Category Archives: Endodontic Surgery

A Compromised Tooth is Still a Tooth.

In my previous post “What to do with a compromised tooth?” I asked everyone about the options for a tooth which appeared to be compromised on X-rays.  Four options were presented: a) endodontic retreatment, b) apical surgery, c) extraction/implant and d) other.  Apical surgery won the race and all responders chose one of the first three options given.  In this case, the fourth option was chosen: Intentional Replantation.

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Intentional replantation procedure allows us to control all the contributing factors to endodontic failure in this case: ruling out the presence of root fracture, removing the subgingival calculus as a result of loss of enamel, removing the resorbing granulation tissue, eliminating possible established extra-radicular infection or biofilm, sealing the root-ends without the need for retreatment and possible further extrusion of obturation material into the lesion, preserving the intact buccal and palatal cortical bone through eliminating the need for apical surgery (Risks: proximity to Greater Palatine nerve and artery, inadequate palatal root length, possible loss of palatal cortical bone post-surgery).

The final radiograph shows the periapical healing after 1 year. Patient is asymptomatic, the tooth is functional with great periodontal health post-restoration, awaiting a crown. Extraction/implant option can wait for now.


Office website: vanendo ,  FaceBook page: @endospecialists


What to Do with a Compromised Tooth?

Endodontic diagnosis for tooth #27: previously treated, symptomatic apical periodontitis.  I/O examination reveals a wide, 6-8mm clinical attachment loss (i.e. probing defect) distal to tooth #27 and loss of distal contact due to enamel fracture.  A CBCT scan shows intact buccal and palatal bone and a significantly shortened palatal root due to external inflammatory root resorption.

intentional replantation

intentional replantation


Office website: vanendo ,  FaceBook page: @endospecialists


How can an apicoectomy help?

Let’s not give up on even the smallest of teeth!

There are times when conventional root canal treatment or retreatment cannot heal every periapical lesion out there. Luckily, we have the option of an apicoectomy – which in today’s terms, means microsurgery. During an apicoectomy, the most apical part of the root tip (usually about 3 mm) is removed. A retropreparation – which is similar to a class one preparation – is made using an ultrasonic tip specially designed and angled for apicoectomy under the microscope. The retropreparation is filled with an MTA material, of which there are many choices now, like the traditional powder that is mixed with sterile water, or even a pre-mixed putty.

In this case, we see a tiny little lateral incisor, which has a ceramic crown that is a few years old, and underneath it, a great big post. The current root canal treatment is somewhat underprepared, and was done more than 15 years ago. The tooth had recently become symptomatic. Is it extraction time for this little tooth? Should we dismantle the crown, remove the post, and retreat it? Should we place an implant now?

This case was ideal for an apicoectomy. This means the patient is able to keep the crown intact and we wouldn’t be compromising restorability by removing the post. With such a short and fine root, we have to be aware of the crown to root ratio, occlusion, and be conservative in our surgical technique.

After a full thickness flap was created, the retropreparation and the MTA retrofilling are seen:

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Here are the radiographs from start to finish: initial presentation, immediately after the procedure, and 6 months after with good healing.


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Micro-surgery Works, Macro-surgery Doesn’t.

When endodontic surgery (a.k.a. apico, apicoectomy) is indicated, certain steps must be followed in order to ensure a successful outcome.  Skipping any of the steps below, specially steps 4 AND 5, may result in failure:

  1. Proper flap design.
  2. Adequate magnification and use of proper instruments.
  3. Root-end resection: to expose the uncleaned isthmi between the canals and to eliminate portal of exits/apical deltas which are more frequently seen in the apical 2-3mm.
  4. Retro-preparation: to create a class I cavity prep for placement of retro-filling material.
  5. Retro-filling: to seal the canal at the apical end, which is ABSOLUTELY NECESSARY for the apical surgery to be successful. Without this seal, the surgery is bound to fail as the root-end resection (Macro-surgery) alone cannot prevent the bugs from coming out of the canal system and causing the periapical lesion.
  6. Primary flap closure: in order to allow the stabilized clot that forms in the surgical site turning into bone in the absence of micro-organisms.

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