Endodontic surgery, also known as apicoectomy, involves surgically resecting the root tip and surrounding pathological tissues to resolve periapical lesions and restore tissue health. It is often performed when root canal treatment fails or has difficulties. The aim is to disinfect the pulp space and seal it to prevent reinfection. Periapical lesions are caused by microbial contamination reaching the apex via caries or trauma. Treatment options include extraction, retreatment, or surgery. Endodontic surgery requires resection of the apex and removal of pathological tissue. Care must be taken near anatomical structures like the maxillary sinus or mental foramen. Both conventional and retrograde approaches are used depending on the clinical situation.

1. Presented by :
Dr. Ahmed elfatory
Oral and Maxillofacial Surgery Department
Zawia University, Faculty of Dentistry
Endodontic surgery

2. HISTORICAL ASPECT TO ENDODONTIC
SURGERY…
 A Mandible in Egypt from 2900 to 2750 BC contained
holes, that could have been made for relief of pain.
 The first recorded endodontic surgical procedure was the
incision and drainage of an acute endodontic abscess
performed by Aetius, a Greek physician–dentist, over
1,500 years.

3. Endodontic surgery
Definition of Endodontic surgery (Apicoectomy)
is the surgical resection of the root tip of a tooth and its removal
together with the pathological periapical tissues to restore these
tissues to functional health.. Accessory root canals and additional
apical foramina are also removed in this way, which may occur in the
periapical area and which may be responsible for failure of an
endodontic therapy.
It is often the last hope for retention of a tooth and therefore
requires the greatest skill, the surgeon must have a thorough
knowledge of the anatomic structures in relation to each other,
including tooth anatomy.
.

4. The aim of endodontic treatment
• The aim of endodontic treatment is to disinfect the pulp space (reducing
the microbial load and removing necrotic tissue) followed by sealing this
space to prevent recontamination. Success rates of 47–97% for primary
root canal treatment have been reported , with failures more likely to be
associated with pre-operative presence of periapical radiolucency, root
fillings with voids, root fillings more than 2mm short of the radiographic
apex, and unsatisfactory coronal restoration

5. Pathogenesis of periapical lesions
The pulpal and subsequent periapical disease is caused by
microbial contamination. This commonly occurs via a carious
lesion and some time occurs due to periodontal disease or
dental trauma. As resultant necrosis of the pulpal tissue lead to
inflammatory products and pathogens and their byproducts to
exit through the apical foramen . This frequently results in the
formation of a periapical lesion , as apical granuloma or cyst
which directly contributes to destruction of the surrounding
dentoalveolar bone. immune response can not manage the
periapical lesion if the source of infection still present .
Therefore, the apical lesion will resolved (( only )) when the
origin of infection is treated ,and the root canal effectively
sealed. an apical sealing will prevent entrance of any remaining
toxins into the surrounding periradicular tissues. Furthermore,
an effective coronal seal is essential to prevent reentry of
microorganisms from the oral cavity into the root canal .
Caries pulp necrosisperiapical abscess or granuloma radicular cyst

6. Treatment options of tooth with periapical
lesions
1. Extraction if the tooth is unuseful or un restorable.
2. Root canal filling if the tooth restorable and there is some
evidence that small periapical lesion may resolved following
successful root canal filling .
3. Endodontic surgery , when there is failure of root canal filling or
there are some difficulty to do root canal filling .

7. Indications for endodontic surgery
1. Failure of nonsurgical retreatment (treatment has been rendered at least two
times) . Teeth with active periapical inflammation, despite the presence of a
satisfactory endodontic therapy.
2. Failure of nonsurgical (initial) treatment and retreatment is not possible
practical. Teeth with periapical inflammation and unsatisfactory endodontic
therapy, which cannot be repeated because of:
• Severely curved root canals.
• Presence of posts or cores in root canal.
• The presence of irretrievable filling material.
3. Teeth with periapical inflammation, where completion of endodontic therapy is
impossible due to:
o Fracture at apical third of tooth.
o Completely calcified root canal.
o Dental anomalies
o Procedural errors during endodontic treatment
• Breakage of small instrument in root canal
• Difficult ledging formation during instrumentation of root canals.
• Root perforation.
• Symptomatic overfilling.
• Foreign bodies driven into periapical tissues.

