Root Canal Surgery|Apicoectomy
Occasionally, a non-surgical root canal procedure alone cannot save your tooth and surgery will be necessary. Root canal surgery can be used to locate small fractures or hidden canals that weren’t detected on x-rays or during previous treatment. Surgery may also be needed to treat damaged root surfaces or the surrounding bone of the tooth.
There are many surgical procedures that can be performed to save a tooth. The most common is called an apicoectomy.
What is an Apicoectomy?
In this procedure, the endodontist opens the gum tissue near the tooth to see the underlying bone and to remove any inflamed or infected tissue. The very end of the root is also removed and a small filling may be placed to seal the end of the root canal and few stitches or sutures are placed to help the tissue heal. Over a period of months, the bone heals around the end of the root. Endodontists are trained to use special microscopes that aid visualization of this procedure.
Basic Outline of the Surgical Procedure:
- Incision and Reflection of the gum tissue
- Removal of bone above the root (if necessary)
- Curettage of infected/inflammed tissue
- Resection of root tip
- Root-end cavity preparation
- Root-end filling
- Closure of Surgical Site (suturing)
- Post-operative Care
Below we will briefly discuss some cases from our clinic where apicoectomies were performed:
A 49-year old male was referred by his dentist to an Endodontist complaining of a ‘bad taste in his mouth’ and a draining pimple’ on his gum adjacent to his mandibular left first molar. The taste had been present for several months and the ‘pimple’ would sequentially enlarge, drain and fill up on a regular basis. Exam revealed a sinus tract (draining abscess) on the attached buccal mucosa adjacent to and associated with the lower left first molar.
A periapical radiograph of the lower left first molar revealed a large area of infection associated with the mesial root of the tooth. The radiograph also demonstrated that there were posts (metal) in both mesial and distal roots .The existing mesial root canal filling was overextended, with 1 mm extruded beyond the radiographic apex of the mesial root.
The treatment options for saving this tooth were either: 1. Non-surgical retreatment or 2. Surgical Retreatment (Apicoectomy). Given that the infection was only related to one root and taking into consideration that the tooth had a crown and there was a metal post obstruction access to the root tip. The best option for treatment without compromising tooth structure was an apicoectomy of the infected root. If the patient had refused this then extraction would have been recommended. Surgery was performed with the following outcome:
A 56 year old female presented to the office complaining of pain and swelling in the upper anterior region. The pain and swelling came on suddenly without any prior signs or symptoms. Examination of the region revealed a swelling above the upper anterior central incisors. She had crowns on these two teeth that were placed over fifteen (15) years ago. The crowns however, looked good and were well-fitting.
Radiographic examination revealed large areas of infection above both roots. Both teeth had no prior root can treatment. Ordinarily, non-surgical root canal treatment would have been first choice for these two teeth by accessing the root canal system by drilling through the back of the crowns. But the radiograph revealed that the crowns were possibly held in place by a cast post. Trying to drill through this would (1) prove difficult and (2) could possibly interfere with the retention of the crown leading to it coming off. So it was decided that the best treatment option for her was an apicoectomy.
A 40 year old male presented with a swelling adjacent to his lower left first molar. The tooth had a crown and a previous root canal that was done about 10 years ago. Radiographic examination showed significant infection around his mesial root. The root canal fillings look good, but if you look closely a fractured instrument can be seen at the apex of one of the mesial roots. Most likely it was the inability to clean this root (due to the instrument) that lead to the persistent infection.
Again, this was another candidate for apicoectomy as it would have been impossible to remove the fractured instrument to facilitate non-surgical retreatment.
The above three cases shows that we can have remarkable healing with this procedure. Endodontists use technology such as microscopes which have increased success rates of this procedure. The use of Cone-Beam CT (CBCT) scans have further improved our ability to diagnose and treat endodontic cases. Despite advances in technology, success also depends on proper patient and /or tooth selection. Once all factors are taken into consideration then can we decide on the best treatment option.