Prognosis










11
Prognosis
Published success rates for endodontic therapies are
often cited as justication for treatment decisions both
in clinical practice and during the American Board of
Endodontics (ABE) examination process. Outcomes are
inuenced not only by the quality of endodontic treat-
ment but also by a number of periodontal, restorative,
microbial, and patient-centered factors. When eval-
uating published success rates, it is important to con-
sider not only the published success rate but also the
criteria used to judge treatment success versus failure.
This chapter presents published success rates for end-
odontic therapies and important prognostic factors that
inuence treatment outcomes. Table 11-1 includes a
summary of prognostic data for all treatment modalities
and the publishing author of the study. For complete
references, please review the individual sections within
this chapter.

209
Prognosis
Nonsurgical Root Canal Therapy
Based on available long-term studies, evidence suggests that nonsurgical root canal
therapy provides predictable outcomes for patients. In an 8-year epidemiologic study of
1,462,936 teeth, Salehrabi and Rotstein found that 97% of endodontically treated teeth
were retained in the oral cavity. Furthermore, 96% of those teeth required no additional in-
tervention. De Chevigny et al found that after 5 to 10 years, 88% of endodontically treated
teeth were radiographically healed, and 94% of teeth were clinically functional.
The endodontic literature cites several prognostic factors that may inuence reported
outcomes. These factors include pretreatment conditions, dental conditions, intratreat-
ment factors, and post-treatment restorative care. Pretreatment conditions capable of
inuencing root canal therapy outcomes include periodontal attachment loss and apical
periodontitis. Setzer et al demonstrated that clinical attachment loss negatively impacts
root canal therapy outcomes. Similarly, the presence of apical periodontitis negatively in-
uences treatment outcomes. De Chevigny et al found that in teeth with normal periapices
preoperatively, 93% of teeth were considered healed, and 97% were functional. However,
teeth with demonstrable preoperative apical periodontitis were radiographically healed
only 82% of the time, and 94% were clinically functional.
Treatment Successful outcome
Nonsurgical root canal therapy
97% (Salehrabi and Rotstein 2004)
88% (de Chevigny et al)
Nonsurgical retreatment
89% (Salehrabi and Rotstein 2010)
86% (Fristad et al)
83% (de Chevigny et al)
Surgical root canal therapy
89% (Tsesis et al)
96% (Rubinstein and Kim)
MTA pulp capping
37% (Barthel et al)
80% (Mente et al)
Calcium hydroxide apexication
77% (Jeeruphan et al)
MTA apexication
95% (Jeeruphan et al)
93% (Witherspoon and Ham)
Regenerative endodontics 100% (Jeeruphan et al)
Table 11-1 Prognostic values for endodontic treatment modalities
Nonsurgical Root Canal Therapy

210
Prognosis
11
Though the presence of apical periodontitis clearly inuences treatment outcomes to a
small degree, the presence of a positive bacteriologic culture immediately prior to the place-
ment of a root canal lling has not been shown to consistently inuence treatment outcomes.
On the one hand, Sjögren et al found that, while cases with a negative culture prior to root
canal lling enjoyed a success rate of 94%, those that had a positive culture prior to root
lling had only a 68% success rate. Other authors were unable to conrm this nding. Peters
et al found that the presence or absence of a positive culture at the time of root lling had no
effect on lesion healing. Similarly, Molander et al failed to demonstrate the effects of positive
bacterial cultures at the time of ll on treatment outcomes.
As is the case with positive bacteriologic cultures, the number of treatment visits does
not inuence treatment outcomes. Penesis et al
found similar outcomes for necrotic teeth
treated in a single visit versus those treated in two visits. These results were conrmed by
Paredes-Vieyra and Enriquez who found no signicant difference between single- and mul-
tiple-visit therapy for necrotic teeth with apical periodontitis. The reported success rates
were 96% for single-visit therapy and 89% for two-visit therapy.
Following completion of root canal therapy, restorative treatment is necessary. The qual-
ity of restorative treatment following root canal therapy has long been discussed as a pos-
sible prognostic factor. Ray and Trope found that the quality of restorative treatment was
more inuential on the outcome of endodontic therapy than the quality of the root canal
itself. On the contrary, Moreno et al found that the quality of root canal therapy was more
inuential on periapical status than the quality of restorative care. Gillen et al, however,
found that the presence of adequate root canal llings with inadequate restorations had
equal odds of suboptimal clinical outcomes as inadequate root canal llings with ade-
quate coronal restorations. Taken together, the results of these three studies demonstrate
the importance of both quality endodontic treatment and excellent restorative care in the
maintenance of diseased teeth.
