Apicoectomy | An overview of endodontic surgery. Why would I need Endodontic Surgery?
Generally, a root canal is all that is needed to save a tooth with an injured pulp from extraction. Occasionally, this non-surgical procedure (the root canal) will not be sufficient to heal the tooth and your endodontist or general dentist will recommend endodontic surgery. The tip of the tooth root is called the apex; ectomy at the end of a word implies removing something. Therefore, an apicoectomy implies the surgical removal of the tip of the root of the problem tooth. A draining pimple in the gum above or below the tip of the root of a tooth reveals the infection from the dead nerve inside the tooth has spread beyond the tooth root and into the surrounding bone. This usually happens before root canal therapy is initiated and resolves by removing the dead nerve. In rare situations, it will happen after a root canal and that suggests an apicoectomy is needed. This surgical procedure can be used to locate root fractures or hidden canals that do not appear on x-rays but still manifest pain in the tooth. Damaged root surfaces or the surrounding bone may also be treated with this procedure.
What is an Apicoectomy? The above diagram illustrates this simple procedure. An incision is made in the gum tissue to expose the bone and surrounding inflamed tissue. The damaged tissue is removed along with the end of the root tip. A root-end filling is placed to prevent reinfection of the root and the gum is sutured. The bone naturally heals around the root over a period of months restoring full function. Careful follow up with dental x-rays and clinical examination is necessary to confirm that the proper healing that is expected has actually taken place. Your surgeon will schedule follow up visits at one week, one month, six months and possibly one year after an apicoectomy is performed. Following the procedure, there may be some discomfort or slight swelling while the incision heals. This is normal for any surgical procedure. Application of ice on the affected side of the face off and on every 20 minutes after surgery for the first 24 hours will help minimize the swelling. To alleviate any discomfort, you will be instructed to take 2-4 ibuprofen (Advil or Motrin), 2 aspirin, or 2 acetaminophen (Tylenol) every 4 hours after surgery. You will be given a prescription pain medication which can be taken in addition if needed. If you have pain that does not respond to medication, please call our office. You may also be given an antibiotic to help eliminate and/or prevent further infection in the area. This should be taken until completely gone regardless of the presence of pain. Surgical Instructions to prepare for apicoectomy This procedure is usually performed using local anesthesia. There are usually no restrictions after the procedure concerning driving or returning to work. If you have requested nitrous oxide (laughing gas) or IV sedation, you will receive special instructions at your consultation appointment about driving and recuperation after the procedure. It is appropriate to eat a light meal and drink fluids before your surgical procedure unless you have elected an IV sedation or Nitrous Oxide/oxygen. In those cases you must have an empty stomach for 6 hours before your procedure. You should also brush and floss after eating and prior to your arrival for your surgical appointment. Continue all medications for blood pressure or thyroid problems and any other conditions as recommended by your physician. If you are a diabetic, you should ask your surgeon for special instructions about your pre-operative diet and how to take your insulin or oral hyperglycemic medicines. You will most likely be asked to stop blood thinners (Coumadin) at least three (3) days in advance of surgery. If there is a question, please call our office prior to your appointment. If you have been advised by your physician or orthopedic surgeon to use antibiotic premedication because of mitral valve prolapse (MVP), heart murmur, artificial heart valve, total hip, total knee or other joint replacement, take your antibiotic one (1) hour before your surgery appointment. If there is a question, please call our office prior to your appointment.
Pos t- Op e rati ve In s tru c ti on s After an Apicoectomy An apicoectomy is usually a simple procedure but it may be more involved depending on the circumstances of your case. Postoperative care is very important. Unnecessary pain and the complications of infection and swelling can be minimized if the instructions are followed carefully. Immediately following surgery: Bite on the gauze pad placed over the surgical site for an hour. After this time, the gauze pad should be removed and discarded and replaced by another gauze pad. Refer to the section on BLEEDING for specific details. Avoid vigorous mouth rinsing or touching the wound area following surgery. This may initiate bleeding by causing the blood clot that has formed to become dislodged. To minimize any swelling, place ice packs to the sides of your face where surgery was performed. Refer to the section on SWELLING for explanation. Take the prescribed pain medications as soon as you can so it is digested before the local anesthetic has worn off. Having something of substance in the stomach to coat the stomach will help minimize nausea from the pain medications. Refer to the section on PAIN for specific details. Restrict your activities the day of surgery and resume normal activity when you feel comfortable. If you are active, your heart will be beating harder and you can expect excessive bleeding and throbbing from the wound. NO SMOKING UNDER ANY CIRCUMSTANCES.
