Apicectomy: Surgical Treatment When Root Canal Re-Treatment Is Not Possible
For people advised that a root-filled tooth may need surgery: an apicectomy, or periradicular surgery, removes infection and the root tip through the gum. This page gives the decision rule for surgery versus re-treatment, the steps, a recovery timeline, published success rates and options if it fails. Guidance says surgery may be considered for a diseased tooth when re-treatment is impractical, has failed or risks harming it.
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Clinically reviewed by Dr Ibraheem Ijaz, dentist · GDC 301711
Medical disclaimer: This page is for general information only. It does not replace an examination or treatment by a dentist.
Dr Ibraheem Ijaz, the practice's principal dentist, reviewed this page. He is a General Dental Practitioner registered with the General Dental Council, number 301711, and his qualifications are BDS, BSc (Hons), MSc (Leeds), PG Dip Implant Dentistry and PG Cert Restorative and Aesthetic Dentistry.
What is an apicectomy?
An apicectomy, also called root end surgery or periradicular surgery, removes infection and the root tip, reached through the gum and bone.
The root end is commonly sealed with a retrograde filling. Removing the tip is called root end resection, and apicoectomy is another spelling.
When is surgery chosen over re-treatment?
Surgery is considered for a diseased root-filled tooth when the root filling is already good, or re-treatment is impractical, has failed or could harm it.
These examples come from the 2020 Royal College of Surgeons of England consensus guideline, which lists others:
| Situation | Guidance points towards |
|---|---|
| The root filling or the seal above it could be improved, or removing the crown poses little risk | Considering re-treatment |
| Blood disorders, anticoagulants, intravenous bisphosphonates, or difficulty coping with a long session | Considering re-treatment |
| Symptoms or progressing disease in a well root-filled tooth, including where re-treatment has failed, could weaken the tooth, destroy a crown or bridge, or mean removing a post at high risk of root fracture | Considering surgery |
| Root anomalies stop treatment through a diseased tooth, a tissue sample is needed, or a suspected perforation or fracture must be seen directly | Considering surgery |
The guideline notes that reports conflict on whether root filling quality affects surgical results. The choice follows a discussion of risks and benefits against no treatment, monitoring or extraction; the final decision is yours.
Should root canal re-treatment be tried first?
Where practical, guidance leans that way: the European Society of Endodontology's guideline says surgery may be considered for a diseased tooth when re-treatment is impractical.
That 2023 recommendation is open because the evidence did not suggest either route works better; evidence on tooth survival was low quality. Our page on root canal re-treatment explains the non-surgical route.
The 2016 Cochrane review found no clear advantage for either route at one, four or ten years, from two trials at high risk of bias (very low-quality evidence). A 2023 review of five studies and 529 teeth, four at high risk of bias, found surgery seemed better for healing and need for further intervention, tooth survival higher after non-surgical treatment, and neither clearly superior.
When is an apicectomy less likely to work?
An apicectomy is less likely to work when the tooth has other problems, such as a poor seal above the root or limited bone support.
The Royal College guideline names these and others, including dental disease not yet stabilised, an unrestorable tooth, a combined gum and root lesion, limited root length, a root fracture, difficult access and relevant medical history.
What happens during an apicectomy?
In general, apicectomy is done from outside the tooth, usually under local anaesthetic.
NHS leaflets and the Royal College guideline describe these steps:
- Flap surgery: a small cut is made, the gum is lifted and a little bone is removed to reach and clear the infected tissue.
- Root end resection: the guideline recommends removing 3 mm, less in some cases.
- Retrograde filling: guideline-recommended ultrasonic tips prepare the root end, which is then sealed.
- Closing: the guideline recommends an X-ray before the gum is stitched.
What is the recovery timeline after an apicectomy?
Sources say most cases settle within about two weeks, with discomfort and swelling usually worst in the first few days.
| When | What sources describe |
|---|---|
| First hours | Discomfort starts as the anaesthetic wears off (East Kent NHS leaflet). |
| Days 1 to 3 | Pain tends to peak in the first 24 hours and swelling between days 1 and 2 (2008 literature update). Where present, both lasted up to three days, then reduced (Royal College). You may need a few days off work, avoiding strenuous exercise (Liverpool NHS leaflet). |
| Days 5 to 7 | Non-dissolving stitches should be removed if the wound is stable (Royal College). |
| About 2 weeks | Dissolving stitches disappear (East Kent). Bruising should normally resolve, and in most cases symptoms have gone (Royal College). |
| First few weeks | Keep the area clean, rinsing gently with mouthwash or warm salt water from the day after surgery if brushing is difficult (East Kent). |
| A few months | A numb gum usually settles. The gum can sometimes shrink back, which may show the edge of a crown (East Kent). |
Bleeding is unusual: East Kent advises pressure for at least 10 minutes, then contacting the treating clinic if it continues.
If pain or swelling worsens rather than settles, or numbness persists, show it to a dentist, or use NHS 111 for urgent problems out of hours (Liverpool). NHS guidance sends swelling around your eye or neck, or swelling that makes it hard to breathe, swallow or speak, to A&E: do not drive, ask someone to drive you or call 999.
