This week’s question is “Retreatment vs apicoectomy – which to use, and when?” Watch my video explanation, and you can also read below. But definitely check out the case images in the video!
Do you ever have trouble deciding on when to do a retreatment versus an apico? When do you do what? What goes into your decision making?
- Are you looking at the quality of the endo?
- Have you discovered any canal obstructions?
- Are you using a CBCT to help make your decision?
- What are you evaluating? Are you evaluating the restorative?
What would you say are your deciding factors? Let me walk you through my thought process and show you how I approach this important decision.
Find Out the Whole Story When Considering Retreatment vs Apicoectomy
The first thing that I do is I look at the quality of the endo and I try to find out the whole tooth story. Is there a missed canal? Can I tell if the previous operator achieved working length? Did they use a rubber dam?
I like to show people the rubber dam so that they understand what I am talking about. When I show them this (see video) and ask if it was used during their treatment and they say no, they like to tell me that their root canal was done years ago and that is the reason why it wasn’t used. Well, my friends, the rubber dam was invented back in 1864, so there are no excuses.
That said, when I show them the rubber dam and they say that they have never used it, that tells me something. It tells me that the entire root canal could still be infected, which could very well be the deciding factor for me on how I need to treat the tooth.
Differences Between the Two
Let’s talk about the key differences between the two procedures if you’re looking at an orthograde retreatment vs apicoectomy. A retreatment will treat the entire length of the canal, while the apicoectomy will treat only around the last 6mm of the canal. If you suspect that the entire root is contaminated, then a retreatment should be your first choice. (And if you suspect a missed canal, then retreatment should definitely be your first choice!)
I also want to know when the tooth was treated (and how many times). Dental school taught me the following: You do the root canal first, and if it fails, you retreat it. If that fails, then you retreat it again before you ever go to the apico. If the tooth has had only one root canal, then I will try to retreat whenever it is possible.
I always try to do whatever I can non-surgically first. (You could say I have become sort of a retreat-o-dontist.) One of the main reasons why I retreat first is simply because, if I’m being completely honest, I just don’t trust that the tooth was disinfected properly (or that there hasn’t been any coronal leakage). So if there is a missed canal, a short obturation or a not-so-good-looking endo, I retreat any chance I can get, especially if it’s never been retreated before.
Looking at an Apicoectomy
Apicos were created for a few main reasons, one being because teeth naturally have a lot going on in the apical third. There are times when, in the last apical 3mm, there are a lot of apical ramifications and isthmuses that can get in your way. The natural anatomy can sometimes be hard to disinfect.
That said, when we do an apico, we resect the tooth at 3mm because this is the level in which you will likely remove all those ramifications. We then do a retroprep that extends 3mm into the canal cleaning it even further and deeper, and then we seal it with a retro filling.
Another great reason to do an apico is if you have an obstruction, like a separated file or some calcification that prevented you from getting patent. The apico again would resect 3mm of the root, most likely exposing the file. Then, your retroprep would likely remove the file and clean in the area around where you can seal the canal properly from the end.
When to Choose Apico Over Retreatment
Apicoectomies are great, and they work really well, but you have to know the right cases to use them. When looking at retreatment vs apicoectomy, it’s important to know that an apico will only achieve disinfection until around to the 6mm level. That said, if you suspect any coronal leakage or coronal contamination, then the contamination will not be addressed. Unfortunately, this could lead to a future failure, like in this picture here (see video).
You can see that this patient had a silver point obturation that was likely failing, which was why an apico was done. Years later, it started to fail, and she developed a sinus tract because the entire length of the root was contaminated. I realized that another apico here was not going to fix this, so I choose to retreat it. Fortunately, the infection went away.
Cases of Failed Apicos
Here are a few more cases where some the apicos failed (see video). This root canal looks like it was done well, but it was tender to percussion again years after the apico. I wasn’t sure what was going on, but I knew that I would have retreated the tooth first prior to this apico. Knowing that, it was going to be my treatment of choice at this point. Now, my postop doesn’t look much different. You can’t tell much, but if you take an off-angle radiograph, you can actually see that there is an extra canal in that root where the apico was done. You would never be able to see something like that unless you accessed it. Sometimes, you have to take a peek inside to really identify the correct treatment.
Here is another case that was apico’ed and was not healing. The CBCT here told us the exact story — there was a missed MB2. When you have a missed canal like this, an apico is not going to work long term. when there is a missed canal like this. You need to make sure you know the entire tooth story before you dive in. You have got to retreat first.
Patient Preferences in Retreatment vs Apicoectomy
Another reason why people prefer an apico is sometimes for restorative reasons like in this patient here (see video).
I didn’t think that an apico is a good long-term solution here because it doesn’t appear disinfected at all. Additionally, the patient was ready to replace the crown and start over due to the esthetics. In this situation, in evaluating retreatment vs apicoectomy, we went with the retreatment. In order to get the job done, however, you have to disassemble the tooth. That said, it’s important that you talk to your patient and let them know their options, along with all the pros and cons. (Which is what we did here. Even though we both felt it was more work on the front end, we knew that it would give him the best result long-term both endodontically and esthetically.)
Retreatment vs Apicoectomy: Other Considerations
It’s true that both procedures have contraindications, but remember that, specifically for the apico, you need to be careful for those special anatomical structures. (Like the sinus and the mental nerve) Also, the second molars can sometimes have too much buccal bone, which makes the surgery very difficult to access. Just keep these contraindications in mind.
Now what about this? (see video) This patient has two posts, but she is asymptomatic and has been asymptomatic for 10 years. You could try to retreat the tooth, but this is a cast post and core, so you must consider that when you are treatment planning. You could certainly do an apico, but you can also do nothing. Remember that doing nothing is always an option, but make sure to communicate with your patient and do good follow-up.
Hopefully, this tutorial helps your decision making when it comes to retreatment vs apicoectomy. Both are great options to save your natural teeth.