Root End Surgery

Though it pains us to admit it, we here at Mountain View Endodontics have to concede that Root Canal Treatment is not always 100% successful. While it is difficult to quantify success rates due to significant variations in how “success” is defined, multiple studies over various decades have established that well-performed non-surgical root canal therapy is highly successful. With regard to the small minority of cases that do not achieve long term success, the causes of failure are many and varied. Some causes such as inadequate length or density of the obturation (often indicative of inadequate chemo-mechanical debridement), contamination during treatment due to improper isolation, or crown-down leakage can be effectively addressed via endodontic re-treatment followed by placement of a new, high-quality coronal restoration. 

Certain other causes of failure, or for certain restorative reasons, endodontic microsurgery may be a better choice.Historically, endodontic surgery (aka root end surgery, apicoectomy) has not had success rates comparable to traditional non-surgical root canal therapy. However, in the last decade or so, advances in equipment and technique have resulted in excellent success. The Fall 2010 Edition of the Colleagues for Excellence newsletter (www.aae.org/colleagues) addresses this topic and lists some of the enhancements that have led to increased success rates. Principal among these are the use of the dental operating microscope to identify previously unidentified and untreated canals, fins or isthmuses, the use of specially designed ultrasonic tips that permit accurate and well-centered retro-preps, and advanced bio-ceramic materials such as Mineral Tri-oxide Aggregate (MTA) that provide an excellent and biocompatible root-end seal. The result of these improvements is that endodontic microsurgery, with proper case selection and technique, results in success rates reported in the mid-to- high nineties whereas traditional root-end surgery resulted in success rates closer to 50%. 

The following report illustrates a clinical scenario in which apical surgery was indicated: The patient reported to the general dentist for new crowns on #’s 8 and 9.

The all-porcelain crowns were over-contoured and were in supra-occlusion.  The crown on #9 split vertically and the pieces were re-cemented by the general dentist.  The teeth had been previously treated endodontically, and upon clinical testing, both had palpation and percussion tenderness. The pre-op radiograph revealed that both teeth had fiber posts and root filling material that had been extruded beyond the apex.

An initial attempt was made to treat the case non-surgically. The fiber posts were removed from both teeth as well as the obturation material in #8 via non-surgical root canal re-treatment.  However, attempts to remove the extruded gutta percha from #9 from an orthograde (through the coronal access) approach were unsuccessful.

Via apical surgery, the extruded material on #9 was removed, both root ends were resected and the roots were sealed apically with bioceramic material.

The patient had minimal post-op pain following the procedure and the natural dentition has been retained thereby avoiding the well-known challenges of implants in the esthetic zone.

#8 following restoration with a new fiber post, core and crown

#9 following restoration