What is Root End Surgery (Apical Resection)?

The Surgical Way to Save a Tooth Without Extraction

Dr. Ali Direnç Ulaşan – Oral and Maxillofacial Surgeon, Milim Dental Bursa

You had a root canal treatment,

you felt better for a while...

But then swelling, throbbing pain, occasional discharge, and bad odor started again.

You are most likely asking yourself these questions:

1. "Did the root canal fail?"
2. "Do I have to get my tooth pulled?"
3. "Is there no other way to save this tooth?"

As a surgeon specializing in oral and maxillofacial surgery in Bursa, I, Dr. Ali Direnç Ulaşan, and the Milim Dental team, frequently see patients coming to our clinic with the following complaint:

"Doctor, I don't want to give up on this tooth; is there one more chance to save it without extraction?"

In most cases, our answer is: Yes, we may have a chance to save the tooth without extraction through root end surgery (apical resection).

In this article, I will explain in a language the public can understand, yet within the correct medical framework:

1. What is root end surgery (apical resection)?
2. Why is root canal treatment sometimes insufficient?
3. In which situations can we save the tooth without extraction?
4. How is the procedure done, how long does it take, and is it painful?
5. What is the success rate, and is it applicable to everyone?

1. Why Might Root Canal Treatment Not Always Be Sufficient?

The purpose of root canal treatment is to clean the nerve and blood vessel bundle (pulp) inside the tooth, thoroughly clear the canal of microbes, and seal it with a special filling material to prevent leakage.

Most of the time, this treatment is very successful, and the tooth is used for years without problems.

However, in some situations:

1. It can be difficult to reach the last part of the canal.
2. A cyst or chronic inflammation may have developed at the root tip.
3. There might be cracks or anatomical variations at the root tip.
4. A previously performed root canal treatment may have been insufficient, and the infection foci in the root may not be completely cleaned.

In this situation, we see:

1. Intermittent swelling.
2. Constant mild sensitivity.
3. Occasional abscess and discharge into the mouth (a fistula, like a small pimple).

At this point, root end surgery (apical resection) offers the chance to surgically clean the problematic root tip without pulling the tooth.

2. What is Root End Surgery (Apical Resection)?

In simple terms:

Root end surgery is the surgical cutting and removal of the root tip of a tooth that has had a root canal but still has inflammation/cyst at the root end, and the cleaning of the surrounding infected tissue.

In other words:

1. We do not extract the tooth.
2. We only take the problematic tip of the tooth root.
3. We clean the inflammation/cyst around the root tip.
4. If necessary, we make the root tip leak-proof by filling it from the inside.

By doing this:

1. We eliminate the focus of infection.
2. We keep the tooth functional in the mouth.

3. In Which Cases Can Apical Resection Be Considered?

Root end surgery is not suitable for everyone or every tooth. First, a detailed examination and radiological evaluation are necessary.

As Dr. Ali Direnç Ulaşan in Bursa, we generally plan apical resection in Milim Dental in the following situations:

3.1. If a root canal was performed but there is still a lesion (dark area) at the root tip

On the X-ray (especially periapical or CBCT – 3D tomography):

1. A dark, round/oval area (cyst or granuloma) is visible at the root tip.
2. The root canal filling looks good, but the lesion persists.
3. The patient experiences occasional swelling or sensitivity.

In this situation, repeating the root canal treatment is also an option; however, in some cases:

1. The canal is not suitable for re-opening.
2. There is a broken instrument inside the canal.
3. The canal anatomy is very complex.
4. The lesion persists despite multiple attempts at root canal retreatment.

That is when apical resection comes into play.

3.2. If a broken instrument is left inside the canal

In some teeth during root canal treatment:

1. A tiny metal file might break inside the canal.
2. This makes it difficult to reach the last part of the canal.

If the broken instrument is in a position that does not cause a problem, it can be monitored. However, if there is an infection/cyst beyond the broken instrument and a lesion has formed at the root tip, root end surgery can surgically remove the broken instrument and the infected root tip and surrounding tissues.

3.3. If there is a cyst or chronic inflammation (granuloma) at the root tip

In some teeth, over the years:

1. A cystic structure may develop at the root tip.
2. This can grow within the jawbone, affecting the tooth and neighboring teeth.

In this case, apical resection is a good solution for both keeping the tooth in the mouth and completely cleaning the cystic tissue.

3.4. If the tooth has a crown/bridge and the root canal cannot be accessed

Sometimes the tooth has a:

1. Zirconium or porcelain crown.
2. Or is part of a bridge system.

Removing this restoration might risk fracturing the tooth. Even if the root canal treatment is inadequate, there is a chance to resolve the issue by surgically reaching the root tip without compromising the superstructure.

4. In Which Cases is Tooth Extraction More Appropriate?

It is not correct to try to save every tooth at any cost. In some situations, tooth extraction may be more sensible and safer than root end surgery.

For example:

1. If there is a longitudinal crack in the root.
2. If a large part of the tooth is lost due to decay or fracture.
3. If there is advanced gum (periodontal) bone loss.
4. If the number and shape of the roots are not suitable for surgery.
5. If the planned prosthetic restoration (crown-bridge) on the tooth does not seem sensible in the long term.

In these cases, instead of trying to save the tooth, it might be more appropriate to extract it and consider solutions like an implant or a different prosthesis.

This decision is made through X-ray + clinical examination + your expectations + long-term planning.

5. How is Root End Surgery Performed? (Step-by-Step)

Many patients ask: "Is root end surgery a difficult procedure with sutures, will it hurt much?"

The truth is, when properly planned, this procedure can be completed under local anesthesia, in a controlled and short time.

