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Apical resection

Synonyms in a broader sense

Apectomy, apex amputation

definition

A root tip resection is used in cases of pronounced root tip inflammation. Under the term root tip inflammation (technical term: apical Periodontitis) in dental jargon is an inflammation in the area of the tip of a tooth.
With a tip resection, the tip of the affected tooth is removed by amputation. (Apectomy, apectomy). The name of this treatment measure describes in dentistry the separation and removal of the tooth root attacked by inflammatory processes with subsequent preparation and filling of the root canals and closure of the affected tooth, i.e. a root treatment.

Need for apicectomy

In the case of more advanced caries, the tooth pulp becomes inflamed with subsequent death. The contents of the infected pulp cavity are removed by the dentist and the cavities are disinfected, prepared and sealed with root filling material. Since the root canal has numerous fine branches at the root tip, not all of them can be reached with the filling material.

This is where bacteria can hide and lead to inflammation and suppuration of the bone surrounding the tip of the root. The pus focus can remain painless for a long time, but it continues to enlarge. If the body is weakened by other diseases, bacteria from this focus can break through the granulation tissue surrounding the pus focus and flood the entire organism. Therefore, such foci must be removed. This can be done by removing the tooth (tooth extraction) or by a root tip resection, or WSR for short.

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Indication for a root tip resection

Radiographically proven focus at the tip of the root.
Teeth with a curved root tip that cannot be completely filled.
As an alternative to extraction to preserve the tooth.
Removal of broken root canal instruments.
Adjacent cysts.
Fractures at the root tip.
When a revision i.e. renewed root filling does not lead to success.
Or. if pain persists for a long time after the 2nd root treatment.

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Pain after root filling
Revision of a root canal treatment

diagnosis

Since the inflammatory process is largely painless, it is only through the X-ray that you can be certain that an inflammatory reaction has formed in the bone due to the spread of bacteria. In some cases, the pus works its way out and forms a fistula on the tooth through which the contents of the focus evacuate.

Read more on the topic: X-ray of teeth

Operational approach

Under local anesthesia, the mucous membrane is cut together with the periosteum (Periosteum) unfolded over the relevant root tip and the bone opened until the root tip is exposed. Then the root tip is removed and the entire focus with the granulation tissue is cleared out.

The root canal can be filled shortly before the operation or it can be done during the surgical intervention. The wound cavity is tamponized, the canal is cleaned, dried and, after the filling material has been introduced, the canal is closed with a pin that protrudes over the opening of the root canal.
The pin is wedged in the canal by pulling it so that no more germs can escape from the canal. Then it is cut off level with the root.

Another method is to close the root canal from the operated side (Retrograde root filling). In both cases the bone cavity is then rinsed out with physiological saline solution or hydrogen peroxide, and the mucous membrane flap is closed with a few sutures. When making the incision, care must be taken to ensure that the suture is underlain by the bone and not on the wound cavity. If the healing process is normal, new bone will form again within a year and fill the wound cavity.

Read more on the topic: Procedure for a root tip resection

General or local anesthesia?

Two forms of anesthesia can be used for apicectomy. Most treatments are performed with local anesthesia, but general anesthesia is also possible, which is particularly common in clinics for anxious patients or patients with disabilities.

But which form can be preferred? In general, general anesthesia carries significantly more risks than local anesthesia, as the drug works throughout the body and not just in the area to be operated on.

General anesthesia is performed by a separate anesthetist who monitors the patient during the operation. This service is not covered by the health insurances, as the standard is local anesthesia and must be completely private. Furthermore, an inpatient admission is often necessary after general anesthesia; the patient does not leave the clinic until the next day.

With local anesthesia, only the area that is being operated on is numbed and the patient is conscious. The form of anesthesia leads to far fewer side effects, possible risks and complications than general anesthesia and is completely covered by health insurance. The anesthetized state is no longer noticeable a few hours after the root tip resection and the patient is completely sane again.

