Apicoectomy:
Definition: It is the cutting off, of the apical portion of the root and curettage of the periapical necrotic, granulomatous, inflammatory or cystic lesion.
Synonym: Apical Surgery, Root Resection, Endodontic Surgery, Root Amputation
Indications of Apicoectomy:
- Apical anamoly of root tip-dilacerations, intracanal calcifications
- Presence of lateral/accessory canal/apical region perforations
- Roots with broken instruments
- Root with overfilling
- Fracture of apical third of root
- Formation of periapical granuloma and cyst
- Draining Sinus tract
- Non responsive to RCT
- Over extension of root canal cement beyond the Apex
- Blocked Root Canal due to any Calcifications
- When patient with chronic peri apical infection
- Teeth with Apical resorption
- Persistent infections after conventional Root Canal Treatment
Contraindications of Apicoectomy:
- Medically compromised patients
- Teeth with deep periodontal pocket and excessive mobility
- Teeth with poor Accessibility
- When there is extensive involvement of Bone
- Danger of involvement of anatomical structure
Steps of Apicoectomy:
In the process of Apicoectomy, there are multiple steps to be followed to reach to the root tip.
Flap Elevation: Retraction of the Gingiva or tissue to gain access to the periradicaular area is required. A localized flap design should be given to access the periradicular bone region of the tooth to be treated. A Vertical incision should be given apical to the junction of horizontal and vertical incision and elevate the flap.
Bone Removal: The Root tips are covered by Bone on the buccal surface, removal of bone helps in gaining access to the periradicalar area of the tooth. There are certain tips which should be kept in mind before going for Bone removal – Always use a sharp and sterile round bur, only light pressure should be given while cutting bone, shaving or brushing strokes should be given while cutting the bone, make sure that there are no important structures which are being harmed while bone cutting.
Root End Resection / Preparation: Root Resection has to be planned depending on the anatomical variations of the Root structure and the pulp chamber as well. There can be many anatomical changes in the pulp structure based on which the length of root to be removed is decided and also the amount of bevel which should be given.
What are the instruments used for Root End Resection in Apicectomy: High Speed hand piece with a surgical fissure bur, round bur and according to a study by Nedderman et al, a low speed tissue bur produced a smooth root surface in comparison to round bur which was rough and gouging of the root surface was seen. Some studies have also shown that use of Er.YAG laser and Ho:YAG laser was found to produce a much smoother and clean root end.
What is the Extent of Resection required: The amount of root surface to be removed is decided based on two simple points – removal of complete granulation tissue to remove foci of infection and to eliminate any anatomical variations of the root structure and pulp chamber to prevent re infection.
Retrograde filling
Re-approximation of the Soft Tissue
Preoperative preparation
- Preoperative Assessment
- Preoperative Consideration
- Preoperative preparation (Intra oral and Extra oral)
- Armamentarium (Standard Surgical set)
- Anesthesia (LA, nasal intubation)
Step by Step Surgical Procedure of Apicoectomy:
- Design of Mucoperiosteal Flap
- Reflection of Mucoperiosteal Flap
- Exposure of Periapical Pathology and Root Tip
- Removal of Periapical pathology
- Ressection of Root Apex (Apical 1/3rd)
- Sealing of the Apex
- Toilet of the wound
- Smoothing of the Sharp Bony margins
- Bleeding Control
- Closure of the Surgical Wound – Suturing
Postoperative instructions, medication and care
Complications of Apicoectomy:
- Infection Flare up
- Cellulitis
- Ludwigs Angina
- Fracture of Maxilla and Mandible
- Soft tissue injury
- Opening of Maxillary Sinus – Oro Antral Fistula
- Secondary Hemorrhage
- Secondary hemorrhage
- Non vitality of Adjacent teeth
- Nerve Injury
- Luxation of adjacent teeth
hi i am a dendist in kabul afganestan
i want to know about complication of apicectomy
Hi Ahmad, as I have listed in the post – Infection Flare up
Cellulitis
Ludwigs Angina
Fracture of Maxilla and Mandible
Soft tissue injury
Opening of Maxillary Sinus – Oro Antral Fistula
Secondary Hemorrhage
Secondary hemorrhage
Non vitality of Adjacent teeth
Nerve Injury
Luxation of adjacent teeth
HI, Dr. Varun!
I am Dr. Asif here form Lahore, Pakistan. Can you please tell me as to how the space which is left after resection of part of the tooth is filled in ?
Regards
draasif@hotmail.com
If the space is not much, there is no need to fill it with any material as the body will take care of it. If the periapical infection was huge and the bone loss apically is big, then it is advisable to use a suitable bone graft to fill the space.
Am A Student Of Dental Therapy And I Need Your Help.
I Want To Know More Of Indications Of Apiceoctomy
Hi , I’m a Tunisian dentist and I want to know if it’s possible to do apicoectomy with only resection of the part of gutta percha above the apex and without retrograde filling
Hi Nersine,
You can just remove the excessive Gutta percha beyond the apex and not do any root tip ressection if there is no peri apical radiolucency. In case there is radiolucency it means the infection or the bacteria might have entered into the apical region of the root tip which can lead to infection in a later stage.
So it is not advisable to just trim the excess GP and leave the root tip, better safe than sorry is what you should be following in such cases. You would not like to take chances after opening the apex and leaving any infection there.
I had a apicoectomy, my stitches keep coming loose. The first time I could have been to blame. But the second no way. I have not eat solid food in 2 weeks. The first time I could see bone in a good size hole. This time I have not touched it to look being afraid I would hurt it. Does a dentist leave a hole there for it to heal alone or should he sew it up. I’m very worried.
Please for a failed RCT that requires Apicoectomy do i need to remove all the previous GP. Or just the sectioning of the root and sealing of the root end alone is enough
It depends on the obturation done, if test of the canal is properly filled without voids and the infection is just isolated to the Peri apical region only the sectioning of the Apex of the root is necessary. If there are voids in the coronal and middle third of the GP removal of complete GP and refilling it before apicectomy is preferred mode of treatment.
Please what the the armamentarium for apicectomy
Thanks
Are there long term complications to Apicoectomy?
Not really, it is similar to a Root canal Treatment, but the procedure is done in reverse. Cleaning the tip of the root where the infection is present, so it is actually a safer treatment option.
Would this be possible to be done on a root tip that is out of bone? (From poor orthodontics)
It would be much easier actually, but will that be sucessful to save a tooth with its root tip exposed, will it be able to survive for long??
In the incidence of fenestration, the root tip exposed but buccal cortical bone still present? It’s a very rare occurrence unfortunately resulting from ortho but could apicoectomy be successful in this situation?