Regeneración ósea con fibrina rica en plaquetas en una cirugía apical / Bone regeneration with platelet-rich fibrin in apical surgery

Introducción: La fibrina rica en plaquetas es una membrana o coágulo de fibrina, que brinda gran cantidad de factores de crecimiento, leucocitos y citoquinas. Esta es una buena alternativa para promover una mejor cicatrización, además de potenciar otros biomateriales con el fin de condicionar una mejor regeneración y en un menor período de tiempo. Su fácil preparación y manipulación, a diferencia de otros preparados plaquetarios, hacen que pueda ser usada en la práctica clínica diaria. Objetivo: Mostrar el manejo de una cirugía apical con aplicación de fibrina rica en plaquetas y su resultado clínico. Presentación de caso: Paciente de sexo femenino, de 47 años, con absceso apical crónico a nivel del segundo premolar superior derecho. Radiográficamente se observó una lesión apical persistente, el instrumento fracturado en uno de los conductos radiculares, el material de obturación sobreextendido y retenedor intrarradicular. Se decidió realizar cirugía apical con obturación retrógrada y relleno óseo en combinación con fibrina rica en plaquetas. Resultados: El paciente evolucionó de forma favorable y se evidenció cicatrización ósea en desarrollo, sin complicaciones. Conclusiones: La utilización de fibrina rica en plaquetas, en combinación de relleno óseo durante la cirugía endodóntica, es una buena alternativa por sus propiedades de regeneración ósea(AU)

Introduction: Platelet-rich fibrin is a fibrin membrane or clot, which provides a large amount of growth factors, leukocytes and cytokines. This is a good alternative to help better healing, in addition to enhancing other biomaterials in order to condition better regeneration and in a shorter period of time. Its easy preparation and handling, unlike other platelet preparations, mean that it can be used in daily clinical practice. Objective: To show the management of an apical surgery with the application of platelet-rich fibrin and its clinical result. Case report: This is the case of a female patient, 47 years old, with chronic apical abscess at the level of the upper right second premolar. Radiographically, a persistent apical lesion was observed, the instrument fractured in one of the root canals, the obturation material overextended, and the intraradicular retainer. It was decided to perform apical surgery with retrograde obturation and bone filling in combination with platelet-rich fibrin. Results: The patient evolved favorably and evidenced bone healing in development, without complications. Conclusions: The use of platelet-rich fibrin, in combination with bone filler during endodontic surgery, is a good alternative due to its bone regeneration properties(AU)

Outcome of intentional replantation of endodontically treated teeth with periapical pathosis: A systematic review and meta-analysis.

The purpose of the present review was to examine success, survival and failure following intentional replantation of endodontically treated teeth with existing periapical pathosis and to determine the factors that might affect the outcome of replantation. Clinical trials, longitudinal studies, case series with >10 cases and at least 1-year follow-up were included. The average rate of success following intentional replantation was 77.23%. Meta-analysis revealed the mean weighted survival to be 85.9% (95% CI: 79.6-91.2) Common complications include inflammatory root resorption (0%-27%) and ankylosis (0%-25%). Variables influencing successful outcome include extra alveolar dry time <15 min; root-end resection (2-3 mm) and cavity preparation (3 mm); manipulation of the tooth using the crown only; and use of an appropriate storage media. The review concludes that intentional replantation is a viable treatment option with acceptable survival rates for endodontically treated teeth with periapical pathosis.

The evaluation of apicectomy without retrograde filling in terms of lesion size localization and approximation to the anatomic structures.

BACKGROUND: The purpose of this study was to evaluate of the patients who underwent apical resection. Besides assess the classification of resection side, localization, lesion size, approximation of anatomic structures and the purpose of the apical surgery retrospectively. MATERIAL AND METHODS: In this stutdy 782 patients and 1191 apical resection applied tooth evaluated. 504 of the patients were famale and 278 were male. Patients age was between 13 and 76 years old and operated between January 2016 and January 2017. The study includes incisor, canine and premolar teeth which had the apical resection as the first time. Operation side evaluated from orthopantomograph and periapical radiographs. RESULTS: There were 1191 teeth operated and 966 of them in maxilla and 225 of them in mandible. The number of the incisor teeth were 871, 177 were canine, 129 were premolar and one of them was molar. The total amount of 468 patients had operated by just 1 tooth, 454 of the operated teeth had cyst on the operation side. Premolar and molar side 21 of the 93 lesion had approximation with maxillar sinus. On the other hand in maxilla 39 of 569 lesion had approximation with nasal cavity. In mandibula 1 of the 15 lesion, which involved mandibular premolar teeth, had approximation with mental foramen. CONCLUSIONS: Apical resection operation mostly done for one tooth, and the lesion size was less than 10 milimeters. Furthermore apical resection mostly done for incisors cause of odontogenic cyst.