Bleeding: A certain amount of bleeding is to be expected following surgery. Since the wound is sutured closed, the bleeding is usually clotted a short time after surgery. Slight bleeding or oozing causing redness in the saliva is very common. For this reason, the gauze will always appear red when it is removed. Saliva washes over the blood clots and dyes the gauze red even after bleeding from the sockets has actually stopped. Excessive bleeding may be controlled by first GENTLY rinsing or wiping any old clots from your mouth, then placing a gauze pad over the area and biting firmly for sixty minutes.Repeat as necessary. If bleeding continues, bite on a moistened tea bag for thirty minutes. The tannic acid in the tea bag helps to form a clot by contracting bleeding vessels. This can be repeated several times. To minimize further bleeding, sit upright, do not become excited, maintain constant pressure on the gauze (no talking or chewing) and avoid exercise. If bleeding does not subside after 6-8 hours, call the office for further instructions (603-356-9755).
Swelling: The swelling that is normally expected is usually proportional to the surgery involved. An apicoectomy generally does not produce much swelling so it may not be necessary to use ice at all. If there was a fair amount of cheek retraction involved with your apicoectomy, then it would be appropriate to apply ice on the outside of the face on the affected side. The swelling will not become apparent until the day following surgery and will not reach its maximum until 2-3 days post-operatively. The swelling may be minimized by the immediate use of ice packs. Sealed plastic bags filled with ice, ice packs, or a bag of frozen peas or corn wrapped in a washcloth should be applied to the side of the face where surgery was performed. The ice packs should be applied 20 minutes on/20 minutes off for the afternoon and evening immediately following your extraction. After 24 hours, ice has no beneficial effect. Thirty-six (36) hours following surgery the application of moist heat to the side of the face may help some in reducing the size of any swelling that has formed. If swelling or jaw stiffness has persisted for several days, there is no cause for alarm. Soft, puffy swelling that you can indent with your finger after oral surgery is very normal. Bright red, rock hard, hot swelling that does not indent with finger pressure which is getting bigger by the hour would suggest infection. This usually would develop around day 3-4 after surgery when you would expect swelling to be going down, not up. If this should occur, please call our office at 603-356-9755.
Temperature:
It is normal to run a low grade temperature (99-100F) for 7-10 days following oral surgery. This reflects your immune response to the normal bacteria that are present in your mouth. A high temperature (>101F) might exist for a 6-8 hours after surgery but no more than that. 2 Tylenol or 2-4 Ibuprofen every 4-6 hours will help to moderate a temperature. A temperature >101F several days after surgery, especially if accompanied by rock hard swelling and increased pain, is usually indicative of infection. You should call the office for instructions if this should occur.
Pain: Pain or discomfort following surgery is expected to last 4-5 days. For many patients, it seems the third and fourth day may require more pain medicine than the first and second day. Following the fourth day pain should subside more and more every day. Many medications for pain can cause nausea or vomiting. It is wise to have something of substance in the stomach (yogurt, ice cream, pudding or apple sauce) before taking prescription pain medicines and/or over the counter pain medicines (especially aspirin or ibuprofen). Even coating the stomach with Pepto Bismol or Milk of Magnesia can help prevent or moderate nausea. For moderate pain, one or two tablets of Tylenol or Extra Strength Tylenol may be taken every three to four hours or Ibuprofen (Motrin or Advil) two-four 200 mg tablets may be taken every 3-4 hours. For severe pain take the tablets prescribed for pain as directed every 4 hours in addition to the Tylenol or Ibuprofen. The prescribed pain medicine will make you groggy and will slow down your reflexes. o Do not drive an automobile or work around or operate heavy machinery if you are taking prescription pain medicine. o Alcohol and prescription pain medicines do not mix! If prescription pain medications are required beyond 4 days, further treatment may be indicated. Please call the office and discuss your situation with us.
Antibiotics: If you have been placed on antibiotics take the tablets or liquid as directed. You should take them on schedule until they are completely gone. Discontinue antibiotic use in the event of a rash or other unfavorable reaction. You should call the office (603-356-9755) to report any such finding or if you have any questions.
Diet: Drink plenty of fluids. Try to drink 5-6 eight ounce glasses the first day. Drink from a glass or cup and dont use a straw. The sucking motion will suck out the healing blood clot and start the bleeding again. Avoid hot liquids or food while you are numb so you dont burn yourself. Soft food and liquids can be eaten on the day of surgery. The act of chewing doesnt damage anything, but you should avoid chewing sharp or hard objects at the surgical site for several days. Return to a normal diet as soon as possible unless otherwise directed. You will find eating multiple small meals is easier than three regular meals for the first few days. You will feel better, have more strength, less discomfort and heal faster if you continue to eat.
