Apicoectomy: The Tooth-Saving Procedure You Need to Know About

Apicoectomy: the tooth saving procedure
Root canal treatment has an impressive success rate, with up to 97% of cases resulting in long-term success (1). But what happens when a root canal fails? That's where apicoectomy comes in.

This endodontic surgery, also known as root-end surgery, is a highly successful option that has come a long way thanks to advances in technology and techniques.

In this article, we'll explore everything you need to know about apicoectomy, from the procedure to aftercare and healing, to help you make an informed decision about your dental health.

What is an apicoectomy?

An apicoectomy, also known as endodontic surgery or root end surgery, is a surgical approach used to treat a tooth infection. It's typically the last resort to save a damaged tooth from being extracted.

Apicoectomy is so-called because it involves removing a portion of the tooth apex or the very tip of the root. This is necessary because when a tooth infection progresses, it can spread down to the apex area, causing a condition known as apical periodontitis. Periapical periodontitis Usually, a non-surgical root canal treatment is enough to remove the infection and initiate healing. However, the damage is sometimes too deep, stubborn, and persistent, even after a well-performed conventional root canal treatment.

This is when endodontic surgery becomes necessary to access the root cause directly and eliminate it once and for all.

When do I need an apicoectomy?

Apicoectomy has long been considered the last resort to save the tooth. This is because, in the past, surgery with its traditional techniques had a lower success rate. In most cases, non-surgical root canal retreatment was the best option, as it had greater chances of saving the tooth.

However, today this is no longer the case. With modern approaches and the emergence of endodontic microsurgery, apicoectomy can be considered a first option in some cases. Its success rates have even exceeded conventional retreatment in some studies (2).

Let's take a closer look at some common situations where an apicoectomy may be needed:

1. Root canal retreatment failure:

If the tooth cannot heal despite well-performed root canal treatment, it often means that it is impossible to reach the entire infection through the traditional way. In this case, surgery will allow direct access to the infection to clear it and help identify the cause of the failure.

2. Technical errors during root canal treatment:

Some professional mistakes can block the tooth's canal, preventing its complete cleaning and shaping. These errors include the fracture of an instrument inside the tooth, perforation of the root, or the extension of filling material beyond the root tip. All of these factors can lead to treatment failure and the need for an apicoectomy. X-ray picture showing instrument fracture

3. For anatomical reasons:

Sometimes the tooth canal is too curved or has calcifications - a pulp degeneration process - that makes it difficult to use endodontic instruments properly. This can make the surgical approach necessary to access these hard-to-reach areas in order to clean and fill the entire canals.

4. The tooth carries a well-fitting post or crown:

The first drawback of non-surgical root canal retreatment is that it first requires removing the existing restoration, such as a crown or post.

Now, if you are satisfied with your restoration and it fits very well, conventional retreatment increases the risk of damaging it and further weakening the tooth. Post crown restoration By performing an apicoectomy, the dentist can access the infected area of the tooth without disturbing the restoration. This approach can save you time and money and reduce the risk of harming your tooth.

5. Cyst:

A cyst is a fluid-filled cavity that forms at the root tip due to a chronic infection. Sometimes it persists or reappears after root canal therapy. In this case, an apicoectomy may be needed to remove it and prevent its re-occurrence.

What is the procedure?

The advancements in surgical techniques and technology have made the apicoectomy procedure more effective and straightforward.

This involves using microscopes, lighting, and biomaterials that promote healing. These modern techniques have significantly increased the success rates of the procedure (3).

Your endodontist or surgeon will first numb the area around the tooth to ensure a comfortable procedure. The three major steps include soft tissue management, hard tissue management, and root tip management.

  1. Soft tissue management: This step involves cutting the gum tissue and gently pushing it aside to expose the bone around the tooth that requires treatment.
  2. Gum incision
  3. Hard tissue management: The second step involves removing a portion of the bone that is covering the tooth to expose the apex of the tooth. This allows the endodontist or surgeon to remove all the infected and inflamed tissue while preserving as much healthy bone as possible.
  4. Bone removal to expose the apex of the tooth
  5. Root tip (apex) management: In the final step, a portion of the root tip is removed to gain access to the root canal. The endodontist will use specialized instruments (high-frequency vibration instruments) to prepare the canal on the apical end and then fill it with a biocompatible material to seal it off. This biomaterial helps prevent any further infection and promotes new tissue growth around the root tip.

    Thanks to modern techniques, it is now possible to fill the entire root canal system through the apex. This helps to prevent any further infection.
  6. Aprex management: preparation and sealing of the root end

Healing and recovery:

After the apicoectomy procedure, it is normal to experience some temporary swelling, bleeding, and discomfort in the first few days. However, there are things you can do to minimize these effects and promote healing.

