Apicoectomy Tutorial – When, Why and How – PDP148

Jaz’s Introduction:
Now, just because it looks good on the radiograph doesn’t mean it was a good quality x-ray. We all know that. But anyway, let’s say it looks like a decent root filling. There are no voids in it, and now you’re really questioning whether it’s really feasible to go down a root canal re-treatment, or is there another option?

And sometimes that other option, which really comes into play in these scenarios is an apicoectomy where a flap is raised, the infection is curetted, and a bit of the root, a bit of the apex is chopped away, and then boney healing takes place. Now this is known as microsurgical endodontics. It used to be done a lot by oral surgeons in the UK at least many years ago.

And now endodontists have reclaimed this territory and suggest that actually this is the way we do it to get high predictability. And that’s exactly what we’re got to discuss in this episode. Hello, Protruserati. I’m Jaz Gulati. I’m joined in this episode by Dr. Peter Raftery, specialist endodontist and his colleague Manpreet Dhesi.

We’ll be talking about. All the things you’d want to know about apicoectomy, does it have a place in general dentistry? How does it compare to an implant in terms of cost benefit analysis? What are the indications and contraindications of this, as well as talking you through the entire procedure from start to end, including the little details such as what is the retrograde filling material of choice?

Protrusive Dental Pearl:
The Protrusive Dental Pearl for this episode, which really compliments this theme of apicoectomy really well, is the GUIDELINES. The peri-radicular surgery guidelines issued by BES and the Royal College of Surgeons. This is such a beautiful document, which covers so many themes of this episode, actually is a great revision for this episode itself, and talks about the indications, contraindications, and really just summarizes really nicely all the guidelines for carrying out peri-radicular surgery.

Now, you can download this document on the Protrusive website. That’s protrusive.co.uk/148 because this is episode PDP 148, so /148, or if you’re on the app, it’s on the Protrusive Vault section of all the different files and infographics and all the different things that you get as a Protrusive premium member.

I’ve also recently added to the premium clinical video section of the app, a complete guide on how I did the walking bleach technique on a patient So discolored and non-vital lateral incisor, how I bleached it internally using the walking bleach technique, which we discussed in the previous episodes. If you haven’t listened already, do checkouts episodes out with Dr. AJ Ray-Chaudhuri.

And then I also show you how I did the bonding, including removal of the old composite. And mocking up and actually lengthening the teeth while respecting the occlusion and making sure that restorations are got to be unchippable. So that’s all in the premium clinical video section. If you’re not already a Protrusive premium member, it might be right up your street.

If you’re a dental geek like me, or for the cost of a tax deductible mandos per month. The website checkout is protrusive.app, or you can download it on the iOS or Android store to check out all the protrusive goodness. Now let’s join the main interview with Peter and Manpreet. Now catch you in the outro.

Main Episode:
Dr. Peter Raftery and Manpreet Dhesi, welcome to the podcast. Peter, we had you a while ago on surgical extrusion technique, which is a really interesting way to save hopeless teeth. And today we’ll be talking about apicoectomy. There’s so many questions that come to mind about apicoectomy, and I know you two are got to be really great in helping us.

But before we go into that, just remind us again, Peter about yourself, your practice, and you Manpreet, it’s the first time on the show. So tell us about yourselves, guys.

[Peter]
Yeah. We are in Hampshire endodontics at the minute. We are coming from, speaking from Haven in Hampshire. Got a branch in Winchester also, but an endodontics only practice. My background was the sort of formal training route at the Eastman a long time ago now. But then as things got busier here, put the feelers out and delighted for about a couple of years now to have had Manpreet. He’s been a great addition.

[Manpreet]
Yep. So I’ve been with an associate with Peter for past two years. I didn’t do full on specialist training. I did a part-time MSC at Queen Mary, which I completed probably maybe six or seven years ago, and now spend three days a week doing purely endo and then two days a week, still doing a bit general practice as well. So, bit of a mix.

[Jaz]
So Manpreet, you did your master’s and now you split your time between practice limited endodontics and also general dentistry. Is your plan potentially in the future to do more and more into endodontics, or do you like the balance and the split kind of like a GDP with enhanced skills?

[Manpreet]
Yeah, I mean, I do like still keeping a hand in with the general dentistry, kind of just so I don’t forget doing all of it, but it does have a knock on effect on my endo as well. So it does help me in terms of being able to restore teeth nicely, sort of tying things in with GDPs who refer. So yeah, maybe eventually I’ll start focusing purely, purely on endo, but for the time being, it’s nice to do a little bit of a mix.

[Jaz]
Okay. Great. Well, thank you very much for the introductions. Now, let’s get to the meat of the episode. So apicoectomy, right. Just for our young colleagues, just so we’re on the same page. When I say, apicoectomy, some endodontics say, ‘we don’t call it that anymore. We call it microsurgical endodontics.’ And that kind of stuff. So I, I’ve heard that one before.

And also the spelling of apicoectomy, I’ve been told before by consultant for spelling it the way it kind of sounds like it should be spelled apparently is different. That always confused me, but that’s just semantics. Tell me, what do you guys mean when you say apicoectomy?

[Manpreet]
So an a apicoectomy for me is a procedure where we purely come from the apical part of the, an apical approach, leave the coronal portion completely alone, and then we’re essentially cleaning the lesion out directly from the bone and resecting a portion of the route as well. And I guess, yeah, there are lots of different terms for it.

We call it surgery. When we’re talking to patients here, we just purely call it apical surgery. But yeah, you’re right. Some people call it microsurgery. When you look at courses, a lot of them, they focus and they call it endodontic microsurgery. So there are a few different names, but yeah, we generally tend to call it either apical surgery or apicoectomy.

[Jaz]
And do you think this is more the domain of the oral surgeon? Or the endodontist because when I was at dental school, the oral surgeons would actually be doing in the hospital department. Cause we didn’t have any endodontists. They’d be doing some apicoectomy and historically I know that it was a lot of oral surgeons who would just dabble and do these root end resections.

