An apicoectomy is a dental procedure that is used to treat a non-healing periapical abscess by removing the root tip and retrofilling the canal to seal it. It is considered a last ditch effort before giving up on the root canal treated tooth and extracting it.
Table of Contents:
What is an Apicoectomy?
An apicoectomy (apico) is a surgical endodontic procedure that is most commonly performed by endodontists. The purpose of the procedure is to remove residual infection from the root tip when traditional endodontic therapy is unsuccessful.
Procedure steps:
Exposure of infection. The gums are reflected and then a hole is drilled through the jaw bone to reach the infection at the tip of the root.
Root tip removal. The root tip with the infection is completely removed via drilling.
Root end filling. The newly cut root tip will be sealed off with a root filling material. We also call this retrofilling the canal since it is done from the opposite end of a traditional root canal treatment.
Apicoectomy vs Root canal
A root canal will clean out the entire canal by navigating it with hand files and rotary files. You can think of it like how a plumber unclogs drain pipes by navigating through it. Afterwards the root canal gets filled with gutta percha.
An apico on the other hand does not navigate through the canals. It goes directly to the source of the infection and just removes the entire infected piece. If you wanted a plumbing analogy, the plumber would just go to the clogged section of the pipe and remove it entirely. Afterwards the canal gets filled with a root end filling material.
When is it needed?
An apicoectomy is typically done after a failed root canal or a failed root canal retreatment. If the tooth has not done either of those endodontic procedures, it is not eligible for this procedure. Basically, it can only be performed on a tooth that has been endodontically treated.
Signs of unsuccessful endodontic treatment:
Residual periapical abscess. If you spot a large radiolucency around the tip of the root of a root canal treated tooth. That is an indication of a residual infection.
Presence of gum boil. A tell-tale sign of a non-healing infection is a gum boil after a root canal. That pimple on the gums is the orifice of a sinus tract that leads to a tooth abscess.
Short obturation. Due to root curvature or canal calcification, sometimes the root canal cannot clean out the tooth completely. That means there may be residual infection inside the tooth. A sign of this is a short obturation or root canal filling that doesn't reach the tip of the apices.
Any of these signs above may be an indication that it would be beneficial to get an apico.
How is an apicoectomy done?
An apicoectomy can be completed in a single dental visit and it should take about an hour. However, for more complicated cases it may require more time. We will describe the steps of the procedure so that you know what to expect.
Apicoectomy steps:
Administer local anesthesia. Numbing gel first, followed by lidocaine injection.
Reflect gum tissue. Open up the gums and peel them back to expose the bone.
Drill through bone. Drill through the bones to access the root tip.
Cut off root tip. Drill away the last 3-5mm of the root tip and remove any abscesses associated with the apex.
Place root tip filling. Retrofill the end of the canal with either amalgam or MTA (mineral trioxide aggregate).
Place sutures. Sitch the gums to close the surgical site.
Return for follow up. Make a follow up appointment for suture removal and evaluation of the healing. There may be scar tissue where the incision was.
You will be numb so the entire treatment should be painless. You do need to take care of the stitches afterwards so please try not to play around with them.
If they're dissolvable, they will fall out on their own within 7-10 days.
If they're non-dissolvable, they will need to be removed by your dentist.
Risks and complications
As with any surgical procedure, there will be potential risks and complications. For an apicoectomy, the two main risks you should watch out for are procedure failure and anatomical contraindications.
Signs of failed apicoectomy:
Worsening tooth pain.
Facial or mouth swelling.
Procedure failure
This procedure is not fool-proof because it can fail. According to literature in 2005, the success rate for endodontic surgery is about 90% when combined with dental operating microscopes and ultrasonic instruments.
However, prior to the advancement in dental technology the rate of success was lower:
Three year study following 93,797 teeth after an apicoectomy.
Cumulative 3 year survival rate was 81.6%
Anterior teeth = 84%
Premolars = 80.4%
Molars = 80.2%
Success was higher for anterior teeth vs posterior teeth.
