Apicectomy (root-end surgery): when it is needed, what happens and how healing progresses

What is an apicectomy?

An apicectomy, also called root-end surgery, is an operation in which the dentist reaches the root tip through the gum and bone, removes inflamed tissue and the tip, and seals the canal with a filling from below. The 2023 European Society of Endodontology (ESE) guideline describes curettage of the lesion, root-end resection, and preparation and filling of the canal end.

The American Association of Endodontists (AAE) describes apicectomy as the most common endodontic surgical procedure, needed when inflammation or infection persists in bone around the root tip after root canal treatment. When performed under high magnification with a microscope or endoscope, it is called endodontic microsurgery.

The procedure is sometimes loosely called tooth resection, although only the end of the root is removed and the tooth stays in the arch. An apicectomy complements rather than replaces root canal treatment when treatment through the crown alone is insufficient.

When is an apicectomy performed?

An apicectomy is performed when inflammation around the root does not heal after root canal treatment and repeating treatment through the crown is impossible, unsuccessful or too risky for the tooth. The 2023 ESE guideline states that the evidence shows no difference in effectiveness between root-end surgery and root canal treatment or retreatment, and allows surgery when non-surgical treatment is not feasible.

A 2016 Cochrane review found no clear advantage of apicectomy over root canal retreatment for healing after one year (RR 1.15) or after 4 and 10 years, with very low-quality evidence. However, more patients reported pain in the first week after surgery (RR 3.34).

The 2020 guidelines from the Royal College of Surgeons (RCS) in the UK list situations in which an apicectomy is indicated.

• The canal cannot be dried and filled because fluid continues to appear despite repeated preparation.
• A lesion around the root causes symptoms or grows despite adequate root canal treatment.
• Retreatment has failed or would require removing a post with a high risk of root fracture or damage to a crown or bridge.
• Anatomical abnormalities or the effects of previous treatment prevent access to the canal through the crown.
• A biopsy of tissue around the root is needed for histopathological examination.
• The root needs inspection because the dentist suspects a perforation or fracture.

When is an apicectomy unsuitable?

An apicectomy is unsuitable when the tooth has a poor prognosis for reasons other than the lesion at its tip. The 2020 RCS guidelines list situations associated with poorer surgical outcomes.

The RCS advises caution when considering repeat surgery on the same tooth, because studies consistently report lower chances of healing after a second operation. When contraindications outweigh the benefits, the alternative is extraction and replacement of the missing tooth.

• A fractured root.
• A tooth that cannot be restored, or a coronal restoration with a poor seal.
• Periodontal disease combined with a lesion around the root, known as an endodontic-periodontal lesion.
• Too little bone around the tooth or a root that would be too short after resection.
• Difficult access to the root tip, where surgical risks outweigh the benefits.
• Uncontrolled oral disease or factors in the medical history relevant to any surgical procedure.

What happens during an apicectomy, step by step?

An apicectomy is performed under local anaesthesia in several stages described by the AAE and RCS guidelines. Before surgery, the dentist assesses an intraoral X-ray, which the RCS says is sufficient for planning in most cases.

The RCS recommends CBCT when ordinary X-rays provide insufficient information, particularly for teeth close to the nerve canal in the lower jaw or the maxillary sinus. The article on CBCT and panoramic X-rays discusses indications and radiation doses.

The material determines how well the canal is sealed from below. In the 2016 Cochrane review, a root-end filling with MTA produced better healing after one year than simply smoothing the existing gutta-percha filling (RR 1.60, one study), while a 2013 meta-analysis linked better results to MTA and an operating microscope (Tsesis et al., 2013).

• Local anaesthesia around the tooth.
• Incision and lifting of the gum to expose bone over the root.
• Opening the bone and removing inflamed tissue beneath the tip; tissue can be sent for histopathological examination.
• Removing the root tip and preparing the end of the canal, often with ultrasonic tips.
• Filling the canal end with a biocompatible material, such as MTA.
• Replacing the gum, placing stitches and taking a postoperative X-ray.

