journal of dentistry 38 (2010) 269275

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Endodontic therapy using magnification devices:

A systematic review
Massimo Del Fabbro *, Silvio Taschieri
Department of Health Technologies, IRCCS Istituto Ortopedico Galeazzi, University of Milan, Via R. Galeazzi 4, 20161 Milan, Italy

article info

abstract

Article history:

Objectives: The purpose of this systematic review was to investigate if the use of magnifica-

Received 12 November 2009

tion devices in endodontics is associated with the improvement of clinical and radiographic

Received in revised form

outcomes.

18 January 2010

Data: The treatment success as determined by clinical and radiographic evaluation after 1-

Accepted 25 January 2010

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

devices for endodontic therapy were considered.

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

An adequate cleaning, shaping and obturation of the root

canal system, is required to achieve healing in endodontic
orthograde treatment or retreatment, while for periradicular
surgery proper root-end management and root-end seal are
essential. Furthermore a sound knowledge of root canal
morphology is important as wide anatomic variation may
be encountered in teeth undergoing endodontic therapy.13

The widespread use of microsurgical instruments and, as a

consequence, the use of well-focused illumination and
magnification devices within the dental equipment has
improved the clinicians ability to treat elusive regions within
the root canal system, increasing the effectiveness and the
quality of endodontic therapy.4
The most common magnification devices that have been
introduced in endodontics are loupes, surgical microscope5,6
and, more recently, the endoscope.7,8 Working using such

* Corresponding author. Tel.: +39 02 50319950; fax: +39 02 50319960.

E-mail address: massimo.delfabbro@unimi.it (M. Del Fabbro).
0300-5712/$ see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2010.01.008

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journal of dentistry 38 (2010) 269275

devices has become a widely accepted practice in non-surgical

and surgical endodontic therapy. Besides increasing the
accuracy of the operative procedures, these devices may
improve diagnostic capability, due to a better visualization of
the treatment field. As an example, they allow detection of
isthmuses, accessory canals or microfractures of the root, that
are otherwise difficult to recognise and treat in the absence of
proper magnification.914 Furthermore, the use of magnifying
loupes and the operating microscope have been shown to
reduce the occurrence of repetitive stress injuries related to
bad posture, by improving working posture.15
However, as usually happens for all innovative techniques
claimed to provide significant advance in the clinical practice,
it is essential to investigate if the use of magnification devices
in endodontic therapy is also correlated to an improvement in
treatment outcomes.
Given these premises, the purpose of this systematic
review was to evaluate the current literature in order to
answer the following questions:
 Is endodontic therapy performed with magnification
devices more effective than that performed without
magnification devices?
 Are different magnification devices equivalent in terms of
clinical outcomes of endodontic therapy?

2.

Materials and methods

2.1.

Inclusion criteria and search strategy

This review aimed at including prospective clinical trials that

compared endodontic therapy performed with or without
using magnification devices or that compared two or more
magnification devices f endodontic therapy. Only patients
who received either surgical or non-surgical endodontic
therapy and were followed up for at least 1 year after
treatment could be included.
The following electronic databases were searched:
Cochrane Oral Health Group Specialised Register, Cochrane
Central Register of Controlled Trials (CENTRAL), MEDLINE 1966
to September 2009, and EMBASE 1980 to September 2009. No
language restriction was placed. For the identification of
studies, detailed search strategies were developed for each
database searched. The main search terms were: endodontic
therapy, endodontic treatment, root canal therapy, endodontic surgery, periapical surgery, periradicular surgery, apicoectomy, root-end management, magnification devices,
microscope, endoscope, loupes. These terms were used alone
and in combination by means of Boolean operators like AND,
OR, NOT.
In addition, all issues of the following journals were handsearched from 1980 to the last issue available at September
2009, as being of particular importance to this review:
Australian Endodontic Journal, International Endodontic Journal;
Journal of Endodontics; Dental Traumatology ( formerly Dental
Traumatology and Endodontics); Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontology; International Journal
of Oral and Maxillofacial Surgery; Journal of Oral and Maxillofacial
Surgery; British Journal of Oral and Maxillofacial Surgery; British
Dental Journal; Endodontic Topics.