  • For the first 24 hours, apply ice to the area with light pressure every 5 minutes, 20 minutes at a time. This will help reduce pain and swelling for the next few days.

  • In case of bleeding, gently apply gauze to the area for 15 minutes. If the bleeding does not stop, contact your dentist immediately.

  • Avoid moving your lips or cheek during the first few days to avoid tearing the sutures.

  • After the first 24 hours, rinse your mouth with salt water several times a day.

  • For the first few days, stick to soft foods and chew on the opposite side.

  • Avoid smoking for at least the first three days.

  • Follow the prescription of your endodontist and keep your appointment to remove the sutures 3-7 days after the procedure.

During the healing process, the gum usually heals and returns to its normal appearance quickly within the first week. On the other hand, the bone takes longer to heal and can last for several months.

Regular follow-ups with your dentist are essential to monitor the healing process. If you experience any abnormal symptoms such as fever, pus discharge, or excessive bleeding, do not hesitate to see your dentist as soon as possible.

Remember, proper care and attention during the healing period can help ensure a successful and smooth recovery.

How successful apicoectomy is?

As with any surgery, it is difficult to predict the exact outcomes and survival rates of the tooth in the coming years. This can depend on many factors, including your tooth condition, age, health status, and most importantly, your dentist's experience.

However, many studies have shown that when apicoectomy is performed properly with the right and modern techniques, the success rate can be very high, comparable or even exceeding the conventional root canal treatment.

  • In a 1–4-year study, Zuolo et al. found 91.2% success in a total of 102 teeth.

  • One study found a 95.3% success rate after one year of follow-up.

  • Another study compared the survival rates of teeth with root-end surgery and non-surgical retreatment for 2 to 4 to 6 years. The apicoectomy survival rates were 93.7%, 90.5%, and 88%, respectively.

What if apicoectomy fails to heal the tooth?

While apicoectomy is generally a successful procedure, there is still a chance that it may fail to accomplish its goal.

According to one study, technical errors during surgery, such as incomplete resection or insufficient root-end fillings, are among the most common reasons for failure.

So, it is important to seek out a specialist with extensive experience in this field to maximize the chances of success.

Ultimately, if the tooth is extensively damaged, with fractures or extensive decay, an apicoectomy may not be able to save it. In this case, extraction may be the last resort. Afterward, you can replace the missing tooth with an implant or a bridge.

Risks and complications of apicoectomy:

Apicoectomy is a safe and effective procedure, but like any surgery, there are some risks involved. The most common complications are swelling, pain, and bruising at the surgical site. Again, these are usually mild and go away on their own after a few days.

However, on rare occasions, unusual complications, such as excessive bleeding and infection, may occur.

Also, some anatomical factors, such as the location of the tooth, proximity to blood vessels or sinuses, and the thickness of the jawbone, can increase the risks of complications.

For instance, if the tooth is too close to a nerve, artery, or sinus, your surgeon may injure them during the procedure. Fortunately, these situations are rare, and the preoperative examination helps assess the proximity of these structures to avoid such risks.

Additionally, certain medical conditions such as uncontrolled diabetes, blood clotting disorders, and immune system disorders may make the procedure inadvisable.

That is why it is essential to inform your dentist of your full medical history and any medications you are taking before undergoing the procedure. By doing so, you can ensure a safer and more successful apicoectomy.

  1. What is endodontic success? How successful is endodontic therapy? https://www.aegisdentalnetwork.com/cced/2017/03/
  2. Is Retreatment Always Necessary Before Endodontic Surgery? https://www.aae.org/specialty/is-retreatment-always-necessary-before-endodontic-surgery/
  3. Possible Causes for Failure of Endodontic Surgery – A Retrospective Series of 20 Resurgery Cases https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8461483
  4. Prognosis in periradicular surgery: a clinical prospective study https://pubmed.ncbi.nlm.nih.gov/11307456/
  5. Prognostic Factors in Endodontic Surgery Using an Endoscope: A 1 Year Retrospective Cohort Study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8461483
  6. Root-end Surgery or Nonsurgical Retreatment: Are There Differences in Long-term Outcome? https://pubmed.ncbi.nlm.nih.gov/33961913/
  7. Prognostic Factors in Endodontic Surgery Using an Endoscope: A 1 Year Retrospective Cohort Study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9103390/
  8. Endodontic Microsurgery: The Significance of Soft Tissue Management in Overall Success https://www.aae.org/specialty/management-of-soft-tissue-in-microsurgical-endodontics/
  9. Tissue conservation in endodontic microsurgery https://www.sop.asso.fr/admin/documents/ros/ROS0000226/2072.pdf