Definition: It is the cutting off, of the apical portion of the root and curettage of the periapical necrotic, granulomatous, inflammatory or cystic lesion.
Synonym: Apical Surgery, Root Resection, Endodontic Surgery, Root Amputation
Indications of Apicoectomy:
- Apical anamoly of root tip-dilacerations, intracanal calcifications
- Presence of lateral/accessory canal/apical region perforations
- Roots with broken instruments
- Root with overfilling
- Fracture of apical third of root
- Formation of periapical granuloma and cyst
- Draining Sinus tract
- Non responsive to RCT
- Over extension of root canal cement beyond the Apex
- Blocked Root Canal due to any Calcifications
- When patient with chronic peri apical infection
- Teeth with Apical resorption
- Persistent infections after conventional Root Canal Treatment
Contraindications of Apicoectomy:
- Medically compromised patients
- Teeth with deep periodontal pocket and excessive mobility
- Teeth with poor Accessibility
- When there is extensive involvement of Bone
- Danger of involvement of anatomical structure
Steps of Apicoectomy:
In the process of Apicoectomy, there are multiple steps to be followed to reach to the root tip.
Flap Elevation: Retraction of the Gingiva or tissue to gain access to the periradicaular area is required. A localized flap design should be given to access the periradicular bone region of the tooth to be treated. A Vertical incision should be given apical to the junction of horizontal and vertical incision and elevate the flap.
Bone Removal: The Root tips are covered by Bone on the buccal surface, removal of bone helps in gaining access to the periradicalar area of the tooth. There are certain tips which should be kept in mind before going for Bone removal – Always use a sharp and sterile round bur, only light pressure should be given while cutting bone, shaving or brushing strokes should be given while cutting the bone, make sure that there are no important structures which are being harmed while bone cutting.
Root End Resection / Preparation: Root Resection has to be planned depending on the anatomical variations of the Root structure and the pulp chamber as well. There can be many anatomical changes in the pulp structure based on which the length of root to be removed is decided and also the amount of bevel which should be given.
What are the instruments used for Root End Resection in Apicectomy: High Speed hand piece with a surgical fissure bur, round bur and according to a study by Nedderman et al, a low speed tissue bur produced a smooth root surface in comparison to round bur which was rough and gouging of the root surface was seen. Some studies have also shown that use of Er.YAG laser and Ho:YAG laser was found to produce a much smoother and clean root end.
What is the Extent of Resection required: The amount of root surface to be removed is decided based on two simple points – removal of complete granulation tissue to remove foci of infection and to eliminate any anatomical variations of the root structure and pulp chamber to prevent re infection.
Re-approximation of the Soft Tissue
- Preoperative Assessment
- Preoperative Consideration
- Preoperative preparation (Intra oral and Extra oral)
- Armamentarium (Standard Surgical set)
- Anesthesia (LA, nasal intubation)
Step by Step Surgical Procedure of Apicoectomy:
- Design of Mucoperiosteal Flap
- Reflection of Mucoperiosteal Flap
- Exposure of Periapical Pathology and Root Tip
- Removal of Periapical pathology
- Ressection of Root Apex (Apical 1/3rd)
- Sealing of the Apex
- Toilet of the wound
- Smoothing of the Sharp Bony margins
- Bleeding Control
- Closure of the Surgical Wound – Suturing
Postoperative instructions, medication and care
Complications of Apicoectomy:
- Infection Flare up
- Ludwigs Angina
- Fracture of Maxilla and Mandible
- Soft tissue injury
- Opening of Maxillary Sinus – Oro Antral Fistula
- Secondary Hemorrhage
- Secondary hemorrhage
- Non vitality of Adjacent teeth
- Nerve Injury
- Luxation of adjacent teeth