Apical Surgery: To Pull Or Not To Pull
You will receive 2 credit(s) of continuing education credit upon successful completion of this course. The purchase price of this course is $98.00


This course will describe the indications and contraindications, for performing or referring a patient for Apical Surgery. With the correct history, radiographic and clinical evaluation, the decision to perform an Apicoectomy, will be weighed against further evaluation, a retreatment option, or extraction. Then a decision is more accurately made as to whether an Implant or a Fixed Bridge (Fixed Partial Prosthesis), a Removable Prosthesis (Fixed or Transitional Tempoary Prosthesis), or doing nothing would be the final treatment plan offered to the patient. This specific workup (check list) is frequently overlooked, leading to a less than ideal outcome. This course discusses and reviews all the options when a tooth is ailing or failing.


Learning Objectives:

Upon completion of this course, the participant should be able to:

  1. Learn the radiographic technique to use when evaluating a tooth for a fracture
  2. List the seven step workup consisting of procedures and tests that should be used when performing, or referring a patient for an apicoectomy.
  3. Understand the principles of GTM, and know the indications and contraindications.
  4. Recognize that the location of a fistula is the key critical diagnostic indicator for the final prognosis.
  5. Identify the signs to differentiate between an endo/perio defect vs. a perio/endo defect, and to understand the difference with respect to the prognosis.



Periapical Surgery as an adjunct to endodontic treatment is a proven technique. With the introduction of new surgical approaches, and a systematic approach to the diagnosis and treatment of compromised teeth, the clinician should be able to more accurately determine the long term prognosis, and/or determine the potential success of a surgical, non-surgical, or replacement treatment option.

  1. Proper case selection and the use of:
  2. Fiberoptics
  3. Magnification
  4. Ultrasonic Retropreparation
  5. Guided Tissue Regeneration and the use of
  6. Cone Beam Computerized Tomography (CBCT) to determine when Apical Surgery is indicated and when it is contraindicated.