8. A-Pre-operative x-ray shows a good
looking root canal, but also a large circular
lesion around the ends of the mesail roots.
Patient is having symptoms of pain and
swelling. Apicoectomy is recommended.
C- X-ray -4 years after Apicoectomy
B-Patient had the root canal, post
and crown done many years ago.
x-ray shows a large cyst growing at
the end of the root and external
root resorption. Re-doing the root
canal will only destroy the post,
crown, and the tooth

9. Contraindications for endodontic surgery
• All conditions that could be considered contraindications for oral
surgery.
Patients with such diseases as leukemia or neutropenia in active
state, severely diabetic patients, patients who have recently had
heart surgery or cancer surgery & older ill patients .
• Teeth with large carious defect (un-restorable)
• Teeth with severe resorption of periodontal tissues (deep
periodontal pockets, great bone destruction ).
• Teeth with short root length( Poor crown and root ratio).
• Teeth whose apices have a close relationship with anatomic
structures (as maxillary sinus or mental foramen)

10. Anatomic considerations
Posterior Mandible
 Anterior maxilla & mandible:
• Access to the root apex in some patients may be unexpectedly difficult
because of long roots, or lingual inclination of the roots
• Surgery of upper centrals can cause injury of incisive canal & its contents.
• Apicectomy on mandibular incisors often is more difficult than expected
because of proximity to the adjacent roots and the need for perpendicular
root-end resection in addition to lingual root inclination, shallow
vestibule, and prominent mental protuberance.
 Maxillary sinus
• Perforation of the sinus during surgery (especially maxillary 5 and 6)is
fairly common (10% to 50%).
• Even without periapical pathosis, the distance between the root apices of
the maxillary posterior teeth and the maxillary sinus sometimes is less
than 1 mm .
• If the sinus opened during the surgery ,the membrane of the sinus
usually regenerates, and a thin layer of new bone often forms over the
root end

11. • If the maxillary sinus is entered during surgery, special care must be taken
to prevent infected root fragments and debris from entering the sinus.
• use of sinuscope, in case of displacement of root tip in sinus.
 Mandibular canal
• computed tomography (CT) imaging can be very useful to determine the
relation of canal with apices of lower teeth
• The average vertical distance from the mandibular canal to the apex of
distal root of the mandibular second molar is approximately 3.5 mm. This
increases gradually to approximately 6.2 mm for the mesial root of the
mandibular first molar and to 4.7 mm for the second premolar .
 Mental foramen
• average location was 16 mm inferior to the cemento-enamel junction of
the second premolar, although the range was 8 to 21 mm.
 Palatal root
• reached from either a buccal or palatal approach
• Take care of Greater palatine artery while taking the palatal approach
• An acrylic surgical stent may be fabricated before surgery to assist
repositioning of the flap and help prevent pooling of blood under the flap

12. Instrumentation
The following instruments are necessary for performing an apicoectomy:
• Sterile towels and gauze
• Mirror ,Probes(hooked,curved) and tweezer
• Local anesthetic syringe and cartridges.
• Scalpel handle and blade (no. 15).
• Periosteal elevator and Flap retractors
• Irrigating syringes with sterile saline
• Suction tips (small, large).
• Microhead handpiece (straight and contra-angle) and microbur
• Special narrow periapical curette
• Ultrasonic unit
• Root end filling material carrier and Root end filling condensor
• Needle holder ,Suture materials & surgical scissor
• Magnification : Loupes and digital Surgical operating microscope

13. The microcondenser should be selected to fit the root-end

14. Micromirror used to inspect resected mesial root of mandibular first molar

16. Types of apicectomy
Types of apicectomy
1. Orthograde (conventional ) apicectomy .
2. Retrograde apicectomy
The purpose of retrograde filling is to obstruct the exit of bacteria and the
by-products of non-vital pulp, which remained in the root canal .
Indication for retrograde apicectomy are :
When the root canal can not adequately cleansed and filled from pulp
champer due to;
a) presence of pulp stone
b) calcified canal
c) unsatisfactory root filling (over or under )
d) fractured reamer in the canal
e) the affected tooth covered by crown

17. 1- pre-surgical preparation
2. Designing ,incision and reflection of the mucoperiosteal flap.
3. Localization of apex, removal of overlying bone to expose the periapical
area
4. removal of pathological tissue
5. Resection of apex of tooth
6-Preparation of the root apex and filling it with retrograde filling( in case of
retrograde apicectomy)
7.Debridement of the Wound & Closure
1- Pre-surgical preparation
A-Clinical assessment Prior to Endodontic surgical procedure which include:
a. - Medical history : general medical condition of the patient ,history of MI,
angina, hepatitis , infective endocarditis ….
- Consideration should be given to patients on anticoagulant medicines
(eg., Coumadin); radiation treatment of the jaw and in pregnancy.
b. Dental history : history of trauma , pain, swelling, root canal filling ,pus
discharge
Steps of endodontic surgery