The reference lists of all identified trials and relevant

review articles were searched for the identification of studies
outside the hand-searched journals. The authors of the
identified controlled trials were also contacted in order to
identify further unpublished or ongoing studies.
The titles and abstracts of all reports identified were
scanned independently by the two reviewers. Full reports
were obtained for trials appearing to meet the inclusion
criteria or for which there was insufficient information in the
title and abstract to make a clear decision. The full reports
were assessed independently, in duplicate, by the two
reviewers to establish whether the trials met the inclusion
criteria or not. Disagreements were resolved by discussion. All
studies meeting the inclusion criteria underwent validity
assessment and data extraction. All studies rejected at this or
subsequent stages, and reasons for exclusion, were recorded.

2.2.

Primary outcomes

The main outcome sought in this systematic review was the

success of the treatment on a patient basis at 1-year and 4-year
follow-up as determined by clinical and radiographic assessment of healing.16
The outcome of endodontic therapy was categorized as
follows: (a) success, that includes both 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 of clinical signs/symptoms (clinical questionable)
associated with incomplete radiographic healing); (c) failure
(presence of clinical signs and symptoms combined with
reduced or persistent radiolucency).1719
Unexpected events/outcomes were recorded if identified in
included studies.

2.3.

Secondary outcomes

Secondary outcomes were related to advantages brought in by

the use of a given magnification device in the clinical
procedure, that may lead to a preference of the operator for
one device over the others, or to the feasibility of managing
with greater accuracy a given clinical situation. Some
examples are the removal of broken instruments from the
canal, the detection of dentinal cracks or the identification of
peculiar anatomical features of the root canal, such as the
presence of isthmuses, that may affect the clinical procedure.
Further aspects considered were the quality of root and rootend filling, the possibility of root perforation repair and the
total time required for completing the clinical procedure.

2.4.

Quality assessment

The quality assessment of included trials was undertaken

independently and in duplicate by the two reviewers as part of
the data extraction process in order to determine the level of
evidence of the included articles.
Included trials were assessed based on the following
quality criteria: concealed allocation of treatment (i.e., masking), completeness of information on the loss of participants

journal of dentistry 38 (2010) 269275

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

the total follow-up duration for each patient included in the

trial was to be at least 4 years. Some preliminary results of this
trial were published in two consecutive articles.23,24 Unpublished data were provided by the authors, allowing to analyze
1-year and 4-year outcomes for each comparison.
In the other included study 129 apicectomies were initially
performed using either endoscope (62 teeth) or naked eye (67
teeth).21 At the 1-year follow-up 54 teeth (45 patients) in the
group using the endoscope and 61 teeth (41 patients) in the
control group could be evaluated. Anterior teeth, premolars
and molars were treated.

2.5.

3.1.

Data synthesis

In order to standardize statistical calculations, the treatment

outcomes were dichotomized. All cases classified as complete
or incomplete healing plus cases classified as uncertain
healing in the absence of clinical signs and symptoms were
considered as successful. Those cases classified as failures
plus those classified as uncertain healing in the presence of
signs and symptoms were considered as unsuccessful. The
patient was considered as the unit of analysis. Those patients
that had multiple teeth treated were classified as unsuccessful
if they experienced at least one unsuccessful case.
For each trial, relative risks (RR) along with 95% confidence
intervals (CI) were calculated to estimate the effect of
interventions. Clinical heterogeneity was assessed by examining the types of participants, teeth, interventions and
outcomes in each study. Only if studies of similar comparisons
reporting the same outcome measures were found a metaanalysis was attempted, using a random effects model.
An intention-to-treat analysis was also undertaken, considering as unsuccessful all patients that have received
treatment but in the trial have been excluded from the
analysis at any time for any reason.
Statistical analysis was performed using the software
Review Manager (RevMan) version 4.2.9 for Windows (The
Nordic Cochrane Centre: Copenhagen, Denmark).

3.

