Apicoectomy – Cost, Procedure, Recovery, Success Rate, Indications, Dental Code

Apicoectomy, also known as root end surgery, is a form of endodontic surgery that becomes necessary when a standard root canal treatment or subsequent endodontic treatment fails to heal an infection in the tooth’s root. This procedure is often the only alternative to extract a tooth, making it a critical treatment option in preserving natural teeth.

Key Facts

• Apicoectomy is a surgical root end procedure, commonly referred to as endodontic microsurgery
• It involves the removal of the root tip (or apex) and sealing the root end
• An apicoectomy is typically considered when a previous root canal treatment hasn’t been successful or has failed over time
• This procedure offers an alternative to tooth extraction, aiming to save and preserve the natural tooth

What is an Apicoectomy?

An apicoectomy, often termed root-end resection, is a surgical procedure performed by an endodontist – a dental specialist trained in diagnosing and treating tooth pain and conducting root canal treatments. An apicoectomy involves removing the tip of the root (root end) of a tooth and infected tissue surrounding it. This minor surgical procedure is typically recommended when there are persisting issues after a root canal procedure, especially with the apical portion of the tooth. The primary goal of an apicoectomy is to remove any inflamed or infected tissue from around the root tip (apex) of a tooth and then seal it to prevent further infection.
The procedure typically involves making a small incision in the gum near the tooth to expose the underlying bone and the root end of the tooth. The infected or inflamed tissue is then removed, along with approximately 2-3 millimeters of the root tip. A biocompatible filling, usually made of a material called MTA (Mineral Trioxide Aggregate) or Biodentine, is then placed to seal the end of the root canal. The gum is then stitched back into place, ensuring that the incision heals properly and allowing the bone to heal around the root over time.

Why It’s Used:Why is an Apicoectomy Performed?

This procedure tackles the limitations of Standard Root Canal Treatment. An apicoectomy is used as a remedy when a tooth that has previously undergone a root canal treatment becomes infected or continues to cause pain. While root canal treatments have a high success rate, there are instances where they might not be able to clear all the bacteria or the tooth may re-infect due to several reasons:

• Complex root canals – complex root structures that were undetected during the initial treatment
• Calcium deposits inside canal system
• Narrow or curved root structures that standard endodontic treatment can’t adequately address that were untreated during the initial procedure
• Delay in placing the crown or other final restoration after the root canal treatment
• A cracked or fractured root

When a previously treated tooth becomes problematic, the tooth can either be extracted, retreated with another root canal, or undergo an apicoectomy. An apicoectomy is often chosen as the best solution because it allows for the inspection of the root for fractures, effective cleaning of the surrounding area, and is less traumatic than a tooth extraction.
In cases where infection lingers or recurs at the root tip despite treatment, an apicoectomy is the next step. This surgery targets the area around the root end, which may harbor residual infected tissue.

Why Do You Need an Apicoectomy?

While root canal therapy is highly effective in treating infections inside the root canal of a tooth, there are instances when it doesn’t entirely resolve the issue. When a previously treated tooth doesn’t heal as expected or causes pain months or even years after treatment, an apicoectomy becomes a viable option. Here are the primary reasons why an apicoectomy might be recommended:

• Persistent Infection: After a root canal, the end of the root tip can sometimes harbor small pockets of infection, which can lead to abscess formation. This infection can persist even after a root canal therapy.
• Complex Root Structures: Some teeth have complex root structures with minute branches where bacteria can hide. These areas might not be accessible during a traditional root canal.
• Calcified Canals: Over time, root canals can become calcified, making them narrow and hard to treat with conventional root canal therapy.
• Failed Previous Treatment: If a tooth has had multiple root canal treatments and continues to fail, an apicoectomy can be a solution to prevent tooth extraction.
• Preventing Extraction: In some cases, an apicoectomy can be the last resort to save a tooth from being extracted.
• Broken Root Tips: If a root tip is fractured or if any instrument fragments are present inside, they can sometimes be removed more effectively through an apicoectomy.

What’s the Difference Between a Root Canal and an Apicoectomy?

Both a root canal and an apicoectomy aim to treat infections within a tooth’s pulp (the innermost part of the tooth) and save the natural tooth.
They are approached differently and used in different circumstances:

• Root Canal: In a standard root canal procedure, the dentist or endodontist accesses the pulp of the tooth from the crown (top). The infected or inflamed pulp is removed, the canal space is cleaned and shaped, and then filled with a biocompatible material called gutta-percha to seal off the canal.
• Apicoectomy: This procedure is a follow-up, typically after a root canal treatment has already been performed and failed to resolve the issue. Instead of accessing the pulp from the crown, the endodontist works from the root’s tip (apex). An apicoectomy focuses on removing just the tip of the root and then sealing it to prevent further infection.

