The Latest on Apicoectomies: When, Why and How

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing apicoectomies, their advantages, and how the procedure has evolved over the years. Our guest is Dr. Ali Nasseh, a clinical instructor and lecturer at Harvard School of Dental Medicine, specifically in the endodontic program. He is the current director of the endodontic microsurgery course at Harvard and also runs a private practice limited to endo in downtown Boston. Dr. Nasseh is also the CEO and president of Real World Endo, an endodontic education, innovation, and medical device company. Dr. Nasseh, it's a pleasure to have you back on the show. Thanks so much, Phil. To our audience, again, I covered this in a previous podcast, the various segments to this endodontic series. You are really lucky to hear Dr. Nasseh, who's an expert in the endodontic field. Not only is he a great practitioner, but he also is a developer and innovator of new products. He understands the clinical aspect and applies it to taking products, commercializing products. And he's been very successful with it. And we're really happy to have him on our show. Actually, there's a series of four. This one, as we mentioned, is on apicoectomies. So to begin, tell us what an apicoectomy procedure is real briefly. Well, I guess as the name indicates, you know, it's the cutting of the apex. But more importantly, it's a question of why do we need to cut the apex? And what are we achieving by doing that? And it essentially is a procedure that is a last resort procedure to save teeth that have had previous root canals or are so calcified that a conventional root canal cannot be done or are somehow, you know, alleged or... uh inaccessible coronally non-surgically so that you need to do um you essentially have to go from the end of the root and uh clog the end of the root or plug plug the end of the root but i usually explain to the patients it's the equivalent of putting a cork in a bottle uh you know we're we have a tooth a canal that still contains bacteria after even having had the root canal there's still some biofilm present so what we do is we go from the end of the root find the end of the root do a little small preparation for the size of a cork that we want and we place the cork essentially seal it and prevent the egress of microbes from inside the tooth to the outside of the tooth. The same idea as a conventional root canal, we're cutting off the source of microbes from inside the tooth so that the patient can do its own healing in the peri apex. Yeah, so let me ask you this question. So most of our audience on this podcast are probably GPs just by simple demographics. We might have some endodontists on, but... I want to ask you is the key thing for a GP, many of them will not be doing apicoectomies in their office. Some do, but many of them will not. So what we're really interested in hearing is looking at the case and saying, is this a case for a retreatment? Is it an extraction? Or is it an apicoectomy? Now, if they're not sure, I guess the GP could refer to an endodontist and be done with it and let them handle it. But in some cases, endodontists aren't close by. just because it could be a very rural area or whatever reason the person is not very mobile, the patient, and they need to get the help they can in that kind of one-off situation. What kind of advice would you offer a GP who's trying to do as much as they can for the patient without referring that patient out regarding that treatment plan that we're talking about? So that's a great question, Phil. I think like anything else, it's important for all members of it. of a dental team to kind of know each other and also be aware of their own capability and what they can achieve. And unfortunately, not all endodontists do enough apicoectomies or they're comfortable doing them or they're just limited to only some front teeth and so on. So it's important for general dentists who have endodontists in their area or familiar with them to kind of find out what the comfort level of the endodontist in their team member is. But to that extent, those who do apicoectomy, I can tell you that apicoectomy is an excellent, excellent option for saving teeth that cannot have revision. So our goal always is to try to do non-surgical revision whenever possible, if it's possible. But some teeth have, you know, very large cast posts and cores. They may have ledges and... uh if there is a large ledge and you can see that there is infection at the end of the root there's no reason to try to go back inside the tooth and then reach the same ledge and still not clean the area beyond the ledge. Essentially, the cause of the infection is the persistence of microbes in the main canal beyond the ledge in those cases. And so apicoectomy would be the ideal option in those types of cases in which you have coronal impediments and the problem is purely at the apex. Now, another key thing is you don't want to do apicoectomy in cases in which you have what's called coronal leakage, in which you have faulty coronal restorations. There is constant introduction of microbes to the inside of the root canal. In those types of cases, we have kernel leakage. Doing an apicoectomy is the equivalent of putting a lid on a garbage can because you are just, you know, that lid or that cork, as I told you at the beginning, is not going to be strong enough to hold off the microbes over the long run. So it becomes a very short and unpredictable procedure. The techniques for epicoectomy have improved dramatically over the years. In the past 20 years, microsurgical techniques have really revolutionized this field, and the addition of bioceramics for retrofilling have really helped improve the success rate. So new success outcome studies for epicoectomy are completely different than what we had in the literature in the past. Epicoectomy that was done as a panacea. to treat failed root canal treated teeth by oral surgeons, which was the equivalent of putting a BB gun of an amalgam right at the end of a tooth. Those things are really out. And now the modern apicoectomy procedure really enjoys a very high success rate. But that is really based on proper treatment planning. The main determinant of your success during apicoectomy. is