And there’s a huge difference. I’m sure you can elaborate in terms of what an oral surgeon does and what endodontist does. So, is it a collaborative thing or do you think endodontics have now stated their claim in this type of surgery?

[Peter]
Yeah, I think they have won that argument. Convincingly comprehensively, I think it will boil down to funding and historical funding structures where everyone knows on the NHS you can get stuff done surgically for free because the NHS chose to fund orthodontics and oral surgery, wisdom teeth out, biopsy of lesions, things like that.

And yeah, apicoectomy was rolled into that. But interestingly, the reason I say it’s the argument I feel is now comprehensive one is that in all of endodontics, the success rate in nonsurgical treatment famously has not really moved much in the last few decades. Lots of theories about that, but it’s frustrating that it hasn’t really come on leaps and bounds.

The only area of endodontics where the success rate has gone from being a little bit hit and miss to wildly predictable and high is, surgical endodontics done via more modern approaches. We just call it modern because no one really wants to hear that. I had a hidden hope of a procedure done on in the past.

For example, we just call it a modern revision. If we are taking out an amalgam that’s nowhere near the apex and filling the canal for the first time with anything. So yeah, it’s the area where endodontics has really come on leaps and bounds is apicoectomy. Which is why we’re so eager for everyone to know that. And I’d love to think a few people, followers, listeners, will be motivated to take the next step towards getting involved.

[Manpreet]
And I guess this is where the microsurgery part of it comes into it as well, because that’s essentially what has made those success rates go up with apicoectomy, being able to do the procedure with much more precision, and I’m sure we’ll come onto that in a little bit.

[Jaz]
So do you think one needs to have a microscope to do a good quality apicoectomy?

[Peter]
No.

[Manpreet]
No, definitely not.

[Peter]
But magnification and illumination of some sort.

[Manpreet]
Magnification for sure. I mean, I personally actually prefer using my loops when I do apicoectomy. I’ve got a couple of pairs of loops. In general here, use a microscope for everything, for all our non-surgical treatment.

But actually, if I’m doing a anterior apicoectomy, I sometimes prefer using my loops just from the fact that you’ve got more flexibility with the field of vision, you can move your head around and visualize things for me, a little bit better. So I actually tend to use my loops and I don’t think and microscope is completely necessary to be able to do apicoectomy.

[Jaz]
How much mag we talking Manpreet?

[Manpreet]
My loops are five and a half.

[Jaz]
Okay.

[Manpreet]
Yeah.

[Jaz]
Good, good, good. That’s pretty decent. But, I mean, obviously most apicoectomy, and correct me if I’m wrong, are anterior and so you’ve got a nice, nicer field of view and we’ll talk about how you manage the soft tissues. Like for example, I’m a big fan of using Optric Gate for my bonding and stuff. Is that the kind of stuff that you’d be using or using like, I don’t know, split down? I mean, that’s got to get in the way obviously. So what kind of things are you using to get the soft tissues out the way?

But before you touch on that, can you just clarify for me, are apicoectomy of posterior teeth still a thing? Do you think there’s a place for that?

[Peter]
Yeah. That’d be more your probably specialist and microscope strictly one of the mic, I believe, with a microscope thing with a microscope treatment or modality. The microscope does allow you to document things nicely with a camera attached. Of course. Yeah. Yeah, yeah, absolutely. You’ll see molar yeah. Anything that’s, we’re an endo only practice. Okay. So we are going the extra mile and a half to not be having to say, I can’t help. So, yeah, absolutely.

What’s the word? The mother of all invention necessity. So yeah, if there’s a molar, well buried in bone part of a bridge and there’s one, clearly one route, that’s the problem then. Yeah, absolutely.

[Jaz]
Okay. And then for anterior teeth, if that’s what mostly is being done, what are you using just to, before we can talk about flaps and stuff, what are you using to keep the soft tissues out the way?

[Manpreet]
So we’re normally just using a normal retractor. Surgical retractor just to keep the soft tissues retracted the whole time. We’re not using any rubber dam or optragate isolation during a surgical procedure. So yeah, it’s pretty much just your normal surgical kit, which a lot of dental practices are going to have. Yeah, because they might have someone who does wisdom tooth extractions, things like this. So, just normal surgical retractors.

[Peter]
Okay, so while we’re talking about retracting stuff, let’s talk us through like in a minute or so, just a general procedure, right. So you got your, we’ll come onto diagnosis, indications, contraindications but just to give people a flavor of what’s involved, for someone who hasn’t seen this before start from raising a flap and what is it that you actually doing that formulates this apicoectomy and how you actually finish the procedure as well.

Yeah. We’ll, following local anesthetic, we’ll get them to mouthwash for about half a minute a minute. So that the sort of field is, reasonably aseptic as can be. And then yeah, when we talk about flaps, we’ll talk about flaps, but you’ll want your blade to be hitting bone so that you have a shot at getting the periosteum and the flap up together.

If you start to shred the periosteum, you’ll know about it. Lot’s of bleeding. lot’s of bleeding. So you’ll try and get that incision onto bone, a very firm incision into the bone. Can’t stress that. Yeah. Then, with a nice new periosteum elevator. Cause I think the ones I’ve seen are usually ancient.

They were bought 10 years ago. And again, that lack of a sharp edge, I think will fray and shred the flap. As you try and get the, there’s clearly the bit of gum that you’re looking to mobilize versus everything that’s staying put. So you’ll try and get, I’ll use a boozer and I’ll try and get a really nice, clean, sharp flap raised, and more often than not, the cases that you’re tackling, as soon as you get the gum out of the way, there’ll be a big circular hole in the jawbone.

Corresponding exactly to what you saw in your pre-op x-ray, and within a few seconds you’re staring at a root tip sat in the middle of that circle. That’s I would say, how most anterior apicoectomy go.