Though the quality of restorative treatment is an arguable factor in the inuence of treat-
ment outcomes, irrefutable evidence exists regarding the necessity of permanent restor-
ative treatment following root canal therapy. Ng et al demonstrated that both the presence
of a full-coverage crown and the presence of mesial and distal contacts positively inuence
success rates. In addition to these ndings, several retrospective studies indicate that the
majority of teeth removed following root canal therapy are not properly restored. Saleh-
rabi and Rotstein found that, of those teeth extracted following root canal therapy, 85%
did not have a denitive coronal restoration. Similarly, Touré et al found that 94% of teeth
extracted following root canal therapy were not restored with full-coverage restorations.
Recently, in a panoramic radiographic screening study of US Air Force recruits, Winward
et al found that, of endodontically treated teeth deemed hopeless, 97% had no cuspal
coverage. Clearly, denitive restorative care following root canal treatment is required for
positive treatment outcomes.
Patients’ immune responses may also play a role in outcomes after nonsurgical root
canal therapy. Marending et al found that a signicant predictor of the outcome of nonsur-
gical root canal therapy was the integrity of the nonspecic immune system. Interestingly,
this factor was found to be as inuential as the technical quality of endodontic treatment.
Prognostic factors associated with nonsurgical root canal therapy are listed in Fig 11-1, and
examples of post-treatment apical periodontitis are presented in Fig 11-2.

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11PrognosisPublished success rates for endodontic therapies are often cited as justication for treatment decisions both in clinical practice and during the American Board of Endodontics (ABE) examination process. Outcomes are inuenced not only by the quality of endodontic treat-ment but also by a number of periodontal, restorative, microbial, and patient-centered factors. When eval-uating published success rates, it is important to con-sider not only the published success rate but also the criteria used to judge treatment success versus failure. This chapter presents published success rates for end-odontic therapies and important prognostic factors that inuence treatment outcomes. Table 11-1 includes a summary of prognostic data for all treatment modalities and the publishing author of the study. For complete references, please review the individual sections within this chapter. 209PrognosisNonsurgical Root Canal TherapyBased on available long-term studies, evidence suggests that nonsurgical root canal therapy provides predictable outcomes for patients. In an 8-year epidemiologic study of 1,462,936 teeth, Salehrabi and Rotstein found that 97% of endodontically treated teeth were retained in the oral cavity. Furthermore, 96% of those teeth required no additional in-tervention. De Chevigny et al found that after 5 to 10 years, 88% of endodontically treated teeth were radiographically healed, and 94% of teeth were clinically functional. The endodontic literature cites several prognostic factors that may inuence reported outcomes. These factors include pretreatment conditions, dental conditions, intratreat-ment factors, and post-treatment restorative care. Pretreatment conditions capable of inuencing root canal therapy outcomes include periodontal attachment loss and apical periodontitis. Setzer et al demonstrated that clinical attachment loss negatively impacts root canal therapy outcomes. Similarly, the presence of apical periodontitis negatively in-uences treatment outcomes. De Chevigny et al found that in teeth with normal periapices preoperatively, 93% of teeth were considered healed, and 97% were functional. However, teeth with demonstrable preoperative apical periodontitis were radiographically healed only 82% of the time, and 94% were clinically functional. Treatment Successful outcomeNonsurgical root canal therapy97% (Salehrabi and Rotstein 2004)88% (de Chevigny et al)Nonsurgical retreatment89% (Salehrabi and Rotstein 2010)86% (Fristad et al)83% (de Chevigny et al)Surgical root canal therapy89% (Tsesis et al)96% (Rubinstein and Kim) MTA pulp capping37% (Barthel et al)80% (Mente et al)Calcium hydroxide apexication77% (Jeeruphan et al)MTA apexication95% (Jeeruphan et al)93% (Witherspoon and Ham)Regenerative endodontics 100% (Jeeruphan et al)Table 11-1 Prognostic values for endodontic treatment modalitiesNonsurgical Root Canal Therapy 210Prognosis11Though the presence of apical periodontitis clearly inuences treatment outcomes to a small degree, the presence of a positive bacteriologic culture immediately prior to the place-ment of a root canal lling has not been shown to consistently inuence treatment outcomes. On the one hand, Sjögren et al found that, while cases with a negative culture prior to root canal lling enjoyed a success rate of 94%, those that had a positive culture prior to root lling had only a 68% success rate. Other authors were unable to conrm this nding. Peters