  1. Ingle, Bakland, 1994 “Endodontics: 4th Edition” Lea & Fabiger , Williams and Wilkins, A Waverly  Company, 1994.
  2. Teeth, Teeth, Teeth, A Thorough Treatise by Sydney Garfield DDS. Pp 49- 53  about Pierre Fauchard, Simon and Schuster, New York, 1969.
  3. Hunter W. The role of Oral Sepsis and of antisepsis in medicine. Lancet (London) 1911;1:79-86; Dent Cosmos 1918; 60:585-602.
  4. Rhein ML. Oral Sepsis. Dent Cosmos 1912;54:529-534.
  5. Whithouse W. New mode of treating dead teeth and alveolar abscess. British J Dent Sci. 1884:27:238-240.  
  6. Baek, SH, Plenk Jr H, Kim S. Periapical tissue responses and cememtum regeneration with amalgam super-EBA and MTA as root-end filling materials. J Endodon 2005; 31:444-9.
  7. Dahlin C. Lindhe A. Gottlow J. Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1998;81:672-6.
  8. Grossman LI. Root canal therapy.  Philadephia: Lea & Febiger;1940.
  9. Anatomy: A Regional Atlas of the Human Body. Carmine D. Clemete.  Lea & Febiger Philadelphia, 1975.
  10. Oral and Maxillofacial Surgery; Archer H, Fifth Edition: W.B.Saunders Company Phaladephia, London, Toronto, 1975. 
  11. Dawood, A. New Technologies in Implant Surgery. Academy News, Academy of Osseointegration. 2006;Vol 17, Number 3; 6-7.
  12. Pompa D. Current Concepts in Periapical Surgery: Dentistry Today. 1997; Vol. 16, Number 12, 96-103.
  13. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants.  J Periodontol. 2003;74(12):1785-1788.
  14. Tarnow D, Cho SC, Wallace S. The effect of inter-implant distance on the height of inter-implant  bone crest. J Periodontal. 2000;71(4)L546-549.
  15. Gutman J. Harrison J. Surgical Endodontics. Cambridge, Mass: Bladkwell Scientific Publication;1991-3.
  16. Langer B, Stein S Wagenberg B, An evaluation of Root Resections (A Ten-year Study); J. Periodontol;1981;52(12):719-722.
  17. Buhler H, Evaluation of Root-Resected Teeth (Results after Ten Years) J. Periodontol.; 1988:59(12);805-810.
  18. Roberts, WE. Bone physiologoy, metabolism and biomechanics in orthodontic practice. Orthodontics:Current Principles and Techniques, 3rd ed. Graber TM and RL Vanarsdall Jr. (Eds), Mosby-Yearbook, St. Louis, 2000, pp 193-257.
  19. Cummings, R.R., Endododntic Surgery. Endodontics. Philaddlphia: Lea & Febiger (1985): 681-692
  20. Gilheany P, Figor D, Tyas M. Apical Dentin Permeability and Microleakage Associated with Root end resection and retrograde filling. J Endodon 1994;20:22-6.
  21. Ruddle,C. Nonsurgical Endodontic Retreatment. Dentistry Today; Feb. 1998.
  22. Boyne, Phil J. Regeneration of alveolar bone beneath cellulose acetate filter implants (abstract)  J Dent Res 1964;43:827.
  23. Nyman, S. Lindhe, J. Karing, T. rylander, H New attachment following surgical treatment of human periodontal disease. J Clin Periodontal 1982;11:494.1.
  24. Dahlin C. Lindhe A. Gottlow J. Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1998;81:672-6.
  25. Dahlin, C, Linde, J. Gottlow and Nyman S. Healing of Maxillary and mandibular bone defects using a memebrane technique Scand. J Plast. Reconstr. Surg. 1990;24:13-19.
  26. Skoglund,  A. Persson, G. A follow-up study of apicoectomized teeth with total loss of the buccal bone plate. Oral Surg Oral Med Oral Pathol 1985;59:78-81.
  27. Pompa D. Guided Tissue Repair of Complete Buccal Dehiscences associated with Paeiapical Defects: a Clinical Retrospective Study. JADA, 1997 Vol. 128, 989-997.                                                                                                                                          
  28. Greenstein G, Cavallaro J, Tarnow D, When to save or extract a tooth in the Esthetic Zone: A        Commentary. Compendium of Continuing Education in Dentistry April 2008; Vol 29, Number 3; 136-145.
  29. Christensen GJ. When is it best to remove a tooth. JADA 1997;128:63.
  30. Salama MA, Salama H, Garber DA. Guidelines for esthetic restorative options and implant site enhancement: the utilization of orthodontic extrusion. Pract Proced Aesthet Dent. 2002;14 (2): 125-130.
  31. Kim S, Kratchman S. Modern Endodontic Surgery Concepts and Practice: A Review J Endodon 2006;32:601-623.
  32. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Endoscopic periradicular surgery: a prospective clinical study. Br J Oral Maxillofac Surg 2007;45:242-4.
  33. Deitrich T, Zunker P, Dietrch D. Bernimoulin JP, Apicomarginal defedts in periradicular surgery: Clalssification and diagnostic aspects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002:94:233-9.
  34. American Association of Endodontists; Treatment Options for the Compromised Tooth: A decision Guide, 2011. www.aae.org/treatmentoptions.
  35. Peterson J, Gutman JL. The outcome of endodontic resurgery: a systematic review. Int Endod J. 2001;34(3):169-175.
  36. Wagner B. Clin Oral Investig. 2000;4(2):74-80.
  37. Tan K. clin Oral Implants Res. 2004;15(6):654-666.
  38. Priest, G. Interntional Journal of Oral and Maxillofacial Implants 1999;14(2):181-188
  39. “Toronto study” done in 2003 published: Journal of Endodontics. 2003;29(12):787-793.
  40. Whitworth JM, British Dental Journal. 2002;192(6):315-327.
  41. EndoSequence: Melding Endodontics with Restortive Dentistry. “New Dimensions in Basic Endodontics”  Seminar given by Dr. Alex Fleury at the Nassau County Dental Society Meeting on Oct. 25, 2013.


American Dental Association is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.