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Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2023 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
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Apicoectomy for Periapical Lesion Treatment after Post Endodontic 
Failure on First Maxillary Premolar (Case Study) 

Diana Soesilo *, Fani Pangabdian, Yongki Hadinata Wijaya, Sinta Puspita 

Conservative Dentistry Departement, Universitas Hang Tuah, Surabaya, Jl. Arif Rahman Hakim 150, Surabaya, Jawa Timur, Indonesia 

Article Info: 
_______________________________________ 
Article History: 
Received 02 Jan 2023     
Reviewed 05 Feb 2023 
Accepted 14 Feb 2023 
Published 15 March 2023 

_______________________________________ 
Cite this article as:  

Soesilo D, Pangabdian F; Wijaya YH, Puspita S, 
Apicoectomy for Periapical Lesion Treatment 
after Post Endodontic Failure on First Maxillary 
Premolar (Case Study), Asian Journal of Dental 
and Health Sciences. 2023; 3(1):1-4 

DOI: http://dx.doi.org/10.22270/ajdhs.v3i1.38    

_______________________________________
*Address for Correspondence:   

Soesilo, Diana; Conservative Dentistry 
Departement, Universitas Hang Tuah, Surabaya, 
Jl. Arif Rahman Hakim 150, Surabaya, Jawa 
Timur, Indonesia 

Abstract 
___________________________________________________________________________________________________________________ 

Introduction. Factors that cause failure of endodontic therapy include incomplete cleaning and shaping 
of root canals and unhermetic obturation. Endodontic failure can lead to periapical lesions. Apicoectomy 
is one of endodontic surgery treatment choice to preserving the tooth with endodontic treatment 
failure. Aim. The aim of this report was to show that in cases of failure of root canal treatment could be 
treat without extraction, however there was an alternative treatments such as apicoectomy that could 
be used to preserve the tooth and its function in the oral cavity.Case. A male 32 years old patient came 
to dentist with persistent pain on upper left first premolar. The tooth had been endodontically treated 
for ten years. Clinical examination tooth #24 had porcelain fused to metal on it, percussion test (+), bite 
test (+), pain on palpation. Radiographic examination showed that tooth #24 had fabricated post 
without gutta percha obturation on apical third. There was 3 mm round periapical lesion on the distal 
side of the tooth. Procedure Apicoectomy and retrograde filling with Mineral Trioxide Aggregate (MTA) 
and bone graft was performed to eliminate that periapical lesion. Conclusion Apicoectomy is one of 
main choice to preserve post endodontic tooth with periapical lesion and post core crown on it, as long 
as possible in oral cavity 

Keywords : Apicoectomy, Periapical lesion, Post endodontic treatment failure  

 

INTRODUCTION 

Purpose of root canal treatment is  cleaning the pulp tissue or 
microorganisms contained in the root canal system so that 
root canal filling can be carried out properly and periapical 
tissue repair occurs.1 The causes of root canal treatment 
failure are many, including incomplete obturation, root 
perforation, external root resorption, periradicular - 
periodontal lesions, overfilling, residual root canal, periapical 
cysts, broken instruments in the root canal, perforation of the 
base of the nasal foramen and coronal leakage.2 

As a result of failure of root canal treatment could cause 
apical lesions. Most periapical lesions (more than 90%) are 
classified as granulomas, radicular cysts or abscesses. There 
is clinical evidence that the larger the size of the lesion, the 
more likely it is a radicular cyst. However, some extensive 
lesions may be granulomas or abscesses. A definitive 
diagnosis can only be confirmed by histological analysis.3  
Recommended treatment for large periapical lesion is  
endodontic surgical treatment because conventional root 
canal treatment of nonvital teeth with widespread periapical 
lesions has a high failure rate.1,4 

Endodontic surgery indications are persistent pain and a root 
canal system that cannot be filled orthogradically. 
Apicoectomy or apical resection is a procedure to reduce the 
root tip of the tooth with periapical curettage, which is 
indicated in post-root canal treatment teeth with developing 
periapical inflammation. The inflammation that develops can 

be characterized by symptomatic complaints in the patient 
and a wider periapical radiolucent area than before root 
canal treatment was started. Apicoectomy is usually followed 
by retrograde filling to seal the root canal ends.5 

Aim of this report was to show that in cases of failure of root 
canal treatment could be treat without extraction, however 
there was an alternative treatments such as apicoectomy that 
could be used to preserve the tooth and its function in the 
oral cavity 

CASE REPORT 

A male 32 years old patient came to conservative dentistry 
specialist with persistent pain on upper left first premolar. 
Tooth #24 had been treated with conventional endodontic 
treatment for 10 years, however for the past three months 
patient felt continous and persistent dull pain.Pain increased 
when chewing food. 