Long-term survival of teeth in the posterior region after apical surgery.

Oftentimes the discussion of long-term success rates and treatment modalities becomes a central issue in consultations with patients. The aim of this study was to retrospectively evaluate survival rates of teeth after apicoectomy in an established private practice for Oral and Maxillofacial Surgery in Kiel, Germany. All teeth treated with apicoectomy between 2001 and 2006 were included. Treatment success was previously defined as preservation of the tooth. Putative influence factors on success as kind and quality of endodontic treatment, additional intraoperative endodontic filling, inflammatory status, tooth mobility, and pre- and postoperative X-rays were further evaluated. A total of 149 teeth could be included. The mean observation period was 6.3 (SD: 4.4) years. In all, 48.3% of these teeth could be retained after a 10-year period. Teeth that received an additional retrograde root canal filling during surgery resulted in a significantly higher success rate (p = 0.0237) compared to those with orthograde root canal fillings or without additional endodontic treatment. The quality of endodontic treatment had no impact (p = 0.125). Our results suggest that apical surgery is a reliable procedure to treat and ensure the survival of symptomatic teeth in the posterior region for several years. A significant improvement was further determined for a retrograde filling.

Contemporary CBCT diagnostics-discovery of a new artery with possible impact on surgical planning: the anterior superior palatal alveolar artery.

PURPOSE: An ongoing clinical trial regarding intra- and post-surgical morbidity in maxillary apicoectomies showed significant higher morbidity for upper canines and palatal roots of upper 1st premolars. Analysis of available presurgical cone beam computed tomography (CBCT)-scans revealed the existence of an unknown bone-canal branching off from the bone-canal or groove of the anterior superior alveolar artery (asaa). Aim of the study was the determination of the contents of this newly found bone canal in human cadaver heads, its prevalence as possible standard anatomical structure and its automatized detection with a contemporary high-resolution TRIUM-CBCT-device in vivo. METHODS: 35 human cadaver heads were dissected, the prevalence of the bone-canal determined and its contents analyzed by histology. 835 consecutive routine high-resolution TRIUM-CBCT-scans from routine patients were analyzed by an automatized detection- and tracing-algorithm for in vivo-determination of prevalence of this bone canal. Automatized detection and additional manual tracing were statistically evaluated by SSPS 20.0 software. RESULTS: The bone-canal was found in 96% of the anatomical specimens, its content identified as artery not described until now and named after the first finder "Arteria Kurrekii". Automatized tracing of TRIUM-CBCT-scans with additional manual tracing revealed an in vivo prevalence of this newly found artery of 95% (p ≤ 0.05). CONCLUSIONS: The newly found anterior superior palatal alveolar artery (aspaa-"Arteria Kurrekii") might have the same clinical impact for surgical procedures in the maxilla as the posterior superior alveolar artery (psaa). Its first detection was enabled by high-resolution TRIUM-CBCT devices and prevalence as standard anatomical structure proven in vivo by automatized CBCT-scan analysis.

Changes of Periodontal Parameters after Apical Surgery: Correlation of Clinical and Cone-beam Computed Tomographic Data.

INTRODUCTION: The purpose of this study was to evaluate the changes of the marginal periodontium 1 year after apical surgery. METHODS: Clinical and radiographic (cone-beam computed tomographic) examinations of 54 teeth treated with buccal access flaps for apical surgery were performed at baseline and after 1 year. Clinical assessment included measurements of probing pocket depth, the level of gingival margin (GM), and the width of keratinized tissue. Subsequently, the clinical attachment level (CAL) and the width of the attached gingiva were calculated. On bucco-oral cone-beam computed tomographic sections, the height and thickness of the crestal bone and the thickness of the alveolar bone were measured at different levels. RESULTS: In general, the calculated mean changes of periodontal tissue and crestal/alveolar bone were only minimal. Significant mean changes included only GM and CAL on midoral aspects and the distance from the cementoenamel junction or restoration margin on midbuccal sites. CAL was further correlated with the thickness of the alveolar bone at 3 mm below the cementoenamel junction or restoration margin. None of the clinically and radiographically calculated mean changes were correlated with sex, biotype, or incision techniques. With regard to age, older patients showed significantly more gingival recession on the buccal aspect compared with younger individuals. Furthermore, mean changes of the midbuccal width of the attached gingiva were positively correlated with the healing outcome, whereas mean changes of the midoral GM and CAL were negatively correlated with the healing outcome. CONCLUSIONS: Within an observation period of 1 year, the marginal periodontium and its underlying bone structures did not suffer from significant changes after apical surgery.

