Is This a Case for an Apicoectomy?
“The last time I had this much fun was a root-canal operation.”
~ Larry Ziegler, American professional golfer
Although root canals are tooth-saving treatments, they certainly do get a bum rap in popular culture!
While patients tend to dread root canals, they are even less happy about losing teeth. Sometimes, though, a conventional root canal is not an option. When that’s the case, what other options might you have for saving the tooth? Sometimes the answer is an apicoectomy.
What is an apicoectomy?
An apicoectomy is a retrograde root canal treatment that involves cutting the apex of the tooth. As Dr. Ali Nasseh, an endodontist who is a clinical instructor and lecturer at the Harvard School of Dental Medicine, runs a private practice and serves as CEO and president of RealWorldEndo, explains, apicoectomy is a last-resort procedure. As such, it is used to save teeth that have a problem that is purely at the apex.
“You essentially have to go from the end of the root and plug it,” Dr. Nasseh says. “I usually explain to patients that it’s the equivalent of putting a cork in a bottle. We have a tooth or canal that still contains bacteria. Even after having had the root canal, there’s still some biofilm present. We essentially seal it and prevent the egress of microbes from inside the tooth to the outside of the tooth.” This allows the patient to heal in the peripheral apex.
When should an apicoectomy be considered?
As Dr. Nasseh points out, our goal is to try to do non-surgical revision whenever possible. That should be the first thing you consider. Unfortunately, non-surgical revision is not always possible.
If the problem is purely at the apex, apicoectomy should be considered when the tooth meets one or more of the following criteria…
· Has had previous root canals
· Is so calcified that a conventional root canal cannot be done
· Has infection at the end of the root beyond a large ledge that prevents you from being able to clean it out
· Has very large cast posts and cores
· Has coronal impediments
That said, apicoectomy is not indicated in cases
· There is coronal leakage, meaning that you have faulty coronal restorations and there is a constant introduction of microbes to the inside of the root canal
· There is a missed canal
Another consideration is whether or not the endodontists in your geographic area do apicoectomies. Some are not comfortable with these procedures or will only do them on anterior teeth.
What is the key to success with these procedures?
“The techniques for apicoectomy have improved dramatically over the past 20 years,” says Dr. Nasseh. “The modern apicoectomy procedure enjoys a very high success rate, but that is really based on proper treatment planning. The main determinant of your success during apicoectomy is treatment planning and your diagnosis as to what is the cause of failure.”
For diagnosis, Dr. Nasseh notes that, “3D imaging has really helped revolutionize cases…because you get so much information. CBCTs have helped tremendously with the decision making between retreatment and surgery.”
With a CBCT you’re aware of the anatomy and have a full view of the entire situation. Is it a candidate for retreatment? If not, how much bone would have to be gone through? Is it close to a vital structure? Are there coronal impediments? Does it meet the criteria for apicoectomy listed above? If not, is an extraction called for? The CBCT can help you answer all of these questions and more.
If an apicoectomy is called for, Dr. Nasseh says that there is a 92% 10-year survival rate for teeth that have undergone endodontic apicoectomy and then retro filled using a “surgical lid” technique that he has developed over the past decade. “92% is phenomenal in my opinion,” he declares, “because you have got to remember that the tooth was already on its way to the graveyard.”