et al found that the presence or absence of a positive culture at the time of root lling had no effect on lesion healing. Similarly, Molander et al failed to demonstrate the effects of positive bacterial cultures at the time of ll on treatment outcomes.As is the case with positive bacteriologic cultures, the number of treatment visits does not inuence treatment outcomes. Penesis et al found similar outcomes for necrotic teeth treated in a single visit versus those treated in two visits. These results were conrmed by Paredes-Vieyra and Enriquez who found no signicant difference between single- and mul-tiple-visit therapy for necrotic teeth with apical periodontitis. The reported success rates were 96% for single-visit therapy and 89% for two-visit therapy. Following completion of root canal therapy, restorative treatment is necessary. The qual-ity of restorative treatment following root canal therapy has long been discussed as a pos-sible prognostic factor. Ray and Trope found that the quality of restorative treatment was more inuential on the outcome of endodontic therapy than the quality of the root canal itself. On the contrary, Moreno et al found that the quality of root canal therapy was more inuential on periapical status than the quality of restorative care. Gillen et al, however, found that the presence of adequate root canal llings with inadequate restorations had equal odds of suboptimal clinical outcomes as inadequate root canal llings with ade-quate coronal restorations. Taken together, the results of these three studies demonstrate the importance of both quality endodontic treatment and excellent restorative care in the maintenance of diseased teeth. Though the quality of restorative treatment is an arguable factor in the inuence of treat-ment outcomes, irrefutable evidence exists regarding the necessity of permanent restor-ative treatment following root canal therapy. Ng et al demonstrated that both the presence of a full-coverage crown and the presence of mesial and distal contacts positively inuence success rates. In addition to these ndings, several retrospective studies indicate that the majority of teeth removed following root canal therapy are not properly restored. Saleh-rabi and Rotstein found that, of those teeth extracted following root canal therapy, 85% did not have a denitive coronal restoration. Similarly, Touré et al found that 94% of teeth extracted following root canal therapy were not restored with full-coverage restorations. Recently, in a panoramic radiographic screening study of US Air Force recruits, Winward et al found that, of endodontically treated teeth deemed hopeless, 97% had no cuspal coverage. Clearly, denitive restorative care following root canal treatment is required for positive treatment outcomes. Patients’ immune responses may also play a role in outcomes after nonsurgical root canal therapy. Marending et al found that a signicant predictor of the outcome of nonsur-gical root canal therapy was the integrity of the nonspecic immune system. Interestingly, this factor was found to be as inuential as the technical quality of endodontic treatment. Prognostic factors associated with nonsurgical root canal therapy are listed in Fig 11-1, and examples of post-treatment apical periodontitis are presented in Fig 11-2. 211Nonsurgical Root Canal TherapyIntraoperative complications, including instrument separation, may not inuence out-comes to a great degree. Panitvisai et al found no signicant decline in healing rates in teeth with an irretrievable le segment following intraoperative le separation when com-pared with teeth in which le separations did not occur or in which the separated fragment was successfully removed. Crump and Natkin found that the odds of an unfavorable out-come increased only when the separated instrument prevented disinfection of the root canal system in the presence of a preoperative lesion. With the advent of new diagnostic technologies including cone beam computed tomog-raphy (CBCT) imaging, it has become clear that the method of outcome assessment inu-ences reported success rates. Liang et al found that when teeth with apical periodontitis were assessed by conventional radiography, 87% were considered healed. However, when CBCT scanning was performed on the same group, only 74% of the cases were considered healed. Similarly, Van der Borden et al found that, while the radiographic success rate at 10 to 37 months postoperatively was 88%, when the same teeth were examined by CBCT, the success rate decreased to 77%. Periodontal attachment lossRestorative statusApical periodontitisMethod of assessment (CBCT vs periapical radiograph)Fig 11-1 Commonly cited factors inuencing the reported outcomes of non-surgical root canal therapy. CBCT, cone beam computed tomography.Fig 11-2 Examples of post-treatment apical periodontitis. (a) A large apical radiolucency is visible at 2 years following initial root canal ther-apy on the maxillary left lateral incisor in a 25-year-old man. (b) A ra-diograph taken 1 year after initial root canal therapy with Thermal lling material [Dentsply] in a 14-year-old boy.a b 212Prognosis11Nonsurgical RetreatmentNonsurgical retreatment, like initial nonsurgical root canal therapy, provides predictable outcomes for patients. In an epidemiologic study, Salehrabi and Rotstein found that after 5 years, 89% of teeth were retained in the oral cavity. Fristad et al found that 85.7% of cases were successful after 10 to 17 years. De Chevigny et al found that after 5 to 10 years, the radiographic success rate for nonsurgical retreatment was 83%, and 94% of teeth remained clinically functional. Outcomes for nonsurgical retreatment are inuenced by several factors. As with initial nonsurgical root canal therapy, nonsurgical retreatment outcomes are negatively inuenced by the presence of preoperative apical periodontitis. De Chevigny et al found that with de-monstrable apical periodontitis, the radiographic success rate of nonsurgical retreatment is 80%, and 93% of teeth are clinically functional. With normal periapices preoperatively, the success rate of retreatment is 93%, and 96% of teeth are clinically functional. In addition to the inuence of apical periodontitis, nonsurgical retreatment outcomes are inuenced by the quality of the initial treatment, albeit in a somewhat paradoxical manner. Gorni and Gagliani isolated the inuence of previous instrumentation on treatment out-comes. They found that if the initial treatment altered the anatomy, success rates were neg-atively affected. In other words, if initial instrumentation led to the inadvertent alteration of root canal anatomy, nonsurgical retreatment is unlikely to improve treatment outcomes. The opposite effect was noted for initial ll quality. De Chevigny et al found that outcomes were more favorable for teeth that, on initial evaluation, demonstrat-ed a poor-quality root canal lling. Those cases that were lled well initially suffered from poorer re-treatment outcomes. Prognostic factors associated with nonsurgical retreatment are summarized in Fig 11-3 and an example of post-re-treatment apical periodontitis is presented in Fig 11-4. a bFig 11-3 Commonly cited factors inuencing the re-ported outcomes of nonsurgical retreatment.Apical periodontitisInitial treatment qualityFig 11-4 Example of failure following nonsurgical root canal retreatment. (a) Evidence of persistent periapical pathology after nonsurgical root canal therapy. Retreatment was completed on the tooth, and additional anatomy was located. (b) Evidence of continued apical pathology was noted 1 year postoperatively. 213Surgical Root Canal TherapySurgical Root Canal TherapyLike nonsurgical root canal therapy or retreatment, surgical root canal therapy performed using modern treatment techniques offers patients predictable outcomes, according to short- and long-term studies. Tsesis et al found that the success rate of surgical endodontic therapy was 89% 1 year postoperatively. Rubinstein and Kim (1999) found a 1-year success rate of 96.8%. When the cases classied as healed at 1 year were followed for an additional 5 to 7 years, 91% of the teeth remained healed (Rubinstein and Kim 2002). Outcomes of surgical root canal therapy are inuenced by surgical technique. While sur-gery performed using modern technologies, including the surgical operating microscope and ultrasonic instruments, are often successful, those using traditional surgical approach-es offer less predictable solutions for patients. De Lange et al found a higher success rate for surgeries using ultrasonic retropreparations than those using burs in a high-speed drill. Setzer et al (2012) found more favorable outcomes for molars using the surgical operat-ing microscope versus loupes. In a study that quantied the effects of surgical technique, Setzer et al (2010) found a 59% success rate when traditional techniques were employed versus a 94% success rate when modern techniques were implemented. Just as surgical techniques have improved, so have lling materials. These improvements have led to superior patient outcomes. Historically, amalgam retrolls were used and report-ed success rates were low. Dorn and Gartner found a success rate of 75% for apical surgery with amalgam retrollings as compared to a 95% success rate for Super EBA [Bosworth] ret-rolls. Recently, mineral trioxide aggregate (MTA) has been recommended for use as a retro-lling material due to improved outcomes. MTA retrolls were associated with better 5-year healing rates than composite retrolls in a recent study by Von Arx et al (2014). MTA may not offer improved success over Super EBA, however. Song and Kim found a 95% success rate for MTA retrolls and 93% for Super EBA retrolls with no statistically signicant difference noted between lling types. Preoperative periodontal status, like material and technique selection, inuences treat-ment outcomes. According to Setzer et al (2011), preoperative attachment loss negatively impacts surgical outcomes. More specically, Von Arx et al (2012) found that mesiodistal bone levels were a signicant predictor of surgical outcomes. Song et al (2013) demon-strated that a buccal cortical plate height