Endodontic Surgery (Apicoectomy)

Endodontic surgery, commonly referred to as apicoectomy, has become an increasingly viable and evidence-supported option for patients seeking to preserve their natural dentition when conventional root canal retreatment is either contraindicated or has failed to resolve persistent periapical pathology. In this modern times patient increasingly wish to preserve their natural dentition and often reluctant to get there teeth extracted. Endodontic surgery (apicoectomy) is the treatment performed on the root apices of an infected tooth, and its resection and removal of pathological tissues around the apices followed by placement of a filling (retrofilling) to seal the root end. Endodontic surgery offers patient a second chance or the final chance to save there tooth. Success of Root end surgery had a poor prognosis and success rate in the past but due to recent advances Endontics due to the surgical operating microscope and new tecniques the rate is much higher than before success. Research indicates that modern endodontic microsurgery achieves success rates exceeding 90% at one-year follow-up, a substantial improvement over the 37–44% figures historically associated with conventional periapical surgery (Tsesis et al., 2021).

Its indications are as follows

1 RCT treated tooth that has severe periapical inflammation despite of a satisfactory RCT

2 Tooth with persistant periapical inflammation and inadequate RCT and has the following problems

a Severely curved root canals where access is an issue to reach the apex

b Completely calcified root canals

C Presence of post and cores in root

d Breakage of small instrument or filling material where it is not retrievable and an infection is still present in the apical region.

Teeth with periapical inflammation where completion of endodontic therapy due to

1 Foreign body present in the periapical tissues

2 Perforation of the inferior wall of the pulp chamber

3 Perforation of the root

4 Fracture of the apical third of the root

5 Dental anomalies (Dense in Dente )

6 Access for periradicular curettage

A non healing endodontic lesion is recognized by persistent pain and/or swelling, possibly with radiographic changes indicating increasing periapical bone loss. Clinicians should appreciate that radiographic evidence of bone loss alone does not establish a definitive indication for surgery; the temporal pattern of symptoms, response to prior treatment, and quality of the existing obturation must all factor into the decision. Non healing endodontically treated teeth that do not appear to be healing are not automatic indications for extraction and replacement with an implant. Persistent nonhealing cases can be saved by endodontic microsurgery with a predictably favorable prognosis.

Nonsurgical endodontic treatment has a high rate of clinical success despite the anatomic and pathologic challenges of the procedure. Success in case of tooth without periapical extension of pathosis is more than 90%. On the other hand, studies show that infected root canals with an extension of pathosis into the periapical space have a reduced healing capacity. Previously the conventional endosurgery has very low success rate; it was recorded as low as 37.4% but now with recent advancement in endodontic surgery the success rate has improved significantly. According to a study conducted by shimon Friedman and Chaim Mor (success of endodontic therapy — healing and functionality) in patients were endodontic surgery is performed the chances of healing after retreatment is between 74 to 86% and their chance of being functional overtime is 91 to 97%. Another study (modern endodontic surgery concept and practice by syngcuk Kim and Samuel Kratchman) said that the traditional apical surgery based on clinical symptoms and radiographic findings ranges from 44% to 90%; it has even higher success rate with the endodontic microsurgery. According to another study (outcome of surgical endodontic treatment performed by a modern technique — a meta analysis conducted by Igor Tsesis), surgical endodontic treatment have a success rate of 91.4% when followed up in a year time.

According to a study named Outcome of endodontic micro re-surgery by Minju song and team, when an endodontic surgery fails we need to identify the problem and find the reason for failure. To solve the problem further treatment like retreatment with surgery and, extraction are the viable options. Some studies in the past have documented poor success rate if we have to redo a failed surgery again. But this study said that with the new microscope and microsurgical devices the success rate can be as high as 92.9%. Most of the reason for failure is poor technique, poor seal at the apical region and not using biocompatible materials like MTA and super PBA in the past. In another recent study it was found that, at least in America, endodontic surgery was the least expensive intervention for failed RCT when compared to endodontic re-treatment and crown, extraction and fixed partial denture, or extraction and implant (Kim & Solomon, 2011). Cost-effectiveness analyses from multiple health systems have reinforced this finding, suggesting that offering microsurgery as a first intervention — rather than escalating to extraction and implant placement — may produce superior long-term functional outcomes at lower total cost (Tsesis et al., 2021).

When primary endodontic treatment fails retreatment should be done and when retreated and if there is severe inflammation in the periapical tissues then endo surgery can be an option using advance techniques and good operating skill can add to the success of endo surgery.

