Apicoectomy / Root End Surgery

Apicoectomy / Root End Surgery

What is Apicoectomy?

tooth anatomy

Synonyms of Apicoectomy

  1. Root End Surgery
  2. Periradicular Surgery
  3. Periapical Surgery

Introduction

Apicoectomy or root end resection is a type of Endodontic surgery where root end resection is done and periapical pathologies are removed

Objectives for Apicoectomy

  1. Curettage - Effective curettage of periradicular pathologies eg.Therapy resistant granuloma, cysts and foreign body reaction
  2. Resection - Surgical resection of root apex where apical ramification cannot be eliminated by conventional root canal treatment
  3. Inspection - Inspection of periradicular area to rule out causes of failure, inspection of isthmus and trace accessory canals in nonsurgical endodontic cases

Indications for Apicoectomy

  1. Failure of non-surgical Endodontic Treatment
  2. Failure of non-surgical Endodontic Retreatment
  3. Failure of previous surgery
  4. Intracanal breakage of endodontic instruments
  5. Blocked root canals due to calcifications
  6. Periapical granuloma or cyst
  7. Anatomical problems - Endodontist unable to reach to the Apical Constriction due to non-negotiable or blocked canals, severe root curvatures; which prevents adequate cleaning and shaping of apical 3rd of the root canal
  8. Horizontal apical root fracture
  9. Iatrogenic Errors during root canal therapy - ledging of canals, blockage from debris, separated instruments, overfilling of canals and apical canal transporation

Contraindications for Apicoectomy

  1. Inadequate periodontal support
  2. Active uncontrollable periodontal disease
  3. Poor restorability with post-endodontic restoration
  4. Teeth with poor accesibility
  5. Proximity of lesions to imporatnt anatomical structures - eg. Inferior alveolar nerve, Lingual nerve, Mental foramen and Maxillary sinus
  6. Extensive bone involvement
  7. Systemic Complications - eg. Bleeding disorders, Severe heart disease, Immunocompromised patient

Steps in Apicoectomy

  1. Case Diagnosis
    • Preoperative medical history
    • Oral and radiographic examination
    • Patient counselling
  2. Preoperative surgical notes
    • Premedication: Antibiotics
    • Illumination
    • Examination and Inspection instruments: micromirrors, periodontal probes, endodontic explorer (DG16)
    • Incision, Elevation and Curettage instruments: 15c blade and handle, Molts curette no. 2 - 4, Jacquette and mini jacquette curettte, periosteal soft tissue elevator
    • Retraction instruments
    • Osteotomy and apical root resection instruments: Impact air 45° handpiece, Lindemann burs, micromirrors and microexplorers
    • Instruments for preparing root end: microsurgical ultrasonic instruments, MTA root end filling material
    • Irrigational instruments: Stropko irrigator, microsuction
    • Hemostasis instruments and materials
    • Suturing materials: suture, needle, needle holder, scissor, forceps and tweezer
  3. Instrumentation: Dental operating microscope
  4. Anaesthesia / Hemostasis
    • Local anesthesia
    • Vasoconstrictor eg. Epinephrine
  5. Management of Soft Tissues
    • Retain the interdental papilla, gingival contour and manage the frenal attachment in anterior aesthetic zone
    • Flap design, preparation and types:
      1. Triangular flap - Single vertical releasing incision
      2. Rectangular flap - Two vertical releasing incision
      3. Semilunar flap - Limited access to surgical area and more chances of scar formation
      4. Sulcular or full thickness flap - Requires both horizontal and vertical incision. It is a design of choice for endodontic microsurgeries
      5. Submarginal Scalloped Rectangular flap (Luebke-Ochsenbein Flap) - Ideal for crowned teeth when open crown margins after surgery are an aesthetic concern. 2 Vertical incison and 1 Horizontal scalloped incision away from gingival tissue
    • Flap elevation: Molts curette no. 2 - 4 is suitable for both elevation and curetting with minimum trauma
    • Flap Reflection : Reflect the flap along with the periosteum to minimize the bleeding during surgical procedure
    • Flap retraction: Retractors are used for proper visibility to access surgical
  6. Management of Hard Tissues (Ostectomy)
    • Study the periapical radiograph and OPG to have the idea of anatomical structures involved in Root end surgeries
    • Removal of cortical plate to expose the root end in Periapical surgeries
    • High torque and low speed instrument is preferred with external coolants eg. Normal saline or distilled water
  7. Periradicular curettage
    • Periapical pathosis is curetted with Molts curette no. 2 - 4
    • Jacquette 34 - 35 curette can be used to completely remove the granular tissue or cystic pathosis with true cystic lining
  8. Apical Root end resection
    • Control of hemorrhage
    • Apical 3 mm of the root tip is resected perpendicular to the long axis of the root
    • Root resection is carried out with the help of bur in an impact air 45° handpiece
  9. Root end preparation (Retropreparation)
    • Traditionally slow speed burs were used for retropreparation
    • Ultrasonics retrotips are recommended for root end preparation
    • Ultrasonic retrotips eg. KiS ultrasonic tips used in conjunction of ultrasonic units increases the cutting efficiency, leaving smooth dentin surface which results in better adaptation of filling material, fewer microfractures and less leakage
    • Operative area is dried isolated after thorough irrigation with normal saline or distilled water
  10. Root end filling
    • Root end filling materials: eg. MTA, Intermediate Restorative Material (IRM), SuperEBA, Glass ionomer cement, Diaket, Composite resin, Resin ionomer hybrids
    • MTA is the best material of choice for root end filling
    • After restoring root end is burnished to a concave finish
    • After restorative material sets area is irrigated with normal saline and dried with sterile gauze
    • Confirmatory radiograph is taken before closing the surgical area
  11. Soft tissue repositioning
    • Some hemorrhage is allowed before attempting suturing
    • Repositioning of flap and compression
    • Repositioned flap is kept moist with moist gauze until suturing has begun
  12. Suturing
    • Reverse cutting needles are used
    • Medical grade adhesive such as Cyanoacrylates suggested for closure of surgical wound in endodontics
    • Single interrupted, interrupted loop suture, Vertical mattress suture and single sling suturing techniques used in endodontic surgeries
  13. Postsurgical care
    • Oral cavity is cleaned
    • Moist gauze is kept over surgical area
    • Post-operative instructions and medications prescribed

Complications of Apicoectomy

  1. Post-operative pain
  2. Post-operative bleeding
  3. Swelling
  4. Abscess formation
  5. Sinus tract formation
  6. Increases tooth mobility