Apicoecto

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 Apicoectomy is the surgical resection

of the root tip of a tooth and its
removal together with the
pathological periapical tissues

Fragiskos

Indications
The indications for apicoectomy include the following cases:
1. Teeth with active periapical inflammation, despite the
presence of a satisfactory endodontic therapy.
2. Teeth with periapical inflammation and unsatisfactory
endodontic therapy, which cannot be repeated because of:
Completely calcified root canal.
Severely curved root canals.
Presence of posts or cores in root canal.
Breakage of small instrument in root canal or the presence
of irretrievable filling material.
3. Teeth with periapical inflammation, where completion of
endodontic therapy is impossible due to:
Foreign bodies driven into periapical tissues.
Perforation of inferior wall of pulp chamber.
Perforation of root.
Fracture at apical third of tooth.
Dental anomalies (dens in dente).

Contraindications
The contraindications for apicoectomy are as
follows:
Concerning the age of the patient and general
health problems, such as severe cardiovascular
diseases, leukemia, tuberculosis, etc.
Teeth with severe periodontal disease (deep
periodontal pockets, great bone destruction).
Teeth with short root length.
Teeth whose apices have a close relationship
with anatomic structures (such as maxillary
sinus, mandibular canal, mental foramen,
incisive and greater palatine foramen).

Armamentarium
The following instruments are necessary for performing an
apicoectomy:
1) Microhead handpiece (straight and contra-angle) and microbur
2) Special narrow periapical curette tips for preparation of the periapical
cavity
3) Apical retrograde micro-mirror and micro-explorers
4) Local anesthetic syringe and cartridges.
5) Scalpel handle.
6) Scalpel blade (no. 15).
7) Mirror.
8) Periosteal elevator.
9) Cotton pliers.
10)Small hemostat.
11)Suction tips (small, large).
12)Irrigation receptacle.
13)Needle holder.
14)Retractors.

Microhead handpiece compared to a conventional

handpiece. With this handpiece, preparation of the
periapical cavity is greatly facilitated in areas with limited

Special narrow periapical curette tips. They are used for

preparation of the periapical cavity in areas with limited
access

Apical retrograde micromirror and micro-explorers for

determining the dimensions of the created periapical
cavity

15) Periodontal curette.

16) Periapical curette.
17) Appropriate burs (round, fissure,
inverted cone).
18) Miniaturized amalgam applicator
for retrograde fillings.
19) Narrow amalgam condensers.

Miniaturized amalgam applicator compared to a

standard amalgam carrier

Instruments and materials for retrograde filling. Amalgam

capsule (top left). Miniaturized amalgam applicator (top
right). Narrow amalgam condensers, with tips appropriately

16) Scissors, needles and no. 30 and

40 sutures.
17) Metal endodontic ruler.
18) Gauze and cotton rolls/pellets.
19) Syringe for irrigating surgical field.
20) Saline solution.

Surgical Technique
The procedure for apicoectomy includes the
following steps:
1. Designing of flap.
2. Localization of apex, exposure of the
periapical area and removal of
pathological tissue.
3. Resection of apex of tooth.
4. Retrograde filling, if deemed
necessary.
5. Wound cleansing and suturing.

PRINCIPLES AND GUIDELINES FOR

FLAP DESIGNS
1) Avoid horizontal and severely angled vertical
incisions
2) Avoid incisions over bony eminences
3) Incisions should be placed and flaps repositioned
over solid bone
4) Avoid incisions across major muscle attachments
5) Tissue retractor must be rest on solid bone
6) Provide adequate visual and operative access with
minimal soft tissue trauma
7) Never split the involved interdental papilla
8) Involve the entire mucoperiosteum

Classification of surgical
flaps
There are two major categories of flap
design:
1) Sulcular full thickness flaps (full
mucoperiosteal flaps)
2) Mucogingival flaps (partial
mucoperiosteal flaps)

 Sulcular full thickness flaps are

further divided into different flap
designs depending on the geometric
shape of the flap;
1) Triangular ( one vertical
releasing incision)
2) Rectangular ( two vertical
releasing incisions)
3) Trapezoidal ( broad based
rectangular)

 Mucogingival flaps are further

divided into two;
1) Submarginal curved
( semilunar)
2) Submarginal scalloped
rectangular ( LuebkeOchsenbein)

Sulcular full thickness flaps

Triangular flap:
1) Created by a horizontal, intrasulcular
incision and one vertical releasing incision
2) Affords good wound healing
3) Minimal disruption of vascular supply
4) Ease of flap reapproximation
5) Main disadvantage is minimal surgical
access
6) Recommended for posterior teeth

