Apicectomy Explanation

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.

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:

The recovery of broken / retained of root-canal / endodontic instruments
Where the root canal is in-filled / blocked / obliterated
The repair of root perforations
Where the root is fractured
Where there is good root canal treatment yet still root pathology
Where the tooth is a crucial support for a bridge and the bridge support is in a reasonable condition (ie the bridge / tooth can readily be ‘saved’)

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

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).

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

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.