Periapical Bone Healing after Apicectomy with and without Retrograde Root Filling with Mineral Trioxide Aggregate: A 6-year Follow-up of a Randomized Controlled Trial.

INTRODUCTION: In cases of post-treatment periapical disease, retreatment may be necessary. To choose the most appropriate retreatment method, knowledge of the long-term prognosis is important. Surgical endodontic retreatment (SER) is a relevant treatment method. This study assessed changes in outcome from 1 to 6 years after surgery. METHODS: SER was performed on teeth randomly allocated to have a MTA root-end filling (MTA group) or smoothing of the orthograde gutta-percha filling after apicectomy (GP group). Patients participating in the 1-year follow-up were reinvited for a 6-year clinical and radiographic examination. Three observers assessed treatment outcome both clinically and radiographically from the 1-year and 6-year follow-up examination. RESULTS: At the 6-year follow-up, 39 of 52 teeth were available and examined (75% participation rate). In the MTA group, 16 of 19 teeth (86%) and in the GP group 11 of 20 teeth (55%) were assessed as successful (P = .04). In the MTA group and the GP group, 80% and 90%, respectively, of teeth assessed as successful at the 1-year follow-up remained successful. All unsuccessful teeth in the MTA group (3 teeth) were lost because of vertical root fracture. CONCLUSIONS: The proportion of healed cases was larger in the MTA group than in the GP group at both the 1-year and 6-year follow-up. Findings indicate that a 1-year follow-up may not be sufficient in assessing the long-term outcome of surgical endodontic retreatment. With a longer follow-up, other factors not directly related to the endodontic treatment may be relevant for a successful outcome. This needs further investigation in larger patient samples.

Patient perceived burden of implant placement compared to surgical tooth removal and apicectomy.

OBJECTIVE: To assess how patients actually perceive implant placement, to evaluate whether patients' perceived burdens are related to specific stages during implant placement, and to compare patients' perceptions during implant placement with other surgical procedures. METHODS: A sample of 287 patients was consecutively recruited. Only patients with implantations (n=45), surgical tooth removal (n=147), or apicectomies (n=95) were included. Patients' perceptions during oral surgery and implantation were assessed using the Burdens in Oral Surgery Questionnaire (BiOS-Q). Effects of treatment on BiOS-Q total and domain scores were assessed using multivariate linear regression analyses, and effect sizes (Cohen's d) were computed. RESULTS: Overall, patients' perceived burdens during oral surgery were low indicated by a mean BiOS-Q total score of 28.5 points, with lowest scores for Side effects (19.4) and highest scores for Anesthesia (34.1). Among treatment groups, implantation was perceived least unpleasant. This was related to lower burdens during Bone and soft tissue manipulation during implantation than during surgical tooth removal (difference: 14.8 points; d=0.8) or apicectomy (difference: 13.1 points; d=0.7). CONCLUSIONS: Implantation has a low overall perceived burden and is significantly less burdensome during bone and soft tissue manipulation than surgical tooth removal or apicectomy. CLINICAL SIGNIFICANCE: Patients can be informed that implant placement is less unpleasing than other commonly performed oral surgery procedures.

Periapical microsurgery: the effect of root dentinal defects on short- and long-term outcome.

