Apicoectomy — Chronic apical periodontitis treatment

Technological advancement in dentistry has opened up more treatment possibilities to achieve better clinical results and upgrade patient comfort. The following discusses how the Er:YAG laser system can stimulate the healing process and reduce post-operative complications in cases of endodontic microsurgery.

By Dr Igor Kriznar

A 46-year-old female patient was referred to the clinic for the treatment of chronic apical periodontitis on tooth 15. The tooth had been endodontically treated approximately five to six years ago and was not vital. The tooth was tender to percussion as well as palpation adjacent to the apex of the tooth. The mobility of the tooth was not increased. The gingiva was healthy in colour and the probing depth was not more than 3mm.

An X-ray showed an occlusal filling reaching all the way to the pulp chamber (Fig. 1). One root could be observed and the apex has a slight curve to the distal. The root filling deviated from the canal trajectory and a root perforation could be seen in the apical part. The periodontal ligament was normal in width but the periapical bone showed a small circular resorption indicating chronic apical periodontitis.

Clinical case

Apicoectomy was performed to eliminate bacterial infection in the root canal system by removing the tissue with inflammation as well as the excess root filling material from the periapical tissues to promote healing. After infiltration of anaesthetic, a marginal incision was performed along tooth 15 and a vertical incision at tooth 14. A muco-periosteal flap was elevated to reveal the apical region of tooth 15 (Fig. 2).

The osteotomy was performed using Er:YAG laser wavelength with a cylindrical tip. When the osteotomy window was large enough, the granulation tissue was removed using an excavator. For the root resection, a cylindrical tip was used and the energy was raised to 400mJ. The surface of the resected root was inspected under an operative microscope and a retrograde preparation was made. For complete removal of the granulation tissue as well as excess root filling material from the bone lacunae, the SWEEPS irrigation protocol using saline can be adopted from endodontics to encourage faster healing.

For this reason, after the retrograde preparation, the AutoSWEEPS mode was used, performing 30-seconds cycles of irrigation with saline solution in the bone lacunae (Fig. 3). After local haemostasis, the retrograde preparation was filled and tightly condensed using MTA (mineral trioxide aggregate) cement (Fig. 4) and the wound was sutured.

Curasept rinsing solution (0.05% chlorhexidine) was prescribed for a week. On the follow-up appointment after a week, the patient had minimal pain. The healing of the wound was satisfactory; slight swelling persisted for only two days after surgery (Fig. 5). On the X-ray, a resected root and a tight retrograde filling could be seen (Fig. 6). The sutures were removed and the patient was scheduled for a follow-up appointment after a year.


This clinical case showed that Er:YAG laser light can also be used in endodontic microsurgery cases. The main benefits include: less vibration, trauma and anxiety for the patient; increased decontamination of the apical part of the root; quicker healing; and fewer post-operative complications compared to conventional therapy.

All steps of apicoectomy can be performed using Er:YAG laser light, including incision and granulation tissue removal. The latest protocols also involve the use of biomodulation (LLLT) with Nd:YAG laser to stimulate the healing process.

Published in Dental Asia September/October 2021 issue.

About the author

Dr Igor Kriznar graduated in 2006 from the Faculty of Medicine in Ljubljana, Slovenia, and began working as an assistant at the Faculty of Medicine, Department of Endodontics and Operative Dentistry. He acquired the professional title of Dental Specialist in Endodontics in 2014. Until the end of 2015, he worked as an assistant at the Faculty of Medicine, where he was engaged in work with students of dentistry in clinical and pre-clinical practice. At the same time, he worked as a dental specialist at the University Medical Centre in Ljubljana. Dr Kriznar was also involved in research work and earned his PhD in endodontics from the same university in 2016. In December 2015, he entered into full-time private clinical practice focusing mainly on endodontics. In 2019, he completed LA&HA Master in Laser Dentistry. Actively participating in many international and local conferences and symposia, he has also published numerous scientific papers in various journals.