Younger patients (under 18) was 93.3% vs older patients (over 84) was 75.6%
The odds of the procedure succeeding is pretty good in our opinion but please do keep in mind that it can fail. There is a 10% chance for failure and it can happen to you even though we often don't like to believe so.
Anatomical contraindications
Due to the proximity of tooth roots nearby important anatomical structures, it may be impossible or unwise to do the procedure. When the roots are too close to these other structures, you risk injuring them and causing other complications.
Important nearby anatomical structures:
Inferior alveolar nerve. The lower molars can be close to the inferior alveolar nerve. Injury will cause numbness in the entire quadrant of lower teeth as well as numbness in the lips.
Mental nerve. The lower premolars can be close to the mental nerve. Injury to the nerve here will cause numbness in your teeth and lips from the premolar to the midline.
Maxillary sinus. The upper back teeth can be close to the sinus and you can potentially cause a perforation. A perforated sinus would elicit similar symptoms and complications as a sinus exposure after a tooth extraction. Imagine a hole in your sinus!
In summary, if you happen to injure one of these structures during the procedure you may end up with other problems you never asked for. Perhaps this treatment isn't worth it if the risks of injury are too high. That is why we call them contraindications.
Costs
The average cost of an apicoectomy is $931.49 and that is without dental insurance. However, the exact cost will differ depending on the tooth type and also the cost of living in your area.
Tooth type | Average Cost | Cost Range |
|---|---|---|
Anterior | $834.70 | $546-$1210 |
Premolar (first root) | $924.71 | $622-$1304 |
Molar (first root) | $1035.07 | $695-$1650 |
Each additional root | $413.81 | $220-$605 |
Note: If your tooth has multiple roots and needs this procedure for each of those roots, it will cost an additional $413.81 for each root.
Tooth types and number of roots:
Premolars - 2-3 roots
Molars - 3-4 roots
Cost with insurance
The average cost of an apicoectomy with insurance is $186.30 with 80% insurance coverage. We've provided an example of coverage breakdown for the procedure with Aetna dental for one of our existing patients.
The patient above has 80% insurance coverage so they have a 20% co-insurance (copayment).
The dental codes used for billing:
D3410 - Anterior tooth
D3421 - Premolar (first root)
D3425 - Molar (first root)
D3426 - Each additional root
For example, if you had the procedure done on a 3 root molar but two of them need it, it would be billed as D3425 + D3426 only.
Alternatives
The only treatment option in lieu of an apico or if it fails would be a tooth extraction. There is simply no other way to treat an infected tooth that does not heal except for removing it from the mouth completely.
However, after the extraction you do have different options for replacing the now missing tooth.
Dental implant. The most conservative way to replace a single missing tooth is with an implant. This is essentially a titanium screw that gets placed into the jaw bone. Afterwards you will get an implant crown placed on top of that.
Bridge. The missing tooth can be replaced with a dental bridge. For this procedure you will need to prepare the tooth in front and behind it in order to fit the bridge. In other words those teeth will be shaved down.
Tooth flipper. A flipper tooth is a temporary partial denture that you can use to replace the missing tooth. Usually people do this if they are unsure about which permanent procedure to choose. It allows them more time to decide.
Outlook
After completing this treatment, you don't have to do anything in particular to take care of the tooth. You can treat it as if it was any other tooth in the mouth.
You brush it twice a day for at least two minutes with a remineralizing toothpaste.
Floss before you go to bed.
Minimize the amount of sugar and carbohydrates that you eat.
As long as nothing happens to it, you can keep the tooth in your mouth (hopefully forever). Although if something does happen to it, the next step would be an implant.
Recovery
The recovery from an apico procedure will vary, ranging from a few days up to a week. It is a surgery but it is nowhere close to the recovery time that is required for a tooth extraction. After all, only about 2-3 mm of the tooth root is being removed in lieu of an entire tooth.
According to our dentists in Long Island City, you may feel some soreness or tenderness for the next few days. Although taking some pain medication should alleviate that and you should be able to continue with your normal daily routine.