Questions about this treatment? Book online or call the practice.
What are the risks of an apicectomy?
The Royal College of Surgeons lists pain, swelling, bleeding and infection as risks of an apicectomy. It adds gum recession, loss of gum height between teeth and damage to the tooth, neighbouring teeth, sinus, nasal cavity or nerves.
Work near a lower-jaw nerve risks temporary or lasting change in feeling in the lip, chin, gums and teeth. If any of these happens after surgery, show it to a dentist.
How successful is an apicectomy?
Pooled apicectomy success rates run from 59% to 94%, varying with technique and materials, and tend to fall as follow-up lengthens.
| Source | Methods | Follow-up | Result |
|---|---|---|---|
| Setzer 2010, 12 studies | Burs, amalgam, low or no magnification | 6 months or more | 59% success |
| Setzer 2010, 9 studies | Microscope or endoscope, ultrasonic tips, Super-EBA, IRM or MTA | 12 months or more | 94% success |
| Torabinejad 2009 | Traditional and contemporary studies pooled | 2 to 4, 4 to 6, 6+ years | 77.8%, 71.8%, 62.9% success; re-treatment 70.9% and 83.0% at the first two (separate studies) |
| von Arx 2012, 191 teeth | Microsurgery; Super-EBA, MTA or Retroplast | 5 years | 129 of 170 examined healed (75.9%; 83.8% at 1 year); 12 extracted, 9 unavailable |
| Pinto 2020, 10 studies | Microscope or endoscope, ultrasonic tips, mostly MTA | 2 to 13 years | 91.3% in trials, 78.4% in prospective studies |
In Setzer, which excluded large lesions, gum disease, repeat surgery, root fractures and perforations, success counts complete or incomplete healing on X-ray with no symptoms. On a stricter measure, a 2001 teaching dental hospital study of 176 teeth at over four years recorded complete healing in 37.4% and 19.4% in its two units.
Pinto's trials re-examined 61% of teeth, its prospective studies 78.7%; its lowest tooth survival was 79% at 10 to 13 years. Among its studies, one recorded 33.3% success in smokers against 80.4% in non-smokers, another 31.5% with root dentine defects against 97.3% in intact teeth. Its authors caution that mainly hospital and university studies can overestimate results in everyday clinical practice, and that outcome reportedly varies with the operator.
Royal College guidance says magnification, by loupes or operating microscope, affects outcome, and calls MTA, a cement that sets in moisture, promising; other calcium silicate cements (bioceramics) may be considered as evidence emerges. Cochrane reviews found no evidence favouring one magnification device (2016, low-quality evidence) and insufficient evidence to favour any one material (2021, eight trials, all at high risk of bias).
These are published research figures, each tied to its own methods, materials and patients.
What are the options if an apicectomy fails?
If infection returns after an apicectomy, the options include repeat surgery or removing the tooth.
NHS leaflets say infection can sometimes return months or years later, even if it was all removed. The Royal College says a second operation should not be considered lightly, as healing is consistently less likely, and weighs it against extraction and a tooth-supported or dental implant replacement.
When should a dentist check a root-filled tooth?
Speak to a dentist if a root-filled tooth hurts or swells; NHS toothache guidance sets out how urgently.
- See a dentist if you have toothache that lasts more than 2 days, that does not go away with painkillers, with a high temperature, pain when you bite, red gums or a bad taste in your mouth, or with a swollen cheek or jaw. Do not go to your GP, as they will not be able to give you dental treatment.
- If you have no dentist or cannot get an emergency appointment, call 111 or visit 111 online.
- Go to A&E if you have toothache and the area around your eye or your neck is swollen, or swelling in your mouth or neck is making it difficult to breathe, swallow or speak. Do not drive: ask someone to drive you or call 999 for an ambulance. Bring any medicines you take.
Is apicectomy done at Deepcar Dental Care?
Yes, apicectomy is done in house at Deepcar Dental Care.
Is apicectomy priced on the fee list?
The practice's fee list does not name apicectomy, and it does not say whether any of its lines covers it.
Where can you read more?
Our guide to treating an infected tooth sets out how root canal treatment aims to keep it. Apicectomy and root canal treatment belong to restorative dentistry, which aims to save natural teeth, while implants replace them.
Patients describe visits to the practice in our patient reviews.
Frequently asked questions
How painful is an apicectomy?
It varies. More people reported first-week pain after surgery than after re-treatment in one trial (87 people, low-quality evidence). In a US questionnaire of 199 patients after microscopic surgery, 46% found it less painful than non-surgical treatment and 38% the same. If pain worries you, show it to a dentist.
Are antibiotics needed for an apicectomy?
Not automatically. The Royal College of Surgeons says the benefit of routine preventive antibiotics has not been evidenced, and Cochrane found no evidence they reduced infection (one trial, 250 people, low-quality evidence). NHS leaflets say a course may sometimes be needed.
How long does bone healing take after an apicectomy?
Bone healing is judged on X-rays over years. The Royal College of Surgeons advises yearly clinical and X-ray follow-up for up to four years, and classes a dark X-ray area that has grown, or stayed the same for four years, as unsatisfactory healing.
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