Apicoectomy

F. D. Fragiskos

13

Apicoectomy is the surgical resection of the root tip ofa tooth and its removal together with the pathologicalperiapical tissues. Accessory root canals and addition-al apical foramina are also removed in this way, whichmay occur in the periapical area and which may beconsidered responsible for failure of an endodontictherapy.

13.1 Indications

The indications for apicoectomy include the followingcases:1. Teeth with active periapical inflammation, despite

the presence of a satisfactory endodontic therapy.2. Teeth with periapical inflammation and unsatis-

factory endodontic therapy, which cannot be re-peated because of:– Completely calcified root canal.– Severely curved root canals.– Presence of posts or cores in root canal.– Breakage of small instrument in root canal or the

presence of irretrievable filling material.3. Teeth with periapical inflammation, where comple-

tion of endodontic therapy is impossible due to:– Foreign bodies driven into periapical tissues.– Perforation of inferior wall of pulp chamber.– Perforation of root.– Fracture at apical third of tooth.– Dental anomalies (dens in dente).

In the above cases, if after the apicoectomy the apexhas not been completely sealed, then retrograde fillingis required, which is described further down. The pur-pose of retrograde filling is to obstruct the exit ofbacteria and the by-products of nonvital pulp, whichremained in the root canal.

13.2 Contraindications

The contraindications for apicoectomy are as follows:All conditions that could be considered contrain-dications for oral surgery concerning the age ofthe patient and general health problems, such assevere cardiovascular diseases, leukemia, tubercu-losis, etc.Teeth with severe resorption of periodontal tissues(deep periodontal pockets, great bone destruction).Teeth with short root length.Teeth whose apices have a close relationship withanatomic structures (such as maxillary sinus, man-dibular canal, mental foramen, incisive and greaterpalatine foramen) and if causing injury to theseduring the surgical procedure is considered proba-ble.

13.3 Armamentarium

The following instruments are necessary for perform-ing an apicoectomy:

Microhead handpiece (straight and contra-angle)and microbur (Fig. 13.1).Special narrow periapical curette tips for prepara-tion of the periapical cavity (Fig. 13.2).Apical retrograde micro-mirror and micro-explor-ers (Fig. 13.3).Local anesthetic syringe and cartridges.Scalpel handle.Scalpel blade (no. 15).Mirror.Periosteal elevator.Cotton pliers.Small hemostat.Suction tips (small, large).Irrigation receptacle.Needle holder.Retractors.

Chapter 13

310 F. D. Fragiskos

Periodontal curette.Periapical curette.Appropriate burs (round, fissure, inverted cone).

Miniaturized amalgam applicator for retrogradefillings (Figs. 13.4, 13.5).Narrow amalgam condensers (Fig. 13.6).

Fig. 13.1. Microhead handpiece com-pared to a conventional handpiece. Withthis handpiece, preparation of the peri-apical cavity is greatly facilitated in areaswith limited access

Fig. 13.2. Special narrow periapicalcurette tips that may be adapted to anultrasonic device. They are used forpreparation of the periapical cavity inareas with limited access

Fig. 13.3. Apical retrograde micro-mirror and micro-explorers for deter-mining the dimensions of the createdperiapical cavity

311Chapter 13 Apicoectomy

Scissors, needles and no. 3–0 and 4–0 sutures.Metal endodontic ruler.Gauze and cotton rolls/pellets.

Syringe for irrigating surgical field.Saline solution.

Fig. 13.4. Miniaturized amalgam appli-cator for retrograde fillings, with a knobthat controls amalgam increment size

Fig. 13.5. Miniaturized amalgamapplicator compared to a standardamalgam carrier

Fig. 13.6. Instruments and materialsfor retrograde filling. Amalgam cap-sule (top left). Miniaturized amalgamapplicator (top right). Narrow amalgamcondensers, with tips appropriatelyshaped so that they may enter narrowareas easily (bottom)

312 F. D. Fragiskos

13.4 Surgical Technique

The procedure for apicoectomy includes the followingsteps:1. Designing of flap.2. Localization of apex, exposure of the periapical area

and removal of pathological tissue.3. Resection of apex of tooth.4. Retrograde filling, if deemed necessary.5. Wound cleansing and suturing.

Designing of Flap. Flap design depends on variousfactors, which mainly include position of the tooth,presence of a periodontal pocket, presence of a pros-thetic restoration, and the extent of the periapicallesion.

