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Endodontic surgery

Apicoectomy (Periapical Surgery)

An apicoectomy is the option that keeps a treated tooth in place when infection at the root has not cleared. Your endodontist plans it from a 3D CBCT scan and works under a surgical microscope. You feel pressure but no pain under local anesthesia, and you are home resting within a couple of hours.

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An apicoectomy (a small surgery on the tip of a tooth's root) clears infection that lingers after a root canal. The endodontist removes the inflamed tissue and the root tip, then seals the end. In a 2025 review of 22 studies, 89% of treated teeth were successful (Ko and colleagues, Restorative Dentistry and Endodontics, 2025). Most people are back to normal activities within a few days. It's usually the final step to save the tooth.

What Is an Apicoectomy?
It’s the microsurgical option for saving a tooth when infection sits at the very tip of the root, beyond the reach of treatment from inside the tooth. You may also hear it called periapical surgery or endodontic microsurgery. At Mid-Florida Endodontics, an endodontist performs it through a tiny opening in the gum, working under a surgical microscope so only the affected root tip is treated. It’s typically considered after a root canal or retreatment hasn’t fully cleared the problem, and it lets you keep your natural tooth.
A calm, composed patient in the operatory before an apicoectomy procedure
Apicoectomy is reserved for cases where non-surgical retreatment is not the right path.

When Is an Apicoectomy Needed?

An apicoectomy is not the first line of treatment, it is indicated when root canal treatment has been performed but a persistent problem cannot be resolved through the crown of the tooth alone. Common indications include:

Persistent Periapical Infection After Root Canal or Retreatment

A periapical lesion (an area of infection and bone damage at the tip of a tooth’s root, visible on X-rays) that fails to heal, or continues to grow, after completed root canal treatment or retreatment indicates that bacteria or infected tissue persists at the root tip that cannot be reached through conventional canal instrumentation.

Canal Anatomy That Cannot Be Retreated From the Crown

Severely calcified canals, a post and core that cannot be safely removed, or an instrument separated at the root tip may make non-surgical retreatment impossible or carry too high a risk of tooth damage. Surgical access from the root end bypasses these obstacles entirely.

Biopsy of a Suspicious Periapical Lesion

Periapical lesions are almost always inflammatory in nature, but occasionally, a lesion that does not respond as expected to treatment requires biopsy to rule out non-inflammatory pathology. Apicoectomy provides both surgical treatment and the tissue sample needed for pathological analysis.

Anatomical Factors Near the Root Tip

Accessory canals, isthmuses, and lateral canals in the apical third of the root may harbor bacteria that are unreachable by instrumentation from above. Resecting the apical few millimeters of the root removes this reservoir of infection entirely.

Why the Surgical Microscope Changes Apicoectomy Outcomes

Traditional apicoectomy, performed without magnification, required a larger surgical access, less precise root-end preparation, and produced more variable outcomes. Under the surgical microscope at high magnification, our specialists operate in a field of millimeter-level precision: resecting the exact amount of root, inspecting the cut root surface for isthmi and lateral canals. Preparing and sealing the root end with accuracy impossible to the naked eye. Research comparing microscope-assisted endodontic microsurgery to traditional surgery shows significantly higher success rates for the microscopic technique.

What Happens During an Apicoectomy?

The procedure is performed under local anesthesia in our office. Most patients are surprised by how manageable it is. Here is exactly what happens:

1

Pre-Surgical CBCT (cone-beam CT, a low-dose 3D X-ray that lets us see the tooth and bone from every angle) Imaging

A 3D CBCT scan maps the root tip position relative to critical anatomy, the inferior alveolar nerve, maxillary sinus, and adjacent root apices. This information determines the precise angle and depth of surgical access and prevents injury to surrounding structures.

2

Local Anesthesia

The area is thoroughly numbed. You will feel pressure during the procedure but no pain. We take all the time needed to ensure you are fully comfortable before proceeding.

3

Gum Tissue Incision and Flap Reflection

A small incision is made in the gum tissue near the affected root. The tissue is gently reflected to expose the bone and root tip below. The incision is designed to heal with minimal scarring and is typically small enough that sutures are removed within a week.

4

Removal of Infected Tissue and Root Tip Resection

The infected tissue surrounding the root tip is carefully removed. The apical 2-3 millimeters of the root are then resected, removing the portion of the root that harbors the greatest concentration of accessory canals and potentially infected debris. The resected root end is inspected under the microscope for any isthmi, cracks, or untreated anatomy.

5

Root-End Preparation and retrofill (sealing the cut root end from the outside during apicoectomy surgery)

A small cavity is prepared in the cut root surface using an ultrasonic tip under microscope visualization. This cavity is then filled with a biocompatible material, typically mineral trioxide aggregate (MTA), a biocompatible dental cement used to seal the root end during apicoectomy surgery . This Seals the root end and creates a bacteria-tight barrier. The precise preparation and sealing under magnification is the feature that distinguishes modern microsurgery from older techniques.

