Exodontia.Info
An apicectomy is a surgical procedure in which the
root-tip of a tooth is removed and the truncated root-
tip is hermetically sealed with a root-filling.

An apicectomy (also known as surgical endodontics, apical
surgery
or peri-radicular surgery) should be considered
only when conventional
endodontic root filling (‘root canal
treatment’) techniques have failed.

A conventional
endodontic treatment is indicated if the
dental pulp (‘nerve’) of a tooth becomes non-vital (dies) or
is likely to be put at risk due to the type or size of
restoration needed to repair the tooth.

During
endodontic treatment, the dentist removes the dead
remnants of the
dental pulp and replaces it with an inert
filling material which is visible on an X-ray.

As there is good evidence that
endodontic re-treatment has
higher success rates than
apical surgery, patients are
advised to pursue a non-surgical treatment if root canal
treatment is initially unsuccessful (
www.aae.
org/patients/patientinfo/faqs/retxsum.htm and www.
britishendodonticsociety.org.uk/patient_information.html).

Most teeth will respond satisfactorily to this type of
treatment and become symptom-free.
Apicectomy / Surgical Endodontics  
– What Is It?
The 2 main indications for apical surgery are:

  1. Obtain a biopsy (where the tooth-tip pathology is greater than 1cm in diameter)
  2. To achieve what could not be done by endodontic re-treatment such as:



Apicectomies
ARE NOT done on:

  • Teeth that have been previously apicected (low success rate for repeat
    apicectomies)
  • Molar teeth (difficult access, low success rate and potential problems with
    nerves & sinuses)
  • Patients who have poor oral hygiene, active gum disease or uncontrolled tooth
    decay
  • Teeth where the post-crowns do not fit the root canal or the post has been re-
    cemented on more than 1 occasion
  • Teeth where there is little tooth substance left to place a crown on afterwards
  • Teeth which have post-crowns that can be removed to allow re-treatment
  • Patients who require intravenous sedation / general anaesthesia
  • Patients at risk from bacterial endocarditis or with blood clotting disorders


There is increased difficulty of the operation due to anatomical & dental anatomical
considerations, such as:

  • Mouth Anatomy.  Small oral opening, a prominent chin, Inferior Alveolar &
    Mental Nerves, active facial & mouth muscles, bony prominences (such as the
    zygomatic process; anterior nasal spine, external oblique ridge) and a
    shallow ‘trough’ (vestibule) between the teeth, cheek and lips can hamper the
    operation.
  • Jaw Bone Thickness.  The jaw bone is thicker in the root tip region and more
    difficult access to the root end


Upper Premolars / Bicuspids, complicated by:

  • Multiple Roots are present that often diverge widely from each other (making
    access for the procedure difficult and hence lower success rate for op)
  • Sinus Floor can often be in close proximity to the tooth tips that are being
    operated on.  There is a chance of perforating into the sinus (10 – 50% of
    cases) and causing acute ± chronic sinusitis (especially if any debris has gone
    into the sinus).
  • Root Anatomy is such that they are often difficult to get a good root canal
    filling (due to isthmus / anastomosis of the root systems).  Hence, the chances
    of success of the apicectomy will be reduced.


Lower Incisors & Canines / Eye-Teeth (Upper & Lower), complicated by:

  • Root Anatomy.  Long and broad roots, that are in proximity to adjacent roots
    and tilted towards either the roof of the mouth (if upper) or the floor of the
    mouth (if lower) (making access for the procedure difficult and hence lower
    success rate for op).



Useful Articles:

Chapter 12.  Endodontic Surgery (2002)

Dental Update 2004.  Root Canal Retreatment. 1. Case Assessment and
Treatment Planning

Dental Update 2004.  Root Canal Retreatment. 2. Practical Solutions

JOMS 2005.  Failed Root Canals - The Case for Apicoectomy (Periradicular
Surgery)

Dental Update 2006.  Root Canal Retreatment

J Endo 2006.  Modern Endodontic Surgery Concepts & Practice - A Review

Int Endo J 2006. Quality Guidelines for Endodontic Treatment.  Consensus Report
of the European Society of Endodontology

Cochrane Database of Systematic Reviews 2007.  Surgical versus non-surgical
endodontic re-treatment for peri-radicular lesions

Chapter 6.  Surgical Endodontics. IR Matthews (2007)

Evidence Based Dentistry 2010.  Surgical Endodontic Surgery Treatment under
Magnification has High Success Rate (J Endod 2009)

J Endod 2010.  Prognostic Factors in Apical Surgery with Root-End Filling - A Meta-
Analysis.

Evidence Based Dentistry 2011.  Endodontic Surgery Prognostic Factors (J Endod
2010)

Roots 2011.  Predictable Apical Microsurgery (Part 1)

Saudi Dent J 2011.  Review Article.  Apical Surgery.  A Review of Current
Techniques & Outcome

BDJ 2012.  Update of Guidelines for Surgical Endodontics - the Position after 10
Years

BDJ 2013.  Oral Surgery - Part 2.  Endodontic Surgery



Useful Websites:

British Endodontic Society - Patient Information

British Endodontic Society - Quality Guidelines for Endodontic Treatment:
Consensus report of the European Society of Endodontology

American Association of Endodontists - Endodontic Surgery

Royal College of Surgeons of England (Faculty of Dental Surgery) - Guidelines for
Surgical Endodontics
Last Updated 4th September 2015