There are three types of flaps principally used forapicoectomy: the semilunar, triangular, and trapezoi-dal. The semilunar flap is indicated for surgical proce-dures of limited extent and is usually created at theanterior region of the maxilla, which is where mostapicoectomies are performed. In order to ensure opti-mal wound healing, the incision must be made at adistance from the presumed borders of the bony de-fect, so that the flap is repositioned over healthy bone.If there is an extensive bony defect, especially towardsthe alveolar crest, then the triangular or trapezoidalflap is preferred. It must be noted that the pathologicallesion, which has perforated the bone and has becomeattached to the periosteum, must be separated fromthe flap with a scalpel. In case of a fistula, the fistuloustract must also be excised near the bone, because, if itis excised at the mucosa, then there is risk of evengreater perforation, resulting in disturbances of thehealing process.

When the apicoectomy is performed at the anteriorregion (e.g., maxillary lateral incisor) and there is anextensive bony defect near the alveolar crest (Figs. 13.7,13.8), the surgical procedure is performed using atrapezoidal flap. The incision for creating the flap be-gins at the mesial aspect of the central incisor and, af-ter continuing around the cervical lines of the teeth,ends at the distal aspect of the canine. With a perios-teal elevator, the mucoperiosteum is then carefully re-flected upwards (Figs. 13.9, 13.10).

Localization and Exposure of Apex. The next stepafter creating a flap is localization and exposure of theapex. When the periapical lesion has perforated thebuccal bone, localization and exposure of the root tipis easy, after removing the pathological tissues with a

curette. If the buccal bone covering the lesion has notbeen completely destroyed, but is very thin, then itssurface is detected with an explorer or dental curette,whereupon, due to decreased bone density, the under-lying bone is easily removed and the apex localized.When the buccal bone remains completely intact, thenthe root tip may be located with a radiograph. Morespecifically, after taking a radiograph, the length ofthe root is determined with a sterilized endodontic fileor metal endodontic ruler. The length measured isthen transferred to the surgical field, determining theexact position of the root tip. Afterwards, with a roundbur and a steady stream of saline solution, the bonecovering the root tip is removed peripherally, creatingan osseous window until the apex of the tooth is ex-posed (Fig. 13.11). If the overlying bone is thin and thepathological lesion is large, the osseous window is en-larged with a blunt bur or a rongeur. Enough bone isremoved until easy access to the entire lesion is per-mitted. A curette is then used to remove pathologicaltissue and every foreign body or filling material, whileresection of the root tip follows (Fig. 13.12).

Resection of Apex of Tooth. The apex is resected(2–3 mm of the total root length) with a narrow fissurebur and beveled at a 45° angle to the long axis of thetooth (Fig. 13.13). For the best possible visualization ofthe root tip (Fig. 13.14), the beveled surface must befacing the dental surgeon. After this procedure, thecavity is inspected and all pathological tissue is me-ticulously removed by curettage, especially in the areabehind the apex of the tooth. If the entire root canal isnot completely filled with filling material or if the sealis inadequate, then retrograde filling is deemed neces-sary.

Retrograde Filling. After beveling of the apex andcurettage of periapical tissues, gauze impregnatedwith adrenaline to minimize bleeding is placed in thebony defect. A microhead handpiece with a narrowround microbur is then used to prepare a cavity ap-proximately 2 mm long, with a diameter slightly largerthan that of the root canal (Fig. 13.15). The cavity maybe enlarged at its base using an inverted cone-shapedbur to undercut the preparation for better retention ofthe filling material (Fig. 13.16). During preparation ofthe cavity, the dentist must pay careful attention to thewidth of the cavity, which must be as narrow as possi-ble, because there is a risk of weakening the root tipand causing a fracture (which may not even be per-ceived) during condensing. After drying the bone cav-ity with gauze or a cotton pellet, sterile gauze is packedinside the bone deficit and around the apex of the

313Chapter 13 Apicoectomy

Fig. 13.8. Clinical photograph of case shown in Fig. 13.7.Arrow points to possible location of lesion

Fig. 13.7. Extensive periapical lesion at maxillary right lat-eral incisor. Indication for apicoectomy

Apicoectomy with Trapezoidal Flap

Fig. 13.9 a, b. Surgical procedure for removal of periapical lesion, together with apicoectomy at lateral incisor of maxilla.Incision for creation of trapezoidal flap. a Diagrammatic illustration. b Clinical photograph

