Background: A persistent periapical lesion should be addressed by orthograde re-root treatment as a first line therapeutic intervention, excluding cases of rare developmental cyst or tumour. In selected cases where endodontic treatment or retreatment is contraindicated a surgical approach to management of the peri radicular tissues may be considered. Within the last decade there have been significant advancements in endodontic microsurgery and an associated rise in clinical success rates. This can be accounted to improved visibility and illumination, the development of more biocompatible root-end filling materials i.e. slow- and fast-setting mineral trioxide aggregate (MTA) materials and the integration of cone bean tomography in endodontic treatment planning. Aim: To review the current available literature on modern endodontic microsurgery To review clinical outcomes and associated factors in endodontic microsurgery compared to traditional root end surgery Methods: A literature review was conducted using online libraries MEDLINE, Embase, Cochrane library, CENTRAL and relevant endodontic, restorative and traumatology journals using a detailed search strategy. References of included studies were hand searched. Conclusions: Despite a lack of large-scale randomised clinical trial the probability of success for endodontic microsurgery (EMS) compared to the outcomes was significantly greater. This is in accordance with the recent publication of Guidelines for peri radicular surgery, Clinical Standards Committee of the Faculty of Dental Surgery, Royal College of Surgeons of England (FDSRCS). These findings should be considered in the future management of clinical cases and regional patient referral protocols.