Apical surgery

Question 1

What are other names for apical surgery?

Answer 1

Apicectomy, root-end surgery, and endodontic surgery.

Question 2

What is the main purpose of apical surgery?

Answer 2

To eliminate infection of endodontic origin when this cannot be achieved by non-surgical methods, to repair iatrogenic/pathological defects, or to diagnose via direct vision when non-surgical approaches are insufficient.

Question 3

List the classifications of endodontic surgery.

Answer 3

Incision and drainage, Periapical surgery, Perforation/resorption repair, Root resection, Diagnostic surgery.

Question 4

What is the purpose of drainage?

Answer 4

Relief of pain by releasing inflammatory/infective material.

Question 5

What anaesthetics are used?

Answer 5

Ethyl chloride or lidocaine to anaesthetise soft tissues.

Question 6

Describe the drainage procedure.

Answer 6

Anaesthetise soft tissue, Make incision with a scalpel blade, Massage soft tissues to encourage drainage, Remove inflammatory infiltrate → immediate patient relief.

Question 7

When is PA surgery indicated?

Answer 7

When a tooth has failed RCT and needs removal of root end and associated pathology.

Question 8

What happens in PA surgery?

Answer 8

Remove the root end, Remove inflammatory tissue, Retro-prep the remaining root canal, Root-end fill, Close flap and evaluate healing at 3–6 months.

Question 9

How is a perforation treated surgically?

Answer 9

Raise flap → identify perforation (common in sclerosed roots) → remove inflammation → seal and restore the defect (often GIC).

Question 10

How is external resorption treated?

Answer 10

Similar to perforation: expose defect → remove inflammatory tissue → seal with material like GIC.

Question 11

When is root resection indicated?

Answer 11

When a PA lesion is limited to one root (e.g., distal root of lower molars), or when one root is fractured.

Question 12

What is the outcome of root resection?

Answer 12

Remove affected root → bone heals around site. Sometimes creates a situation like “turning a molar into two premolars.”

Question 13

Why is diagnostic surgery used?

Answer 13

For unclear cases where a fracture or pathology cannot be identified non-surgically.

Question 14

What may diagnostic surgery reveal?

Answer 14

Vertical or internal fractures extending down the root canal, Problems requiring extraction.

Question 15

What is hemisection?

Answer 15

Cutting a tooth in half to remove a compromised part.

Question 16

What is trephination?

Answer 16

Creating a bone window to encourage healing.

Question 17

What is decompression?

Answer 17

Draining cystic fluid from a large lesion (often anterior) to shrink lesion before definitive surgery. Patients irrigate with syringe; sometimes lesion resolves completely.

Question 18

What is intentional reimplantation?

Answer 18

Extracting a tooth atraumatically, root-filling it extra-orally, then reimplanting. Used when conventional endodontics is not feasible.

Question 19

What is orthodontic traction for ferrule?

Answer 19

Atraumatically extracting tooth → repositioning 2–3 mm coronally for ferrule → splinting until PDL heals → then restoring tooth.

Question 20

Why is CBCT important before apical surgery?

Answer 20

Identifies missed canals, Assesses anatomy (roots, mental foramen, sinus), Helps ensure non-surgical retreatment has been fully attempted.

Question 21

How does loss of cortical plate affect prognosis?

Answer 21

Success rate decreases significantly because granulation tissue cannot be scraped against cortical bone.

Question 22

Why must mental foramen location be considered?

Answer 22

To avoid mental nerve injury during lower molar surgery.

Question 23

What do we look for on CBCT when assessing molars?

Answer 23

Whether lesion involves mesial, distal, or both roots.

Question 24

What is an osteotomy?

Answer 24

Removal of cortical bone to access lesion/root apex.

Question 25

Describe the root resection process.

Answer 25

Remove apical 3mm (contains most accessory anatomy), New technique: resect at 90°, NOT 45° (reduces exposed tubules), Use ultrasonic tips to retroprep 2–3 mm of GP, Place retrograde filling (MTA/bioceramic).

Question 26

Why is MTA preferred?

Answer 26

Highly biocompatible, Osteoinductive (induces bone growth onto material), Osteoconductive (bone grows along surface), Leads to almost complete healing.

Question 27

What are the main indications?

Answer 27

When infection cannot be eliminated non-surgically, Repair of pathology/iatrogenic issues not accessible otherwise, Diagnostic uncertainty requiring direct vision or biopsy, When non-surgical retreatment risk outweighs benefit (e.g., sclerosed canals, posts).

Question 28

List the contraindications.

Answer 28

Operator inexperience, Patient medical or psychological issues, Difficult access (e.g., lower incisors, high frenal attachment, deep vestibules), Local anatomy issues (sinus proximity, nerves, vessels), Poor restorative or periodontal prognosis, Patients with large lesions difficult to anaesthetise.

Question 29

Current guidelines on apical surgery?

Answer 29

Considered specialist-level procedure.

Question 30

Principles of flap design?

Answer 30

Balance between access, vision, and minimising recession.

Question 31

Factors affecting flap design?

Answer 31

Size/site of lesion (never incise directly over lesion), Crowns/veneers (higher recession risk), Depth of sulcus/vestibule, Frena, muscle attachments, Thin biotype (more recession), Bony prominences, Often extend incision beyond canine for lateral incisor surgery.

Question 32

Full mucoperiosteal flap types

Answer 32

Triangular, Rectangular, Trapezoid.

Question 33

Limited mucoperiosteal flaps

Answer 33

Submarginal, Papilla base.

Question 34

What occurs once flap is raised?

Answer 34

Identify lesion, Often find existing bony fenestration, Create osteotomy window, Remove granulation tissue, Resection and retro-preparation.

Question 35

Retropreparation steps?

Answer 35

Use ultrasonic tips, Remove 2–3 mm GP from root end, Create clean cavity for filling.

Question 36

What materials are used today?

Answer 36

MTA or bioceramic cement (superior to amalgam).

Question 37

Pre-operative factors

Answer 37

Age (younger = better healing), Health (systemic diseases ↓ success), Symptoms present, Tooth location, Size of lesion, Amount of bone loss, Quality of coronal restoration, Re-surgery lowers success.

Question 38

Intraoperative factors

Answer 38

Bevel angle, Resection level (3mm optimal), Retrograde filling material, Use of magnification, Hemostatic agents, Bone grafting (avoid unless significant cortical loss).

Question 39

What are overall reported success rates for endodontic surgery?

Answer 39

25–85% (older data; does NOT reflect modern microsurgical techniques).

Question 40

What improves success?

Answer 40

Good case selection, High-quality initial RCT, Modern microsurgical approach, Use of bioceramics, CBCT planning.

Question 41

Answer 41

submarginal flap

Question 42

Answer 42

rectnagualr flap