Fig. 13.10 a, b. Reflection of mucoperiosteum and exposure of labial alveolar plate after elevation of flap. a Diagrammaticillustration. b Clinical photograph

314 F. D. Fragiskos

Fig. 13.11 a, b. Removal of labial bone covering apical third of root. a Diagrammatic illustration. b Clinical photograph

Fig. 13.12 a, b. Removal of periapical lesion with hemostat and curette. a Diagrammatic illustration. b Clinical photo-graph

Fig. 13.13 a, b. Resection of apex with fissure bur and beveling at a 45° angle. The resection faces the surgeon and is at adistance of 2–3 mm from the root tip

315Chapter 13 Apicoectomy

Fig. 13.14 a, b. Diagrammatic illustration (a) and clinical photograph (b) showing beveled root of lateral incisor

Fig. 13.15 a, b. Preparation of cavity at root tip of tooth using microhead handpiece. a Diagrammatic illustration. b Clin-ical photograph

Fig. 13.16 a, b. Cavity created (inverted cone-shaped) where filling material is to be placed. a Diagrammatic illustration.b Clinical photograph

316 F. D. Fragiskos

Fig. 13.17 a, b. Placement of filling material in cavity of apex using miniaturized amalgam applicator. a Diagrammaticillustration. b Clinical photograph

Fig. 13.18 a, b. Condensing of amalgam with narrow amalgam condenser. a Diagrammatic illustration. b Clinical photo-graph

Fig. 13.19 a, b. Diagrammatic illustration (a) and clinical photograph (b) showing the apex of the tooth with retrogradefilling complete

317Chapter 13 Apicoectomy

tooth, in such a way that only the prepared cavity ofthe root end is exposed. Splattering of amalgam1) isthus avoided at the periapical region. The amalgam isplaced inside the cavity with the miniaturized amal-gam applicator and is condensed with the narrowamalgam condenser (Figs. 13.17, 13.18). The excess

amalgam is carefully removed and the filling issmoothed with the usual instruments (Fig. 13.19).

Wound Cleansing and Suturing of Flap. After place-ment of the amalgam, the gauze is carefully removedfrom the bony defect and, after copious irrigation withsaline solution, a radiographic examination is per-formed to determine if there is amalgam splatteringin the surrounding tissues. The flap is repositionedand interrupted sutures are placed (Figs. 13.20,13.21). Healing of the periapical area is checkedevery 6–12 months radiographically, until ossificationof the cavity is ascertained. In order to evaluate theresult, a preoperative radiograph is necessary, whichwill be compared to the postoperative radiographslater.

When apicoectomy is performed in the anterior re-gion (e.g., maxillary central incisor) and the size of thelesion is small, and when there are esthetic crowns onthe anterior teeth, the semilunar flap is preferred.

The procedure in such a case is similar to that of thepreviously mentioned surgical procedure employingthe trapezoidal flap (Figs. 13.22–13.35).

1) Amalgam is the most commonly used retrograde fillingmaterial. Recently, though, IRM and Super-EBA cementhave been considered choice materials, with preparationof the cavity being performed in exactly the same way asthat for amalgam.

Fig. 13.20 a, b. Operation site and placement of sutures. a Diagrammatic illustration. b Clinical photograph

Fig. 13.21. Radiograph taken before suturing of flap, whichshows retrograde amalgam filling

318 F. D. Fragiskos

Fig. 13.22. Radiograph of maxillary central incisor, show-ing periapical lesion and unsatisfactory filling of the rootcanal

Apicoectomy with Semilunar Flap

Fig. 13.23. Clinical photograph of the case shown inFig. 13.22

Fig. 13.24 a, b. Surgical procedure for apicoectomy at maxillary left central incisor. Semilunar incision made for flap.a Diagrammatic illustration. b Clinical photograph

Fig. 13.25 a, b. Reflection of flap and retraction with broad end of periosteal elevator. a Diagrammatic illustration.b Clinical photograph

319Chapter 13 Apicoectomy

Fig. 13.26 a, b. Removal of bone covering apex of tooth. a Diagrammatic illustration. b Clinical photograph

Fig. 13.27 a, b. Exposing periapical lesion and apex of tooth together after removal of respective buccal bone. a Diagram-matic illustration. b Clinical photograph

Fig. 13.28 a, b. Removal of periapical lesion with hemostat and periapical curette. a Diagrammatic illustration. b Clinicalphotograph

