Chapter 1

Principles of Apicectomy
Technique
The term apicectomy is one that is commonly employed The apical constriction is of the greatest importance
and will be used in this manual. However, the word is to the success of endodontic therapy. It acts as a barrier
misleading because it places undue emphasis on a to the passage of debris during instrumentation and as a
relatively trivial part of the surgical procedure . stop for instruments, cement and the filling point.
A successful apicectomy technique depends partly on Following obturation of the root canal, the constriction
surgical skills, but as importantly on a logical approach, becomes occluded with cementum which forms a phys-
which must be based on a sound knowledge of endodon- iological barrier (Figure 1.1). Once noxious matter has
tic theory. ceased to pass from the canal into the tissues surround-
ing the tooth, the body's defence and repair mechanisms
will satisfactorily resolve the majority of apical lesions
The Apical Constriction
(Figure 1.2).
The principal aims when root filling are, first, to cleanse
the root canal of debris and, second, to obturate it to
the base of the apical constriction with some form of
filling material so that noxious matter cannot escape
into the supporting tissues.

Cementum plug
Cementum

_ ........_ _ _ _ _ __ a

Gutta·percha Cement sealant

POint

...;;;::;,;...-.._ _ _ _~ b
Figure 1.1 The apical constriction acts as a natural
'stop' .to the passage of instruments and debris. Figure 1.2 a, b, Repair of apical lesion following a
When the canal is properly filled the apical foramen conventional orthograde root-filling (review - 14
will eventually become occluded with cementum months)
9

I. E. Barnes, Surgical Endodontics

© I. E. Barnes 1984
10
Figure 1.3 Silver points pa$sed down the buccal and
lingual canals of a lower incisor. The cementation of
either one of these points would probably have
effected an apical seal. Removal of the root-tip
during apicectomy will result in failure unless both
canals are filled
The apical constriction is also a valuable safeguard
against the consequences of diagnostic error. For
example, in the case of the lower incisor illustrated in
Figure 1.3, the obturation of either the buccal or the
lingual root canal would probably effect an adequate
apical seal because both canals converge and join at the
end of the root. Resection of the root-tip during apicec-
tomy would result in eventual failure unless both canals
had been identified and filled.
When a tooth is apicected, the apical constriction is
removed with the terminal portion of root. As a result,
the chances of long-term endodontic success are reduced
for three reasons. First, because the root canal is
exposed at a more coronal level, where it is larger in
cross-section. A cemental barrier is less likely to form
Surgical Endodontics
over this relatively large area of (non-physiological)
root-filling material than it is within the small apical
constriction (Figure 1.4). Second, because removal of
the root-tip may expose a second, possibly unrecognized
root canal (see Figure 1.3). Third, because some canals
are so irregular in cross-section that they cannot be
instrumented to a circular shape and thus the greater
part of the apical seal may be comprised of cement
sealant (Figure 1.5). Should the sealant be soluble, it
may over the years be lost into the tissues, so that a
dead-space develops between the filling-point and canal
wall. If this occurs the filling may fail. The use of an
insoluble cement may prevent such a loss, but in prac-
tice the problem is usually overcome by placing an
insoluble sealant in the irregular terminal portion of the
canal (Figure 1.6). Silver amalgam is most often used
for this purpose and is termed a 'retrograde filling'. If
the absence of signs and symptoms is used as a measure,
amalgam can be considered to be well tolerated by the
body. However, histological and radiological evidence
suggests that amalgam may cause a mild foreign-body
reaction in the adjacent tissues. There is, in addition, an
increasing concern about levels of mercury absorption
and toxicity. A retrograde amalgam filling must there-
fore be considered a poor substitute for the physiologi-
cal seal that is formed by cementum within the apical
constriction as the result of a successful root filling.
An 'apicectomy' should not be considered to be an
elective procedure, but should be undertaken only when
conventional orthograde root filling techniques are im-
practicable or have failed.
Figure 1.4 a. The tip of a No. 15 file just fits into the
apical foramen of this upper central incisor. b. The
surface area of the gutta-percha and cement sealant
that are exposed following removal of the root-tip is
far greater than that of the intact apical foramen