Regenerative strategies in apical surgery with and without biomaterials: a systematic review

Abstract

Objectives: This systematic review compares the clinical efficacy and radiographic outcomes of membrane-based regeneration, bone grafting, and platelet concentrates in cavities resulting from apicoectomy, assessing healing rates and the quality of newly formed bone. Methods: Following PRISMA 2020 guidelines, a literature search was performed in PubMed, Cochrane Library, ScienceDirect, Wiley, and Scopus databases for articles published between January 2000 and December 2025. Eligibility criteria were defined using the PICOS framework, and included studies were evaluated based on clinical and radiographic parameters with a minimum follow-up of six months. Results: Eighteen clinical studies were included. Findings were heterogeneous and predominantly of low to very low certainty. Although some studies suggested potential benefits of regenerative adjuncts in complex defects, such as through-and-through and apicomarginal lesions, a substantial proportion found no statistically significant advantage over conventional apical surgery. Smaller lesions (<3 mm) generally responded favorably to conventional surgery, whereas larger defects may benefit from adjunctive regenerative approaches in selected clinical situations. Conclusions: Overall, the available evidence suggests a potential benefit of combining physical support (biomaterials) and biological stimulation (platelet-rich fibrin) in regenerative apical surgery. However, findings remain heterogeneous and should be interpreted cautiously. Technique selection should consider defect morphology, lesion characteristics, and available resources. Further standardized and methodologically robust studies are required to strengthen the current evidence base.