With general anesthesia, it takes a few hours for the patient to wake up and is usually dazed all day. In general, it can be said that local anesthesia is the normal anesthetic for apicectomy.

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Local anesthesia at the dentist
General anesthesia at the dentist

Advantages and disadvantages of general anesthesia

advantages
General anesthesia is particularly indicated for anxious patients and people with disabilities, who would hinder a regular form of therapy due to their limitations.
With general anesthesia, the patient is not aware of the root tip resection due to the blockage of consciousness and consequently cannot be influenced by negative experiences.
disadvantage
Nevertheless, general anesthesia is generally essential, as the drug works throughout the body and not just locally.The risk of complications from general anesthesia depends on general health and systemic diseases.
Furthermore, an inpatient admission is often necessary after general anesthesia; the patient usually does not leave the clinic until the next day.
General anesthesia is not covered by health insurance and is a private service that is billed at around three hundred euros. Upon awakening, the patient is drowsy and incapable of acting.
Complications such as nausea and vomiting are to be expected with an average of 10% probability. Serious complications are very rare and there is a 0.009% probability that general anesthesia can be fatal. Therefore, the patient should weigh up beforehand whether the time and money invested as well as the risk is worth it to prefer general anesthesia over local anesthesia.

Side effects of apicectomy

As with any surgery, bleeding can occur.
An opening of the maxillary sinus is possible in the posterior region. Damage to nerve fibers can also occur, although this is reversible, albeit only after a long time. With short roots, a tip resection can loosen the tooth, which is now provided with a shortened tooth root. Inflammation after the apex resection is also possible. This is often accompanied by the formation of pus.

Read more on the topic: Inflammation after apicectomy

Pain after an apicectomy

After any surgical procedure, pain is likely because each cut presents a new wound and irritation.
The body tries to initiate the wound closure and sends out pain signals in the process. Therefore, the doctor recommends taking pain medication immediately after the procedure. The symptoms subside completely after a few days, provided there are no complications such as infection of the wound. In this case, the discomfort can persist indefinitely, if it does not go away at all, extraction is the only way out.

More on this: Pain after an apicectomy

Pus formation after a root tip resection

If pus drains from the sewn wound after a root tip resection, there is massive inflammation, which can also lead to swelling and an abscess. An abscess describes a collection of pus in an encapsulated cavity.
This development can lead to severe symptoms and should be followed up by a doctor. It may well happen that an antibiotic is prescribed and the dentist has to make the pus drain through a relief incision. Patients often complain of a "big cheek".
Diffuse swelling on the gums or in the area of the tip resection is completely normal during the healing process. Any swelling that has persisted for more than 2-3 weeks that does not subside with cooling or is accompanied by severe pain should be presented to the doctor or dentist.

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Secondary bleeding

Postoperative bleeding is a possible complication after an apicectomy. The occurrence of secondary bleeding can have various reasons. Most often it is due to the negligent behavior of the person concerned, who exercises himself physically too early and thus overworks. The blood pressure and pulse skyrocket and the wounded area is supplied with more blood, which leads to secondary bleeding.

Resting is therefore essential for regeneration and for wound closure without complications. Furthermore, blood-thinning medication and a seam that is not sewn tight enough can also lead to bleeding. Patients with “blood thinners” belong to the risk group who are more likely to develop secondary bleeding. Incorrect permanent cooling also causes the body to signal hypothermia and increased blood pressure and blood flow are the result, which can lead to rebleeding.

Formation of an abscess after apicectomy

The abscess is the alternative complication of a failed apicectomy next to the fistula.
The remaining bacteria become active and multiply. They produce pus and in this case not a duct through which it is released, but an encapsulated collection of pus. This results in swelling, severe pain and functional restrictions of the jaw. If the abscess is not incised early enough to allow the pus to drain, there is a risk of acutely life-threatening sepsis (blood poisoning). If the causing tooth no longer has a hold due to the abscess formation, it is removed in most cases.