6

Closure and Healing

The tissue flap is repositioned and sutured closed. A bioresorbable membrane may be placed to support bone regeneration if significant bone loss was present. Sutures are typically removed at a follow-up appointment 5-7 days later.

Surgical microscope used by MFE endodontists during apicoectomy
Microscope magnification is what makes modern apicoectomy outcomes possible.

What Is Recovery Like After an Apicoectomy?

Days 1-3

Peak Swelling

Swelling and bruising in the area are expected, this is a normal surgical response, not a sign of complication. Take medications as prescribed or recommended by your provider. Eat soft foods and avoid the surgical area.

Days 4-7

Suture Removal

Swelling begins to subside. A follow-up appointment removes sutures. Most patients are comfortable returning to normal activities within a few days, though strenuous exercise should be avoided for about a week.

Months 3-12

Bone Healing Confirmed

Periapical bone healing is monitored with follow-up imaging. Full bone regeneration takes several months to a year. Successful healing is confirmed when the lesion has resolved on imaging.

Important: Ice packs applied to the outside of the face can help manage swelling in the first 24-48 hours after surgery, heat and ice may both be used as directed by your provider. Always follow your provider’s specific post-operative instructions. Contact us if you develop significant worsening of swelling after day 3, fever, or signs of wound dehiscence.

Recovery calendar at home: calm, normal routine after apicoectomy
Day-by-day recovery typically tracks faster than patients expect.

What Are the Success Rates for Apicoectomy?

Microsurgical Apicoectomy: High Success in Appropriate Cases

A meta-analysis published in the Journal of Endodontics found that endodontic microsurgery, apicoectomy performed under microscope magnification with ultrasonic root-end preparation and MTA (mineral trioxide aggregate, a biocompatible cement used to seal the root tip during surgery) retrofill, achieves success rates of approximately 92-94% at follow-up, significantly higher than outcomes reported for older macro-surgical techniques. Appropriate case selection, 3D pre-surgical imaging, and microscope-guided precision are the primary drivers of these outcomes. (Setzer FC, et al. Outcome of endodontic surgery: a meta-analysis of the literature. J Endod. 2010;36(11):1757-1765.)

Frequently asked questions

What is an apicoectomy?
An apicoectomy is a small microsurgical procedure that treats persistent infection at the very tip of a tooth's root, called the apex. Your endodontist makes a small opening in the gum near the root tip, removes the inflamed tissue and the last few millimeters of the root, then places a biocompatible seal so the canal is closed off from the bottom. It is most often used when a previous root canal was not enough on its own.
Is an apicoectomy painful?
An apicoectomy is performed with local anesthesia, the same way a routine filling is. You should feel pressure and movement during the procedure but not pain. Most patients describe the recovery as similar to having a wisdom tooth area treated: a few days of mild soreness and swelling that responds well to over-the-counter anti-inflammatories or whatever your dentist recommends.
How long does an apicoectomy take?
Most apicoectomy procedures take 60 to 90 minutes from start to finish, including numbing, the microsurgical work, and placing dissolvable or removable sutures. Your endodontist works under a high-power surgical microscope, which lets the procedure stay precise and conservative. You will be home and resting within a couple of hours of arriving.
How long is the recovery after an apicoectomy?
Most patients are back to normal routine within 2 to 3 days. Mild swelling and tenderness are typical for the first 48 hours, and we recommend soft foods, gentle brushing around the area, and rest for the first day. Sutures come out at about a week if they are not the dissolvable kind, and full healing of the underlying bone takes several months but usually requires no activity changes from you.
Why would I need an apicoectomy instead of another root canal?
Apicoectomy is usually recommended when a tooth has already had a root canal and retreatment is not the best option, often because of an existing crown, a post inside the canal, or anatomy that makes the infection only reachable from the root tip. Your endodontist will review your CBCT 3D imaging with you and explain why apicoectomy is the most conservative way to save your tooth in your specific situation.
How successful is an apicoectomy?
Modern apicoectomy performed by an endodontist with a surgical microscope and biocompatible root-end materials has a long-term success rate commonly reported in the 85 to 95 percent range. The combination of magnification and current-generation seal materials has improved outcomes dramatically compared to older versions of the procedure. Your specialist at Mid-Florida Endodontics will give you a personalized success expectation based on your imaging.
Will I need a new crown after an apicoectomy?
Most patients do not need a new crown after an apicoectomy because the procedure is performed from the outside of the tooth, near the gum line, leaving your existing crown undisturbed. This makes apicoectomy a strong option when you have a high-quality crown or post that you do not want to disturb. Your general dentist will continue to monitor the existing restoration at routine cleanings.
How soon after an apicoectomy can I eat normally?
Soft foods are best for the first 24 to 48 hours so the surgical site is undisturbed while the initial healing happens. Most patients are back to normal eating within 3 to 5 days, avoiding the immediate area for a little longer. Your endodontist will give you a simple post-op sheet with specifics, and your nearest MFE location is one phone call away if you have any questions during recovery.

Persistent infection after a root canal?

When a root canal was not enough, periapical surgery removes the infection at the source and saves the tooth.

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