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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