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Abscess on the tooth
Abscess in the jaw

Formation of a fistula after an apicectomy

The formation of a fistulous duct is a possible complication after an apicectomy. The fistula duct is a drainage channel of a focus of inflammation that forms in the direction of the least resistance either inside or outside the oral cavity and constantly secretes pus. As a complication after the apicectomy, a fistulous duct indicates that not all of the inflammatory cells of the chronic inflammation have been removed or that the inflammation extends beyond the surgical window that was chosen to clean the apex.

A second apicectomy, in which a larger part is cut off, is now considered a possible therapy. In addition, the fistula duct is surgically removed in order to remove all bacterial cells. If this therapeutic approach also fails, it must be considered whether the tooth is still worth preserving and, if the symptoms persist, it must be removed. However, removal is always the last resort, as every means is tried to save the tooth.

Find out more about the topic: Fistula on the gums

swelling

After the apicectomy has been performed, it will take some time for the wound to heal. Swelling after an operation is a common side effect after such an operation. The pain that occurs after the anesthetic can be combated well with painkillers, but cooling from the outside with an ice pack is also beneficial, as it counteracts the swelling.
This does not turn out to be excessively large. The ice should never come into direct contact with the wound, but rather be wrapped in a cloth and held on the outside of the cheek.

The swelling can be mild to moderate, exactly how big, but cannot be predicted. If the patient is also taking blood thinners, there is a higher probability that a bruise will form. The swelling also depends on how intense the procedure was. It usually peaked on the second day after the operation and should have subsided by a maximum of seven days after the operation.

More information on this topic: Swelling after an apicectomy

Risks

Since the root tip resection is a surgical procedure, the patient must be informed of the possible risks by the dentist before the actual treatment begins.
The most common side effects that occur in the course of a root tip resection depend on the position of the tooth to be treated and the initial state of the tooth root tip to be treated.

A special risk in the maxillary posterior area is the risk that the surgical procedure can result in a so-called maxillary sinus opening. This leads to the unwanted creation of a connection between the oral and maxillary sinuses (one of the paranasal sinuses). This fact is due to the fact that the bony lower jaw enters into close, neighborly relationships with nerves and blood vessels.
The "large" mandibular nerves are particularly at risk (Alveolar nerve and Lingual nerve). If one or both of these nerve branches are irritated or injured, temporary loss of sensitivity can usually be expected. The ability to perceive different tastes can also be limited at times. In the majority of cases, the reduction in feeling and / or taste regress by itself after a while, but there are also patients who have suffered a permanent loss of sensitivity since a root tip resection was performed in the lower jaw.

In addition to the specific risks, which are strictly dependent on the location of the tooth to be treated, there are other general dangers in the case of a surgical apicectomy.
As with any operation, the root tip resection can lead to wound healing disorders and / or infections in the surgical area. In addition, when using general anesthesia, the usual risks apply, including cardiovascular failure in particular.

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Wound healing disorder on the tooth
The risks of general anesthesia

forecast

The prognosis for an apicectomy is positive. According to studies, root tip resection has a success rate of over ninety percent if an adequate form of therapy is carried out. With the tip resection, a tooth can be fully reintegrated into the dental arch and included in dental prosthesis planning. The new techniques of root resection offer highly effective ways to treat a tooth in a minimally invasive way and is now a routine procedure.

The treatment makes the tooth symptom-free and can therefore be preserved over the long term. Even so, apicectomy cannot save all failed root canal-treated teeth. Longitudinally fractured teeth or perforated root fillings that fail to penetrate outside the tooth are just a few examples of teeth that can only be extracted.

Duration

The duration of a root tip resection cannot be given in minutes or hours. This depends on the patient's situation, the degree of difficulty of the procedure, the experience and skills of the attending physician or possible complications that may arise during treatment.

As a rule, you can aim for a value of 15-30 minutes per apical resection. After the procedure, you should rest for at least two to three days to give the wound a chance to heal. You shouldn't do any sport in the first week. The procedure itself usually takes place under local anesthesia, so that you should only consume pulpy food and fluids again when the anesthesia subsides (approx. 2 hours) so as not to injure yourself.