[Jaz]
Hey guys, it’s Jaz. I’m just interfering again with another piece of feedback for the Occlusion Basics and Beyond course, OBAB occlusion.online.

So we’ve had our first delegate complete module two. Module two is a beast. There are 48 lessons. So on lesson 48, where we do like the wrap up, I encourage all the delegates to write a summary of what did you learn during this module? And we do that for all five modules. But this is what Dr. Andrew Hong had to say.

He said, ‘ my biggest takeaway was looking and identifying wear facets. I picked up the obvious ones that missed the others, something for me to work on. The articulating paper marks is now making sense to me. Thank you for the wonderful presentation. The other concept I took away was a positive and negative errors with articulators.’

So we were like, thank you so much. It’s great that you’re making so much progress. And then Andrew replied saying, ‘thanks Mahmoud, will do. I will reiterate that this is great material. Well done to both yourself and Jaz for putting this together.’ So, Dr. Andrew Hong, a massive shout out to you for being one of the first delegates to finish module two.

You’ve still got three, four, and five to look forward to, and we look forward to reading more of your reflections as you progress through the course. So regardless of whatever stage you are in your career, if occlusion confuses you, you need OBAB in your life. So check out occlusion.online to enroll. Get one year of access. To rinse it as much as you can. You get mentorship on the forum and a starter kit delivered to you. This is occlusion made tangible. Now, back to the main interview.

And so at that point, so I’ve never actually seen one, I’ve seen maybe some videos of one being done at that point, yes, the root end resection will start and there’s, I remember being at some lectures many years ago talking about that the angle in which you do it to not expose tubules and stuff. So maybe you can talk about that. But once you get to that stage, are you actually using hydrochloride? I know it sounds like a silly question. I’m guessing not, but what kind of disinfection protocol are you using at that point?

[Manpreet]
So, I guess your main thing here is once you’ve reflected your flat back, once you’ve visualized your lesion, your main thing that you’re trying to do is to remove all that infected tissue. And so you’ll be using your curettes and you’ll be detaching all that infected granulation tissue from the bone, from the healthy bone, and that’s what you’re really focusing on in that first part of the procedure. Sometimes you’ll find that tissue really detaches nicely. Sometimes you might have to work at it a little bit more, and there’s a bit of a technique to detaching it.

And then once you’ve done that, once you’ve cleaned that lesion out, you’ve got this nice crypt, you’ve got this nice big open cavity in the bone, which is hopefully nice and solid. Then you’re looking at resecting your root, and you’re exactly right. You want to try and come in as horizontal as possible when you’re resecting your route and you’re aiming really to remove probably about three millimeters in a normal case from the tip of your root.

[Peter]
And why is that?

[Manpreet]
And that there’s a good reason for that. And that’s because most of your, when you think of a tooth, when you think of your root canal system at the tip of your root, in that final two or three millimeters, you have a lot of complexities, a lot of lateral branches, et cetera. And so when you are removing that three millimeter tip, you are removing all those irregularities.

You want to come in as horizontal as possible. And that’s because when you have a beveled root resection, you’re exposing a lot more tubules and you’re creating a lot more of a surface area where you can get bacteria leaking in again. So horizontal resection. And then really we want to try and use specific ultrasonic tips as well. I don’t know if there’s different brands which make the ultrasonic tips.

[Peter]
Yeah, I think, so the majority of your bacterial killing is probably, removing three millimeters of habitat, literally cutting out the root tip. And so the bacteria that are in those nooks and crannies and the habitat that they could otherwise occupy.

But then you’ll, then you will probably go for a three millimeter retro prep with an ultrasonic tip. And that is the equivalent of, I says mechanical debridement. So you’re mechanically you get a bit of heat with an ultra sonic tip. But yeah, you are mechanically debriding the inside of the canal.

That’s another nod towards our trying to kill bacteria when a case is going incredibly well and bleed, blood bleeding has stopped nicely. Then yeah, you absolutely can introduce sodium hypochlorite. If you have, I’d say it, it wouldn’t be on your first case or even your fifth case. But yeah, when things are going really nicely, I will introduce a little bit of sodium hypochlorite.

[Jaz]
Okay.

[Peter]
We’re talking a lot less than one milliliter and it’s sat ever so nicely in there. But don’t forget a bit of dilute sodium hypochlorite does not do any harm. In extruded sodium hypochlorite under pressure does harm, but simply bathing. And, but if by accident a droplet were to spill out over the retro prep into the crypt, it will do less than zero hung.

[Jaz]
Okay, so it’s quite different to a hypochlorite accident. That’s a different beasto. We’ve covered that before in a medical legal episode we covered, so it’s good to know actually, just to make it tangible. A few points that come to mind. When you’ve done your root end resection or raise a flap and you’ve curated out all the junk, what’s stopping the bone? Just constantly bleeding and filling up the crypt with blood. How do you get that moisture control from the bleeding?

[Manpreet]
It quite often does. And one way that we try to normally control that bleeding is just with packing gauze, sterile gauze into that crypt. You can soak that gauze in some hemostatic and pack that into the crypt. You may have to keep on replacing that throughout, but that normally does enough to stop the bleeding so that you can actually visualize your root and you can carry out your prep and place your retro fill.

Sometimes you’re lucky and you’re doing a procedure, you’re cleaning everything out and everything’s just nicely under control. There’s not much bleeding at all. I guess another thing which makes a difference is actually your local, at the beginning, putting plenty of local in there, actually injecting it.

Through when you’re giving that buccal infiltration, actually trying to guide your needle into the lesion, so you’re injecting it in there and getting some vasoconstrictor into that lesion.

[Peter]
Yeah, that’s something that’s very different from what anyone will have done before. So you, you’re lining up an a apicoectomy case and you are deliberately trying to get the tip of the local aesthetic needle into the lesion.

