What is an apicectomy?

Root canal treatment and apicectomy

When a tooth suffers from severe trauma, or extensive dental decay, or is subject to considerable cavity preparation using a dental drill to remove the decayed tooth structure, living tissues within the pulp chamber and root canal may become inflamed as a response to such stimuli.

The inflammation in the pulp (known as pulpitis) may be reversible and the tooth may recover, or the inflammation may be irreversible, and result in an increase in the pressure within the tooth and failure of the blood supply to the pulp resulting in the death of the soft tissues of the pulp and root canal.

This dead tissue within the root canal system and pulp chamber may provide a suitable source of nutrition for bacteria and may support the development of a pulp or root canal infection. The treatment for this is either a root canal treatment or removal of the tooth.

Root canal treatment:

The dead and infected pulp and root canal tissues must be removed to eliminate infection and this is undertaken by a procedure called root canal treatment. This treatment may be provided by a general dentist or a specialist Endodontist who has undergone postgraduate training to specialist level. To achieve the best results, such treatment is best provided using a surgical microscope.

The root canal is cleaned thoroughly, filed to create a smooth fluted shape, irrigated well and after drying, a root canal filling material, usually “Gutta Percha” is placed in such a way as to completely fill the root canal system creating a seal, thereby preventing ingress or egress of infection.

The chance of success

If this procedure is performed effectively, and in the absence of any root cracks or micro-fractures, a root canal treatment may be effective in eliminating the infection and allow the tooth to continue to provide long term function and aesthetics. However, generally teeth that have been root filled should receive a crown to provide additional strength for the tooth to minimize the chance of tooth fracture later. Failure to provide a crown may result in failure of the tooth despite successful root canal therapy and significant treatment cost.

Sometimes, root canal treatment is unsuccessful, or not possible due to a blocked root canal or adversely shaped root canal or multiple accessory canals, and the infection persists at the tip of the root. This is often associated with an inflammatory response around the root tip that leads to pain of a throbbing nature and extreme tenderness when the tooth is tapped or a heavy load is applied to the tooth as in chewing.

Continued infection

Gradually, following establishment of pain, pus may form around the  root tip in the bone. This pus will then track along the line of least resistance and may establish a drainage channel called a draining sinus. Pus may be seen draining through a small swelling in the gum but in the case of posterior upper teeth, the pus can drain into the maxillary sinus above the roots of the upper premolar and molar teeth.

Following an unsuccessful root canal treatment the only treatment options are an “apicectomy” or removal of the tooth.

What is an apicectomy?

An apicectomy is a minor dental surgical procedure to remove the end of the root of a dead tooth. It may also require a filling to seal the open root canal. The procedure is designed to remove both the infected part of the root tip and clean out any infection from the.

An apicectomy is therefore a viable alternative to tooth extraction in many cases.

I’m not in pain so why does anything need to be done?

Infection around a root tip may lead to drainage of pus either into the mouth through a draining sinus or into the maxillary sinus through the sinus floor, very quickly. As long as pus can drain, there may be an absence of a build-up of pressure and so the patient may not experience pain. Even though you may not be experiencing any pain, it is important to follow up with your treatment to prevent the infection spreading to local tissues, adjacent teeth and adjacent structures.

If infection is left untreated it can lead to general symptoms including a feeling of being unwell, a fever, loss of apatite, general lethargy and local involvement of the lymph nodes that may become swollen and tender as a result of the drainage of the infection from the area through the lymphatic channels.

What happens during an apicectomy?

The procedure involves making a small incision in the gum over the region of the root tip on the lip or cheek side of the tooth. The end of the root is cut away from the remaining root structure and removed from the patient. Usually there is a hole inside the bone around the root tip and this may be filled with infection or granulation tissue. This hole must be cleaned thoroughly using either manual curettage or using high frequency vibration tips known as either ultrasonic or piezo-surgical equipment.

A seal must be established at the open root canal. This can involve applying a heated instrument to the gutta percha in the canal and due to its thermoplasticity (softening and flowing when heated), a new and effective seal may be re-established. Sometimes an additional sealing restoration (a retrograde root filling) is added to the end of the root using a variety of materials including Mineral Trioxide Aggregate (MTA) or other modern biologically inert and bioacceptable material.

An apicectomy is usually carried out under a local anaesthetic, but sometimes sedation or a general anaesthetic may be required. Your dentist, dental surgeon or endodontist will advise you on this. The process takes approximately 30-45 minutes.

How will I feel after an apicectomy?

You may feel some discomfort in the area for 24-48 hours after the treatment and your dentist will be able to advise you on suitable painkillers, anti-inflammatories and possibly antibiotics.

Sutures (stitches) will be required in order to close the incision wound. There may also be bruising and gradual swelling of the area for 3-4 days but this will subside from day 4 onwards and is part of the healing process and is not an indication of a failed procedure.

You should plan to have a very quiet day after the treatment and the next day as well if possible.

Remember: Exercise, smoking, drinking of alcohol or vigorous mouth washing should be avoided. Hot drinks are advisable once the numbness has worn off to avoid burning your mouth. Warm to hot drinks and hot water mouthwashes (no salt is required) help heat the local tissues thereby increasing blood flow through the tissues and this in turn improves the ability of the tissues to heal.

Following surgery: ice packs should applied to the face over the surgical site for 10-20 minutes every hour for 3 days (or as often as you can) as this will help control the swelling and bruising.

Medicated mouthwash: Ideally a 0.2% Chlorhexidine mouthwash should have been started a couple of days before surgery (either Savacol or better still Curasept) to reduce the bacterial numbers in the mouth reducing the risk of post-operative infection.  Savacol used for more than 10 days will leave brown stains on teeth while Curasept has an anti-discolouration system and does not stain.

Oral hygiene: Good tooth cleaning and tongue brushing should be continued throughout the mouth only being careful in the area of the surgery.  Here, avoid brushing for 5 days, relying on the chlorhexidine to minimise the bacterial palque build-up.

After 5 days a gentle soft post-surgical brush or a baby’s tooth brush should be used gently to remove any plaque from the surgical site gradually returning to normal effective full mouth brushing over the next week to 10 days. If you normally use an electric brush ask your surgeon when you may start using it again at the surgica site.

What about aftercare?

Your dentist may have decided to use resorbable (dissolving) sutures, which will disappear after between 7 and 21 days. A review appointment will be arranged for you after about 7-10 days.  If sutures fail to dissolve ask your surgeon to remove them, though normally they will fall out as soon as you resume brushing the surgical site.

What about the long term?

You will need to be monitored after surgery.  This is usually achieved by a series of follow-up X-rays to ensure the area around the former root tip fills in with bone, indicating full healing and confirming successful elimination of infection.

How much will it cost?

Costs can vary for this surgery and will depend on the extent of infection and the degree of bone destruction around the root tip.  Extensive bone damage resulting from infection may require bone grafting at the same time as the apicectomy and this will be explained at the time of your consultation.  Where a tooth has more than one root, addition time is required and surgery will be more extensive and the cost will be proportionately greater.  An estimate will be provided prior to surgery at the time your informed consent is requested.

Need further advice?

Call in at our practice at NQ Surgical Dentistry, 183 Kings Road, Pimlico or call us on 07 4725 1656 and speak to any of our knowledgable team who will be able to offer you a consultation with Dr Colin Priestland.  Alternatively you can visit our website on www.nqsurgicaldentistry.com.au and check out our patient information area for information on a large number of areas of dentistry, periodontics (gum disease), oral surgery, implant treatment, and many other areas.  You can also contact us on the website and ask us a question. You can like us too on Facebook!