After an apicectomy has been performed, the body initiates the wound closure, which in most cases can take up to 2 weeks. After the sutures are pulled after about 7 days, the wound heals completely. The gums can still need up to a month after they have closed before they are back to normal. If complications arise, such as bacterial infection of the wound, healing and wound closure can be slowed down.

Usually, those affected are on sick leave for 2-3 days after the root tip resection surgery. The inability to work is usually accompanied by sick leave, which is determined depending on the severity of the intervention. The more complicated and time-consuming the operation, the longer the sick leave and incapacity for work. The regeneration time increases with the extent of the intervention.

costs

The cost of a root resection (Apectomy, apex amputation) are usually fully covered by both statutory and private health insurances. For this reason, the patient generally does not have to pay any excess. But there are also certain exceptions to this rule, as is unfortunately often the case in dentistry. In the case of entire treatment methods or individual treatment steps, costs to be paid by the patient concerned may arise.

In general, health insurance companies only cover the most cost-effective variant of any dental treatment that ensures the success of the therapy. Higher-quality procedures and / or the choice of better materials can make an additional payment on the part of the patient necessary.
In the case of a tip resection, a so-called retrograde tip resection (Apical amputation) With microsurgical preparation of the root canals, according to numerous studies, the chances of success are much higher than with the well-established methods.

Since mid-2012, this therapy method, or the microsurgical preparation and the closing of the root canals, has not been fully paid for by statutory health insurance companies. The exact costs and, if applicable, the co-payment of a root tip resection cannot be given in general terms. This is due to the fact that the price of the apicectomy mainly depends on the treatment effort, the materials used and the subsequent tooth filling material (because this is not always paid for by the health insurance) is dependent.

Basically, with an apicectomy, as with almost all dental treatments, the patient has the choice between various procedures that are more or less expensive or, as already mentioned, do not incur any costs for the patient himself.
The portions that are not counted among the health insurance benefits can ideally be fully covered by additional dental insurance. An approximate price list of the costs to be paid can be based on the existing dental accounting rules (Schedule of fees for dentists) put together.

However, since additional factors are calculated in the private dental billing, no precise information can be given about the actual price. The workload is given a high relevance in this form of billing, so a higher rate can be calculated for patients who, for example, have a strong saliva flow, have crooked tooth roots or are prone to major bleeding. For the time-consuming retrograde apicectomy (Apectomy, apex amputation) With the use of optically magnifying aids, either a microscope or magnifying glasses, costs of around 50 to 100 euros are incurred.

The apicectomy can generally be performed painlessly under local anesthesia.
Above all, those patients who suffer from severe fear of dental treatment, however, often want treatment with more extensive sedation (for example with laughing gas) or anesthesia. In these cases, additional (comparatively high) costs arise for the patient in question, which are not covered by the health insurances or only in exceptional cases.

Resection of the apex of the molar tooth

A root tip resection in the molar area can be a major challenge for the treating dentist or oral surgeon.
On the one hand, this surgical measure turns out to be difficult, especially in the case of a molar tooth with crooked roots, on the other hand, the possibility of opening the maxillary sinus must be expected in the area of the maxillary molars.

Root resection in pregnancy

In principle, dental interventions should not be performed during pregnancy if possible, as there is always a risk for the expectant mother and the unborn child. The first trimester, the period from the beginning of pregnancy to the third month, is the most dangerous and unstable, as interventions can also lead to infant death.

The second trimester, months three through six, is the most stable part of pregnancy and is the only period of time when dental treatments are even performed. This includes minor interventions, but no apicectomy. Although local anesthesia is possible during pregnancy, as some anesthetics have a high rate of protein binding, which means that the agent cannot reach the unborn child, surgical intervention is nevertheless associated with a risk.

For the expectant mother, despite the local anesthesia, stress is caused, which is transmitted to the child and can cause premature labor or damage the child. You should therefore wait until the birth is over so as not to put the mother or child at risk.

Which antibiotic works best?