Oral Hygiene: Good oral hygiene is essential to proper healing of any oral surgery site. You can brush your teeth the night of surgery but rinse very gently. Vigorous rinsing should be avoided until the day following surgery. The day after surgery you should begin rinsing at least 5-6 times a day especially after eating. Salt water (cup of warm water mixed with a teaspoon of salt) is ideal but plain water is also OK. Mouthwash has an alcohol base to it so it may be pretty zingy when it comes in contact with fresh oral wounds. After a few days, dilute the mouthwash in half with tap water and rinse out your mouth. This will make it taste and smell better. You can gradually build up to full strength mouthwash as you feel more comfortable.
Smoking:
No smoking for 48 hours after surgery. Smoking retards healing dramatically. After 48 hours, if you feel you need so much as one Tylenol or aspirin to control pain, you should avoid any smoking of any kind. This usually reflects that the clot has not grown enough to cover all the exposed bone in the surgical site. The exposed bone is filled with raw nerve endings. Until the nerve endings are covered with a healthy blood clot, they will cause pain. Smoking will just slow this process significantly and make the pain even worse. Therefore, if there is any question about smoking.....DON'T DO IT.
Activity: You should keep physical activities to a minimum for 6-12 hours following surgery. If you are considering exercise, throbbing or bleeding may occur. If this occurs, you should discontinue exercising. Keep in mind that you are probably not taking normal nourishment. This may weaken you and further limit your ability to exercise.
Root Canal Surgery, Endodontic Surgery, Apicoectomy (Apico) and Retrofill (retro) or When is this procedure done? Nonsurgical endodontic treatment alone cannot maintain some teeth. Endodontic surgery includes any surgical procedure used to remove inflammation and/or infection from your roots and surrounding areas or to repair a given problem. Endodontic Surgery can help maintain your tooth in situations such as: Diagnosis. In particular for root fractures. If you have persistent symptoms which do not appear on a radiograph or x-ray, your tooth may have a tiny fracture. In many cases, surgery allows the visualization of your root to determine the problem. Vertical root fractures begin at the end of the root typically and extend toward the chewing surface. They often go unnoticed until surrounding bone and gums become inflammed/infected. Treatment for a single rooted teeth is usually extraction. Multirooted teeth may have the affected root removed in some cases. See also Vertical Root Fractures. Unable to treat to near the end of the root. Sometimes narrow channels, calcium deposits, or extremely torturous canal systems are unable to be treated to the end. In some cases, there are several branches near the end of the root that were not treated in the previous nonsurgical treatment(s). Unable to treat to additional canals. Due to variable anatomy, treating all the canals in a tooth can be more of a challenge then possible with today's technology nonsurgically. Failure to heal after nonsurgical treatment. In a few cases, a tooth may fail to heal or the tooth becomes painful/diseased years after the initially successful treatment even when the original treatment is done to ideal. While there may be many reasons, it potentially may be due to a cyst that must be mechanically removed or bacteria that have embedded themselves at the end of the root causing persistent infection.
Damaged root surfaces or surrounding bone. We don't understand all the details, but sometimes the body will begin to eat a hole into the tooth. We call the process resorption. Depending on the location, it is commonly repaired surgically.
What is the most common endodontic surgical procedure or 'root canal surgery'? The most common surgical procedure is called root end resection. We usually cut off the very tip of the root and place a filling at the end of the root to help seal the root structure. This used to be called apicoectomy and retrofill or "apico" and "retro". The American Association of Endodontists decided that apicoectomy was not very patient friendly so it retermed the procedure root end resection. They feel it describes the procedure better. The Anatomy of a Tooth with Previous Unsuccessful Endodontic Therapy
What Happens During Endodontic Surgery? A local anesthetic will be given. An opening is made near the tooth by reflecting the gum tissue away from the tooth. This allows us to see the area and surgical portion of the treatment is completed. If root end resection is completed we remove the inflammed and/or infected tissue, cut off the root end and place a filling to help seal the end of the root. To me, it's more important to do it the very best we can then to meet a specific time criteria. Let's look at the basic steps for root end resection with root end filling. The Root End Resection with Root End Filling Procedure
Gum Tissue Opened Tissue Removed
Root End Resected Root End Filled
Bone Healed
Gum Tissue Opened Tissue Removed. Gum tissue is reflected near the tooth to give access to the tissue at the end of the root. Then the inflammed and/or infected material is removed.