INTRODUCTION: The purpose of this prospective clinical study was to evaluate the clinical outcome of endodontic microsurgery on roots exhibiting the presence or absence of dentinal defects at 1-year and 3-year follow-up period. METHODS: One hundred fifty-five teeth were treated with periapical microsurgery using a modern microsurgical protocol in a private practice setting. The root apices were resected and inspected for dentinal defects with a surgical operating microscope and a 0.8-mm head diameter light-emitting diode microscope diagnostic probe light. After inspection, root-end preparations were performed using ultrasonic tips, and root-end fillings were placed. Follow-up visits occurred at 1 year and 3 years postoperatively. The primary outcome measure used was the change in the radiographic apical bone density, and the secondary outcome measure used was the absence of clinical symptoms. RESULTS: Of the 155 treated teeth, a total of 134 teeth were assessed at the 1-year follow-up and 127 teeth at the 3-year evaluation. In the "intact" group, 94.8% healed at 1 year, and 97.3% healed at 3 years. In the "dentinal defect" group, 29.8% healed at 1 year, and 31.5% healed at 3 years. The baseline root condition of either "dentinal defect" or "intact" showed a statistical difference in the healing outcome at both 1 and 3 years. CONCLUSIONS: This prospective periapical microsurgery study showed a significant superior clinical outcome for intact roots when compared with roots with dentinal defects at both 1 year and at 3 years postoperatively.

Layered socket Grafting using an anorganic bovine bone mineral-collagen composite.

Following tooth extraction, socket grafts are commonly used to prevent incomplete healing and to optimize the bony site for implant placement (1). Many particulate, composite, and putty-like bone grafting materials either with or without a membrane have been used as socket grafts. This article introduces the layered socket grafting technique for socket grafting without the use of a membrane or primary closure. This technique uses a particulate anorganic bone mineral to graft the apices of sockets and then a composite material consisting of anorganic bovine bone mineral and collagen for the superior or crestal one-third of a socket or defect. When grafting sockets, the technique is fast and does not require the use of releasing flaps or primary closure and can also be used to manage large periapical defects.

Apical surgery: endoscopic findings at the resection level of 168 consecutively treated roots.

AIM: Endoscopic evaluation of the cut root face after root-end resection during apical surgery. METHODOLOGY: Consecutive cases undergoing apical surgery from June 2006 to May 2008 were enrolled. After root-end resection, the cut root face was inspected with a rigid endoscope and the following findings were assessed: number of canals, presence of isthmus, presence and location of craze lines/cracks, frosted dentine, and gaps between root filling material and dentine. Craze lines/cracks, frosted dentine and gaps were further correlated with the age group of the patient (<45 vs. ≥ 45 years), the type of treated tooth and the presence or absence of a post/screw. RESULTS: The final material included 168 resected roots. The highest frequency of isthmuses was found in mesial roots of mandibular first molars (88.5%). A craze line/crack was seen in 9.5%, frosted dentine in 79.8% and gaps in 83.3% at the cut root faces. Significant differences were observed for the location of the microfindings at the resected root surfaces (buccal vs. mesial vs. lingual vs. distal, P > 0.0001). Premolars had significantly more craze lines/cracks than anterior teeth (P = 0.006) and molars (P = 0.000). Frosted dentine was significantly more frequently seen in premolars (P = 0.027) and molars (P = 0.001) compared to anterior teeth. The age groups and the presence or absence of a post/screw did not significantly influence the findings. CONCLUSIONS: Frosted dentine and gaps were frequently observed with endoscopy at the resected root surfaces. The type of tooth appeared to affect the occurrence of a craze line/crack and of frosted dentine.

Clinical evaluation of a modified marginal sulcular incision technique in endodontic surgery.

The authors evaluated periodontal parameters following apical surgery using a new marginal sulcular incision. In 65 cases, surgical access was achieved by means of a sulcular incision technique without the involvement of the adjacent periodontia and the interproximal papillae and in 33 cases by means of a submarginal trapezoidal technique. Periodontal parameters (probing pocket depth, gingival recession, clinical attachment loss, and tooth mobility [periotest]) were recorded at baseline and after 6 months. Scar formation and the loss of papilla height were evaluated photographically. No significant changes in the attachment level and no loss of papilla height were found in either group. A slight gingival recession (0.2 +/- 0.4 mm) corresponding to the decrease in pocket depths occurred on the buccal aspect with the sulcular incision. Tooth mobility was significantly increased in both groups immediately and 6 months after surgery. Scar formation was more unfavorable with the submarginal incision.

Retreatment of a resected tooth associated with a large periradicular lesion by using a triple antibiotic paste and mineral trioxide aggregate: a case report with a thirty-month follow-up.