How successful is an apicectomy?

Studies report healing after apicectomy using modern techniques in about 9 out of 10 cases. A review of 21 studies found success rates of 94% for endodontic microsurgery and 59% for traditional surgery, with a 1.58-fold higher chance of success for microsurgery (Setzer et al., 2010).

A 2013 meta-analysis restricted to modern techniques reports 89% success after one year; procedures using microscope or endoscope magnification performed better than those using loupes (Tsesis et al., 2013). The RCS guidelines cite a study in which 98% of teeth remained in the mouth 4 to 10 years after surgery and note that healing rates decline slightly over time.

According to the RCS, prognosis is influenced by absence of preoperative pain and symptoms, a lesion smaller than 5 mm, a well-condensed existing canal filling, use of high magnification and MTA, and whether surgery is first-time or repeat. These are study averages, not a prediction for an individual tooth.

What is healing like after an apicectomy?

Recovery after an apicectomy is usually mild: the AAE says postoperative discomfort is generally slight, and most patients return to normal activities the next day. According to the RCS, pain or swelling usually eases after the first 3 days, and in most patients symptoms resolve completely by the second week.

Bone around the root tip rebuilds over the following months, so the outcome is assessed on follow-up X-rays rather than when discomfort stops. The RCS recommends a clinical check and X-ray annually for up to 4 years after surgery.

The table shows the usual course of healing. Contact the surgery if any of the signs listed below the table appear.

• Pain or swelling that increases rather than eases after the third day.
• Fever and enlarged lymph nodes may indicate infection: contact the surgery urgently. Once treatment has started, the RCS recommends reassessment within 24 to 48 hours.
• Bleeding from the wound that does not stop with pressure.
• Swelling that makes breathing or swallowing difficult: hospital emergency department (SOR) or the emergency number 112.

Apicectomy or extraction: how is the decision made?

An apicectomy makes sense when the root is intact, the tooth can be restored with a tight seal and there is enough surrounding bone. Extraction is more appropriate for a fractured root, an unrestorable tooth or after unsuccessful surgery when another attempt has little chance. The article on root canal retreatment compares retreatment, apicectomy and extraction in detail.

Extraction does not finish treatment, because the gap usually needs an implant, bridge or denture. A 2013 Cochrane review states that implants are traditionally left unloaded for 3 to 8 months, so several months usually pass between extraction and an implant crown, whereas a tooth remains in the arch throughout bone healing after apicectomy.

The dentist decides after examination and an X-ray, often with a CT scan, also taking periodontal health and the restoration plan into account.

How much does an apicectomy cost, and does the NFZ cover it?

The cost of an apicectomy depends on the scope of surgery and whether a CT scan or histopathological examination is needed. In the clinic's price list, “Resekcja wierzchołka korzenia” (apicectomy) costs 500 zł, “Resekcja wierzchołka korzenia z biomateriałem” (apicectomy with biomaterial) 1 500 zł, “Tomografia komputerowa- szczęka lub żuchwa” (CT scan of the upper or lower jaw) 300 zł and “Badanie histopatologiczne” (histopathological examination) 100 zł. The dentist sets the final scope and cost after examination, and prices may change.

The NFZ, Poland's National Health Fund, lists apicectomy among funded oral surgery services only for front teeth, from canine to canine in both arches, and only for children and young people up to 18 years of age. Adults do not have this procedure in the list of NFZ-funded services (Ministry of Health regulation, t.j. Dz.U. 2025 poz. 615, załącznik nr 5, legal status as of 24 October 2026).

How it works at DentalBlue

At DentalBlue in Białystok, the clinic's own radiology unit takes CBCT scans, panoramic and intraoral X-rays, so a lesion around the root can be assessed before deciding on surgery without referral elsewhere for imaging. Root canal treatment and retreatment are also performed under a microscope. Oral surgery is carried out under local anaesthesia or, for patients found suitable at a joint dental and anaesthesiology consultation, under general anaesthesia. A consultation can be arranged by phone.