your treatment planning and your diagnosis as to what is the cause of failure. If you have a missed canal, you don't want to do an apicoectomy. You just want to go back in there and find that canal and do a conventional root canal. You know, if you don't have a ledger, if you don't have coronal impediments, try to revise first and then do the apico. But apico still has a place because there are external biofilms in some cases. And those cases, despite how many times you may do a retreatment successfully, it looks great. It may not heal. You just have to get out there and remove the apical lesion. Yeah, at Penn Endo, the school that I graduated, we were taught when a case fails and you don't have a fractured post in there or a fractured instrument or some sort of impediment where you can't get down conventionally, you absolutely do a retreatment first and then you do some long-term calcium hydroxide treatment and that may take months. You just change it every month or so and put a fresh loading dose or whatever you want to call it of calcium hydroxide into the whole system. And then when you see some resolution, you go ahead and obturate. And the apicoectomy was something that was done really in our school, not all schools, but we were very conservative with surgery. And it was done only in cases where there was no other alternative to conventional treatment or retreatment. I know you talked about the bioceramic material as a retrograde filling, and that's obviously a big improvement. But with 3D imaging and also the success of single tooth implants. How has that affected the treatment plan of doing APIGOS? That's a really, really good question. I mean, 3D imaging has really helped revolutionize cases. I mean, I've done now in my career, I've done about 27,000 cases. I can tell you the first 20,000 were without a CBCT and the last 7,000 have been with a CBCT. And every time I look at a CBCT, I wonder how the heck did I do those first 20,000? Because you get so... the treatment planning, you know, treatment planning is the number one source of our success clinically in everything we do. And treatment planning is based on the principle of proper diagnosis. So you can only achieve your proper diagnosis when you have all the information and you get so much information from a CVCT and you can plan properly and so on. So CVCTs have really helped tremendously with this decision-making between retreatment and surgery because you, first of all, you can, You're aware of the anatomy. You see how much bone you have to go through. You know, is it a missed canal? If it's not, if it's a missed canal, you do the retreatment first. But if you see everything has been treated already adequately, you could have seen already from your bite wing that you have a nice coronal restoration in place. Then all you have to do is to decide, is it close to a vital structure? What are the risks and the benefits? And you make a simple calculation like that within the envelope of your own. capability and your level of comfort and you will do well and you know as you mentioned by the way penn has an excellent surgical program um there are not that many schools around the country that do as many surgeries uh penn is one of the ones i'm trying to get our school i'm actually now the directory of the surgery program at our school or the harvard postdoc endo program so my goal is to get all of our residents to be completely comfortable with surgery because i think once you have that level of comfort with surgery you're going to really have the confidence to manage cases now when it comes to implants The studies that have been done at Penn with seven-year studies, and actually I just had a study done in my own office with survival of endodontically apicoectomies and retrofilled teeth using a technique that I've developed over the past 10 years, we managed to have about a 92% survival rate in these cases over 10 years. The Penn study kind of was actually fairly similar to that as well with using these microsurgical techniques. So I think about a 92% survival rate is not... bad it's very comparable to implants if not more and it's a fraction of the time it's a one appointment deal for the patients and it doesn't require this lengthy procedure of going through implant plus it's your own tooth at the end of the day yeah no aesthetically no question yeah that's right aesthetically no question about i mean back in the day when single tooth implants were really trending to the point they still are but i mean when they really just emerged Even Cole Misch, the late Cole Misch, he was a tremendous educator and proponent of implants. He said certain root canals, you should just do an extraction because single tooth implants will give you a better success rate. I'm not sure that still holds with today's techniques. It doesn't hold because there have been numerous studies that have been done now to show that the success rate of root canals exceed that of implants. It used to be at the beginning. That was a 90s and early 2000 thing when the implant industry essentially took over the narrative. and ran with the idea that, look, implants are better than your own teeth. Now we're having a political discussion. It's like we're having a debate here, which I love. Hearing the perspective from an endodontist, we got to get an implant guy here as well. And you guys could duke it out. Although, I mean, there's no question about it. All the studies are actually showing this right now. Many of my most biggest referrals for epicoectomy and these procedures are now the biggest implant people in town. Because they're going to realize now over the years, once a little bit of time has passed and these people have placed the implants, have seen that, look, it's not 100% bill of goods that they were sold, that there are problems with these things. Yeah, and you get peri-implantitis and there are also things that could happen. Yeah, peri-implantitis is the same thing as apical periodontitis. It's the same biome, the same problem. They decide that it's not a problem. So the key thing for me in my understanding, as I'm a retired endodontist, but I love talking about this stuff. But the key thing is the CBCT. We're talking about really, really precise knowledge and