We’re always told, aren’t we to just barely touch bone and then retract? So not to disturb the perio, but in these instances, if you don’t introduce local anesthetic into the mushy soft tissue, occupying the space where bone should be, then curating that stuff is got to be very, very painful. And I would just say, I’m certain that the stuff that’s causing the bleeding, preventing your visualization is the soft tissue occupying the space where bone should be.

So I probably would just spend the first few minutes curating, curating, curating. And once you’ve done that thoroughly, that’s the stuff that pumps blood in my, typically.

[Jaz]
Got it. And then just another real world question, like, if GDPs were to tackle their first place question that might Protruserati might be thinking right now is, do I need a special handpiece? Is there a risk of surgical emphysema if they use their standard fast handpiece with the air mist and the water, or do you have to use saline? These are the real world questions that might be going through someone’s head. Any advice on that guys?

[Manpreet]
Yeah, you don’t want to be using your normal fast hand piece. Your normal air turbine. You want to be using something specifically for surgical procedures. So you’ve got a few options. That could be a reinventing turbine that could be an electric hand piece. But yeah, you don’t want something which is going to be blowing air into that surgical area. You want to have a specific hand piece, which is made for during surgery.

[Jaz]
Okay. I thought so, but it’s just helpful to clarify for that. So I think that’s enough on the procedure because I’d really like to get into indications and contraindications. Cause this is a big one when dentists are faced with that diagnostic dilemma and they’re thinking of referring or doing the case themselves.

What would you say is a, let’s start with contraindications might be easier, right? Like a crappy root canal, primary root canal treatment. How far do you go with that? What are the contraindications and therefore how do we spin that on his head and say, what is the ideal scenario for apicoectomy?

Because remember Peter, we talked about the hopeless teeth and the surgical extrusion. You gave some very good guidelines. Okay? Yeah. Well, this is a good scenario. This is a bad scenario. What kind of guidelines can you give to us for choosing the right tooth?

[Peter]
Well, if I could, I’ll start off with some of the more dry, formal bit and then I’ll let Manpreet give you his sort of personal flavor on the job as it were. But the British Endo website, British Endo Society website has free PDFs, very recently updated guidelines for surgical endodontics, which has contraindications also. Again, almost like an exam answer would be medical people who you don’t want to be doing surgical procedures on MRONJ and RRONJ and the other ones. The radiation boney non-healing type people iv bisphosphonates, along oral bisphosphonates with steroids for an extended period.

People who are so, I guess, incredibly unwell, the ASA classification, people who, I don’t tend to find that the INR or blood thinners are an issue, if I’m honest. But yeah, I’ll let maybe Manpreet whilst there’s a good list of them, an exam style answer on this PDF that’s freely available. Maybe Manpreet who has more recently embraced it, I’d say is younger than me. So, he might be able to give you some of his real world more day to day answers.

[Manpreet]
Yeah. I guess when you’re assessing a case for apicoectomy, there’s a couple of things which I think of. And your usual, your standard situation is that you’re got to have a tooth in front of you, which has already had a root canal treatment, a root canal treatment’s failed, and now you’re thinking of what are you got to do next?

So for me, I’ll sort of look at this and I think, is there a coronal issue here? Is there something that is leaking and causing bacteria to leak in coronally, or is this a purely apical issue? Because that’s got to guide you on what approach you’re taking. If there’s something going on coronally, you are going nonsurgically, you are doing a, a re-RCT.

And what I mean by coronal, I mean is there a very poor filling on the tooth, which is leaking? Is there a very poor crown which has bad margins around it? Is there a post crown which has come off recently and bacteria has leaked in? All these things. You are not looking at doing that, doing an apicoectomy.

You are looking at going in non-surgically and revising everything. If everything coronally is perfect, we often ask the patient if they’ve got a crown on the tooth or they’ve got post on the tooth, has this ever come off? Has this come off recently in the last couple of years? If everything is fine from a coronal aspect, then a apicoectomy starts to become a realistic option.

And so in those sort of situations, I think what I would look at is the quality of the root filling, the existing root filling. And I always ask myself, is this a root filling, which is instantly improvable? Is there areas of that root filling which can be made better? Is it halfway down the root? Is it a really crappy root canal to begin with?

Because if it is, then again, ongoing non-surgically. If that root canal is generally looking good, if that is a root canal treatment, which has been already retreated in those sorts of situations, then I’m leaning more towards surgery and apicoectomy, it has to be really for me, a root filling, which is serving its purpose, and I’m not going to gain much by redoing that root canal.

[Jaz]
That’s brilliant. The only issue which you guys probably say this all the time and you guys are more aware of this than any of the GDPs, but when we see a radiograph and when we see a root filling that looks apparently decent, we don’t know if hypochlorite was used. We don’t know if rubber dam was used.

How do you make that judgment to, yeah, okay. Just cause it looks good is actually good. There is a bit of a leap of faith in terms of how well the root canal treatment was done. Right?

[Manpreet]
It definitely is. And again, this is where during your examination, you’re asking questions like, who did the root canal? Was this done by a specialist or someone with special interest? Do you remember your dentist placing-

[Peter]
Hold up a rubber dam.

[Manpreet]
A rubber dam. Yeah.

[Peter]
Do you recognize this? Do you recognize this? And if they’re not instantly like, oh, that thing, you’re like, okay, possibly wasn’t used, you know?

[Jaz]
It’s getting little clues, right? Because it is difficult.

[Peter]
Possibly in the real world. The biggest tip of the balance is, is there expensive, good looking, recent prosthodontics on top of this tooth? And if there is, it might be that the dentist is perfectly reasonably chosen not to revise an endo on a tooth that they’re incorporating into a bridge because the endo looks all right and has been there for, it looks sort of 8 out of 10. It hasn’t been a bother, I don’t think it’s got to be very easy to sell on top of the expensive bridge to that person, an specialist root canal, redo, just in case it becomes a problem.