 Rectangular flap:
1) Formed by intrasulcular, horizontal incision and two
vertical releasing incisions
2) Surgical access is increased in this flap
3) This flap design useful for mandibular anterior teeth,
multiple teeth and teeth with long roots e.g. maxillary
canines.
4) This flap design not recommended for posterior teeth
5) Main disadvantages are reapproximation and wound
closure are difficult
6) Postsurgical stabilization is difficult
7) Greater potential for postsurgical flap dislodgment

 Trapezoidal flap:
1) Similar to rectangular flap except
two vertical releasing incisions
intersect the horizontal,
intrasulcular incision at obtuse angle
2) Broad based flap with vestibular
portion being wider than the
sulcular portion

 Horizontal flap:
1) Also know an envelope flap
2) Created by a horizontal,
intrasulcular incision with NO
vertical releasing incision
3) Limited surgical access

Mucogingival flaps
Semilunar flap:
1) Inadequate visual and operative
access
2) Utilized for incision and drainage
procedure
3) Leaves a noticeable scar

 Submarginal scalloped rectangular

(Luebke-Ochsenbein):
1) Scalloped incision in the middle of the
attached gingiva
2) The angle of the incision in relation to the
cortical plate is 45 degree because this
angle provides the widest cut surface
3) Major disadvantages are excessive
bleeding, potential for flap shrinkage,
delayed healing and scar formation

Premedication
The following drugs are used in endodontic
surgeries which are recommended before
and after surgical endodontics:
1) Anti-inflammatory analgesics 400mg
ibuprofen just before the surgery to
minimize postsurgical inflammatory
response
2) Tranquilizers if the patient is anxious
about the surgery, 10mg diazepam
taken 15-30mins before the surgery

3) Antibiotics patients with diabetes or heart

valve problems should be premedicated with
antibiotics giving 500mg Amoxicillin before
and after the surgery
4) Antibacterial rinse to reduce oral
microflora, patients should be instructed to
use a 0.12% chlorhexidine gluconate
mouthrinse night before surgery, the
morning of surgery and one hour before the
surgery. Rinsing should be continued after the
surgery for 1 week

Designing of Flap
There are three types of flaps
principally used for apicoectomy:
1) The semilunar
2) Triangular and
3) Trapezoidal

 When the apicoectomy is performed

at the anterior region (e.g., maxillary
lateral incisor) and there is an
extensive bony defect near the
alveolar crest
Extensive periapical lesion at
maxillary right lateral incisor.
Indication for apicoectomy

Clinical photograph of case

shown.
Arrow points to possible location
of lesion

 The surgical procedure is performed

using a trapezoidal flap.
The incision for creating the flap
begins at the mesial aspect of the
central incisor and, after continuing
around the cervical lines of the teeth,
ends at the distal aspect of the
canine.

Surgical procedure for removal of periapical lesion, together with

apicoectomy at lateral incisor of maxilla. Incision for creation of
trapezoidal flap. a Diagrammatic illustration. b Clinical photograph

 With a periosteal elevator, the

mucoperiosteum is then carefully
reflected upwards

Reflection of mucoperiosteum and exposure of labial alveolar

plate after elevation of flap.

Localization and
Exposure of Apex
1) When the periapical lesion has
perforated the buccal bone,
localization and exposure of the root
tip is easy, after removing the
pathological tissues with a currette

2) If the buccal bone covering the

lesion has not been completely
destroyed, but is very thin, then its
surface is detected with an explorer
or dental curette, whereupon, due to
decreased bone density, the
underlying bone is easily removed
and the apex localized.

3) When the buccal bone remains

completely intact, then the root tip
may be located with a radiograph.
More specifically, after taking a
radiograph, the length of the root is
determined with a sterilized
endodontic file or metal endodontic
ruler. The length measured is then
transferred to the surgical field,
determining the exact position of the
root tip

 With a round bur and a steady

stream of saline solution, the bone
covering the root tip is removed
peripherally, creating an osseous
window until the apex of the tooth is
exposed.

 Enough bone is removed until easy

access to the entire lesion is
permitted.

A curette is then used to remove

pathological tissue and every foreign
body or filling material,
while
Removal of periapical
lesion with hemostat an
curette
resection of the root tip follows

Resection of Apex of
Tooth
The apex is resected (23mmof the
total root length) with a narrow
fissure bur and beveled at a 45
angle to the long axis of the tooth

 For the best possible visualization of

the root tip, the beveled surface
must be facing the dental surgeon.