In essence, while a root canal addresses the problem from within the tooth, an apicoectomy addresses it from outside the tooth.

Is it painful?

One of the most common concerns regarding any dental procedure is the pain involved.
For an apicoectomy:

• Before the Procedure: The endodontist will use local anesthesia to numb the area, ensuring the patient feels no pain during the surgery. Some patients may experience slight discomfort from the injection, but once numbed, the procedure itself is painless.
• After the Procedure: It’s typical for patients to experience some degree of discomfort or minor swelling in the days following the apicoectomy. This can usually be managed with over-the-counter pain medications or prescriptions given by the endodontist. Applying a cold pack to the affected area can also help alleviate swelling and pain.

What’s the procedure like? What are the steps?

The apicoectomy procedure, though intricate, is usually straightforward.
Here’s a breakdown of the steps involved:

• Consultation: The endodontist will first take X-rays to get a clearer image of the tooth and surrounding bone. This helps in planning the procedure.
• Local Anesthesia: To ensure the patient feels no pain during the procedure, a local anesthetic is administered to numb the area around the affected tooth.
• Incision and Access: The endodontist makes a small incision in the gum to expose the underlying bone and the root end of the tooth.
• Removal of Inflamed/Infected Tissue: The infected or inflamed tissue, as well as approximately 2-3 millimeters of the root tip (or apex), are removed.
• Sealing the Root: A biocompatible filling, often made of Mineral Trioxide Aggregate (MTA), is placed to seal the end of the root canal. This step is crucial to prevent further infection and to ensure the healing of the surrounding bone.
• Closure: The gum is stitched back into place. The stitches are usually dissolvable and will disappear on their own within a week or so, but this can vary depending on the type of stitches used.
• Post-operative Care: The endodontist will provide aftercare instructions. This often includes recommendations on oral hygiene, any necessary dietary restrictions, and guidance on managing pain or discomfort.
• Follow-up: It’s essential to have a follow-up appointment, usually a week after the procedure, to ensure proper healing. The endodontist will inspect the area, possibly take X-rays, and ensure everything is healing as expected.

Post-apicoectomy and recovery

The recovery process after an apicoectomy is essential in ensuring the best results and avoiding complications. After the procedure, patients may experience slight swelling and minor discomfort. Appropriate pain medication is prescribed to manage any pain. Most patients can return to their normal activities within a couple of days. The gum tissue heals within a few weeks, while the bone may take a bit longer to heal properly.
Here’s precisely what you can expect:

• Immediate Aftercare: Patients should avoid eating until the numbness from anesthesia wears off to avoid biting the cheek or tongue. Mild swelling and discomfort are common after the procedure. Using a cold pack can help reduce swelling.
• Oral Hygiene: It’s crucial to keep the area clean to prevent infection. Patients should gently rinse their mouth with warm salt water several times a day. Regular brushing should be continued, but be gentle around the surgical site for a few days.
• Dietary Adjustments: Soft foods are recommended for the first few days. Patients should avoid crunchy, spicy, or hot foods, and refrain from using a straw to prevent disruption of the healing site.
• Medication: Pain relievers and antibiotics may be prescribed. It’s essential to take them as directed by the endodontist.
• Regular Check-ups: Following the surgery, the endodontist will schedule a few check-ups to monitor the healing process, remove any non-dissolvable stitches, and address any concerns.
• Returning to Daily Activities: Most patients can return to their daily routines within a day or two. However, they should avoid strenuous activities and exercises for a few days post-surgery.

Effectiveness of Apicoectomy: Success Rate

Apicoectomy procedures have a high success rate, especially when performed by experienced endodontists, as confirmed by the American Association of Endodontists. Various studies have indicated different success rates, but many fall within the range of 85% to 95%. Long-term follow-up studies show that many teeth treated with an apicoectomy can last for the rest of a patient’s life.
Several factors influence this:

• The Complexity of the Procedure: Teeth with more roots, such as molars, can be more challenging to treat compared to single-rooted teeth.
• The Quality of the Root-end Filling: The seal at the root end is vital in preventing infections, so the better the seal, the higher the likelihood of success.
• Patient Health: Overall health, oral hygiene habits, and adherence to post-operative care guidelines can affect the healing process and the ultimate success of the procedure.
• Recurrence of Infection: The success of the procedure can be compromised if an infection recurs or if there was a misdiagnosis of the initial problem.