Results

The electronic search strategy provided 420 studies. No further

trial was identified by hand-searching. From the analysis of
the abstracts of these studies, only four trials,2124 all dealing
with endodontic surgery, were identified as eligible for
inclusion in this review.
After reviewing the full text of the four eligible trials, one
was excluded due to inadequate study design.22 Therefore,
three trials were included for data analysis.21,23,24 Two of
them23,24 were indeed part of the same randomized study in
which a total of 99 patients (152 teeth) were included
(unpublished information). This study aimed at assessing
the outcome of endodontic surgery using three different
magnification devices. Twenty-nine patients (39 teeth) were
initially treated using surgical loupes as the magnification
device, 34 patients (50 teeth) were treated using the endoscope
and 36 patients (63 teeth) using the surgical microscope. The
patients were recruited over a 3-year period (from December
2001 to December 2004) and, according to the original protocol,

Quality assessment of the included studies

The evaluators of radiographic outcome as well as the

statisticians were masked to patients and treatment groups
in all included trials.
Sample size calculation prior to the beginning of the study
was made in the randomized trial23,24 but not in the von Arx
study.21 However, in the RCT this was undertaken on a tooth
basis while group allocation occurred on a patient basis.
Because of such discrepancy sample size calculation should be
considered inadequate.
In the RCT the various groups were comparable at entry for
age, gender, tooth types, size of periradicular lesions, while a
similar comparison was not available in the von Arx study.21
All patients were selected according to strict inclusion criteria
aiming at achieving homogeneity for the general health status
of the patients, as well as for the oral and systemic conditions
that are known to affect the outcome of endodontic surgical
procedure. In conclusion, the two articles reporting of the RCT
were judged as being at moderate quality of evidence, while
the von Arx study was judged to be at a low quality of evidence.

3.2.

Endoscope versus surgical loupes

No statistically significant difference was found for surgical

treatment outcome between the group treated with the aid of
the endoscope and the group treated with the aid of surgical
loupes at each follow-up time. On a patient-based analysis
(Figs. 1 and 2) RR was 0.83 (95% CI 0.135.44) for the 1-year
comparison and 0.81 (95% CI 0.125.26) for the 4-year
comparison.
In the group treated with endoscope there were two cases
of uncertain healing in two patients with persistence of
symptoms that were accordingly classified among unsuccessful cases.
In the group treated with loupes there were two failures in
two patients and one uncertain healing without symptoms
that was classified among successful cases.
The number of unsuccessful cases did not change over
time, while a few dropouts were recorded at each follow-up.
The overall success rate on a patient basis was 93.1% at the 1year and 92.3% at the 4-year follow-up for the endoscope group
and, respectively, 91.7% at the 1-year and 90.5% at the 4-year
follow-up for the group using loupes.
The results of the intention-to-treat analysis indicated a
slightly better outcome for patients treated using the endoscope as compared to those treated using magnifying loupes.
RR for the intention-to-treat analysis was 0.41 (95% CI 0.12

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journal of dentistry 38 (2010) 269275

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.

Endoscope versus surgical microscope

Unpublished data relative to 1-year and 4-year follow-up

allowed a more complete view of the trend of treatments
outcome than was reported in the article. No statistically
significant difference was found for surgical treatment
outcome between the group treated with the aid of the
endoscope and the group treated with the aid of surgical
microscope at either follow-up time. On a patient-based
analysis RR was 1.13 (95% CI 0.255.19) for the 1-year
comparison and 1.55 (95% CI 0.288.62) for the 4-year
comparison (Figs. 3 and 4).
In the group treated with endoscope the pool of patients
included both the cases of the previous clinical report by
Taschieri et al.23 and further patients treated in the period

between November 2003 and December 2004. Among the new

cases included, some molar teeth were also treated. In total,
three cases in three patients were unsuccessful out of 31
patients evaluated at the 1-year follow-up (unpublished data)
and the same three cases were still classified as unsuccessful
at the 4-year follow-up (out of 29 patients evaluated).
In the group treated using the surgical microscope three
cases in three patients out of 35 evaluated at the 1-year followup were unsuccessful (unpublished data), whilst one of them
did not return for the 4-year follow-up. The overall success
rate on a patient basis was 90.3% at the 1-year and 89.7% at the
4-year follow-up for the endoscope group and, respectively,
91.4% at the 1-year and 93.3% at the 4-year follow-up for the
group using the microscope.
The intention-to-treat analysis performed considering as
unsuccessful all patients lost to follow-up, showed similar
outcomes for patients treated with the aid of the endoscope as
compared to those treated using the surgical microscope at
any follow-up. RR for the intention-to-treat analysis was 1.59
(95% CI 0.495.14) for the 1-year comparison and 1.06 (95% CI
0.452.50) for the 4-year comparison.