For apicectomy, amoxicillin is usually prescribed, which has been shown to work best in combating bacteria in the oral cavity.
If there is a penicillin allergy, clindamycin is used, which also has a positive effect. Treatment becomes difficult in the case of resistance to both antibiotics, as alternative groups of antibiotics have to be used that do not function optimally in the oral cavity.

Homeopathy for a root resection

With a root tip resection, homeopathy can help to regenerate the immune system quickly and to alleviate pain symptoms. As the sole form of therapy, it does not manage to heal the inflammation under the root tip, but it can support the healing process after a root tip resection and strengthen general well-being.
Arnica preparations are recommended. However, the medication of the globules should take place in consultation with the treating dentist.

Smoking after an apicectomy

For smokers, nicotine consumption should be stopped for at least two weeks following a root tip resection. Smoking can have an enormously negative influence on wound healing and the approach of the wound edges. The wound healing disorder arises from the harmful and dirty substances that get into the oral cavity and thus to the wound through smoking.

The "dirt" lays on the fresh wound and can cause inflammation. In addition, nicotine intake worsens blood circulation. Possible consequences of tobacco consumption following a root tip resection are delays in wound healing, circulatory disorders and the development of inflammatory processes in the area of the operation. In addition, after a root tip resection, smoking can lead to acute circulatory problems, dizziness, nausea and even vomiting.

But smoking is not only harmful after an operation, it can also be involved in the fact that a root tip resection occurs in advance. The poorer blood circulation makes smokers more prone to bacterial inflammation.
Because the blood vessels are narrowed, such an inflammation is usually recognized much later, since there is no possibility of bleeding gums.

The inflammation is already in a further stage, which can lead to permanent damage. The susceptibility to tooth decay is also increased. In summary, these are all the first steps that attack the tooth and can lead to root inflammation, which can result in a root canal filling, a root tip resection or even an extraction of the tooth.

Read more on the topic: Apicectomy and smoking

When can you consume alcohol again?

After a root tip resection, alcohol should be avoided on the same day as well as one day after, as it causes the Slow down wound healing and can affect. Alcohol dilates the vessels and the Decreased blood clottingwhich is important for the wound healing process. If an antibiotic is taken, alcohol is not recommended for the entire duration of the intake.

When can I eat again?

Food can still be consumed on the day of treatment after the operation of the root tip resection.
As soon as the local anesthesia has completely subsided and the patient can feel something in all soft tissues again, he is allowed to eat and drink. If the anesthesia persists, the person may bite soft tissue or burn themselves on hot drinks without realizing it.

If the local anesthesia no longer works, the patient should try to chew carefully on the side that was not operated on. Soft, lukewarm foods are best. Furthermore, dairy products must be avoided for the first few days after the operation due to the risk of infection with lactic acid bacteria. Coffee, nicotine and alcohol are also counterproductive in the days immediately after the procedure, as consuming them can cause complications in wound healing.

Alternatives to apical resection

A root canal treatment is mistakenly not an alternative to the tip resection. It usually precedes the tip resection.

With a root tip resection, as the name suggests, only the area of the root tip is used. The root canal system is not included in this treatment.
These must be cleaned thoroughly and filled completely tight.
A root resection cannot replace such a treatment, so a well-executed root canal filling is the prerequisite for a good root resection.

There is no real alternative to apicectomy. If a root canal treatment does not bring the desired success, a resection is the last tooth-preserving step. There is no other method to save the tooth despite extensive carious destruction. If the root canal filling is not tight or the resection does not have the desired effect, these interventions can be repeated.

In the event of failure, the next step is to extract the tooth. Later, either an implant or a bridge is made, but the natural tooth has been lost, which one tries to prevent with an apicectomy. The aesthetic result of an artificial tooth will never come close to that of a natural tooth.

Read more on the topic: Alternatives to apicectomy

Summary

A root tip resection is always indicated if the normal root treatment did not lead to the desired goal and a pus focus has formed at the root tip. It is a good alternative to tooth extraction as it ensures that the tooth is preserved.