Follow-Up Care

After an apicoectomy, it’s essential to have regular follow-ups with the endodontist or the referring dentist. Patients may need core and post restorations if the tooth has significant structural damage. In cases where a tooth can’t be saved, options like a removable partial denture may be considered.
Here’s what to expect in these follow-up appointments:

• Monitoring Healing: The primary objective of the first follow-up, usually within a week after the surgery, is to monitor the healing process and ensure there are no complications.
• Stitch Removal: If non-dissolvable sutures were used, they would be removed during the initial follow-up.
• X-rays: Post-operative X-rays may be taken to observe the bone healing around the root end.
• Addressing Concerns: Any concerns or discomforts that the patient may be experiencing can be discussed and addressed during these appointments.
• Long-term Monitoring: Depending on individual cases, the endodontist might schedule periodic X-rays in the months following the apicoectomy to ensure that the bone is healing well and there’s no recurrence of infection.
• Continued Care Recommendations: The dentist or endodontist will advise the patient on any specific oral hygiene practices, medication, or other care measures to aid in recovery and maintain oral health.

In conclusion, an apicoectomy can be an essential procedure to save a tooth that might otherwise need extraction. Regular follow-up ensures the success of the surgery and addresses any concerns in the healing phase.

Apicoectomy Risks and Complications

While generally considered a safe and effective endodontic surgery, the procedure does carry some inherent risks and potential complications, as with any surgical procedure.
Here are some of the notable risks and complications associated with an apicoectomy:

• Infection: Despite the sterile environment and preventive measures, there’s always a small risk of infection at the surgery site. This can usually be managed with appropriate antibiotics and proper post-operative care.
• Bleeding and Blood Vessels Damage: Minor bleeding is expected after an apicoectomy, but excessive bleeding can occur in some cases. This is typically manageable through local measures or, in rare cases, may require further medical attention.
• Swelling and Pain: Some degree of swelling and pain is normal after the procedure. These symptoms are generally temporary and can be effectively managed with appropriate pain medication and cold compresses.
• Nerve Damage: If the surgical site is near nerves, particularly in the lower jaw, there’s a risk of temporary or, in rare cases, permanent nerve damage. This can result in numbness or a tingling sensation in the lips, tongue, chin, teeth, or gums.
• Sinus Complications: For apicoectomies performed on upper teeth, especially the maxillary molars, there’s a risk of sinus cavity involvement. This could potentially lead to sinusitis or the formation of a communication between the mouth and the sinus cavity.
• Tooth Fracture: During the procedure, there’s a risk of fracturing the tooth, especially if it’s already weakened. In some cases, this may necessitate the extraction of the tooth.
• Failure of the Procedure: While apicoectomies have a high success rate, there’s still a chance that the procedure might not resolve the infection or prevent further complications, potentially leading to the need for additional treatment or tooth extraction.
• Damage to Adjacent Teeth: There’s a small risk of damage to adjacent teeth or dental restorations during the surgery.
• Jaw Problems: Some patients might experience temporary difficulty in opening their mouth wide, or discomfort in the jaw joint (TMJ) area after the procedure.
• Recovery Issues: In some cases, the healing process may take longer than expected, or the bone may not heal properly around the new root-end filling.
• Allergic Reactions: Although rare, there’s a possibility of allergic reactions to the materials used or medications prescribed.

It’s important for patients to discuss these potential risks with their dentist or endodontist before undergoing an apicoectomy. Understanding these risks helps in making an informed decision and preparing for the post-operative recovery period. Additionally, following the dentist’s post-operative instructions carefully can significantly reduce the likelihood of complications.

The Bottom Line

An apicoectomy is a valuable procedure in the field of endodontic surgery, offering a chance to save a tooth that might otherwise need to be extracted. While more invasive than a traditional root canal, it is a safe and effective procedure when done by a skilled endodontist. It is a treatment option that involves removing just the infected part of the tooth’s root, preserving as much of the natural tooth structure as possible. As with any surgical procedure, there might be some discomfort or pain post-operation, but it’s typically manageable. Proper post-operative care and adherence to the endodontist’s instructions play a crucial role in ensuring a smooth and swift recovery. With a high success rate and typically only minor post-surgical discomfort, an apicoectomy is an important procedure for dental professionals and patients to consider when faced with persistent root infections.

This article is complete and was published on August 25, 2023, and last updated on December 18, 2023.