greater than 3 mm signicantly improved clinical outcomes. Periodontal probing depth, in addition to bone height, was shown to inuence outcomes, with probing depths of less than 3 mm associated with more favorable outcomes (Lui et al). The communication of endodontic pathology with periodontal attachment loss also signicantly impacts outcomes. Kim et al found that isolated endodontic lesions had signicantly better outcomes, with a success rate of 95%, compared with endodontic- periodontal lesions, which had success rates of 78%. Prognostic factors associated with surgical root canal therapy are presented in Fig 11-5, an example of postsurgical apical peri-odontitis in Fig 11-6, and a successful surgical case in Fig 11-7. The inuence of initial surgery versus revision is often discussed in the literature. While historically revisions of apical surgery were thought to have a diminished prognosis, a re-cent study found that resurgery may achieve excellent outcomes if performed with modern techniques. Studies by Peterson and Gutmann as well as Gagliani et al illustrate the histor-ical perspective. Peterson and Gutmann found that surgical revisions achieved a success 214Prognosis11Fig 11-5 Commonly cited factors inuencing the reported outcomes of surgical root canal therapy.Fig 11-6 Six years postoper-atively, a patient was referred for evaluation of recurrent apical pathology following apical surgery with an amal-gam retroll.Ultrasonic vs bur preparationMagnicationRetroll materialPeriodontal statusInitial vs revision surgerya bFig 11-7 Radiographic success after surgical endodontic therapy. (a) Immediate postoperative radiograph. (b) One-year postoperative follow-up showing reformation of the peri-odontal ligament space and the absence of apical pathology.rate of only 36%, while Gagliani et al found a slightly higher 59% success rate. Recently, however, Song et al (2011) found that revision surgery had a 92% success rate if modern techniques were used during the revision procedure. Vital Pulp TherapyVital pulp therapies include pulp capping and both full and partial pulpotomies. These ther-apies maintain the vitality of the radicular pulp tissue, thus permitting further development of radicular dentin in immature permanent teeth. Studies comparing the two treatment modalities exhibit a large range of reported outcomes. Bjørndal et al reported that the success rate for vital pulp therapy was between 32% and 35%. On the other hand, Aguilar and Linsuwanont reported that the success rate of vital pulp therapy, particularly on carious exposures, was between 73% and 99%. Results clearly vary depending on the study.The reported outcomes for pulp capping, which involves coverage of presumed healthy pulp tissue without its removal, vary in the literature. Barthel et al reported that, following 215Treatment of Immature Necrotic TeethTreatments for immature necrotic teeth include apexication and regenerative endodontic therapy. Studies on both treatment modalities report favorable success rates. A recent long-term study by Pace et al found that 94% of immature teeth treated with MTA apexi-cation were healed 10 years postoperatively. Jeeruphan et al looked at survival, which measures the mere presence of a tooth in the mouth, as compared to success, which looks at healing (see chapter 1). They found that the radiographic survival of MTA apexication was 95%, whereas for calcium hydroxide apexication, the survival rate was 77%. However, both treatments presented a long-term risk of cervical fracture. Outcomes for teeth being treated by apexication methods are inuenced by preoperative apical periodontitis and the number of treatment visits. Mente et al reported that success rates for apexication are lower in the presence of preoperative apical periodontitis. Additionally, Mente et al reported that success rates were less favorable if treatment were performed over several visits. Witherspoon and Ham found that the success rate of MTA apexication treatment was 93.5% if performed in a single visit and 90.5% if performed in two visits. An MTA apexi-cation case is presented in Fig 11-9. Treatment of Immature Necrotic Teethpulp capping of carious pulp exposures, regardless of the material used, 45% of teeth became necrotic after 5 years and 80% after 10 years. They also reported that the success rate of pulp capping with MTA after 3 years was 37% and after 10 years was 13%. Mente et al, on the other hand, reported that the long-term success rates for direct pulp caps with calcium hydroxide were 58% and with MTA were 80%. Reported success rates for pulpotomy treatment, which involves amputation of the ex-posed pulp tissue, are also favorable. Swift et al found that 90% of teeth treated by pul-potomy using eugenol were pain free at 6 months postoperatively. Murray et al found that 78% of teeth treated by pulpotomy maintained the vitality of the radicular pulp tissue at 1 year postoperatively. An MTA pulptomy case is depicted in Fig 11-8. Fig 11-8 Apexogenesis performed on the maxillary left lateral incisor of a 10-year-old girl. (a) Immediate postoperative