 After this procedure, the cavity is

inspected and all pathological tissue is
meticulously removed by curettage,
especially in the area behind the apex
of the tooth.
If the entire root canal is not
completely filled with filling material or
if the seal is inadequate, then
retrograde filling is deemed necessary.

Retrograde Filling
Gauze impregnated with adrenaline to
minimize bleeding is placed in the
bony defect.
A microhead handpiece with a narrow
round microbur is then used to
prepare a cavity approximately 2 mm
long, with a diameter slightly larger
than that of the root canal

Preparation of cavity at root tip of tooth

usingmicrohead handpiece

 The cavity may be enlarged at its

base using an inverted cone-shaped
bur to undercut the preparation for
better retention of the filling material

 After drying the bone cavity with gauze

or a cotton pellet, sterile gauze is
packed inside the bone deficit and
around the apex of the tooth, in such a
way that only the prepared cavity of the
root end is exposed.
The amalgam is placed inside the cavity
with the miniaturized amalgam
applicator and is condensed with the
narrow amalgam condenser

 The excess amalgam is carefully

removed and the filling is smoothed
with the usual instruments

Wound Cleansing and Suturing

of Flap
After placement of the amalgam, the
gauze is carefully removed from the
bony defect and, after copious
irrigation with saline solution, a
radiographic examination is performed
to determine if there is amalgam
splattering in the surrounding tissues.
The flap is repositioned and
interrupted sutures are placed

Radiograph taken before suturing of flap, which shows

retrograde amalgam filling

 Healing of the periapical area is

checked every 612months
radiographically, until ossification of
the cavity is ascertained.
In order to evaluate the result, a
preoperative radiograph is necessary,
which will be compared to the
postoperative radiographs later.

Root end filling materials

Amalgam is the most
commonly used
retrograde filling
material. Recently,
though, Super-EBA and
MTA cement
have been considered
choice materials, with
preparation
of the cavity being
performed in exactly the
same way as
that for amalgam. Other

 Similarly, when apicoectomy is

performed in the anterior region (e.g.,
maxillary central incisor) and the size of
the lesion is small, and when there are
esthetic crowns on the anterior teeth,
the semilunar flap is preferred.
The procedure in such a case is similar
to that of the previously mentioned
surgical procedure employing the
trapezoidal flap

Radiograph of maxillary central incisor, showing periapical lesion

and unsatisfactory filling of the root canal

Clinical photograph of the

case

Surgical procedure for apicoectomy at maxillary left central incisor.

Semilunar incision made for flap

Reflection of flap and retraction with broad end of

Removal of bone covering apex of tooth

Exposing periapical lesion and apex of tooth together after removal

Removal of periapical lesion with hemostat and

periapical curette

Resection of apex of tooth at a 45 angle

Preparation of cavity at apex with

microhead handpiece

prepared cavity ready for placement of

Placement of filling at root tip with miniaturized

amalgam applicator

Condensing amalgam at periapical cavity with narrow amalgam

peration site after placement of sutures

Periapical radiograph
taken after suturing o
flap, showing
retrograde amalgam
filling

Amalgam splatter at operation site, as a result of improper

manipulations for removal of excess material

Post operative
instructions
Do not do difficult activity or strenous exercise for the
rest of the day
Do not take alcohol or chew tobacco
Good diet and drink lots of liquids for the first few days
Do not lift up the lip or pull back your cheeks. This
may pull the stitches and cause bleeding
A little bleeding is normal
There may be little swelling and bruising of the face
Place an ice bag on face where surgery was done
After 8 hours of the surgery the ice bag should not be
kept but use a hot wet towel on the face. Do this for
the next 2 to 3 days
Rinse the mouth with chlorhexidine mouthwash two
times a day for 5 days
It is important to remove the stitches after 2 days

Complications
The most common perioperative and
postoperative complications that may
occur during and after the surgical
procedure, respectively, are:
Damage to the anatomic structures in
case of penetration of the nasal
cavity, maxillary sinus and mandibular
canal with the bur.

 Bleeding from the greater palatine

artery during apicoectomy of palatal
root.

 Splattering of amalgam at the

operation site, due to inadequate
apical isolation and improper
manipulations for removal of excess
filling material

 Staining of mucosa due to amalgam

that remained at the surgical field
(amalgam tattoo)

 Healing disturbances, if the

semilunar incision is made over the
bony deficit or if the flap, after
reapproximation, is not positioned on
healthy bone.

Wound dehiscence, as a result of improper design of s

 Dislodged filling material due to

superficial placement, as a result of
insufficient preparation of apical
cavity

Malpositioned retrograde obturation material, due to insufficient

preparation of apical cavity

 Incomplete root resection, due to

insufficient access or visualization
and misjudged length of root