Apicectomy

Question 1

What is apicectomy?

Answer 1

Endodontic surgical procedure where apex of the tooth is removed and root end cavity is prepared and filled with biocompatible material (such as MTA)

It involved accessing the apical third area through the buccal/labial cortical plate via flap access

Granulomatous tissue is removed along with apical portion of the root

Question 2

Indications for apicectomy

Answer 2

When Orthograde Endo is not possible : due to persistent exudation into RCS despite debridement; progressive periradicular lesions
Progressive /symptomatic periradicular lesion in well root filled tooth but: RCT failed , Orthograde can cause detrimental damage to structural integrity and can be destructive to restoration/prosthesis; if need to remove post with a risk of root fracture
When developmental or iatrogenic abnormalities prevent ortho RCT (open CEJ-exposed dentine, lateral canals)
When biopsy of periradicular tissue is required
When visualisation of periradicular tissues required (e.g. perforation/root fracture, palato-gingival grooves, mucosal fenestration, cracks, resorptive lesions)
Obturation material overfill

Question 3

Contraindications for apicectomy

Answer 3

Primary disease not stabilized
Poor coronal seal
Unrestorable tooth
Evidence of perio-endo lesion
Root fracture present
Compromised bone support/short root length
Poor access
Medical history
Operators skills/experience

Question 4

Assessment of tooth and patient

Answer 4

Local considerations:
- tooth angulation and access
-sound coronal restoration
-favourable perio attachment levels
-absencenof traumatic occlusion
-presence of well condensed root filling

General considerations:
-stability of primary disease
-adjacent structures
-no inflammation
-gingival bio type, smile line- regarding the flap

Question 5

Anatomical considerations for apicectomy

Answer 5

Maxillary sinus and nasal cavity - if root tip is close to sinus or nasal cavity

Mental nerve and IAN nerve- if root tip close to the nerve

Vasculature

Question 6

Apicectomy procedure

Answer 6

Mucoperiosteal flap -sulcular or submarginal)
Apical area accesses though the buccal cortical plate using handpiece with reverse exhaust/speed increasing or piezosonic device)
Granular tissue is removed and the bony crypt is curreted to remove pathological tissue
Apical portion of the root is removed (usually 3 mm)
New root end is prepared and internally bevelled and root ending filled with MTA or reinforced ZOE (IRM…)

Question 7

Risks and benefits of apicectomy

Answer 7

Risk: pain, bruising, tenderness, bleeding, loose tooth, repeated infection, gingival recession

Benefits:

Question 8

Aftercare and follow up

Answer 8

Monitoring tooth clinically and radiographically for healing/reinfection annually up to 4 years
Ideally full boney infill in periapical area will be seen by 48 months post op

Royal collage of surgeons- guidelines for periradicular surgery 2020