Apicoectomy - An endodontic surgery when Root Canal Treatment fails

Apicocectomy surgical root canal treatment

Apicoectomy – a good option after root canal treatment failure

We earlier discussed in our last article about the root canal treatment. Here we will see that what if your root canal treatment fails? The commonest treatment after root canal treatment fails is root end resection or an apicoectomy. In this procedure, the apical end of the root is removed and sealed.

Why apicoectomy needs?

 

  • In the case of failure of nonsurgical endodontic treatment: in cases when after root canal treatment there is a persistence of symptoms and nonsurgical retreatment is not possible.
  • In case if previous surgery fails- due to lack of employing microsurgical instruments and magnification aids like a dental operating microscope. Such cases require re-surgery.
  • Anatomic difficulties: in the case of sharp tooth curvature or nonnegotiable canals that prevent cleaning and shaping of the apical third. Read our article on root canal anatomy.
  • Horizontal apical root fracture: such traumatic injuries require resection if the apical end becomes necrosed and nonsurgical treatment is not possible.
  • Iatrogenic error: some errors caused during root canal treatment like ledging of canals, separated instruments or overfilling causing foreign body reaction require surgical intervention.

 

When not to go for apicoectomy?

  • Lack of periodontal support and uncontrolled periodontal disease.
  • Poor restorability with post-endodontic restoration.
  • Lesions close to anatomical structures like inferior alveolar nerve, lingual nerve, mental foramen, maxillary sinus that are at a high risk.
  • Systemic complications like bleeding disorders, severe heart disease, and immunocompromised patients.

Treatment plan for apicoectomy

The right to information to the patient before the apicoectomy procedure

Before surgical treatment, the patient should be informed and made aware of the treatment by the dentist or the endodontist such as:

  • What is to be done in apicoectomy?
  • How is it to be done?
  • Why is it done?
  • How successfully will healing occur?
  • What are the alternative treatments?
  • What are the risks of the treatment?

Generally, apicoectomy – a surgical endodontic procedure is a painless procedure. Likely it is performed in the dental chair with a similar anesthesia that is used in fillings.

Some kind of reaction may occur after treatment like a sore tooth or gum pain, swelling probably small but can be large but will subside gradually with time. Paresthesia can occur for some time due to the treatment is done in the area most probably if it is lower jaw but it will be normal in some time.

Routine instructions will be given immediately after treatment home care, diet routine, and medications. No tooth will be treated unless there is a reasonable chance for success and if success rates are below average then you will be prior informed. And after the surgical procedure within few days or weeks, your dentist or endodontist will restore the tooth with a crown or filling.

Required investigations before apicoectomy

Some investigations are must before going for an apicoectomy. They are:

  • Bleeding time
  • Clotting time
  • Diseases encountered with coagulation like hemophilia, Christmas disease
  • A condition associated with hyperprothrombinaemia
  • Thrombocytopenia
  • Abnormalities of capillaries like purpura, ehler danlos syndrome, Von-Willebrand’s disease, leukemia
  • Patients on anticoagulant and antiplatelet therapy

Surgical procedure of apicoectomy

It involves management of both soft tissues and hard tissues.

Soft tissue includes:

Flap design and preparation

Tissue incisions, elevations, and retractions are done in such a way that it can facilitate easier and faster healing.

A sharp incision deep into the bone at one stroke is done. It is made through the gingiva and the periosteum to the cortical bone using firm pressure and one single stroke. Multiple strokes cause improper healing, difficult suturing and scar formation.

Place the incision in a way causing less trauma to the supporting tissues and maintaining the interdental papilla intact mainly in the anterior esthetic zone and even posterior.

A design of choice for endodontic microsurgery is sulcular full thickness flap. The papilla based flap is recommended for recession free healing. The mucogingival flap is preferred for crowned anterior teeth for esthetic reasons.

Flap elevation

Many elevators are available for flap elevation but amongst them molts curette no 2-4 is suitable for both elevation and curetting with less trauma. You have to take care to use to elevator protecting the bone and not to tear the flap. And it is advised to reflect the flap along with the periosteum to reduce the amount of bleeding during the entire procedure.

Flap retraction

The main aim of retraction is to provide proper visibility and access onto the surgical area.choose a retractor with wider and thinner cutting ends than others.

Hard tissue management

A procedure is done to remove the cortical plate for exposure of the root end. Once the flap is elevated and placed in the position the surgical area is taken into control.

Technique:

  • Maintain hemostasis
  • Locate the breach in the cortical plate with an explorer(DG16). In a case of cystic pathosis, the plate would be thinned out giving egg shell crackling appearance.
  • If a cortical plate is seen intact take an IOPA with a sterilized gutta percha cone to approximate the root end portion and the apex with the pathosis.
  • Locate the root end with the help of radiograph and in a case of the thick cortical plate now you can easily remove it.
  • Cut the bone with effective speed and coolant that is a major consideration in this procedure. High-torque, low-speed instrument is preferred with external coolant at the cutting end of the bus is most effective.
  • Most endodontists prefer using 45-degree handpiece with no 6 or no 8 round bur or no 57 fissure bur for atraumatic osteotomy.
Apical curettage

After osteotomy is done you need to curette the socket with molts curette and jaquette curette alternately to remove all of the granulation tissue and cystic pathosis with the cystic lining. The lining is removed from both facial and lingual aspect and also from the root tip. As the granulation tissue is very vascular done fail to achieve hemostasis during the procedure.

Apical root end resection

The apical 3 mm of the root tip is resected perpendicular to the long axis of the tooth. For this, a microscope with low magnification mode is very useful. Inspect the root tip that is removed for the accuracy of the cut and the cystic lining or granulation tissue.

Root end preparation

In root end preparation ultrasonic retro tips have been used for increased cutting efficiency leaving the dentin surface smooth yet a bit rough to enhance the adaptation of filling materials, few microfractures and less leakage. These microtips are mainly stainless steel, diamond coated or zirconium nitride.

Root end restoration

The prepared root end is dried and isolated with irrigation with normal saline or distilled water. The canal seen through the cut end of the root is located.

Filling materials used are:

  • MTA
  • Intermediate restorative material
  • Super EBA
  • Glass ionomer cement
  • Diaket
  • Composite resin and resin ionomer hybrids

Once the root end is restored it is burnished to a concave finish and the area is cleared of all debris with normal saline and it is thoroughly dried with a gauze. Before suturing the flap a radiograph is taken to check whether the root tip is properly removed and the root end restoration is in place. The retracted flap is placed to its original position from where it was elevated and covered with a moist gauze so that it can get back its elasticity and physiological moistness.

Conclusion

Apicoectomy is nothing but a basic simple, the painless endodontic microsurgical procedure that is a very good alternative for salvaging your tooth if your root canal treatment fails.