So I do think and I think it’s reasonable that the dentist might well then put some new, expensive, good looking prosthodontics onto the teeth and then Murphy’s Law, St. Patrick’s Day the other day, things might flare up. And then we are looking to preserve that expensive prosthodontic work.

[Jaz]
I mean, how far do you go? I mean, you were talking mostly about, let’s talk about anterior teeth. A lot of times you can root treat through a crown. You guys are way more experienced than I am at that, but it’s probably the post that obviously you think, okay.

Yeah, we’ve gotta look at the other side here. But in terms of drilling through zirconia, anterior crowns, for example, to do a re-treatment, does that worry or bother you as a limited endodontics?

[Manpreet]
No. No. Something we do commonly, I think zirconia is actually not as difficult to drill through as a lot of people think it is. I was told a little tip a while ago by someone somewhere. It might have been been on your podcast to use a red band polishing bur when you’re going through zirconia and it works wanders, you’re through the zirconia in no time at all.

So going through a crown and redoing and endo is something that we do very commonly, but I’d start to say that that’s when you do start to need good magnification. You do start to need a microscope when you’re doing something like that because it’s very, very easy to not be able to see what you’re doing underneath.

[Jaz]
Yeah, yeah. There’s always more risk involved when you’re going through crowns and stuff. Totally concur. Yeah. Using a a yellow band or red band bur does help cutting through zirconia for sure.

In terms of cost benefit analysis though, right? It’d be nice to know, there’s forums on Facebook and dentists talk all the time, like, ‘okay, how much people charging for implants nowadays?’ And the general consensus is, 2.5 to 4k. How much, if you don’t mind me saying, is roughly the range of a apicoectomy? Because one of the considerations one may have, because if you’re doing surgery anywhere and the patient’s suitable for surgery, then instead of doing the apicoectomy to extract the offending tooth, graft it and then go for an implant in the future, that’s something that’s got a discussion that you, I’m sure you have as part of your consent.

So if you do a cost benefit analysis, what’s that looking like for versus an implant?

[Peter]
But we have a very narrow range is single figure. We charge a fee per procedure per tooth, whether it’s non-surgical treatment, non-surgical re-treatment, apicoectomy, just whatever it is. We’ve just got this one figure comfortably less than a thousand pounds.

So yeah, I suppose we’re trying to incentivize people to give it a go. The modern mantra is save teeth, et cetera, and if they’re happy with that bridge, or casting. If they don’t, if they’re not saying, yeah, it falls out all the time. And even if it you or I’m itching to replace it, as soon as I spend some money on this tooth, some of the money I spend on will be getting that gray margin removed.

But if they are entirely happy with the casting usually is, then yeah, I would just leave it alone and just sort of go up above apicoectomy wise. Yeah. So I think we are costing them for the cost for exploring whether an apicoectomy is got to work is about a quarter of the price of an implant.

And it’s kind of over with in two hours. There isn’t a scan, a graft. Wearing a flipper plate for a few weeks.

[Jaz]
No, no. Lab bill.

[Peter]
Multiple surgical, yeah. Nice. Yeah. No lab bill there, so. I don’t know, is that kind of, if this works, I am streets ahead financially. I think patients are thinking, but yeah. We are not successful, a hundred percent of the time. So for those people, I’m sure they see it as a unfortunate waste of money.

[Jaz]
So let’s talk about that. What are the accepted success rates in the literature? And do we have any data? It’d be really interested to know if there’s any data on, I know there is data. I couldn’t quote you the authors right now, but for GDP primary endo versus specialist primary endo. That kind of data I’ve seen around. Is there anything on the apicoectomy side, just in general, what other success rates we’re looking at? Obviously every case is different, but also do we know about GDPs versus specialists in that domain?

[Peter]
Well, yeah. Another useful free PDF download is from the Royal College of Surgeons that we all make sure you have, but in their document, they quote, ‘Success apicoectomy success rates in the sort of nineties, low nineties. So that is where it has really come on leaps and bounds with just modern everything.

Modern materials. Modern equipment, materials. Literally. Yeah. Modern materials, modern instruments, and modern concepts. So, yeah. Nineties. Yeah. Apicoectomy is, I would say very predictable.

[Manpreet]
In a lot of the literature now, the success rates for apicoectomies aren’t particularly different to the success rates of normal endo. They’re up there in the same sort of ballpark and from experience in practice as well. I’d say that probably 90% of the cases we do heal up.

[Jaz]
And in terms of GDP, do we have any GDP data? I mean, I don’t know how many GDPs are doing this kind of work, to be honest, to do. But, an experienced GDP who has some surgical skills and raises flaps, this is a nice little thing to add on in terms of keeping your interest and try and go the extra mile safe teeth. Do we have any data on how GDPs are, are ferrying when it comes to apicoectomies?

[Peter]
No, I don’t believe that. I don’t believe that exists. But distant recollections from training and when I was literature, savvy, there just was an appreciable difference between the apicoectomy coming out of the oral surgery department and apicoectomy is coming out of the endo department for fairly obvious reasons.

The oral surgery department are using amalgam. They’re not using, they are slash were using amalgam. They were generally, I suppose, being remunerated at a lower level, which possibly, probably influences the time they might attribute to that procedure. And I suppose we have that intimate knowledge from the all the ortho grade treatments, intimate knowledge of the kinks and the looks and the crannies that we are maybe dealing with.

[Jaz]
Mm-hmm.

[Peter]
So there’s an appreciable, significant daylight of distance between the success rate from modern techniques, materials equipment compared to traditional, but I don’t think there’s the exact answer to your exact question. Unfortunately. However, we are all for and all about dentists getting involved.

