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, and you felt better for a while...

But then if 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 as much as possible, and seal it with a special filling material to prevent leakage. Most of the time, this treatment is quite 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/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)?

Simply put:

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 summary:

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, we both eliminate the focus of infection and continue to 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 at 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.

While repeating the root canal treatment is also an option, apical resection becomes the agenda if:

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 retreatment attempts.

3.2. If a broken instrument is left inside the canal

During root canal treatment in some teeth, a tiny metal file may break inside the canal, making it difficult to reach the last part. If a lesion has formed at the root tip beyond the broken instrument, root end surgery can surgically remove both 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, a cystic structure can develop over the years, growing within the jawbone. 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

If the tooth has a valuable fixed restoration (Zirconium, porcelain crown, or is part of a bridge) and removing it risks breaking the tooth, there is a chance to resolve the issue by surgically accessing the root tip without compromising the superstructure, even if the root canal treatment is inadequate.

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 tooth root.
2. If the tooth is largely lost due to decay or fracture.
3. If there is advanced gum (periodontal) bone loss.
4. If the root number and shape are not suitable for surgery.
5. If the long-term prosthetic plan does not seem sensible.

In these cases, pulling the tooth and considering solutions like an implant or a different prosthesis may be more appropriate. 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:

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

Some discomfort after apical resection is normal.

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

The success rate of apical resection is high when combined with the correct indication, technique, and good root canal treatment, with studies reporting success rates in the 70–90% range.

Success is affected by:

1. Root number and anatomy.
2. Size and type of the lesion.
3. Quality of the restoration on the tooth.
4. Patient factors (oral hygiene, smoking, systemic diseases like diabetes).
5. Surgeon's experience and techniques used.

In Bursa, at Milim Dental, Dr. Ali Direnç Ulaşan achieves long-lasting, problem-free teeth by using digital imaging (CBCT) for accurate planning, atraumatic surgical techniques, and careful post-op follow-up.

8. Frequently Asked Questions (FAQ)

1) Root end surgery or tooth extraction—which is more sensible?

If the tooth's roots and gum support are solid, saving the tooth with apical resection is highly valuable. However, in cases of root cracks or advanced bone loss, extraction followed by a predictable solution like an implant may be more appropriate.

2) Is there a lot of pain during or after the procedure?

The procedure is pain-free during the surgery under local anesthesia. Post-op pain is typically mild-to-moderate and well-controlled with prescribed painkillers.

3) Can the same tooth undergo apical resection again?

In some exceptional cases, yes, but the success rate of secondary apical resection is lower. In recurring cases, extraction and alternative solutions are often more realistic.

4) If I have a cyst at the root tip, must I definitely have surgery?

The decision depends on the cyst's size, its effect on neighboring structures (nerve/sinus), and your symptoms. Cysts that cause chronic infection and enlarge the jawbone usually require surgery, often combined with apical resection.

5) Can I use my tooth immediately after apical resection?

Generally, yes, but we advise avoiding chewing hard foods on that side in the initial days. Complete "forgetting about the area" (internal bone healing) might take a few months, which we monitor during follow-up.

9. Conclusion: Give Root End Surgery a Chance Before Extraction

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 preserving your tooth.
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?"

Dr. Ali Direnç Ulaşan and the Milim Dental team in Bursa would be happy to perform a detailed examination and imaging to determine the most accurate, long-term healthy decision for your tooth.