• Apicectomy may be appropriate in cases where orthograde RCT has failed and cannot be improved, or where restorative/ surgical factors require root end surgery
• Poor coronal restoration and suboptimal root fillings generally preclude the provision of apicectomy
• Apical surgery should be followed by appropriate clinico-radiological monitoring

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Abbreviations

Apical surgery and apicectomy can be considered in cases where primary orthograde root canal treatment has failed and orthograde retreatment is deemed inappropriate or insufficient.

• Previous treatment carried out to guideline standard but symptomatic or progressing periradicular disease in an optimally root-filled and restored tooth

  • Symptomatic or progressing periradicular disease in a well root-filled tooth where RCT:

    • Has failed

    • Would be detrimental to the structural integrity of the tooth/restoration

    • Would involve post removal with a high risk of root fracture

  • Where biopsy of periradicular tissue is required

• Suboptimal quality root filling with scope to improve with orthograde retreatment

  • Insufficient time following RCT to allow bony infill in an asymptomatic tooth

  • Poor coronal seal

  • Unrestorable/ periodontally-compromised tooth

  • Perio-endo lesion

  • Root fracture

Referrals for apical surgery should ideally include dated pre-RCT and post-RCT periapical radiographs, alongside any further imaging that demonstrates ongoing periradicular pathosis. Upon assessment, periapical radiography is preferable to an orthopantomogram, unless a more extensive lesion is present. Where conventional radiography does not provide sufficient information to diagnose or treatment plan a case, CBCT imaging may be required. Such instances include lesions close to the inferior alveolar/ mental nerve or the maxillary sinus, assessment of root fractures, iatrogenic damage or resorption.

Since there is good evidence to suggest that endodontic re-treatment has a higher success rate than apical surgery, patients will be advised to pursue a non-operative route if obturation is radiographically incomplete or short of the root apex. In order to prevent recontamination and failure of apical surgery, all patients should also have a satisfactory coronal seal.

More comprehensive guidelines and evidence-based recommendations are available here:

RCS/ BES Guidelines for Periradicular Surgery 2020

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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