[Jaz]
Absolutely. Well that’s good because like I said, it adds another string to people’s bow. It is a good thing to have. I’m just got to load up a photo, guys, because the next question is about do you always need, like, I think we’ve kind of touched on it, if you’ve got like a really good orthograde restoration, sorry. Like a coronal restoration, well sealed looks pretty, and you’ve got a good root feeling. Yes. This is in play. You’re considering an apicoectomy, but I’ll show you a recent case. This is my grandfather in law. Let me just see if I can show you so those who are listening will describe it. So he’s got a resin bonded bridge, which you may remember from a video I posted on YouTube.

It debonded. I didn’t do it in the first place, but it debonded. But I had the privilege of going through a full protocol and showing you how I rebond these bridges. So that’s what we’re looking at here. And next to it is a singular crown on an 82 year old gentleman. It’s got a root filling and instead of me saying about the quality of the root filling based on how it looks, I’ll get you guys to judge that because this is what you do day in, day out and it’s got a lovely round.

I don’t know, i’ll size that is maybe 10 millimeters. You guys are again, a better judge than I am. Radicular pathology. Nice circular one. So what do we think about this Coronal restoration? What do we think about this root filling and the diagnosis of the pathology that we see? Is that cystic? Is it the granuloma? What are your thoughts, chaps?

[Manpreet]
So I guess when, when I look at that, in answer to your original question, you wouldn’t necessarily have to redo that endo underneath there. Again, sort of as I was mentioning before, if I’m happy with the seal on that crown, I definitely wouldn’t be redoing that endo just as a precursor to going in and doing surgery.

But I guess my concern here with this tooth would be the fact that that lesion extends so far up that root and how much root are you going to have left here when you clean out that lesion and resect it, is there going to be enough for that tooth to be strong enough? Is that that’s a very heavily prepared tooth?

Is that root cracked? Because there’s a, it looks like to me as a little bit of a communication crestally on that mesial side of that route. So there’s a few things that would worry me about going in and trying to save this tooth with a surgical procedure.

[Jaz]
Peter, anything from you though?

[Peter]
Well, yeah. But if we were to, I just, I’m repeating the point really. It is just that if we were to insist on taking the crown off, revising the endo prior to any surgery, it just becomes from a faff and a cost point of view and an inconvenience point of view, unattractive, unpalatable. So what your grandfather in-law might go for is if someone could say, well, look, I could execute a really modern apicoectomy and do you know what, if it’s endodontic in aetiology, it probably will resolve.

And if it doesn’t, it won’t. Which is a little bit maybe imprecise in terms of the 21st century offering to a patient. However, in the real world is the language, a lot of patients I think can digest. Pretty much instantly. Well, oh yeah. So if that tooth compromised in support though, it might, if it’s not wobbly pre-op, I’m thinking I can only make it better.

So yeah, if it is not wobbly grade two or above, if it’s grade one or less and it, yeah, I think that when I get in there and do my bit, I’m got to be making it firmer, not less firm. So Yeah. And from our previous podcast about extruding teeth. I’ve got a great faith that teeth can function reasonably on less root, buried in bone than we would otherwise think.

[Jaz]
So obviously we’re talking about the crown root ratio, which is always important to consider. And I know this is limited information. This is not how we do in dentistry. We want to fall diagnosis, full picture, the occlusion, the pocketing. But with this limited information, we’ll get a vote from each of you, with the limited information provided based purely on radiograph, which is not how we do dentistry, but just for the, amuse me, are we going for a re RCT? So that would involve either going through the crown or dismantling the crown doing the re-RCT, and then restoring the crown or doing a new crown potentially depending on what we find inside. Versus go straight in for the apicoectomy for this 82 year old fairly healthy gentleman otherwise.

[Manpreet]
Personally, if he was keen on treating and saving that tooth, I wouldn’t be redoing that root canal. I don’t see much benefit to be gained from that. I would be going in and just dealing with it surgically the benefit of just purely going in one procedure in and out. See how it heals, see how it responds.

[Peter]
Well, a lesion of that size and of that vividness I don’t find will often heal nonsurgically. It is true that big lesions heal, and you do see those people with their five year follow ups, et cetera. However, there’s something really attractive. Within a single procedure, doing a nice, modern, thorough apicoectomy, scooping out all the mush, letting fresh blood bleed in there, which in the absence of any infection will become rock, heart, bone, nice and quickly. So, yeah, I would absolutely be offering surgery.

[Jaz]
That’s what actually I was thinking as well because of how well defined that radiolucency was and therefore it may well need some surgical intervention anyway, right. And to extend some time for this tooth, rather than having to go through and a come some process of drilling through the crown.

And yeah, we know that lower incisors that have got crowns, especially way back when, when he had it, is not an ideal restorative scenario. Can you guess, any guesses as what’s what the NHS hospital said?

[Peter]
Yeah, I wonder. The oral surgery department, we can’t help.

[Jaz]
Yes. So they said, you need to, we need to tick this box that you’ve had a re-RCT. Can we tick this box or not? No, we can’t therefore, no apical surgery. So it’s like a tick box thing for them. Like, okay, no re-RCT, no surgery. So they sent him back saying, okay, find someone to do a re-RCT. So I’ll be sending him to Ammar Al Hourani for a consultation now to see if he fancies this and let’s see what he says.

[Peter]

Yeah. Yeah. Well, I look forward to seeing how it goes. Yeah. Now we’re invested.

[Manpreet]
I guess the only thing I would say about that case is a CBCT scan might show that there’s an extra root canal inside. There may be a link branch or something, in which case, maybe you’d consider going in and redoing it.

But yeah, that’s the only thing I can, that’s the only possible reason why I would be taking off the crown and redoing the root canal on that.

[Jaz]
Yeah, good point. As someone who’s had all four of his lower incisors root filled, and all four had two canals, yes I can definitely vouch for that, but that’s for a story for another time.