320 F. D. Fragiskos

Fig. 13.30 a, b. Preparation of cavity at apex with microhead handpiece. a Diagrammatic illustration. b Clinical photo-graph

Fig. 13.31 a, b. Diagrammatic illustration (a) and clinical photograph (b) showing prepared cavity ready for placement offilling

Fig. 13.29 a, b. Resection of apex of tooth at a 45° angle. a Diagrammatic illustration. b Clinical photograph

321Chapter 13 Apicoectomy

Fig. 13.32 a, b. Placement of filling at root tip with miniaturized amalgam applicator. a Diagrammatic illustration. b Clin-ical photograph

Fig. 13.33 a, b. Condensing amalgam at periapical cavity with narrow amalgam condenser. a Diagrammatic illustration.b Clinical photograph

Fig. 13.34 a, b. Operation site after placement of sutures. a Diagrammatic illustration. b Clinical photograph

322 F. D. Fragiskos

13.5 Complications

The most common perioperative and postoperativecomplications that may occur during and after thesurgical procedure, respectively, are:

Damage to the anatomic structures in case of pen-etration of the nasal cavity, maxillary sinus andmandibular canal with the bur.Bleeding from the greater palatine artery duringapicoectomy of palatal root.Splattering of amalgam at the operation site, due toinadequate apical isolation and improper manipu-lations for removal of excess filling material(Fig. 13.36).Staining of mucosa due to amalgam that remainedat the surgical field (amalgam tattoo) (Figs. 13.37,13.38).Healing disturbances, if the semilunar incision ismade over the bony deficit (Fig. 13.39) or if the flap,after reapproximation, is not positioned on healthybone.Dislodged filling material due to superficial place-ment, as a result of insufficient preparation of api-cal cavity (Fig. 13.40).Incomplete root resection, due to insufficient ac-cess or visualization and misjudged length of root(Fig. 13.41). As a result, the apical portion of theroot remains in position and the retrograde fillingis placed improperly, with all the resulting conse-quences.

Fig. 13.35. Periapical radiograph taken after suturing offlap, showing retrograde amalgam filling

Fig. 13.36. Amalgam splatter at operation site, as a result ofimproper manipulations for removal of excess material

Fig. 13.38. Periapical radiograph of the case shown inFig. 13.37

Fig. 13.37. Staining of mucosa due to amalgam that re-mained at surgical field after apicoectomy (amalgam tat-too)

323Chapter 13 Apicoectomy

BibliographyAbdal AD, Retif H, Jamson C (1982) The apical seal via the

retrosurgical approach: II. An evaluation of retrofillingmaterials. Oral Surg 54:213–222

Andreasen JO, Pitt-Ford TR (1994) A radiographic studyof the effect of various retrograde fillings on periapi-cal healing after replantation. Endod Dent Traumatol10:276–281

Archer WH (1975) Oral and maxillofacial surgery, 5th edn.Saunders, Philadelphia, Pa.

Arens D, Adams W, DeCastro R (1981) Endodontic surgery.Harper and Row, Philadelphia, Pa.

Barkhordar RA, Pelzner RB, Stark MM (1989) Use of glass-ionomers as retrofilling materials. Oral Surg Oral MedOral Pathol 67:734–739

Barnes IE (1981) Surgical endodontics – introduction, prin-ciples, and indications. Dent Update 8:89–92, 95–99

Bellizzi R, Loushine R (1991) A clinical atlas for endodonticsurgery. Quintessence, Chicago, Ill.

Block RM, Bushell A (1982) Retrograde amalgam proce-dures for mandibular posterior teeth. J Endod 8:107–112

Bramwell JD, Hicks ML (1986) Sealing ability of four retro-filling techniques. J Endod 12:95–100

Caccioli P (1992) Apicectomy: localization and isolationof the radicular apex. Acta Biomed Ateneo Parmense63:97–100

Cheung LK, Lam J (1993) Apicectomy of posterior teeth – aclinical study. Aust Dent J 38:17–21

Cohen S, Burns R (1987) Pathways of the pulp, 4th edn.Mosby, St. Louis, Mo.