The stages are roughly as follows:

5.1. Local Anesthesia

The area to be operated on is numbed with local anesthesia, just like for a tooth extraction. When performed with the correct dose and technique, you will not feel pain during the procedure, only pressure and touch.

5.2. Gum flap opening (surgical window)

A small incision is made in the gum area of the tooth to reach the root tip. A surgical window is created in the gum tissue and the underlying bone so that the root tip can be seen.

5.3. Removal of the root tip and infected tissue

The infected final part of the root tip is cut and removed with special burs. The surrounding inflamed/cystic tissues are cleaned and sent to the laboratory for pathology examination, if necessary.

5.4. Retrograde filling (if needed)

In some cases, it may be necessary to intervene the root tip from the inside. A leak-proof filling material (retrograde filling) is placed in the cut section of the root tip. This prevents any possible leakage from the canal above from reaching the root tip.

5.5. Cleaning the area and suturing

The surgical area is washed and cleaned. The gum tissue is returned to its original position and closed with sutures. Gauze is placed on the area after the procedure, and you are given advice for the first few hours.

5.6. How long does the procedure take?

For a single-rooted tooth in the upper front area, the procedure usually takes between 20 and 40 minutes. The duration may be longer depending on factors such as the lower jaw, multi-rooted teeth, and bone structure.

In general, it is a one-session, day-case procedure; you can usually go home after the procedure and manage the day with simple painkillers.

6. Post-Root End Surgery: Pain, Swelling, Healing

As with any surgical procedure, some discomfort after apical resection is normal.

6.1. Pain

After the anesthesia wears off, you may feel mild-to-moderate pain in the area. This is usually controlled within the first 24–48 hours with prescribed pain medication.

6.2. Swelling and Bruising

Slight swelling, especially in the upper front jaw area, and rarely small bruises may occur. Cold application (ice compress externally for the first 24 hours) helps reduce swelling.

6.3. Daily Life

It is important to avoid very hot food/drinks, chewing with the operation area, smoking, and heavy exercise on the first day if possible. Most patients return to their daily routine to a large extent within 1–2 days.

6.4. Suture Removal

Sutures are usually removed at the control appointment within 7–10 days. During this period, the gum largely closes, and then the bone tissue slowly reforms from within.

7. What is the Success Rate? How Reliable is it?

The success rate of apical resection is high, combined with the correct indication, correct surgical technique, and good root canal treatment.

Various scientific studies report success rates in the 70–90% range.

Factors affecting success:

1. The number and anatomy of the tooth's roots.
2. The size and type of the lesion at the root tip.
3. The quality of the prosthetic restoration to be placed on the tooth.
4. The patient's oral hygiene, smoking habits, systemic diseases (diabetes, etc.).
5. The surgeon's experience and the techniques applied.

As Dr. Ali Direnç Ulaşan in Bursa, at Milim Dental, in apical resection procedures, we achieve long-lasting, problem-free teeth by using:

1. Digital imaging (CBCT) for accurate planning.
2. Atraumatic surgical techniques.
3. Retrograde filling at the root tip in necessary cases.
4. Careful post-operative follow-up.

8. Frequently Asked Questions (FAQ)

1. Is root end surgery or tooth extraction more sensible?
2. This entirely depends on the tooth's condition. If the tooth's roots are sound, gum support is sufficient, and it can be used for many years with the planned crown, saving the tooth with apical resection is very valuable. However, in situations like a root crack or advanced bone loss, planning a more predictable solution like an implant after extraction may be more appropriate.
3. Is there a lot of pain during or after the procedure?
4. The procedure is done with local anesthesia; when an appropriate dose of anesthesia is provided, you will not feel pain during the surgery. Afterward, there may be mild-to-moderate pain, which is controlled with prescribed painkillers. Most of my patients state, "It wasn't as bad as I expected."
5. I had apical resection on the same tooth before; can it be done again?
6. In some exceptional circumstances, it may be possible, but the success rate of secondary apical resection is lower. In such recurring cases, tooth extraction and alternative prosthesis/implant solutions often become more realistic options.
7. If I have a cyst at the root tip, must I undergo surgery?
8. Factors such as the size of the cyst, its effect on the tooth and neighboring structures, your level of complaint, and its proximity to structures like nerves/sinuses determine this decision. While some small lesions can be monitored, cysts that thin the jawbone, affect neighboring teeth, or become a focus of chronic infection usually require surgery. This surgery is often performed in combination with apical resection.
9. Can my tooth be used immediately after apical resection?
10. Generally, yes, but we advise you not to chew very hard foods with that area in the first few days. Since internal bone healing takes longer, it may take a few months until you feel like you have completely "forgotten about the area." We monitor the healing process in regular check-ups during this period.

9. Conclusion: Give Root End Surgery a Chance Before Extracting the Tooth

In summary:

1. A persistent abscess and root tip lesions after root canal treatment do not necessarily mean the tooth must be pulled.
2. Apical resection (root end surgery) offers the opportunity to surgically clean the focus of infection while keeping your tooth in your mouth.
3. When the right patient and tooth are selected, teeth that can be used for many years with high success rates can be achieved.

If you are a patient who has:

1. Had a root canal but still experiences swelling,
2. A "spot" visible at the root tip on the X-ray,
3. Been advised to get the tooth pulled but are wondering, "Can we give this tooth one more chance?"

As Dr. Ali Direnç Ulaşan and the Milim Dental team, specializing in oral and maxillofacial surgery in Bursa, we would be happy to perform a detailed examination and imaging to determine the most accurate plan for you.

Remember: It is not correct to try to save every tooth, nor is it correct to pull every tooth immediately. The important thing is to make the wisest, most long-term healthy decision for your tooth.