Root End Resected Root End Filled. The end of the root is removed since it is usually the problem area. Sometimes the end of the root may have embedded bacteria in the rooth structure or branching of canal system which was untreatable with current techniques. A filling helps seal the end. I usually use MTA or Mineral Trioxide Aggregate which is really sterilized for medical use portland cement. It is one of the most biologically compatible materials ever devised for use in dentistry. This material was very difficult to place until I designed a set of carriers to place it. See News
Bone Healed. Over a period of months, sometimes years, bone heals around the end of the root. This means after the surgery is completed, we usually follow up until it heals (or you stop comming to us!)
What kind of Materials are placed in the Root end filling process? A sealing material such as Mineral Trioxide Aggregate (MTA or Portland Cement), Zinc Oxide and Eugenol, and/or composite/glass/resin ionmer (glass and organic acid +/or plastic resin). It will NOT contain amalgam when completed in our office. I've never heard of this 'MTA' stuff. What else is it used for?
apicoectomy (root canal surgery) An APICOECTOMY is a surgical procedure to clean the root end. Teeth that have abscessed or that have suffered pulp death are candidates for root canal (endodontic) therapy. Root canal therapy cleans the root space and seals the root with a sterile rubber material. Sometimes, conventional root canal treatment cannot sufficiently clean and seal the root space. This may be due to an excessively curved root or obliterated canals that are hard to find. If conventional root canal therapy was unsuccessful, infection and bone damage (red arrow) will continue to be present at the tip of the root. If the root is severely curved or is inaccessible due to a post (black arrow), your dentist may recommend an apicoectomy as a procedure to maintain the tooth. An apicoectomy is done with local anesthesia (novocaine). A small incision is made through the gum, at the root tip, and the dental drill is used to gain access to the root end. The infected area around the root tip is thoroughly cleaned and the root end is shaped back to where the root canal filling is sound. In some cases a (retrograde) filling is placed in the tip end of the root. This procedure serves to create a good seal to prevent further infection. The incision is then sutured closed. Teeth with apicoectomies have a good prognosis although they are slightly debilitated because they have inherently less root structure than an intact, healthy tooth. Toothology contains extensive information on this topic. If multiple subtopics are not currently displayed under this topic to the left, you have entered Toothology's public website. Apicoectomy I have found that root canals rarely fail. When a root canal fails it is usually do to one of the following:: Unusual and undetectable tooth anatomy. Small accessory and lateral nerve canals that can not be instrumented.
Cyst formation Cracked tooth Most of the "failures" can be saved, with the exception of a severely cracked tooth, with a surgical procedure called an apicoectomy. This surgery involves removal of the the root tip or "apex" of the tooth root. This is normally where abnormal root anatomy and extra canals are present. During the procedure, the area around the root tip is also cleaned or curettaged to remove any granulation (abnormal healing) tissue and cystic formations. Apicoectomy is an in office procedure performed by an Oral Surgeon or Endodontic specialist. The area is numbed with a local anesthetic and you may have IV sedation to relax you. Pain medication will be prescribed to keep you from experiencing any discomfort. The area may be sore for three to four days days. Surgical Details
Opening and Root Tip Cut
Root Tip Removed Reverse Filling Placed
Complete Healing
The gum is reflected (lifted) from an area adjacent to the root area of the tooth. Access to the root tip is then made by removing the thin bone covering the end of the root. A small part of the the root tip is then removed and the remaining root is checked to make sure it is sealed. Apical or Retrofilling (reverse filling) will be required to seal all canals that are found that are not properly sealed . Without proper sealing of all the canals present in a tooth the procedure will not be successful. The area around the root tip is then cleaned and curetted. The gum is placed back into position and sutured (stitched). After healing all infection at the tip of the root should disappear and bone should heal to fill in the area around the root tip. Hemisection Hemisection is a surgical procedure which involves removing only one root of a multi-rooted tooth, and may be required in one of the following situations:
Endodontic Failure of an individual root which is not retreatable Bone Loss around an individual root (periodontal disease)
These teeth usually do very well with one less root. Removing the front root of a lower second molar and using it as a bridge anchor (abutment) to replace a missing first molar, prevents the need for a partial denture or dental implant. Treatment Procedure
Step 1 After the tooth is anesthetized, an opening is made through the crown into the pulp chamber.
Step 2 The lengths of the roots' canals are determined.
Step 3 Unhealthy pulp is removed. Canals are cleaned, enlarged and shaped using progressively larger endodontic files.
Step 4 Canals are filled and sealed. A metal post may be added for structural support or to retain restorative materials.
Step 5 The tooth is sealed with a tempory filling. Usually a gold or porcelain crown adds further protection.
The material used to fill your root canal will probably last you a lifetime, but eventually the filling or crown may need to be replaced.