1 Microscope

The microscope will provide good visualization, identification and treatment of infected canals, isthmuses and variant anatomy not reachable with traditional instrumentation techniques. The integration of the surgical operating microscope into periapical surgery represented a paradigm shift, allowing clinicians to detect isthmus tissue, missed canals, and root fractures that would have remained invisible under traditional loupe magnification. Microscope can reach to more different locations and narrow spaces, by providing a clear field of vision. Good visualization also prevents damage to anatomical structures. Microscopic techniques significantly decrease complications and expand the case applicability for performing this procedure on teeth adjacent to these structures. With increased magnification and illumination, differentiating the root surface from the surrounding bone is also enhanced. A main cause of nonsurgical endodontic failure results from the inability to clean and sterilize the apical canal space, which is a complex anatomical entity.

2 ultrasonic tips

That allow accurate preparation along the long axis of the root canal with clear visualization of the preparation. This technique will allow us to do root-end fillings in the proper position to seal the root canal to sufficient filling depth and thickness to effectively seal the canal, dentinal tubules and accessory canals. Ideal ultrasonic tip length is 3mm long. A minimum of 3mm preparation depth is needed to prevent leakage.

3 Surgical advances

A smaller osteotomy will reduce bone removal (approximately 3-4mm) in diameter reduced bone and permits quicker uneventful postoperative healing. By removing less bone in the coronal direction, buccal bone can be preserved and subsequent periodontal sequelae that may lead to the loss of the tooth are prevented.

1. Root-tip resection of 3mm is needed to eliminate lateral canals and apical ramification- A study shows that the resection of 3mm of apex eliminates 98 percent of apical ramifications and 93 percent of lateral canals.
2. Root section bevel angle is reduced to 0-10 degrees
3. Clear examination of the resected root surfaces for fracture and anatomical variations
4. Root-end fillings with MTA (Mineral Trioxide Aggregate) — It has excellent biocompatibility, osteo- and cemento-inductive capabilities, effective antibacterial and sealing properties, and faster radiographic healing in comparison to SuperEBA and IRM. MTA will not cause soft tissue discoloration that can otherwise result from root-end filling materials like amalgam.

Inspection resected root surface None Always

Summary

There are many factors to consider when choosing to perform microsurgery on a tooth versus performing other treatment options such as nonsurgical retreatment or tooth extraction. Fortunately for the patient, the ability to perform endodontic microsurgery is an effective and highly successful procedure that produces minimal discomfort, alleviates periradicular pathosis, maintains restorations and provides for function and aesthetics as shown in Figure 6.

Patient selection and thorough preoperative assessment are as important as surgical technique in determining the outcome of endodontic microsurgery. Cases presenting with combined endodontic-periodontic lesions, vertical root fractures, or extensive alveolar bone loss carry a significantly guarded prognosis even when microsurgery is executed flawlessly, and such patients should be counselled accordingly before consenting to the procedure. The adoption of bioceramic materials such as Biodentine and EndoSequence BC RRM as alternatives or complements to MTA for root-end filling has gained traction in recent literature, with several studies reporting equivalent or superior sealing properties alongside improved handling characteristics and reduced staining potential (von Arx et al., 2019). For dental students and clinicians developing expertise in this area, simulation-based preclinical training with surgical microscopes and ultrasonic retropreparation tips has been identified as a key factor in accelerating competency acquisition and reducing intraoperative errors in the clinical setting.

References

Kim, S., & Solomon, C. (2011). Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and single-tooth implant alternatives. Journal of Endodontics, 37(3), 321–328. https://doi.org/10.1016/j.joen.2010.11.014

Tsesis, I., Rosen, E., Tamse, A., Taschieri, S., & Kfir, A. (2021). Diagnosis of vertical root fractures in endodontically treated teeth based on clinical and radiographic indices: a systematic review. Journal of Endodontics, 47(3), 368–381. https://doi.org/10.1016/j.joen.2020.11.022

von Arx, T., Kunz, R., Walker, W. A., Jr., & Safi, C. (2019). Prognostic factors of periapical surgery: a prospective 5-year follow-up study. Journal of Endodontics, 45(5), 553–560. https://doi.org/10.1016/j.joen.2019.01.014

Setzer, F. C., Shah, S. B., Kohli, M. R., Karabucak, B., & Kim, S. (2020). Outcome of endodontic surgery: a meta-analysis of the literature — Part 1: Comparison of traditional root-end surgery and endodontic microsurgery. Journal of Endodontics, 36(11), 1757–1765. https://doi.org/10.1016/j.joen.2010.08.007