Apicoectomy (Root-End Surgery)

An apicoectomy (root-end surgery) is a minor surgical procedure for a tooth that has had root canal treatment but still has inflammation at the tip of its root. The gum and the thin layer of bone over the root tip are opened, the inflamed tissue is cleaned out, the last few millimetres of the root are cut away, and the end of the canal is sealed from below. The tooth stays where it is; the filling, crown or bridge on top is left untouched.

Its aim is to save a tooth that is facing extraction. But it is not the answer to every stubborn infection; below we explain when it works and when it would be wasted effort.

Why does infection persist after root canal treatment?

Root canals are not straight tubes. Near the root tip in particular there are side canals, fine branches and curves, and some of these may be impossible to reach during root canal treatment. Colonies of bacteria settled on the outside of the root tip, a cyst that cannot be reached from inside the canal, or filling material that was pushed out past the root tip during treatment can also keep the inflammation going. Patients usually notice this as recurring mild pain, a small pimple on the gum that opens and closes from time to time (a fistula), or simply a dark area on the X-ray that does not shrink.

The last three millimetres or so of the root is where these branches are most concentrated. That is exactly the part removed in an apicoectomy.

Root canal retreatment first, or straight to surgery?

In most cases the first choice is redoing the root canal treatment: the old filling is removed and the canals are cleaned again from scratch. This approach reaches the whole canal, whereas surgery only cleans its end. Even so, there are situations where surgery comes first:

• the tooth has a long post that could damage the root if removed, or a new, well-fitting crown or bridge;
• the canal is blocked, has a broken instrument inside it, or its course was altered during earlier treatment;
• the inflammation persists despite properly performed retreatment;
• a tissue sample is needed to establish exactly what the lesion at the root tip is.

Sometimes the two are planned in sequence: the root canal is redone first, healing is monitored, and if that is not enough, surgery follows.

Which teeth is an apicoectomy not suitable for?

A tooth with a vertical crack in its root cannot be saved by cutting off the root tip; the crack remains an open route for bacteria, and the right decision is usually extraction. The procedure also loses its point in teeth whose roots are already short, teeth that have lost bone support to advanced gum disease, and teeth with too little structure left to carry a new filling or crown: taking a few more millimetres off the root could leave such a tooth unable to bear load. With a tooth like that, the honest answer is not to buy time with surgery but to plan what will replace it.

How is the root tip reached?

1. CBCT scan and plan. The position of the root tip, the size of the lesion and nearby structures — the nerve in the lower jaw, the sinus in the upper jaw — are assessed on a three-dimensional image.
2. Anaesthetic and access. Under local anaesthetic, the gum is lifted through a small incision and a window is opened in the thin bone over the root tip.
3. Cleaning and resection. The inflamed tissue is removed and the root tip is shortened by about three millimetres. The tissue removed is sent for pathology examination; if the lesion turns out to be a large cyst, the cyst is removed together with its lining at the same appointment.
4. Sealing the root end. A small cavity is prepared in the cut end of the canal and sealed with a tissue-compatible bioceramic material.
5. Stitches. The gum is stitched back into place; the stitches usually come out within a week.

On front teeth the procedure usually takes between half an hour and an hour. On molars, especially in the lower jaw, it takes longer because the root is harder to reach; for these teeth, other options sometimes make more sense than surgery.

Apicoectomy recovery: what to expect

Thanks to the anaesthetic, you generally feel no pain during the procedure. For the next two or three days there will be swelling and tenderness; the swelling is usually most noticeable on the second day, and there is sometimes mild bruising on the lip or cheek. A cold compress on and off during the first day, soft food for a few days and gentle oral hygiene that does not strain the area are all you need. Do not keep pulling your lip out to look at the stitches; this can open the wound.

The bone takes months to fill in. X-rays at six months and at one year show whether the dark area is shrinking. Studies report healing in the large majority of cases treated with modern apical surgery techniques; even so, the outcome depends heavily on choosing the right tooth. If swelling on your face grows rapidly, or you have a fever or difficulty swallowing, do not wait: contact us or go to the nearest emergency department, wherever you are.

At our clinic in İzmir, this decision is made after a CBCT scan and a review of the previous root canal treatment. The cost depends on the position of the tooth, whether retreatment is also needed and any additional procedures; you receive a written, itemised quote after the examination.