Optimising Outcomes in Endodontic Microsurgery: Evidence, Uncertainties and Future Directions.

Endodontic microsurgery (EMS) is a reliable treatment modality for managing persistent or recurrent periapical pathologies, particularly when conventional nonsurgical retreatment is infeasible or has failed. Various factors influence EMS outcomes, among which the lesion type is a key determinant. Isolated endodontic lesions generally exhibit favourable outcomes, whereas combined endodontic-periodontal lesions and through-and-through defects are clinically challenging and associated with less predictable outcomes. The adjunctive use of regenerative procedures, such as bone grafts, barrier membranes and biologically active agents, aims to enhance periapical healing; however, current evidence remains inconclusive, and further studies with clear lesion-type classification are required to determine their true benefits. Guided surgical approaches, including static, dynamic and robot-assisted systems, have been introduced in EMS to enhance surgical precision and predictability. These technologies appear particularly beneficial in small isolated lesions or when critical anatomical structures must be protected, but further studies are required to validate their clinical effectiveness. This review encourages clinicians to approach EMS with a clear understanding of the effect of lesion type on the prognosis, and to critically assess the usefulness of adjunctive regenerative procedures and advanced technologies based on lesion-specific considerations. Although predictable outcomes are mostly dependent on sound diagnosis, thoughtful case selection, and meticulous surgical techniques, accumulating evidence and technical progress suggest that the indications for EMS may be reasonably expanded in well-selected cases.