INTRODUCTION: Trauma to the teeth and supporting structures is a frequent problem among children. Endodontic treatment is necessary for 41.3% of traumatized teeth. Two of the most important criteria for successful endodontic treatment are the elimination of microorganisms and apical sealing. A combination of antibiotic drugs (metranidozole, ciprofloxacin, and minocycline) is used to eliminate target bacteria, which are possible sources of endodontic lesions. For cases in which apical sealing is difficult, specific materials to plug the apical region have been advocated. Mineral trioxide aggregate (MTA) has become the material of choice because it is biocompatible and has bacteriostatic action. METHODS: This case report describes the nonsurgical retreatment of a traumatized tooth that had already undergone unsuccessful apical resection associated with a large periradicular lesion. A combination of antibiotic drugs was used as an intracanal medicament, and MTA was used to obtain a hermetic seal of the lateral tooth that had undergone unsuccessful apical resection. RESULTS: On follow up, the tooth was clinically and radiographically asymptomatic for 30 months. CONCLUSIONS: The results of this case show that MTA and triple antibiotic paste can be used clinically in the treatment of an unsuccessfully resected tooth associated with a large periradicular lesion.

Histopathological profile of surgically removed persistent periapical radiolucent lesions of endodontic origin.

AIM: To determine the types of periapical lesions associated with root filled teeth with persistent periapical pathosis that required surgical treatment based on specific inclusion and exclusion criteria. METHODOLOGY: Periapical lesions from a consecutive clinical sample of 100 patients were examined histopathologically to determine a definitive diagnosis. RESULTS: Females were more represented (n = 56), the average age was 46.5 years and there were no age differences between gender or lesion type. A diagnosis of periapical granuloma was the most common finding with a similar number present in females (n = 40) and males (n = 37). A cyst was present in 18% of the cases with a majority of females (n = 12) represented in the sample. Evidence of foreign material, with an appearance consistent with endodontic sealer materials, was seen in 25 periapical granulomas, two cysts and one scar. Two periapical scars were seen, one had a history of apicectomy and amalgam root-end filling while the other was associated with extruded root filling material. CONCLUSIONS: By using defined clinical inclusion and exclusion criteria a predictable clinical diagnosis of a persistent periapical lesion due to endodontic origin can be reliably made. Periapical granulomas and cysts were the most common periapical lesions of endodontic origin associated with persistent periapical pathosis with the overall incidence of periapical cysts similar to previous studies. The presence of endodontic material in a high proportion of periapical lesions suggests a cause-effect association with the inference that clinicians should employ canal preparation techniques that limit apical extrusion of material.

Surgical and nonsurgical endodontic treatment-induced stress.

This observational study compared physiologic and psychological indicators of stress between two groups of 30 healthy patients undergoing either surgical or nonsurgical endodontic treatments. Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure were monitored during care sessions. The patients were asked to score their anxiety before treatment and to report pain, stress, and/or discomfort experienced during care. Variations in HR and SBP were significantly dependent on treatment group (HR: F = 6, p < 0.001; SBP: F = 4, p = 0.05). Intergroup differences increased during the active steps of the treatment, such as local anesthesia, rotary instrumentation, periradicular curettage, root filling, and field removal. Moreover, the level of stress experienced during the care procedure was correlated to the level of anticipated anxiety in both groups. This study raises questions on the indications for anxiolysis or sedation in endodontic patients as a means of preventing the neurophysiologic consequences of stress.

Risk factors for tooth loss in an adult population: a radiographic study.

AIM: The aim of the present study was to estimate the incidence and identify risk factors for tooth loss during a 5-year period in a randomly selected Danish population. MATERIAL AND METHODS: In 1997 and 2003, 473 randomly selected adults received a full-mouth radiographic examination. The total number of teeth was 12,444. For each tooth, the following information was recorded from the radiographs: marginal bone level, filling, crown, root canal post, root filling, apicectomy, periapical status and caries lesion. Unconditional and conditional logistic regression analyses were used to identify risk factors for tooth loss. RESULTS: During the study period, 107 teeth in 60 individuals were lost. On the individual level, reduced marginal bone level and apical periodontitis (AP) were highly associated with tooth loss. On the tooth level, a reduced marginal bone level, AP and apicectomy were strongly associated with tooth loss. Canines were not lost often, whereas tooth loss was more frequently observed in molars and premolars than in incisors. CONCLUSIONS: A reduced marginal bone level and AP were associated with tooth loss over time. Furthermore, there was a higher risk of tooth loss in the posterior regions than in the anterior region.

Aesthetic flap design for correction of buccal fenestration defects.

