Apicoectomy

(Other names: APICECTOMY, ROOT-END RESECTION) It is the ablation of apical portion of the root-end attached soft tissues.

Indications

• Inability to perform nonsurgical endodontic therapy due to anatomical, pathological and iatrogenic defects in root canal.
• Persistent infections after conventional endodontic treatment.
• Need for biopsy.
• Need to evaluate the resected root surface for any additional canals or fracture.
• Medical reasons.
• Lack of time.
• For removal of iatrogenic errors like ledges, fractured instruments, and perforation which are causing treatment failure.
• For evaluation of apical seal.
• Blockage of the root canal due to calcific metamorphosis or radicular restoration.

Guidelines for Bone Removal

1. Adequate anesthesia and hemostasis is necessary.
2. Always sterilize the handpiece before use.
3. Flush the water lines connected to dental unit thoroughly before use.
4. Use sharp and sterile round burs.
5. Amount of pressure should be light while cutting the bone.
6. Handpiece either high speed or low speed should be used with coolant.
7. Cut bone in a shaving or brush stroke method.
8. Visibility of the operative site should be good in order to increase the success of procedure. Position the handpiece, bur, suction tip and operating light in right direction to increase the visibility.
9. Avoid deep penetration (3-5 mm) during cutting.

Factors to be considered before root-end resection

Instrumentation

High speed handpiece with surgical length fissure bur usually results in satisfactory resection. Use of round bur may result in gouging of root surface where as crosscut fissure burs can lead to uneven and rough surface.

In a study by Nedderman et al it was found that use of round burs produce ditching of the root surface where as crosscut fissure burs produce the roughest root surface. Use of low speed tissues bur showed to produce the smoothest root surface.

Recently studies have shown the use of Er:YAG laser and Ho:YAG laser for root end resection but among these Er:YAG laser is better as it produces clean and smooth root surface. Advantages of use of laser in periradicular surgery over the traditional methods include:

1. Reduction of postoperative pain.
2. Improved hemostasis.
3. Reduction of permeability of root surface.
4. Potential sterilization of the root surface.
5. Reduction of discomfort.

Extent of resection

Factors to be considered while performing root-end resection are:

1. Access and visibility of surgical site.
2. Anatomy of the root, i.e. its shape, length, etc.
3. Anatomy of the resected root surface to see number of canals.
4. Presence and location of iatrogenic errors.
5. Presence of any periodontal defect.
6. Presence of any root fracture.
7. Need to place root-end filling into sound tooth structure.

According to Cohen et al the length of root tip for resection depends upon the frequency of lateral canals and apical ramifications at the root-end. They found that when 3 mm of apex is resected, the lateral canals are reduced by 93 percent and apical ramifications decreased by 98 percent. Whereas a root resection of 3 mm at a 0 degree bevel angle eliminates most of the anatomic features that are possible cause of failure.

Angle of Root-end Resection

Earlier it was thought that root-end resection at 30-45° from long axis of root facing buccally or facially provides:

• Improved visibility of the resected root-end.
• Improved accessibility

Recently, several authors presented evidence that beveling of root-end results in opening of dentinal tubules on the resected root surface that may communicate with the root canal space and result in apical leakage, even when a retrofilling has been placed. Nowadays a bevel of 0°-10° is recommended with ressection at the level of 3 mm. Short bevel of 0° is almost perpendicular to long axis of the tooth. It has following advantages:

1. Short bevel allows inclusion of lingual anatomy with less reduction.
2. If multiple canals are present, increase in bevel causes increase in distance between them.
3. For preparing long bevel more of tooth structure has to be removed.
4. Short bevel makes it easier for the clinician to resect the root end completely.
5. With short bevel more of lingual anatomy can be assessed with less of tooth destruction.
6. With Longer bevel, it is more difficult to keep instruments within long axis of the tooth. It is always preferred to keep instruments with in long axis of the tooth so as to avoid unnecessary removal of radicular dentin. This can be achieved with short bevel.
7. Long bevel exposes more dentinal tubules to the oral environment, this can result in more microleakage over a period of time.

Irrespective of the angle or extent of the resection, the main fundamental of the root resection is that it should be complete and no segment of root is left unresected.

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