information about where we need to do the surgery. And like you said, you don't know how you did the surgery on your first 20,000 cases. And by the way, that's a lot of cases you've done. You look great for someone that's done 27,000 cases. The three-dimensional aspect of the radiographic diagnostic tool of CBCT is just invaluable to doing something like an apico. That, I think, has improved the prognosis and the results, like you're talking about, bringing it to up to 92%. And 92% for an apicoectomy is phenomenal, in my opinion, because you've got to remember that tooth is already on its way to the graveyard. So the answer to the question of the title of this podcast, do they work, we have to say, yes, they do. So last question to wrap this up because we're running out of time on this podcast. What are some of the apicoectomy and retrofilling techniques and what are their advantages? And we can do that in about two or three minutes. Sure, definitely. Well, I mean, there are the traditionally and originally we use amalgam as a retrofilling and then that kind of evolved once MTA came out. We started to use MTA, but it was difficult to apply to the site. And then later on with these bioceramic materials came out, especially the putty, the technique that I kind of developed was because the lid technique, the surgical lid technique, which involved the combination of using the injecting the sealer or the flowable material into the retro preparation and then bringing a little a dab of the putty material up on top of it to close off the surface. But the advantage of this technique is, is that it's incredibly, just like hydraulic condensation that we developed at Revolodendos, the idea here is to simplify and make the process that was previously far more difficult, more efficient, and more approachable to the clinician. Especially during surgery, you have a very small window of time for bleeding and so on. So you can control the bleeding for a short period of time. You want to have an efficient retrofilling technique. And this surgical lid technique, is the most efficient method of retrofilling. Essentially what I do when I time myself, it's anywhere from 10 to 20 seconds per canal that it takes in order to do your full retrofilling. And that's super fast. And that's the technique that we're teaching at the school right now to all residents. And they're learning it so quickly and applying it right away. In fact, I time their procedures. You remove the diseased tissue at the apical part of the root. Three millimeter ultrasonic tip is put at 90 degrees angle to the cut surface of the root. And then we basically drive that up. the root in the same direction. So the art of it is really following the curvature of the root properly and you can go into it without really weakening the tooth too much on that side and create that little plug and then fill that plug without getting any voids in there. as quickly as possible without having to use too much static agents that cause inflammation and other kinds of side effects postoperatively. So this is an advantage of that. I just wanted to fill, before we close, bring up a topic that is, I'm sure it's very important to general dentists, other restorative dentists, because they always hear, especially this is a kind of a narrative, again, that has been promoted by people who place the implants, say, oh, if you do an apico on a tooth, you can't do the implant afterwards because there's always a hole at the end of the road. That is a form of a confirmation. bias that has been so fascinating because some of the people that I work with kind of constantly say that. They say, every time I go to remove a tooth that has had an apicoectomy, when I remove it, there is that hole that you made to do, that apicoectomy has been done, it's still there. And I say... Do you understand what you're saying? You're dealing with a biased sample. You're taking out the failures. Obviously, in those cases, there is a lesion at the apex. You're not seeing the 92% success cases to do an implant on because they're still in the mouth. So that's an interesting and it's an important thing. So because to risk analysis, should you do an implant? Should you do an apico? That is a decision that a qualified endodontist, well-trained to do surgery should be a part of. Because if they're not comfortable doing the surgery, obviously, there's no point in doing an apico. Then go to the implant, obviously. The implant people are saying, the implant doctors are saying that if you do an apicoectomy and it fails, now you don't have a super high prognosis on the single tooth implant because of the bone loss in the apical area? Is that what? they're saying? Yeah, the bone loss at the apical area can, first of all, as I said, if the apical has been done with proper treatment planning and you're not doing it cavalierly, I would not do an apicoectomy unless I think it has a 90% success rate or above. If I think it has a lower success rate than, you know, 80 to 90%, then obviously, you know, you want an implant would have. probably a higher success rate in those cases so then you would want to have an implant the question here is that those people that are seeing those you know tend to eight to ten percent failures or that's not a good enough reason to extract the tooth that there's a ten percent chance that it could fail potentially right i mean because in that case then the moment you have any kind of a filling in a tooth you should get an implant because all of those things that we do have a certain success and failure rates so you know it's kind of akin to saying that you know you're gonna have to commit suicide to avoid death right You don't want to do this too early. You want to end on that one. Yeah. Okay. So that's the first on our podcast show, but that's an interesting analogy to end the podcast on. Maybe they'll not watch the whole thing or not listen to the whole thing. But no, anyway, Dr. Nasseh, it's been great. Again, really appreciate your time. I know you have another podcast with me. I'm going to be talking about the rotation versus reciprocation. with instrument motion which is going to be cool so we'll do that soon until then thank you very much and we'll see you on the next podcast thanks so much