18. c. Clinical examinations :
 Intraoral : caries ,quality of coronal restoration , periodontal status
,pocket ,mobility ,occlusal function of tooth , oral hygiene, tenderness
vitality of affecting teeth and adjacent teeth.
 Extraoral : by inspection , palpation , any swelling or sinus discharge.
d. Proper radiographic evaluation : periapical (intraoral ) or OPG
(extraoral) radiograph should be taken to evaluate :
 The size and extension of the periapical lesion.
 The condition of the roots ( if root canal filled ,severely curved root ,or if
there is any foreign body in the periapical area ) .
 The quality of root canal treatment.
 the condition of the alveolar bone and if the lesion is extended to the
adjacent roots or vital structures.
o Acute periapical abscess the radiograph show a slight or no evidence of
periapical radiolucency, Chronic periapical abscess on the radiograph
show as break in lamina dura at the apex of the root and periapical
radiolucency .
o Periapical cyst and granuloma look like periapical abscess (break of lamina
dura and radiolucency ) but with well defined border , cyst usually
surrounded by sclerotic border (white line).

19. o The periapical lesion may reach large size without evidence of
radiographical radiolucency ,because of osteolytic lesions in cancellous
bone which is difficult to detect by conventional radiograph ,
radiolucency appear when there is destruction in the cortical bone .
B- Informed Consent Specific to Surgery
The condition should be explained to patient in a simple easy way , and
patient must be thoroughly advised of the benefits, risks, and other
treatment options and must be given an opportunity to ask questions.
C- Selection of the anesthesia
1-local anaesthesia : infiltration or nerve block
2- General anaesthesia
To regain loss of anesthesia during surgery….
 Providing additional infiltration anesthesia is difficult after a full
thickness flap has been reflected
 A supplemental block injection may be useful for mandibular teeth and
maxillary posterior teeth
 An intraosseous injection also may be used to regain lost anesthesia,
but even when it is effective, the area of local anesthesia often is
smaller than desired for a surgical procedure
D-Preparation of instrument of surgery

20. 2. Designing ,incision and reflection of the mucoperiosteal flap.
Rules For Flap Design :
• The base is wider than the free margin.
• Incision must not be placed over any bony defect (should extend beyond bony
defect and away from the periradicular lesion; these might cause postsurgical
soft tissue fenestrations or nonunion of the incision).
• Incision should be perpendicular to the bone surface to involve the whole
mucoperiosteum.
• The size of flap should be large enough (extension of at least one tooth beyond
affecting tooth) for good access and decrease tension during reflection (The
actual bone resorption is larger than the size observed radiographically ) .
Vertical Incision
o Incision should be made parallel to the supraperiosteal vessels in the attached
gingiva and submucosa
o No cuts should be made across frenum .
o Incision should be placed directly over healthy bone.
o Incision should not be placed superior to a bony eminence.
o Dental papilla should be included or excluded but not dissected.
o Incision should extend from the depth of the vestibular sulcus to the midpoint
between the dental papilla and the buccal gingival .

21. Horizontal Incision
o This incision extends through the gingival sulcus to the crestal bone of the
alveolar bone.
Types of mucoperiosteal flap of endodontic sursgery :
A-Triangular flap :
one vertical releasing incisions and one Horizontal intrasulcular incision
Indications
1. midroot perforation repair
2. periapical surgery of one or two tooth
3. periapical surgery of short roots
Advantage
1-easily modified
2- additional vertical incision
3- extension of horizontal components
4- easily repositioned
5-maintains the integrity of blood supply
Disadvatage
1) limited accessibility
2) tension creates on retraction
3) gingival attachment severed and possible crestal bone loss

22. B. Rectangular (trapezoidal) flap:
Two vertical releasing incisions and one Horizontal intrasulcular incision.
Indications
1. Periapical surgery of multiple teeth
2. Periapical surgery if there are large lesions
3. Periapical surgery of long roots
Advantages
1. Good surgical access & visibility
2. Reduces retraction tension
3. Facilitates repositioning
Disadvantages
1) More difficult to incise & reflect
2) may lead to dehiscence formation during healing
3) Possible gingival recession and crestal bone loss

23. D. Semilunar flap :
Full-thickness flap in alveolar mucosa at level of tooth apex .
Indications
1-Indicated mainly for long teeth or small lesion.
2-indicated when the esthetics of the gingival margin cannot be compromised
(maxillary teeth with crowns).
Advantages
1-maintains integrity of gingival attachment
2- eliminates potential crestal bone loss
Disadvantages
1. limited access & visibiltiy
2. predisposed to streching & tearing
3. tendency for increase hemorhaging
4. crosses root eminences
5. repositioning is difficult
6. healing is associated with scarring

