


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The above subject search was linked to the Cochrane Highly Sensitive Search Strategy for identifying randomisedcontrolled trials in MEDLINE (sensitivity maximising version) (2008 revision) as referenced in Chapter 6.4.11.1and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1(updated September 2008).

2 Search strategy for the Cochrane Oral Health Group Trials Register((endodontic* or "root canal$" or apicoectom* or apicectom* or (apical* AND (surgery or surgical*)) or(orthograd* and fill*) or (retrograd* AND fill*)) AND (microscop* or endoscop* or orascop* or loupe* or magnifyor magnification))

3 Search strategy for the Cochrane Central Register of Controlled Trials (CENTRAL)#1 ENDODONTICS/#2 Exp Root canal therapy#3 APICOECTOMY/#4 endodontic* [ti,ab,ky]#5 (apical NEAR surgery) or (apical NEAR surgical*)#6 (apicectom* or apicoectom*)#7 ((orthograd* NEAR fill*) or (root NEAR therap*) or (root-end NEAR resect*) or (root-end NEAR fill*)#8 (“root canal*” NEAR prepar*)#9 (retrograde* NEAR fill*)#10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9#11 (microscop* or endoscope* or orascop* or loupe*)#12 (magnification or magnify or magnified#13 Exp MICROSCOPY#14 #11 or #12 or #13#15 #10 AND #14

4 Search strategy for EMBASE via OVID1. ENDODONTICS/2. "Root Canal Therapy".mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,device manufacturer, drug manufacturer name]3. Apicoectomy.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, devicemanufacturer, drug manufacturer name]4. endodontic$. ab,sh,ti.5. (apical and (surgery or surgical$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name,original title, device manufacturer, drug manufacturer name]6. (apicectom$ or apicoectom$).mp. [mp=title, abstract, subject headings, heading word, drug trade name,original title, device manufacturer, drug manufacturer name]7. ((orthograd$ adj6 fill$) or (root adj6 therap$) or (root-end adj6 resect$) or (root-end adj6 fill$)).mp. [mp=title,abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drugmanufacturer name]8. (("root canal$" adj (prepar$ or obturat$)) or "dental pulp devitali$").mp. [mp=title, abstract, subject headings,heading word, drug trade name, original title, device manufacturer, drug manufacturer name]9. (retrograd$ adj6 fill$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,device manufacturer, drug manufacturer name]10. or/1-911. (microscop$ or endoscop$ or orascop$ or loupe$).mp. [mp=title, abstract, subject headings, heading word,drug trade name, original title, device manufacturer, drug manufacturer name]12. (magnification or magnify).mp. [mp=title, abstract, subject headings, heading word, drug trade name,original title, device manufacturer, drug manufacturer name]13. exp Microscopy/14. or/11-1315. 10 and 14The above subject search was linked with the Cochrane Oral Health Group search filter for identifying controlledtrials in EMBASE:


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1. random$.ti,ab.2. factorial$.ti,ab.3. (crossover$ or cross over$ or cross-over$).ti,ab.4. placebo$.ti,ab.5. (doubl$ adj blind$).ti,ab.6. (singl$ adj blind$).ti,ab.7. assign$.ti,ab.8. allocat$.ti,ab.9. volunteer$.ti,ab.10. CROSSOVER PROCEDURE.sh.11. DOUBLE-BLIND PROCEDURE.sh.12. RANDOMIZED CONTROLLED TRIAL.sh.13. SINGLE BLIND PROCEDURE.sh.14. or/1-1315. ANIMAL/ or NONHUMAN/ or ANIMAL EXPERIMENT/16. HUMAN/17. 16 and 1518. 15 not 1719. 14 not 18

Graphs

Magnification devices for endodontic therapy

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