Danin J, Linder L, Sund ML, Stromberg T, Torstenson B,Zetterqvist L (1992) Quantitative radioactive analysis ofmicroleakage of four different retrograde fillings. Int En-dod J 25:183–188

Delivanis P, Tabibi A (1978) A comparative sealability studyof different retrofilling materials. Oral Surg 45:273–281

Dorn S, Gartner A (1990) Retrograde filling materials: a ret-rospective success-failure study of amalgam, EBA, andIRM. J Endod 16(8):391–393

Feldman M (1994) Microscopic surgical endodontics. NYState Dent J 60:43–45

Ferreira FB, Ferreira AL, Gomes BP, Souza-Filho FJ (2004)Resolution of persistent periapical infection by endodon-tic surgery. Int Endod J 37(1):61–69

Fragiskos F (1990) Study of the support of a special designedendodontic implant in preserving teeth demonstratingindications for extraction. (Experimental study in dogs).Research monography, Athens

Frank AL, Glick DH, Patterson SS, Weine FS (1992) Long-term evaluation of surgically placed amalgam fillings.J Endod 18:391–398

Gans BJ (1972) Atlas of oral surgery. Mosby, St. Louis, Mo.Gondim E Jr, Figueiredo Almeida de Gomes BP, Ferraz CC,

Teixeira FB, de Souza-Filho FJ (2002) Effect of sonic andultrasonic retrograde cavity preparation on the integrityof root apices of freshly extracted human teeth: scanningelectron microscopy analysis. J Endod 28(9):646–650

Fig. 13.39. Wound dehiscence, as a result of improper de-sign of semilunar incision

Fig. 13.40. Malpositioned retrograde obturation material,due to insufficient preparation of apical cavity

Fig. 13.41. Periapical radiograph showing unsatisfactoryapicoectomy at maxillary second premolar, due to failure todefine root before resection

324 F. D. Fragiskos

Grung B, Molven O, Halse A (1990) Periapical surgery ina Norwegian county hospital. Follow-up of 477 teeth.J Endod 16:411–417

Guerra JA (1992) Root end isolation for retrograde fillings.J Endod 18:39–41

Gutmann JL (1993) Parameters of achieving quality anes-thesia and hemostasis in surgical endodontics. AnesthPain Control Dent 2:223–226

Gutmann JL, Harrison JW (1985) Posterior endodontic sur-gery: anatomical considerations and clinical techniques.Int Endod J 18:8–34

Gutmann J, Harrison J (1991) Surgical endodontics. Black-well, Boston, Mass.

Harrison JW (1992) Surgical management of endodonticallytreated teeth. Curr Opin Dent 2:115–121

Jerome CE, Hill AV (1995) Preventing root tip loss in themaxillary sinus during endodontic surgery. J Endod21(8):422–424

Jesslen P, Zetterqvist L, Heimdahl A (1995) Long-term re-sults of amalgam versus glass ionomer cement as apicalsealant after apicectomy. Oral Surg Oral Med Oral PatholOral Radiol Endod 79:101–103

Kellert M, Chalfin H, Solomon C (1994) Guided tissue re-generation: an adjunct to endodontic surgery. J Am DentAssoc 125:1229–1233

Kellert M, Solomon C, Chalfin H (1994) A modern approachto surgical endodontics: ultrasonic apical preparation.NY State Dent J 60:25–28

Koerner KR, Tilt LV, Johnson KR (1994) Color atlas of mi-nor oral surgery, Mosby-Wolfe, London

Kramper BJ, Kaminski EJ, Osetek EM, Heuer MA (1984) Acomparative study of the wound healing of three types offlap design used in periapical surgery. J Endod 10:17–25

Kruger GO (1984) Oral and maxillofacial surgery, 6th edn.Mosby, St. Louis, Mo.

Laskin DM (1985) Oral and maxillofacial surgery, vol 2.Mosby, St. Louis, Mo.

Lazaridis N, Karabouta-Voulgaropoulou E, Martis C (1979)Apicoectomies in molars. Views and conclusions fromour experience. Odontiatriki 12:55–71

Lilienthal B, Punnia-Moorthy A (1991) Limitations of rota-tional panoramic radiographs in the diagnosis of maxil-lary lesions. Case report. Aust Dent J 36(4):269–272

Lyons AJ, Hughes CE, Dixon EJ (1995) A 5-year audit ofoutcome of apicectomies carried out in a district generalhospital. Ann R Coll Surg Engl 77:273–277

Maddalone M, Gagliani M (2003) Periapical endodontic sur-gery: a 3-year follow-up study. Int Endod J 36(3):193–198

Mattison GD, Von Fraunhofer JA, Delivanis PD, AndersonAN (1985) Microleakage of retrograde amalgams. J En-dod 11:340–345

McGowan DA (1989) An atlas of minor oral surgery. Prin-ciples and practice. Dunitz-Mosby, St. Louis, Mo.

