Tag Archives: root canal surgery

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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