So to answer bluntly, do you always need a re-RCT? I think the answer there is no, you don’t always, because you gotta take every case from its Merit and look at what’s on top. Are you happy with that? Answer that, yeah. It’s not a guaranteed rule that you have to always have a re-RCT before considering apicoectomy.

[Peter]
Just a Reading District Hospital by the sounds of it. Isn’t that where you are? Up in barkshire, pan born or something?

[Jaz]
The hospital was, it was either GUYS or Eastman. It was one of the two.

[Peter]
Eh, yeah. No, so no, outside of the ivory towers. No. It’s just, it’s not I incredibly infrequent. Yeah. In the real world of Endo, incredibly infrequent. One or the other, it just becomes unrealistic to do both.

[Manpreet]
By the time you factor in re root canal, apicoectomy, a crown. You’re looking at significantly more. Possibly in an implant. So yeah, not realistic.

[Jaz]
Yeah. So for pragmatic reasons, sometimes it is appropriate to make apicoectomy the next choice and not necessarily go, always going for the re-RCT when the conditions are right. So final question before I ask about GDPs trying to get into the skill is just a little bit, just tell me retrograde filling of choice nowadays. So, we’ve in the past amalgam then, I know IRM was in favor. Is it now MTA and biodentine, or is there something newer that I don’t know about?

[Peter]
I think we differ on that. What’s your go-to?

[Manpreet]
There’s a few options. There’s a few options. So, IRM is good because it’s easy to handle. And that can’t be overstated. When you are in the middle of a surgical procedure, you’ve got this very, very, very tiny retro prep, which you’re trying to fill.

You may have a short window of time to get that filling in before your crypt fills up with blood again. So IRM is very good in that respect because it’s nicely packable. MTA is very, very good, but it is difficult to handle, the original MTA. The one which you mix as a powder and a cement. Very, very difficult technically to place into your retro filling.

But nowadays there’s newer materials. There’s a bio ceramic putties, which you can get, which are available from all sorts of places, and they are basically MTA based, but much easier to place. And I think that’s what a lot of people are starting to shift over to. But I would say we use IRM a fair bit, don’t we?

[Peter]
Yeah. Your MSC coordinator Chung, he’s got a good paper showing no difference in the outcome, but the vasectomies between IRM and MTA. Yeah, I absolutely latched onto that paper and yeah, I find a IRM, I’m so familiar with it. I know when it’s on the turn and I can really start to pack it. I don’t get that with biodentine or MTA or those putties. Yeah.

[Jaz]
Okay. So something we already have, which is good to know.

[Peter]
Familiarity. Yeah.

[Jaz]
Exactly. And then, so just last question before I ask you about actually getting the right tools and whatnot to do this because you mentioned a little bit about the surgical kit and stuff, but what are the different things that, which you might need to get, but, just last question, grafting.

So once you’ve done your, procedure and you are happy and you put your retrograde filling, do we need to put some cow bone in there or what is the sort of packing procedure, if you like, of the crypt?

[Peter]
None. No substitute for a blood clot. Blood is incredible. That’s why the Kardashians are putting it all over their face. Blood, blood is incredible. Our blood clot. Yeah. Just blood. You break, if your kid breaks his god forbid, breaks their bone. You just put the two ends of the bone together and the blood clot does the rest. Blood clot, no grafting, no membranes. Generally I can think about one case of where I’ve used membranes.

One case I’ve used grafting. But lots of cases that have succeeded without it. But yeah, you be careful not to get too, I’m feeling I want to be careful of not getting too overcomplicated, but yeah, no, if you eradicate the infection and the blood clot will become bone.

[Jaz]
Okay, brilliant. So tell us about equipment, because I think so much of the success, even specialized mirrors and the ultrasonics that you said, what kind of kit would a dentist to invest in to get some predictable outcomes? So we’re as far away from the oral surgery way of doing it as possible and closer towards microsurgical endodontics.

[Manpreet]
So yeah, I think there’s, to be able to do an apicoectomy using microsurgical techniques. There are a few. Bits and pieces that we need to have. We’ve already touched on magnification, I think for the GDP out there.

Loops. Loops are definitely sufficient. We’ve touched on the hand pieces. I think the ultrasonic tips are brilliant. Absolutely recommended. I personally tend to use a 3 millimeter retro prep for most cases, and I think that would be sufficient for most GDPs.

[Peter]
And just describe what they are.

[Manpreet]
So they’re sort of your normal ultrasonic tip is that shape, but these retro prep tips are like that. And so you can bring your ultrasonic tip in same angle as your handpiece, but that tip can actually hook into the end of the root. It can clear out about three millimeters of a root canal space.

Gives you a really, really nice clean area, which you can pack your retro filling into. So I’d definitely recommend those ultrasonic tips. I’d definitely recommend, like you said, some micro mirrors. Micro pluggers. Again, micro surgically. If we’re going to see what we’re doing properly, we need small mirrors to be able to get into that root surface.

We need small pluggers to be able to pack into that very, very tight space to condense that filling in there. And then, yeah, what sort of material are we going to pack it with? So we use IRM, but I guess that’s up to the dentist themselves.

[Jaz]
Well, I think to get a feel for the kit and stuff and to really delve deeper, I won’t expect anyone to listen to start doing it in the back of this podcast.

Obviously it’s a good overview and start to get you to think about it as an option whether you are referring it or considering doing it. Tell us about the type of courses out there for dentists at the moment. Is it something that you run or something that you recommend for dentists to consider?

[Peter]
If I may just briefly, quick, but I once saw a Hugh 3D glossy document came out and it had various eminent clinicians talking about their ideal set of instruments for this procedure. Free gingival graft, that procedure, second stage implant surgery. But endo was overlooked, so I got in touch with them and this is probably 10 years ago now. Hu-Friedy UK and specifically Chris Mason, but we sort of put together a Rolls Royce of a kit for modern endosurgery now with a specific accent on the listeners who are thinking of getting involved.

