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Question: Does Apicoectomy Have a Place in Dentistry?
Barry P. Levin, DMD
This is not a simple question, and thus not easy to provide a short answer. First, the apicoectomy should not be totally abandoned in my opinion. However, the indications are fewer than in the past.
The involved tooth needs to be assessed for its prognosis after apical surgery. Periodontal attachment level, mucogingival status, mobility, role in the arch, and crown:root ratio after apicoectomy are a few criteria requiring diagnosis. If the tooth can be re-treated with conventional endodontics, this should be attempted first.
As with all dental procedures, proper diagnosis must precede treatment. Is the tooth experiencing recurrent apical pathology because it is fractured? Is the lesion due to an incompletely obturated apical root segment? How much supporting bone is lost due to infection? These questions must be answered prior to initiating treatment.
With CBCT (cone-beam computed tomography) being readily available, a three-dimensional assessment of the lesion and tooth can be assessed before a treatment plan is finalized. If the resultant crown:root ratio after apicoectomy will significantly affect the tooth’s prognosis, then extraction and implant placement should be considered. However, if the tooth is serving as an abutment for a fixed prosthesis, every effort should be made to maintain the affected root, preventing the loss of multiple functional dental units. If the tooth presents with mucogingival deficiencies, the cost:benefit of performing apicoectomy and corrective soft-tissue surgery needs to be compared with the predictable treatment of extraction and implant placement.
Another consideration, which may be aided diagnostically with CBCT, is the anatomic position of the apex. If surgical access to the apex requires manipulation of tissue in proximity to vital structures—such as the maxillary sinus, the inferior alveolar canal, mental foramen or mylohyoid ridge—perhaps the morbidity of these procedures is outweighed by the less invasive nature of extraction and implant surgery.
In a private practice setting, patient management also plays a crucial role in treatment planning. The example of a patient who has recently received a full-coverage restoration, then required root canal therapy due to the irreversible pulpal trauma induced by restorative measures, creates an uncomfortable situation for all parties. This patient may not be receptive to extraction of this tooth without every effort to maintain the tooth being pursued first. It may be appropriate to extract this tooth; however, maintaining the natural dentition should always be the primary goal of all dentists involved in patient care.
In my opinion, all parameters discussed above must be addressed and each situation lends itself to unique courses of treatment.
Louis E. Rossman, DMD
There absolutely is a place in dentistry for apicoectomies. Endodontic surgery is a successful and predictable procedure. The literature tells us that contemporary endodontics enjoys a 97% success rate. If a tooth requires nonsurgical or surgical retreatment, the success rate remains above 90%. An endodontist should be a part of treatment planning to evaluate the patient and determine through diagnosis if the procedure will be successful.
Modern endodontics allows us to evaluate the anatomy and potential etiology of failure with the clinical examination and the addition of CBCT. The surgical procedure is completely different than in years past. Previous success rates were based on older techniques and materials. Today the endodontist incorporates a surgical operating microscope and ultrasonic tips to prepare the apical portion of the root canal. This is much more effective than older handpieces. The materials for sealing the apex, including MTA (mineral trioxide aggregate), have proven to show biologic healing far above what was once used.
Of course, prior to surgery, the tooth needs to be evaluated to determine the periodontal disease/health and the quality of the previously performed endodontic treatment. If poor technique was used with the restoration or the endodontics, or if leakage exists with the restoration or the previous endodontic procedure, endodontic surgery may not be necessary. In these instances, nonsurgical retreatment may be all that is needed. In cases such as root fractures, endodontic treatment, including surgery, may not be able to save the tooth; it may need to be extracted and replaced with an implant. By involving an endodontist in treatment planning, the patient is able to consider all options to treat—and hopefully save—the tooth.
It is not a question of endodontics or implants. Implants are a great procedure to replace the missing tooth, and they enjoy a high level of success. What is needed is confidence in surgical endodontic success. Today’s endodontic office uses knowledge, instruments, and materials that provide patients virtually painless endodontic procedures that will give decades of health and function. No matter how effective modern tooth replacements are, nothing is as good as the natural tooth. The pay-off for choosing endodontic surgery could be a healthy, functioning natural tooth for the rest of the patient’s life.
Anil Kohli, BDS, MDS
“Our objective should be the perpetual preservation of what remains than the meticulous restoration of what is missing.”
This quote by M.M. De Van succinctly answers the question of relevance of surgical endodontics in cases with persistent apical periodontitis. Ortho-grade non-surgical endodontics therapy is a predictable and successful mode of disinfecting root canals. However, there are instances when non-surgical endodontics will not be an optimal solution. These may include cases with extra-radicular infections, true cysts, foreign body reactions, or cholesterol clefts, and in cases when the root canal is inaccessible due to calcifications, ledges, or presence of an intraradicular post. Such cases will warrant two options: the easier one is to recommend an extraction followed by an implant prosthesis. However, an equally suitable, and more conservative, option is a surgical retrograde procedure. With the advent of the DOM (dental operating microscope), microsurgical instruments, ultrasonic tips and MTA (mineral trioxide aggregate), surgical management of persistent extradicular infections should be the first line of treatment. The prognosis of this approach has been validated in a meta-analysis of literature recently published in the Journal of Endodontics.
About the Authors
Barry P. Levin, DMD, is clinical associate professor at University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania. He also has a private practice in Elkins Park, Pennsylvania.
Louis E. Rossman, DMD, is president-elect of the American Association of Endodontists Foundation in Chicago, Illinois. He also has a private practice in Philadelphia, Pennsylvania.
Anil Kohli, BDS, MDS, is former president of the Dental Council of India, former adjunct professor at Tufts University, and former dean of Baba Farid University of Dental Science in Punjab, India.