Flapless immediate implant surgery has been proposed as a means of reducing the surgical trauma to soft tissue and maintaining natural gingival anatomy. The aesthetic outcome in such cases may, however, be jeopardized when localized horizontal and vertical deficiencies occur. In order to correct such deficiencies, a novel flap design was developed that protected the soft tissue that had the most significant impact on the patient's appearance. This aesthetic buccal flap (ABF) was created coronally so that the supraosseous soft tissue remained undisturbed and allowed the use of guided bone regeneration techniques to correct apical dehiscences. The likelihood of obtaining an optimal aesthetic result was, therefore, enhanced.

Patient discomfort following periapical surgery.

OBJECTIVE: The aim of the study was to assess patient discomfort following periapical surgery. STUDY DESIGN: Forty-two patients with apical periodontitis were allocated to apicectomy with either smoothening of the gutta-percha root filling or a retrograde root filling with mineral trioxide aggregate (MTA). RESULTS: Pooling all patients, VAS score for pain peaked 3 hours postoperatively (mean VAS = 29). The VAS score for swelling peaked 1 day postoperatively (mean VAS = 41). Patients' overall perception of postoperative discomfort was induced by (questions asked at the day for suture removal): Oral awareness (36 yes, 6 no); swelling (30 yes, 12 no); compromised chewing ability (18 yes, 24 no); pain (15 yes, 27 no). There was no correlation between the operating time and VAS scores for pain and swelling (r < or = .25, P > .11). CONCLUSIONS: Patients experienced little pain and moderate swelling after periapical surgery. Oral awareness was the most reported reason for postoperative discomfort. The operating time was not a decisive factor in relation to postoperative discomfort.

Histological assessment of pulp condition after apical vital root transection in one root of multirooted teeth in dogs: a preliminary study.

One of the most important aspects in surgery is the healing process after the periapical surgery. Past studies have shown occasional encounters with vital root resection and have noted varying degrees of pulpal response after root resection in periodontal disease. The purpose of this investigation was to observe the pulpal and periapical responses to intentional apical vital root transection in one root of multirooted teeth of German-Canadian dogs over a 6-month postoperative period. This is an experimental study performed on left maxillary and mandibular quadrants of four adult German-Canadian dogs after a 3- and 6-month period. Four teeth were assessed in each interval. One of the roots of multirooted teeth in the left quadrant of both maxillary and mandibular jaws was surgically transected. Tissue blocks were prepared by routine histological methods after 12 and 24 weeks after the surgery. The results showed a disruption of the normal pulpal architecture, with initial pulpal degeneration and subsequent early replacement by the periodontal ligament tissue after 24 weeks. Hypercementosis was seen around the apical portion of the root in all specimens. Pulpal regeneration was seen in the both upper and lower molars (p = 0.03). Resorption took place only in two specimens (p = 0.46). The inflammation in the 12th week was more than the 24th week. The pulp of multirooted teeth remains vital after transection of the apical part of the root in dogs. Longer follow-up periods are recommended because root canal therapy or extraction is indicated if resorption, necrosis, or ankylosis is seen.

Changes of periodontal parameters following apical surgery: a prospective clinical study of three incision techniques.

AIM: To evaluate periodontal changes following apical surgery, and to relate changes to the type of incision and to the type of restoration present at the gingival margin (GM). METHODOLOGY: Periodontal parameters [probing depth (PD), level of GM and clinical attachment, plaque and bleeding indices] were recorded at baseline and 1 year following apical surgery. The periodontal changes were calculated and assessed with respect to the incision technique (intrasulcular incision, papilla base incision and submarginal incision), as well as to the presence and type of a restoration margin in contact with the gingiva. RESULTS: One hundred and eighty-four teeth could be evaluated. No significant differences between the three incision techniques were found regarding changes in PDs and plaque index over time. However, significant differences between the intrasulcular and submarginal incisions were found for changes in levels of GM and clinical attachment. For example, with the intrasulcular incision, there was a mean recession of 0.42 mm at buccal sites, whereas using the submarginal incision there was a gain of 0.05 mm. No statistically significant influence could be demonstrated for the presence and type of restoration margins, or the smoking habit of the patient. CONCLUSION: The type of incision was found to affect changes significantly in periodontal parameters within an observation period of 1 year following apical surgery, whereas the restoration margin and smoking habit did not prove to have any significant effect.