Federico Foschi

Background Regenerative techniques are increasingly being advocated in endodontic apical surgery (AS) to enhance the healing of periapical lesions. Various grafting and membrane materials are employed as adjuncts to modern AS. Objectives This systematic review aimed to answer the following PICO question: In patients with apical periodontitis (P) what is the impact of bone grafting with/without barrier membrane materials (I) compared with surgery without grafting materials (C) on the outcome of AS evaluated clinically and radiographically (O). Methods A systematic search was conducted in four databases (Embase, Web of Science, PubMed and Cochrane Central Register of Controlled Trials) until 1 August 2023. Google Scholar was also manually searched. Studies with a prospective randomized design were included. Cochrane risk‐of‐bias (RoB) tool 2.0 assessed bias. Two independent reviewers performed the study selection, data extraction and appraisal of studies. Meta‐analysis was performed using R3.5.1 software. Results From the identified 2582 studies, eight randomized clinical trials were included for meta‐analysis. Two studies had low RoB, while six had some concerns. Analysis revealed significantly better outcomes when surgery involved bone regeneration techniques than conventional surgery (OR = 2.18, 95% CI: 1.32–4.31, p = .004). Subgroup analyses on individual grafts (OR = 0.22, 95% CI: −0.99 to 1.44, p = .720) (OR = −0.09, 95% CI: −1.42 to 1.23, p = .885) and membranes (OR = −1.09, 95% CI: −2.94 to 0.76, p = .247) and their combinations (OR = 0.03, 95% CI: −1.50 to 1.55, p = .970) did not yield any significant results. The type of membrane used did not significantly impact the outcome (OR = −1.09, 95% CI: −2.94 to 0.76, p = .247) nor did altering the combination of graft/membrane. Discussion This systematic review examined the effects of bone grafting with/without membrane placement on the outcome of AS. It highlights the potential advantages of regenerative techniques and the need for further research in this area. Conclusions Based on current evidence, bone grafting with/without barrier membrane placement significantly improves healing after AS. Subgroup analysis of resorbable membranes or grafting did not significantly influence the outcome. The combination of membrane and graft was also not significant. Future well‐designed, randomized controlled trials in this area are essential before these materials can be recommended for routine use to enhance healing outcomes in AS. Registration PROSPERO (CRD42021255171).