view. (b) Six-month radiographic follow-up showing continued root devel-opment and the absence of apical pathology.a b 216Prognosis11Nonvital BleachingLittle data on nonvital bleaching outcomes can be found in the literature. In a subjective study on patient and practitioner satisfaction 5 years postbleaching, Glockner et al found that 98% of patients were satised with the results. Dentists, however, were slightly less pleased with the long-term results, as only 80% of practitioners reported satisfaction with long-term outcomes. Regenerative endodontics provides an alternative to apexication in the treatment of im-mature necrotic teeth. This treatment encourages further development of radicular dentin, thus decreasing the risk of cervical fracture. The majority of publications regarding regen-erative endodontic therapy are lower-level-of-evidence studies, including case series and case reports, with the exception of two cohort studies (Kontakiotis et al). In one of the cohort studies, Jeeruphan et al reported a 100% survival rate for teeth treated with regenerative endodontic therapy. In a recent study comparing outcomes of apexication and regenerative endodontic therapy, Alobaid et al found the two treatments to provide statistically equivalent results. A successful regenerative endodontics case is presented in Fig 11-10. Fig 11-9 MTA apexication performed on a 10-year-old boy. (a) Im-mediate postoperative radiograph with evidence of periodontal liga-ment (PDL) widening. (b) Two-year follow-up radiograph with evi-dence of normal PDL structures and the absence of apical pathology.a ba bFig 11-10 Successful regenerative endodontic therapy. (a) Preop-erative view. (b) Follow-up radiograph taken 1 year postoperative-ly. An increase in root length and width as well as apical closure is evident in addition to the healing of the apical radiolucency. 217BibliographyTreatment of Endodontic Disease in the Primary DentitionThe treatment for diseased primary teeth can involve both pulpotomy and pulpectomy treat-ment, depending on the extent of pulpal involvement. In vital primary teeth with carious pulp exposures, pulpotomies are the treatment of choice. Fuks et al reported high success rates for pulpotomies with diformocresol and ferric sulfate at 83% and 93%, respectively. Success rates may be higher for teeth treated with MTA. Holan et al found that pulpotomies performed with MTA achieved a success rate of 97% at 2 years. Necrotic primary teeth may be treated by pulpectomy and maintained to prevent space loss in the primary dentition. Coll and Sadrian reported a 78% success rate for pulpectomies in primary teeth. This treatment, however, is not without risk. Enamel defects, over-retention, and alteration of the path of eruption of the permanent successor have been noted (Coll and Sadrian). BibliographyIntroductionBarthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious exposures: Treat-ment outcome after 5 and 10 years: A retrospective study. J Endod 2001;26:525–528.de Chevigny C, Dao TT, Basrani BR, et al. Treatment outcome in endodontics: The Toronto study—Phase 4: Initial treatment. J Endod 2008;34:258–263.Fristad I, Molven O, Halse A. Nonsurgically retreated root lled teeth —Radiographic ndings after 20-27 years. Int Endod J 2004;37:12–18.Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, Khewsawai P, Hargreaves KM. Mahidol study 1: Comparison of radiographic and survival outcomes of immature teeth treated with either regenerative endodontic or apexication methods: A retrospective study. J Endod 2012;38:1330–1336.Mente J, Hufnagel S, Leo M, et al. Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp capping: Long-term results. J Endod 2014;40:1746–1751.Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and super-EBA as root-end lling material. J Endod 1999;25:43–48.Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: An epidemiological study. J Endod 2004;30:846–850.Salehrabi R, Rotstein I. Epidemiologic evaluation of the outcomes of orthograde endodontic retreatment. J Endod 2010;36:790–792.Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y, Ceresoli V, Del Fabbro M. Outcomes of sur-gical endodontic treatment performed by a modern technique: An updated meta-analysis of the literature. J Endod 2013;39:332–339.Witherspoon DE, Ham K. One-visit apexication: Technique for inducing root-end barrier forma-tion in apical closures. Pract Proced Aesthet Dent 2001;13:455–460.Nonsurgical Root Canal TherapyCrump MC, Natkin E. Relationship of broken root canal instruments to endodontic case progno-sis: A clinical investigation. J Am Dent Assoc 1970;80:1341–1347.de Chevigny C, Dao TT, Basrani BR, et al. Treatment outcome in endodontics: The Toronto study—Phase 4: Initial treatment. J Endod 2008;34:258–263. 218Prognosis11Gillen BM, Looney SW, Gu LS, et al. Impact of the quality of coronal restoration versus the quality of root canal llings on success of root canal treatment: A systematic review and meta-analy-sis. J Endod 2011;37:895–902.Liang Y-H, Li G, Wesselink PR, Wu M-K. 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