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abstract
Article history:
Objectives: The purpose of this systematic review was to investigate if the use of magnifica-
tion devices in endodontics is associated with the improvement of clinical and radiographic
outcomes.
18 January 2010
Data: The treatment success as determined by clinical and radiographic evaluation after 1-
year follow-up was the main outcome. The main search terms used alone or in combination
were: endodontic treatment, endodontic therapy, endodontic surgery, apicoectomy, periapical surgery, microscope, endoscope, loupes, magnification devices.
Keywords:
Sources: The authors searched MEDLINE, Embase, Cochrane Oral Health Specialized Regis-
Apical surgery
ter, Cochrane Central Register of Controlled Trials for articles published up to September
Endodontic treatment
2009 plus hand-searching of relevant journals and reference list of pertinent reviews and
Endoscope
included studies.
Magnification devices
Study selection: Prospective clinical trials comparing endodontic therapy performed with or
Surgical loupes
without using magnification devices, as well as trials comparing two or more magnification
Surgical microscope
Systematic review
Conclusions: Three prospective studies were included, all dealing with endodontic surgery.
No significant difference in outcomes was found among patients treated using magnifying
loupes, surgical microscope or endoscope. Similarly, no difference was found with or
without using the endoscope. No comparative study on magnification devices was found
regarding orthograde endodontic treatment. The type of magnification device per se can only
minimally affect the treatment outcome. Well-designed randomized trials should be performed to determine the true difference in treatment outcomes when using a magnification
device in both orthograde and surgical endodontic treatment, if any exist.
# 2010 Elsevier Ltd. All rights reserved.
1.
Introduction
270
2.
2.1.
2.2.
Primary outcomes
2.3.
Secondary outcomes
2.4.
Quality assessment
271
over time, randomization (if applicable), sample size calculation, definition of exclusion/inclusion criteria, definition of
success criteria, comparability of control and treatment
groups at entry, calibration and blinding of evaluator(s) for
outcome assessment. The authors of the included studies
were contacted for clarification or to provide missing
information whenever possible.
In order to summarising the quality of evidence of the
studies, they were scored according to the GRADE System: (a)
high quality of evidence; (b) moderate quality of evidence; (c)
low quality of evidence; (d) very low quality of evidence.20
2.5.
3.1.
Data synthesis
3.
Results
3.2.
272
Fig. 1 Patient-based analysis of the 1-year outcomes for the comparison between cases treated using an endoscope and
those treated using magnifying loupes.
1.45) for the 1-year comparison and 0.58 (95% CI 0.241.39) for
the 4-year comparison.
One of the first patients included in the trial was recently
evaluated after 6 years of follow-up. He was treated in
December 2001 using surgical loupes and was classified as
unsuccessful (radiographic failure in the absence of symptoms) at each follow-up included the 4-year one. This patient
showed radiographic improvement (incomplete healing) 2
years after the formal end of the trial, so that it could be
considered as a late success (unpublished observation). The
reviewers believe that it is worthwhile to reporting this event,
though it does not affect the conclusions of the present
analysis.
3.3.
3.4.
Fig. 2 Patient-based analysis of the 4-year outcomes for the comparison between cases treated using an endoscope and
those treated using magnifying loupes.
273
Fig. 3 Patient-based analysis of the 1-year outcomes for the comparison between cases treated using an endoscope and
those treated using a microscope.
Fig. 4 Patient-based analysis of the 4-year outcomes for the comparison between cases treated using an endoscope and
those treated using a microscope.
3.5.
Secondary outcomes
Fig. 5 Patient-based analysis of the 1-year outcomes for the comparison between cases treated using an endoscope and
those treated using naked eye.
274
4.
Discussion
Many studies have been published in the endodontic literature, showing that magnification devices like the microscope
or the endoscope allow the detection of microstructures not
identifiable with the naked eye.912,2529 As a natural consequence it has been suggested that such devices are helpful, at
least in theory, for improving clinical outcomes because all
phases of the root/root-end management can be performed
with greater accuracy. Conversely, prospective comparative
clinical studies evaluating the outcome of endodontic treatment using different magnification devices are extremely
scarce, as was found in the present review.
Of the four prospective trials that were identified, all
dealing with endodontic surgery, one had to be excluded from
the analysis. This study compared a group of patients treated
without magnification devices versus a group treated with the
aid of a surgical microscope.22 However, the two groups were
also treated using different surgical protocols and materials.
In the study by von Arx et al. after 1-year follow-up the
outcome for cases treated with the aid of the endoscope was
better (but not significantly better) compared with control
cases treated with the naked eye and micro-mirrors.21 The
tooth-based success rates for this study, after dichotomization
according to the criteria of the present review were,
respectively, 94.5% for the group treated using an endoscope
and 88.5% for the group treated without using magnifiers. On a
tooth basis the data relative to the endoscope are very similar
to those reported in the randomized study included in this
review.
In the latter trial the patients were randomized to the
different treatment groups, while the outcomes were presented on a tooth basis, as this is the conventional way of
reporting data in the endodontic literature. This discrepancy
was due to technical reasons since it was very difficult to treat
multiple teeth of the same patient using different magnification devices as each of them requires a specific technical setup
before starting surgery. In the present review, however, it was
possible to analyse and present data both on a patient basis
and according to intention-to-treat analysis. From the results
of this randomized trial, no significant difference could be
found at any observation time among the clinical outcomes of
treatment groups in which different types of magnification
devices were adopted.
The first of the two papers published by Taschieri et al. was
a preliminary report in which no molar teeth were treated.23
The rationale for such a choice was that, as happens for all
new medical techniques also the endoscope required a period
of training, the so-called learning curve. During this period,
the most complex cases such as molar teeth, for which both
the access for instruments and the proper positioning of the
magnifier (and, consequently, a correct view angle) are made
difficult by anatomical location, were not selected for this
study. Subsequently, the endoscope was used routinely for the
treatment of molar teeth, and these cases were included
during the last year of recruitment, as mentioned in the
second clinical report.24 The overall number of molar teeth
treated with the aid of magnifiers is however very low in this
study (n = 16). The external validity of the results of this study
could therefore be confined to anterior teeth and premolars,
5.
Conclusion
references
275