Just prior to us doing this, this evening, I was in touch with Chris Mason at Hu-Friedy, and he sort of, he might expect one or two emails from someone. And he’ll have costed up a bare bones of a kit that you could do endo with the mirror, the pluggers, the little curettes, things like that.

So there’s a reasonably convenient one place gets, you could one stop shop perhaps for a, maybe a small and a large surgical kit. I think the small one’s about five instruments and the large one’s maybe about 12. On the subject of courses-

[Jaz]
I mean, I’ll put the link by the way. I’ll put if someone may want to get the kit. So I’ll put the link in the show notes for anyone who’s interested in the kit that you said would be a good one to, for a GDP to look into.

[Peter]
Courses that I’m aware of. My old buddy, Daniel Flynn is later this year, he’s toothsaver.co.uk. Later this year, he’s taken a bunch of delegates out to Columbia to do an in-depth endosurgery course.

[Jaz]
That is cool.

[Peter]
So that sounds like real intense. Yeah. Up in Manchester, endo 61 is the practice, the immediate past president of the British Endo Society, I believe immediate or maybe one prior Sanj Bhanderi. He is very active as well in promoting his endosurgery course.

[Jaz]
Sanj was a great guest of the podcast. I don’t know if you’ve got to listen to that one very real world about irreversible pulpitis and hot pul ps and how to manage that. So yeah, it’s anything by Sanj is always appreciated. Thank you.

[Peter]
Yeah. So elsewhere, there’s the Italian guys who run sort of Delta Dental Academy. I think they have an offering where it’s sort of like a live demonstration, I believe. But there’d be three ports of call for anyone with a mobile phone can send off your email.

[Jaz]
Yeah. Well, I appreciate you, you’re putting together some ideas, different people to learn from on this technique that you guys are so passionate about and you want GDPs to consider. I definitely think it adds a new string to their bow and makes it more fascinating and even if dentists don’t go ahead and consider doing apical surgery, in that way they’ll get a few nuggets in terms of diagnosis, in terms of what’s actually needed what to consider, what’s a reasonable referral and when they might actually be better off.

Looking at the coronal restoration and re-RCT. So it paints a good picture for the GDP to consider. Any final words, chap? I really appreciate the time this evening. Any final words on, apicoectomy as an overview for the general dentist.

[Peter]
But one point want to say is that the listeners, Protruserati, should be emailing slash badgering their local endodontist. What we do here in Hampshire is on occasion we’ll get a dentist to send in a case. But they’ll also often say, PS, I’m sort of doing an MSC and will, it has happened where the person patient has come here, the dentist has come here. I’ve set aside a couple of hours in my time. I should confess.

I take the fee, the endo fee, but I’ll watch them, supervise them, do the surgery, and usually then, where I can make it work and viable is that the dentist will then take the stitches out 4, 5, 6, 7 days later and do the follow up. Et cetera. But yeah, if someone were to email us, say, look, I’ve got this case.

Do you think it’s a good one to start with then? Yeah. It is not beyond the realism that they might be able to do the apicoectomy at their local endodontic place. We do that.

[Jaz]
I mean, that is brilliant. I mean, that is the highest and best form of learning, right? That is way beyond you in shadowing that is actually having over the shoulder someone watching and guiding you.

It’s a bit like what they do in the implant world, right? So why can’t we have it in the endo world? So, well done Peter, for having that kind of availability and allowing dentists to do that. That’s a hats off to you, mate.

[Peter]
Yeah.

[Manpreet]
So as someone who comes from more of a general dentist background and hasn’t done specialist training and always used to absolutely hate surgery and always shy’d away from it, I would say to anyone out there that once you’ve done one or two apicoectomy, they are nowhere near as difficult.

Or as scary as you think they are. I would second what Peter says. That’s what I did myself. I watched a few procedures a good few years ago, got my hands stuck in to the point where I was comfortable to have a go myself. And just from doing one by yourself, you gained that confidence, that real world experience of trying to figure out what you’re doing. And then from there you’ll be happy to tackle anything. It’s just having a go at it in the first place.

[Jaz]
Like with anything in dentistry, like any new technique.

[Peter]
Almost finished with a riddle, but cause I’m conscious the time, et cetera, but getting comfortable with surgery makes your non-surgical treatment and offering better. Definitely haven’t got the time to expand on that, but it’s one that might rattle around. Yeah. You take on more, your more, if you think I can rescue this surgically should the need a right. You just become a better non-surgical endodontist if you are at least of surgically.

[Jaz]
Amazing. Well, guys, I really appreciate you guys giving up your time and talking about a topic that’s almost overlooked. It’s definitely the first time we’ve covered apicoectomy, so as well overdue. And I appreciate what you guys do, especially Peter with you guys having dents over and getting them to do it so they can learn. I mean, I just love that so much. So I appreciate your time.

Please send me those links so I can populate the show notes with the PDFs and the links and how dentist can reach out to you to collaborate and work together and just getting advice from, because you are very good at helping dentists out based on that hopeless teeth episode that we did as well.

So we appreciate your time and wisdom. I know you are a busy father as well as an endodontist. So, guys, thank you so much for giving your time up.

[Peter]
Thank you very much. Go from strength to strength. Good luck. Yeah, keep it up.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. If you are a Protrusive Premium member, you’re just a few questions away from gaining some CPD on the app. So just answer a few questions. Get your CPD email to you by Mari, who’s my CPD lead, and it’s also a great way to validate your learning. Now remember that some of the things that Peter and Manpreet shared, the documents they sent me, they’re on the website /PDP148.

That’s protrusive.co.uk/148. As well as the RCS guidelines Peter’s also sent me like a recommended equipment list. Like if you’re a general dentist who wants to do this kind of treatment, what is the kit that you should buy? And that’s all there provided by Peter. Thanks so much, Peter for that, and Mandeep, and I’d catch you guys in the next episode.

Thank you again for listening all the way to the end.