oral surgeon doing apicoectomy

Root end resection or apicoectomy: cost, surgery, complication and failure rate

An apicoectomy, also known as retrograde root canal treatment or root end resection, is a micro-surgical endodontic procedure to remove the tooth’s root tip (apex). It is required when an infection develops or persists after the endodontic treatment or retreatment. A filling made of amalgam or composite resin is used to seal the end of the root.

Step by step apicoectomy surgery treatment

If your dentist thinks an apicoectomy is the dental treatment you need, he or she may referrer you to an endodontist or an oral and maxillo facial surgeon. These last two clinicians are dentist who have two to six of additional training in diagnosis and root canal treatment and in oral surgery respectively.

Before root-end resection surgery

Preventive consultation

The preventive consultation is necessary for the oral surgeon to collect all the necessary information about your overall health condition and your past medical history. This is the right time to let the endodontist whether if you take medicine, supplements or over the counter drugs; just to avoid medicine interaction.

X-rays exam

Before to proceed with the surgery, the professional need to study the specific case and evaluate the best procedure. In order to get the whole picture, the doctor will take x-rays exam to precisely locate the infection and the bone condition.

Antibacterial oral rinse and antibiotics coverage

A few days before apicoectomy surgery, the oral surgeon will prescribe you an antibacterial mouthwash with chlorhexidine to lower the bacteria load.

Even if an apicoectomy is a microsurgery procedure there is always the risk an infection starts. Antibiotics such as those for dental abscess should be taken three days before root-end resection till two or three days after apicoectomy.

During surgery

Local sedation

The first step of the procedure requires the local anesthesia administration to numb the oral cavity area the endodontist will work on.

If you suffer because of heart disease, you should inform your doctor in advance to avoid local anesthetic with adrenalin or epinephrine.

For anxious people who suffer because of dentist phobia. IV sedation or laughing gas (nitrous oxide) can be the right solution to undergo the surgery without fear (the last two types of local anesthesia may increase the apicoectomy cost).

Gum flap creation

With a dental scalpel, the oral surgeon will cut the gingiva and lift it to expose the jawbone

Osteotomy

To get access to the root tip, the doctor has to remove a small quantity of bone.

During the bone drilling, the operating site is constantly sprayed with physiological solution to keep the temperature under control. In fact, high temperature could damage the bone and compromise the healing.

Infection and root tip removal (apical resection)

Once the endodontist had directly access to the infected peri-apical tissue, the infection removal step begins. Using a microscope and ultrasonic instruments, the surgeon removes the infected and necrotic tissue (granuloma, cyst or abscess) near and around the root tip. The surgical microscope helps the clinician to better distinguish the infected material from the healthy one.

The last crucial steps involves the resection of a few millimeters of the root tip (3 to 4 millimeters).

Dental canal shaping, disinfecting and sealing

After root end resection, the doctor will disinfecting the remaining part using sodium hypochlorite.

The very last surgical step requires to seal the root canal (retrograde filling). The filling materials are different: amalgam, composite resin, dental cement made of zinc oxide eugenol. These seal materials need a few minutes to harden. then it is possible to shape the hardened filling using special drills.

At this point, the clinician will flip back the connective gingival tissue and apply a few stitches that will stay in place for a week or less.

Recovery and post op instructions

Even though apicoectomy is considered surgery, hospitalization is not required and the recovery is very fast.

After the procedure you can go back home a follow the doctor instructions:

  • for the first 12 hours after the surgery, you should keep the ice-bag on the treated area alternating 15 min on and 15 min off.
  • Do not brush close to the stitches, you may accidentally remove them
  • Do not smoke or eat spicy food (at least for the 5 days after the procedure);
  • Do not touch suture with your tongue or fingers and do not flip the lip to check the stiches (they are there, don’t worry);
  • Continue to take antibiotics prescribed by the oral surgeon and, in case of pain, over the counter drugs works very good.
  • After an apicoectomy it is highly recommended to pay attention to your diet that should be liquid for the first 3 days and soft for the next 3. After stitches removal you can go back to your usual diet.

Follow-up

A week after the apicoectomy procedure, your dentist will remove the stitches (if they do not dissolve by them self). In addition the clinician will check the healing process as well as the scar formation.

Pain, discomfort and swelling usually decrease in 5 or 7 days and completely disappear within two weeks.

How much is the apicoectomy cost ?