Clinical examination tooth #24 had porcelain fused to metal 
on it, percussion test (+), bite test (+), pain on palpation (Fig 
1).Radiographic examination showed that tooth #24 had 
fabricated post without gutta percha obturation on apical 
third. There was 3 mm round periapical lesion on the distal 
side of the tooth (Fig. 2). 

                       Open Access                                                                                                                                                                                                            Case Report                                          

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http://dx.doi.org/10.22270/ajdhs.v3i1.38


Soesilo et al                                                                                                                                         Asian Journal of Dental and Health Sciences. 2023; 3(1):1-4 

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Fig 1. Clinical examination tooth #24 

 

Fig 2. Radiographic examination tooth #24 

After the patient signed the informed consent, the surgical 
area was disinfected using iodine. Infiltration anesthesia was 
performed on the posterior superior alveolar nerve and the 
nasopalatine nerve with Lidocaine 2%. Incision was done 
with semilunar flap design (Fig 3) located at the apical region 
of the tooth using a #15 scalpel blade pressed right against 
the periosteum of the alveolus bone, then the flap was opened 
using a raspatorium (Fig 4) 

 

Fig 3. Incision with semilunar flap design 

 

Fig 4. Flap was opened with rasparatorium 

Cortical bone was removed around the root tip of tooth #24 
with a form bone bur and irrigated with saline. After that, the 
reduction was continued with a fissure-shaped bone bur so 
that the periapical area was opened and a clear view was 
obtained to the apex area of tooth #24. Extraction of the 
lesion, enucleation, and curettage were performed at the tip 
of the tooth root with irrigation using saline. The apex of 
tooth #24 was resected and smoothed with a horizontal 
carbide fissure bur in the buccal palatal direction (Fig 5) 

 

Fig 5. Apex of tooth #24 was resected and smoothed with a 
horizontal carbide fissure bur 

Root canal  was prepared retrogradely using ultrasonic in the 
middle with a depth of 2 mm to place the MTA (Mineral 
Trioxide Aggregate) material. The operating area was 
irrigated with saline until the operating area was clean. The 
MTA filler was stirred until homogeneous and then applied to 
the prepared and condensed parts (Fig 6). Bone graft was 
applied to the affected area (Fig 7). 

 

Fig 6. MTA was applied retrogradely on resected root canal 

 

Figure 7: Bone graft was applied on affected area 

After repositioning the flap, the suturing procedure was 
performed using an atraumatic needle with silk thread (Fig 
8). Prescription of antibiotics (Clindamycin 300 mg, taken 
twice a day for 5 days), analgesics (cataflam 50 mg taken 
twice a day for 3 days), and it is recommended to always 
maintain oral hygiene. Patients were given control 
instructions 1 week postoperatively to remove suturing 
thread. Afer suturing removal, the patient moved to another 
city so unfortunatelly we couldn’t follow up our surgery 
treatment. 

 

Fig 8. Flap reposition with suturing procedure 



Soesilo et al                                                                                                                                         Asian Journal of Dental and Health Sciences. 2023; 3(1):1-4 

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DISCUSSION 

The success of root canal treatment is obtained from good root 
canal preparation and filling, especially in the apical third. The 
filling must be hermetic so that there is no empty space so that 
microorganisms cannot live there.6 

The cause of the failure of root canal treatment in this case 
showed that the obturation of the root canal was lost when 
gutta-percha was taken in the fabricated post manufacturing 
process. Failure of root canal treatment can be overcome by 
root canal retreatment or surgical endodontic treatment. Root 
canal retreatment aims to repair pathological damage caused 
by failure of previous root canal treatment.4 

