An apicoectomy (WSR) (synonyms: amputatio radicis dentis; apectomy; apical osteotomy; surgical root filling; radical surgery of apical periodontitis (inflammation of the periodontium (tooth-supporting apparatus) just below the root of the tooth; apical = “tooth rootward”); root tip amputation) is a surgical procedure in which the root tip of a previously root-treated tooth and the inflamed area surrounding the root tip are removed. It serves to preserve the affected tooth by eliminating the inflammation. For this purpose, under local anesthesia (local anesthesia), access is created through the bone to the root tip by means of an osteotomy (surgical cutting of bone or the excision of a piece of bone). The final root filling of the already root-treated tooth can also be placed intraoperatively (during the operation). While root filling is essential for success, additional retrograde closure of the root canal (from the newly created root tip) is not mandatory. The surgery is a routine procedure in dental practice. It is necessary in the case of apical periodontitis (disease of the periodontium affecting the root apex area) if a root canal treatment performed in advance does not result in freedom from inflammation. In this case, a chronic apical inflammation occurs with the formation of granulation tissue as a defensive reaction, which can no longer be brought to healing with conventional methods.
Symptoms – Complaints
Typical symptoms or complaints that lead to the planning of an apicoectomy are:
- Pain, localized or radiating
- Feeling of pressure
- Acute flare-up of chronic inflammation of the periapical space (space surrounding the root apex), possibly with abscess formation (formation of an encapsulated collection of pus)
- Fistula formation
- Bite or knock sensitivity (percussion dolence).
- Radiographically: widened periodontal gap surrounding the root apex (periapical).
Diagnostics
The following diagnostic measures are necessary before making a treatment decision:
- Clinical examination to determine whether the tooth is worthy of preservation.
- Percussion test (checking the sensitivity to bite).
- Sensitivity test, thermal or electrophysiological.
- X-ray of the tooth and its surrounding structures
- Weigh concomitant diseases (blood clotting; immune deficiency; diabetes mellitus and many more), subsequently e.g. initiation of laboratory tests or concomitant antibiotic therapy.
Therapy
The aim of apicoectomy is to bring pathological (pathological) changes such as apical granulomas, cysts (pathological fluid-filled cavity with independent wall) and periodontitis (inflammation of the periodontium) in the periapical (surrounding the root apex) area to heal, thereby preserving the tooth.
Indications (areas of application)
- Persistent apical periodontitis (inflammation of the periodontium (periodontium) just below the tooth root; apical = “tooth rootward”) with clinical symptoms on a root-filled tooth
- Persistent apical periodontitis with increasing osteolysis (bone dissolution) in radiographic follow-up on a root-filled tooth
- Cyst formation at the apex (root tip).
- Clinical symptoms, the cause of which is root filling material overflowing into the neighboring structures of the apex (root tip)
- On teeth that due to their anatomy – e.g. due to strong bending – are not regular with a root canal treatment, which show clinical symptoms or have a conspicuous X-ray findings.
- In the case of apical osteolysis (bone dissolution) from about 5 mm in diameter even without clinical symptoms.
- In the event of fracture of an instrument that serves to prepare the root canal before root canal filling, provided that it cannot be removed via the root canal
- In the case of a via falsa (wrong path; here: perforation of the root canal wall) near the apex.
- In case of fracture (break) of the apical third of the root.
- In apical periodontitis of a root-filled tooth supplied with post, where the post cannot be removed to revise (renew) the root filling.
Contraindications
- General diseases that would also prohibit extraction (tooth removal).
- Surgery during an acute putrid exacerbation (flare-up inflammation associated with pus formation).
- Surgery on teeth with severe periodontitis marginalis (inflammation of the periodontium starting from the gingival margin with bone loss).
The surgical procedure
- Local anesthesia (local anesthesia).
- Incision for the formation of a mucoperiosteal flap (mucosa-bone skin flap), e.g. arch incision according to Partsch; e.g. gingival margin incision, if the marginal periodontium (periodontal apparatus) is to be provided with periodontal surgery at the same time
- Exposure of the apex (root tip) by removing the overlying bone.
- Exposure of the entire root apex and creation of a bone window large enough to separate the ramification area (area of the root apex where the nerve branches laterally) and clear out the inflammation of the surrounding tissue
- Separation of the apex and removal of the inflamed tissue.
- If not already done in advance, now conventional root filling.
- Retrograde filling (filling from the root tip) of the former nerve entry site at the newly created apex.
- Final irrigation of the resection cavity.
- Reduction (repositioning) of the wound flap and suture care.
Routinely, apicoectomy is performed without a surgical microscope. However, in difficult cases, its use facilitates the accurate identification of the root apex, the observation of its surface texture and the detection of ramifications (ramifications of the nerve exit site). In combination with special microsurgical instrumentation, it is also possible to keep the bone wound smaller, if the extent of inflammation permits, and to perform retrograde filling more accurately in more difficult cases.
After surgery
- Lack of movement in the surgical area
- Two days of intermittent cooling with cold packs (refrigerator temperature only, not freezer) to minimize edema (swelling)
- Suture removal after about eight days
Possible complications
- Unusual bleeding intraoperatively (during surgery).
- Postoperative bleeding (rare)
- Nerve injury, e.g., to the mental nerve (branch of the inferior alveolar nerve from the mandibular nerve, which supplies the skin around the chin and the lower lip) during resection (surgical removal) of lower premolars (anterior molars)
- Maxillary sinus opening during resection of upper molars.