The apicoectomy cost depends on the different factors such as:

  • The position of the tooth
    front teeth are more easy to treat than molars.
  • The doctor specialization
    usually endodontist and maxillo facial surgeon charge more than general dentists because of their additional training.

Price with insurance

With the insurance coverage the price of an apicoectomy is more affordable: $150-$500, depending on the insurance policy terms

Price with no insurance coverage

The average apicoectomy cost with no insurance is about $900 to $1,500 but there are patients who spent even more (from $1,200 up to $4,000).

Additional costs

The conventional root end resection is performed practicing the local anesthetic injection. If you prefer intravenous (IV) sedation or laughing gas, you can expect to pay an additional fee (around $400).

Dental x-rays and follow-up examination may not be included in the final price. To avoid unpleased surprises It is highly recommended to ask the doctor a full quote.

Risk and complication

Sinuses infection

When the procedure involves the back upper molars there is the risk of sinuses infection, that’s why the doctor prescribes antibiotics.

Nerve damage

An additional apicoectomy risk is connected with the nerve located in the lower jaw, very close to the roots to be treated. X-rays allow the professional to limit the chance to permanent damage that nerve or creating temporary paresthesia.

What root end resection is used for ?

The apicoectomy surgery is the second choice to remove and cure the bacterial infection located close or around the dental apex (the root tip of a tooth). The first choice is represented by the conventional endodontic treatment but in some cases cannot be performed.

The medical term “infection” is very generic therefore here is a brief list of different types of dental infection the root end resection can solve:

Granuloma

The dental granuloma is the first defense against the spread of infection from the inside of the tooth to the tissues around the root of the same. Granuloma is a chronic inflammation, generally, asymptomatic nonsuppurative (it does not produce pus) that comes from a pulpitis (the next phase of caries) not treated.

Dental cyst

Radicular cyst is an inflammatory response caused by the human body reaction to dental pulp necrosis.

Periapical abscess

Periapical abscess or dental infection is the result of bacteria attack to the tissue inside the tooth. when bacteria try to exit the tooth through the small all where nerves come in, the body reaction is a barrier to limit the infection to spread. Abscesses cause pain, swelling and pus.

While root canal therapy is the mainly procedure to treat periapical abscess there are situation the dentist has to switch to apicoectomy because the conventional way doesn’t allow the treatment. Just think of a cracked tooth.

When apicoectomy can be better than root canal ?

There are different reasons why your endodontist may prefer apicoectomy over the standard  endodontic therapy and you can find the most common listed below:

Smaller secondary root branches

The scope of the conventional procedure is to remove any infected tissue from the dental canal.

In order to achieve that scope, the clinician uses small manual endodontic files or even the laser. However, if the dentist cannot clean and seal the secondary micro-roots, bacteria may hide there inside and the infection will restart a few time later.

Obstructed root canal

Endodontic files used for the standard procedure may break when they are within the canal and it is almost impossible to remove them. In this particular case the canal itself becomes blocked.

When the dentist has already performed an endodontic therapy a post and a prosthetic crown are in place and do not allow the dentist job.

When situations like these occurs, the only alternative to reach and remove the infection is an apicoectomy.

Abnormal root shapes

There are a lot of patients who have curved root shapes. When dental roots are not straight, endodontic instruments cannot reach the tip of the canal where the infection is located. The result is that infection can easily restart again and again or becomes chronic.

Treating the case by accessing from the dental apex, the percentage of success increases.

Infection due to fractured or cracked tooth

In case of accident or sport contact your front upper teeth are at high risk to break. When it happens, the root is exposed and bacteria can easily trigger the infection that reaches the tip of the dental root.

Usually the dental infection that is located so deep in the tooth creates an abscess with pus and cheek swelling (periapical abscess).

The cracked tooth doesn’t allow the dentist to go with the endodontic treatment because a piece of cementum can block the way. An apicoectomy is the only way to reach and treat the infection as well as to fill and seal the root apex (retrograde filling).

Alternative

If for whatever reason the root-end resection cannot be done or you don’t want to undergo such surgery, there is only one alternative to apicoectomy: the tooth extraction.

Once the affected tooth had been removed you should consider to replace it with a dental bridge or a dental implant and a prosthetic crown. The tooth replacement ensures the perfect bite which is very important for aesthetic and functional reasons.

When to alert your dentist ?

2 or 3 days after an apicoectomy procedure the pain and the swelling should decrease. If this doesn’t happen you should call your dentist; an infection could start and it is better to caught it in time.