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:

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

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

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)


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 15th July 2011