Meechan JG, Blair GS (1993) The effect of two differentlocal anesthetic solutions on pain experience followingapicectomy. Br Dent J 175:410–413

Nik-Hussein NN (1994) Dens invaginatus: complicationsand treatment of non-vital infected tooth. J Clin PediatrDent 18:303–306

Nixon CE, Lin L, Jandinski J (1991) Evaluation of three sili-cone-based materials as potential retrograde fillings insurgical endodontics. J Endod 17:479–482

Nordenram A, Svardstrom G (1970) Results of apicoec-tomy. A clinical radiological examination. Swed Dent J63:593–604

Olmez S, Uzamis M, Er N (1995) Dens invaginatus of a man-dibular central incisor: surgical endodontic treatment.J Clin Pediatr Dent 20:53–56

Oynick J, Oynick T (1978) A study of a new material for ret-rograde fillings. J Endod 4:203–206

Pannkuk TF (1991) Endodontic surgery: principles, objec-tives, and treatment of posterior teeth. Part I. Endod Rep6(2):8–14

Papadogeorgakis N (1994) The significance of apicoectomyand retrograde filling in preservation of teeth. Odonto-stomatologike Proodos 48:118–133

Persson G (1973) Prognosis of reoperation after apicoec-tomy. A clinical radiological investigation. Swed Dent J66:49–67

Peterson LJ, Ellis E III, Hupp JR, Tucker MR (1993) Contem-porary oral and maxillofacial surgery, 2nd edn. Mosby,St. Louis, Mo.

Rud J, Andreasen JO, Moller-Jensen JE (1972) A follow-upstudy of 1,000 cases treated by endodontic surgery. Int JOral Surg 1:215–228

Saad AY, Clem WH (1990) The use of radiographs in periapi-cal surgery. Oral Surg Oral Med Oral Pathol 69:361–365

Sailer HF, Pajarola GF (1999) Oral surgery for the generaldentist. Thieme, Stuttgart

Schoeffel GJ (1994) Apicoectomy and retroseal proceduresfor anterior teeth. Dent Clin North Am 38:301–324

Selden HS (1991) Radiographic pulpal calcifications: normalor abnormal – a paradox. J Endod 17:34–37

Skoglund A, Persson G (1985) A follow-up study of apico-ectomized teeth with total loss of the buccal plate. OralSurg Oral Med Oral Pathol 59:78–81

Stabholz A, Khayat A, Weeks DA, Neev J, Torabinejad M(1992) Scanning electron microscopic study of the apicaldentine surfaces lased with ND:YAG laser following api-cectomy and retrofill. Int Endod J 25:288–291

Sykaras SN (1995) Endodontics: pathology and therapeu-tics, vol 2. Zita, Athens

Taylor GN, Bump R (1984) Endodontic considerations asso-ciated with periapical surgery. Oral Surg 58:450–455

Tsatsas B (1988) Contemporary endodontics. Parisianos,Athens

Valavanis D, Spyropoulos G, Kerazoudis N (1990) The sig-nificance of endodontic therapy before an endodonticsurgery. Odontostomatologike Proodos 44:387–394

Vertucci F, Beatty R (1987) Apical leakage associated withretrofilling techniques. J Endod 12:331–335

Waite DE (1987) Textbook of practical oral and maxillofa-cial surgery, 3rd edn. Lea and Febiger, Philadelphia, Pa.

Weine F (1989) Endodontic therapy, 4th edn. Mosby, St.Louis, Mo.

Wesson CM, Gale TM (2003) Molar apicoectomy with amal-gam root-end filling: results of a prospective study in twodistrict general hospitals. Br Dent J 195(12):707–714, dis-cussion 698

325Chapter 13 Apicoectomy

Wiscovitch JG, Wiscovitch GJ (1995) Surgical apical repairwith Super-EBA cement: a one-visit alternative treatmentto apexification. J Endod 21:43–46

Woo YR, Wassell RW, Foreman PC (1990) Evaluation ofsealing properties of 70 degrees C thermoplasticizedgutta-percha used as a retrograde root filling. Int EndodJ 23:107–112

Zetterqvist L, Hall G, Holmund A (1991) Apicectomy: acomparative clinical study of amalgam and glass iono-mer cement as apical sealants. Oral Surg Oral Med OralPathol 71:489–491