24. Envelope or Horizontal flap
Single-sided flap created by a single horizontal incision along the cervical lines of
the teeth( intrasulcular incision) .
Indications
1. cervical resorptive defects
2. cervical area perforations
3. periodontal procedures
4. Apicoectomies of palatal root of molar
Advantages
1) no vertical incision
2) ease of repositioning
Disadvantages
1. limited access & visibiltiy
2. difficult to reflect & retract
3. predisposed to streching & tearing
4. gingival attachment severed

25. C- Submarginal flap
A Scalloped horizontal incision in attached gingiva 3 - 5 mm short of the gingival
margin Follows contours of the gingival margin with one or two releasing
incisions depends on how much access is required
Indications
1-indicated when the esthetics of the gingival margin cannot be compromised
(maxillary teeth with crowns).
2- periapical surgery in anterior region of teeth with longs roots
3- wide band of attached gingiva
Advantages
1. Ease in incision & reflection
2. Good visibility & access
3. Ease in repositioning
4. Maintains integrity of gingival attachment
Disadvantages
1. Contraindication for this flap if there are periodontal breakdown, large
periapical lesion and short root
2. Horizontal component disrupts blood supply
3. vertical component crosses mucogingival junction

26. 3-Localization of apex, removal of overlying bone to expose the
periapical area
• 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
curette.
• If the buccal bone covering the lesion has not been completely destroyed, but
is very thin, then its surface over expected site is detected with an explorer or
dental curette, due to decreased bone density, the underlying bone is easily
removed and then apex localized.
• When the buccal bone remains completely intact, then the root tip may be
located with a radiograph where the length of the root is determined from a
prior radiograph or new radiograph with use intracanal file measurement or a
surgically placed lead-foil indicator .
• After that creating an osseous window with surgical bur (round bur) until the
apex of the tooth is exposed , Care is taken not to damage the adjacent roots
• Enough bone is removed until easy access to the entire lesion is allowed.

27. 4. removal of pathological tissue
• A curette is then used to remove pathological tissue and every foreign body
or filling material
• Biopsy: To determine the definitive diagnosis of periapical pathology , a
tissue sample is removed and then send it to an oral pathologist for a
histologic evaluation

28. 5. Resection of apex of tooth
• The apex is resected (2–3mm of 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 exactly
removed by curettage, especially in the area behind the apex of the tooth.

29. 6-Preparation of the root apex and filling it with retrograde filling
 The ultrasonic tip is used for retropreparation. The tip is placed at the apical
opening of the canal and guided gently deeper into the canal as it cuts.
 Once the retropreparation is completed the prepared cavity is inspected. The
gutta-percha at the base is recondensed with small 0.5 mm microplugger ,
 The aim of placing root end filling material is to establish an apical seal that
inhibits the leakage of residual irritants from the root canal into the surrounding
tissues.
 A wide variety of retrograde filling materials have been used as ; gutta-percha,
amalgam, MTA Mineral trioxide aggregate , glass ionomer, composite resin.

30. 7.Debridement of the Wound & Closure
• After placement of the amalgam, the gauze is carefully removed from the bony
defect and, after copious irrigation with saline solution .
• Radiographic examination is performed to determine if there is amalgam
splattering in the surrounding tissues.
• The flap is repositioned and interrupted sutures are placed.
• When suturing is complete, sterile, moist gauze is placed over the flap, and
pressure is applied for 5 minutes.
• The patient also is given verbal and written postoperative instructions
• Reviews after 3-4 months ,12 months and 3 years

32. The complications of endodontic surgery
 Hemorrhage due to systemic disease - to avoid careful history before surgery
 Excessive bleeding may occur due to Injury blood vessels as the bleeding from
the greater palatine artery during apicoectomy of palatal root.
 Damage to the mental nerve
care should be taken while making incision on the buccal aspect in the lower
premolar region due to the possibility of injuring the mental nerve which lies
superficially and in close proximity to the teeth apices
 Damage to the anatomic structures in case of penetration of the nasal cavity,
maxillary sinus and mandibular canal with the bur.
 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)
 Dislodged retrofilling material due to superficial placement, as a result of
insufficient preparation of apical cavity
 Incomplete root resection, due to insufficient access or visualization .As a
result, the apical portion of the root remains in position and the retrograde
filling is placed improperly .

33.  Healing disturbances, if the semilunar incision is made over the bony
defect or if the flap, after reapproximation, is not positioned on healthy
bone
 Other Post-operative Complications as
 Hemorrhage
 Pain
 Edema
 Infection