ApicoectomyFig. 1

Microsurgical Apicoectomy

When a root tip is inflamed, it is reduced by means of operation. The root canal is cleaned from the direction of the tip, it is then treated and tightly closed again with the help of cement. Apicoectomies help to remove inflamed tissue or cystigerous tissue at the root tip as well as to remove possibly infected canals within the last 3 mm from the root tip.
The time required for doing an apicoectomy depends on the number of roots of the tooth or on the number of roots of a tooth that have to be shortened, respectively.

When is an apicoectomy carried out?

  • Failure of a conventional root canal treatment
  • Blocked root canal (obliteration, pins or broken root canal instruments)
  • Root canal sealer: Massively overfilled canals with involvement of neighbouring structures
  • Via falsa, which is resistant to conventional therapy
  • Radicular cysts
  • Horizontal root fractures in the lower third

ApicoectomyFig. 2

Which advantages does the use of the microscope have for the patient?

  • The complete closure of the root canal means that the inflammation of the root will heal in the long run.
  • By magnification and by using the microsurgical equipment, the wound and the access through the bone to the root tip get smaller. This results in a merely small swelling after the intervention and in less pain.
  • Improved safety in order not to injure the endangered neighbouring structures, such as nerves and roots of neighbouring teeth.

Which advantages does the microscope offer the surgeon during an apicoectomy?

  • The optical magnification of the area under surgical treatment allows the imaging and treatment of the root canal system and of the endangered anatomic neighbouring structures.
  • Complete illumination of the area under surgical treatment, also for angular optical paths.
  • Use of microsurgical equipment and suture material

ApicoectomyFig. 3

Root canal treatment or extraction?

Due to their major bendings, natural roots can often not be broadened through the root canal by technical instruments and can thus not be disinfected either. Germs remain in the root. This results in pain and bite sensitivity concerning the tooth, despite of the root canal treatment. Figure 3 gives an example of a 180 degree bending in a root. The last resort for the tooth is the detaching of the extremely bended and infected part of the root.

Figure 4 shows how the root canal branches out at the root tip. This makes it very difficult to remove the germs from this area and possibly leads to a failure of the root canal treatment.

ApicoectomyFig. 4

The following findings were made during the inspection of the root canal:

  • Sandglass-shaped connections between the canals
  • Unfilled ampulla-shaped protrusions
  • Unfilled lateral canals
  • Microfractures

Results from apicoectomies in Dr Stefan Möller's practice in the year 2003

In case of 156 apical lesions (groups A-C according to Kim, 2001), a complete ossification of the apical lesions as well as freedom from symptoms was achieved for 133 root tips six to twelve months after a microsurgical apicoectomy with retrograde closure. For 10 lesions, a partial regeneration was seen with freedom from symptoms. 13 apical lesions showed no healing tendencies and remained symptomatic with pathologic findings. After 12 months, this equals a success rate of 85.2 %.

Conclusion

Considering the size of the structures to be treated, the use of microsurgical techniques seems essential for endodontic surgery.
A tight retrograde closure of the neoapex is obligatory. With an up to 20-fold magnification, the operating microscope allows a good illumination of the operating area. The ergonomic work posture and the distance accommodation relieve the surgeon during longer interventions.
After 12 months, we achieve a complete ossification of the lesions with freedom from symptoms in 85 % of the cases in the defect classes A-C (Kim, 2001). No pathologic findings are seen.