3.4.

Endoscope versus naked eye

In the study by von Arx 48 of the 54 teeth treated with the

endoscope and evaluated at the 1-year follow-up showed
complete healing (88.9%), three teeth showed uncertain
healing (5.6%) and three were classified as failure (5.6%).21
Therefore in the test group a total of 51 successful cases

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.

journal of dentistry 38 (2010) 269275

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.

(94.5%) out of 54 were reported. In the group treated with the

naked eye 46 of the 61 teeth evaluated at one year successfully
healed (75.4%), 8 teeth (13.1%) had uncertain healing and 7
(11.5%) were classified as failure. Hence in the control group a
total of 54 successful cases (88.5%) out of 67 were reported. No
patient reported multiple failures, so that on a patient basis
91.1% and 82.9% success was recorded for the test and control
group, respectively. In this study no effect related to the tooth
type and location was reported. Since the exact number of
patients initially treated in each group was not available, the
intention-to-treat analysis could not be performed for this
comparison.
On a patient-based analysis (Fig. 5) RR was 0.39 (95% CI 0.11
1.41) for the 1-year comparison.

3.5.

Secondary outcomes

No clinical study specifically assessed the advantage of

magnifiers for the removal of a broken instrument from the
canal, the detection of dentinal cracks, the identification of
unusual morphological features, or any other secondary
variable that might influence the clinical procedure. Some
of them were sporadically reported in a few studies but never
statistically assessed. As an example, in one of the included
articles it is said that, based on the operators experience, the
time required for completing the surgical procedure is on the
average 45 min longer for the endoscope as compared to
other magnification devices, due to the need for repeated
cleaning of the lens.23

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.

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4.

journal of dentistry 38 (2010) 269275

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,

while the effect of using a given magnifier for the treatment of

molar teeth still has to be determined. It is necessary to
perform more focused studies for evaluating if the treatment
of molar teeth may benefit from the use of visual enhancers.
A further concern regarding the included studies is due to
the presence of patients with multiple teeth treated, that have
a greater chance of experiencing a negative outcome respect to
those that had a single tooth involved. This would cause 95%
CIs to be narrower than they should be if the number of
patients were coincident with the number of teeth treated,
further increasing the risk of bias of the trials.
No systematic evaluation has been performed for any of
the secondary variables that might suggest a superiority of one
magnification device over the others. In the absence of
differences in the clinical outcomes, a precise assessment of
these secondary variables could be important in the choice of a
specific magnification device.
Though the use of magnification devices is a widely
emphasized issue in the endodontists community, the overall
quality of studies regarding this topic is rather poor, confirming what was also pointed out by other reviews that
specifically aimed at assessing the level of evidence of the
endodontic literature.3033
In order to understand if there is a significant advantage of
using a magnification device in endodontics, or to quantify the
superiority of a given magnifier in specific clinical situations,
more long-term well-designed randomised trials have to be
performed and reported according to the Consolidated
Standards of Reporting Trials (CONSORT) guidelines.34

5.

Conclusion

A very low number of controlled prospective studies have been

found in this review, and none of them was judged to be of
high quality. The results of the present review, based on the
best possible evidence available to date, would suggest that
there is no apparent advantage of using a specific type of
magnification device as an aid for better visualization in
endodontic surgery.
A lot of indications deriving from in vitro studies or studies
with low and very low evidence level present in the
endodontic literature suggest that the use of a device for
visual enhancement may have many technical and clinical
advantages in most endodontic procedures. On the other
hand, limited evidence has been found that the use of a
magnification device in any endodontic procedure is related to
a better clinical outcome as compared to the same procedures
performed without magnifiers.

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