Apicoectomy is one of alternative treatment in cases of failure 
of conventional endodontic treatment. In the case report of 
Pedroche, et. al the patient had retreatment with conventional 
endodontic treatment on the maxillary left molar but the 
patient still felt persistent pain and on radiographic 
examination there was a periapical lesion at the mesiobuccal 
root apex. After apicoectomy treatment and then control after 
7 months, it showed on clinical examination and radiography 
the fistula had healed.7 

Another comparative case was the case report by Irwandana,. 
et al which showed endodontic treatment failure because of an 
overfilling root canal filling on the maxillary right incisor and 
the presence of a radicular cyst around the tooth. The 
treatment was apicoectomy with retrograde filling using 
Mineral Trioxide Aggregate (MTA). After 6 months, on clinical 
examination there was no lumps on the palatum and on 
radiographic examination the lesion had shrunk. 8 

Cavity preparation at the apical tip of tooth #24 was 
performed for placement of retrograde filling material using 
MTA. Retrograde placement of the filling material should be 
prepared at the apical end in a direction parallel to the 
occlusal plane until the tip of the gutta-percha is visible. MTA 
has many advantages, which is it has excellent 
biocompatibility, has a bactericidal effect with a pH of 12.5, is 
non-cytotoxic, and is non-mutagenic.9 The ingredients 
contained in MTA are calcium silicate, bismuth oxide, calcium 
carbonate. Calcium sulfate, and calcium aluminate. Mixing 
MTA with water will form amorphous calcium oxide crystals 
consisting of 49% phosphate, 33% calcium, 6% silica, 3% 
chloride, and 2% carbon.6,10 

Witasari, et. al analized inflammatory reaction of the pulp 
tissue with direct pul pcapping agents calcium hydroxide, 
MTA, and Portland cement for 7, 14, 42 and 90 days. On day 
42, calcium hydroxide showed an inflammatory reaction 
whereas the MTA and Portland cement materials reaction 
have been seen since day 7th. This could be assumed that the 
work system MTA and Portland Cement induced tissue faster 
than calcium hydroxide. This was consistence with the 
statement that the MTA had effects that work faster in forming 
the hard tissue than calcium hydroxide.11 

Bonegraft administration in this case aimed to accelerate bone 
healing. Giving bone grafts to the surgical site, in addition to 
accelerating healing, also induced host cells to form lost 
bone.11 The process of bone formation or osteogenesis 
involves osteoblasts or progenitor cells present in the graft 
material and osteoinduction, the ability of bonegraft material 
to stimulate the formation of a scaffold or scaffold for host 
stem cells to grow, in the process of osteoinduction many 
growth factors influence the change of host stem cells into 
osteoblasts. Growth factors that play a role in this process 
include platelet-derived growth factors (PDGFs), fibroblast 
growth factors (FGFs) and transforming growth factor-β 
(TGFs-β). These four materials serve as basic properties in the 

formation of new bone which occurs in direct parallel with the 
interconnections between bones.12  

The use of bone substitution materials such as bone graft is an 
alternative to regenerate damaged bone tissue. Bone graft is 
one of the scaffolds that plays a role in tissue engineering for 
bone tissue regeneration. It is necessary to design a bone graft 
as an appropriate and appropriate scaffold so that new bone 
growth can be generated. Regeneration of bone tissue requires 
various factors between the appropriate scaffold design with 
mechanical strength, porosity, speed of degradation involving 
the release of appropriate molecular signals, biocompatible 
materials are the alloys needed in regenerating bone tissue so 
that bone defects can be restored.13 Bone graft material 
selection depend on its biocompatibility, bioresistability, 
sterility, structural integrity, and adequate porosity for the 
growth of new blood vessels, compressive strength, cost 
factor, and ease of manipulation of the material.14 

Suturing was performed using an atraumatic needle with silk 
thread by sewing the flap to its original position. The purpose 
of flap repositioning is that the wound can be completely 
closed, and to prevent secondary infection during the wound 
healing process.15 

CONCLUSION 

Treatment of tooth 24 with a diagnosis of previously treated 
teeth with dental granuloma could be performed with 
endodontic surgery. The use of MTA material in this case was 
the right choice and bone graft application was needed for 
alveolar bone regeneration.  

CONFLICT OF INTEREST 

There was no conflict of interest between authors 

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