In dentistry, preserving natural teeth is a top priority. Apicoectomy, also known as root end surgery, is a surgical procedure that offers a second chance to an inflamed tooth root after an unsuccessful root canal treatment. But what exactly is apicoectomy? When is it recommended, and what are its contraindications? How is the procedure performed, and what should patients be mindful of during recovery? In this article, we address all these questions!
What is apicoectomy? Is it the same as root resection?
Apicoectomy, also known as root end surgery, is a dental procedure in which the tip of the tooth’s root and the surrounding inflamed tissue are removed. It is typically performed after unsuccessful root canal treatment(s). If the surgery is successful, the tooth can be preserved, preventing tooth loss.
In contrast, root resection is the process through which one of the tooth’s roots is removed completely.
When is root end surgery needed?
Apicoectomy is performed when severe inflammation affects the tissues around the tip of a tooth’s root. These advanced infections, which damage the bone and connective tissues, are often the final stage of a process that typically begins with simple tooth decay. Poor oral health due to poor hygiene habits is usually the underlying cause. As tooth decay progresses, bacteria can reach the dental pulp, which contains the nerves and blood vessels that nourish the tooth. In response to infection, these tissues may die. When the inflammation becomes too severe to be treated with antibiotics, root canal therapy is performed to remove the dead tissue and seal the root canals with a biocompatible material.
There are tiny openings at the tip of the tooth roots that allow blood vessels and nerves to enter the tooth. If bacteria penetrate these openings, they can cause inflammation around the tooth roots, leading to the deterioration of both bone and connective tissue. In severe cases, this process can only be halted with an apicoectomy, during which the infected tissues are removed. While this is the most common scenario, there are other situations that may require an apicoectomy.
Cases where root canal treatment is not feasible, for example:
- When the root canal is not accessible due to narrowing caused by mineralization, curvature, or the presence of a post.
- When the root canal cannot be properly dried before filling.
Or if the following complications arise during root canal treatment:
- A tool breaks inside the root canal.
- The root filling material is overextruded beyond the root tip into the periodontal tissue, causing inflammation.
- Instruments used to widen the root canal have been misdirected, creating unintended pathways.
An apicoectomy is also necessary in cases where:
- A cyst has formed at the root tip. These fluid-filled, benign lesions put pressure on the bone tissue, leading to its deterioration.
- There is a chronic inflammation around the root tip that does not respond adequately to treatment.
Contraindications of apicoectomy
It is essential to mention the contraindications of this procedure. While it is a minor oral surgical intervention, it is not always feasible.
For instance, if the tooth has already been root-filled, the filling should be no older than six months and must be intact. In most cases, the root canal filling is performed immediately before the apicoectomy.
If the tooth cannot be adequately stabilised after the procedure, an apicoectomy is not recommended. This may occur if there is significant bone loss due to inflammation or if the root is too short to provide sufficient support after removing the affected portion. Generally, the lower third of the root is removed, approximately 2–5 mm. However, if the remaining root is too short, it may compromise the tooth’s stability.
Health-related risks must also be considered. The procedure may not be suitable for patients with bleeding disorders or certain heart and liver conditions. Additionally, due to the presence of nerves in the lower jaw, performing an apicoectomy on lower molars is discouraged as it can lead to severe complications. Lastly, if there is a deep periodontal pocket around the tooth, apicoectomy is not advised.
The process of apicoectomy
The procedure takes approximately 45 minutes and is performed under local anaesthesia, ensuring it is painless.
- Initial examination and consultation
The process begins with a thorough examination and consultation. In many cases, the procedure builds upon previous treatments carried out at the clinic. An X-ray is always required, and for precise localisation of the tooth root, your dentist may also request a 3D CBCT scan. - Preliminary root canal treatment (if necessary)
If the tooth has not been root-treated before, this will be carried out before proceeding with the apicoectomy. - Local anaesthesia
The first step of the surgery is administering local anaesthesia to ensure a pain-free procedure. - Gum incision and flap formation
The gum tissue is gently lifted from the bone surface to provide access to the affected area. - Bone window creation
A small opening in the bone is made using a surgical drill to expose the root and surrounding tissues. - Removal of the root tip and the infected tissue
The root tip, as well as all inflamed and damaged tissues are carefully removed. - Retrograde root filling (if necessary)
If necessary, a small hole is drilled into the root tip, and a special sealing material is applied to ensure a tight closure of the root canal system. - Wound closure
Finally, the surgical site is closed with sutures to promote healing.
What should you pay attention to after the surgery?
Apicoectomy is not a major surgery, but certain precautions must be taken. Mild swelling and pain after the procedure can be managed with ice packs and painkillers.
It is essential to avoid smoking, consuming hot food and drinks, and engaging in strenuous physical activities.