Endodontic Microsurgery for Post-Treatment Apical Periodontitis: A Case Series
Abstract
Persistent post-treatment apical periodontitis may remain after root canal treatment when microbial control is incomplete or orthograde retreatment is impractical. This four-case series describes endodontic microsurgery performed with magnification, root-end resection, ultrasonic retro-preparation, and calcium silicate-based retrograde materials, and places the cases in the context of a focused narrative review. Preoperative cone-beam computed tomography was used for surgical planning. The cases involved symptomatic or suppurative lesions in previously treated teeth for which existing crowns, posts, or prior retreatment limited further orthograde management. At 4–6 months, all patients were clinically asymptomatic and the available periapical radiographs showed early favorable healing. No standardized postoperative pain scores were collected. A focused narrative search of PubMed/MEDLINE, Crossref metadata, and journal websites identified nine recent case reports or small series (26 patients/cases) published from 2022 through August 2026. The reports included conventional, guided, navigated, and bone-lid approaches, together with case-based microbiologic and histologic findings; reported clinical outcomes were generally favorable but heterogeneous. The cases in this report are distinct from the 2023 case published by Soesilo et al.; no text or figures from that report were reused. Because this is a small uncontrolled series with short follow-up and nonstandardized outcome assessment, the findings are preliminary. Endodontic microsurgery can be considered a tooth-preserving option in carefully selected cases when nonsurgical retreatment is not feasible, but longer prospective follow-up with standardized clinical and radiographic outcomes is required. Keywords: Apicoectomy; Cone-beam computed tomography; Endodontic microsurgery; Post-treatment apical periodontitis; Root-end filling.
1. Pinto D, Marques A, Pereira JF, Palma PJ, Santos JM. Long-term prognosis of endodontic microsurgery: a systematic review and meta-analysis. Medicina (Kaunas). 2020;56(9):447. doi:10.3390/medicina56090447.
2. Huang S, Chen NN, Yu VSH, Lim HA, Lui JN. Long-term success and survival of endodontic microsurgery. J Endod. 2020;46(2):149-157.e4. doi:10.1016/j.joen.2019.10.022.
3. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature - Part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2010;36(11):1757-1765. doi:10.1016/j.joen.2010.08.007.
4. Gliga A, Imre M, Grandini S, Marruganti C, Gaeta C, Bodnar D, et al. The limitations of periapical X-ray assessment in endodontic diagnosis: a systematic review. J Clin Med. 2023;12(14):4647. doi:10.3390/jcm12144647.
5. Thakur V, Kaul R. Apicoectomy: a review of clinical concepts and techniques. J Oral Res Rev. 2025;17(1):77-82. doi:10.4103/jorr.jorr_14_24.
6. Soesilo D, Pangabdian F, Wijaya YH, Puspita S. Apicoectomy for periapical lesion treatment after post endodontic failure on first maxillary premolar (case study). Asian J Dent Health Sci. 2023;3(1):1-4. doi:10.22270/ajdhs.v3i1.38.
7. Lara Munoz AG, Chavez Mestanza EA, Buitron Recalde MR, Lara Munoz AG. Clinical case report of non-surgical and surgical endodontic treatment (apicoectomy). Salud Cienc Tecnol. 2024;4:536. doi:10.56294/saludcyt2024.536.
8. Wang HH, Lam C, Myneni SR. Resolution of a cystic endodontic-periodontal lesion utilizing combined apicoectomy and guided tissue regeneration: a case report. Clin Adv Periodontics. 2022;12(2):94-100. doi:10.1002/cap.10149.
9. Hashem Q. Healing of extensive through-and-through periradicular lesion using apicoectomy without bone grafting: a case report with 3-year recall. Case Rep Dent. 2025;2025(1):7225338. doi:10.1155/crid/7225338.
10. Rajic VB, Mikus T, Gabric D, Vuletic M, Verzak Z. Bone tissue reparation and regeneration using bioactive material in endodontic surgery: a case report. Lijec Vjesn. 2023;145(5-6):216-220. doi:10.26800/lv-145-5-6-6.
11. Manishaa B, Sajjan GS, Kinariwala N, Madhu Varma KM, Ponnada N, Bagu SV. Endodontic dynamic navigation for precise apical microsurgery: case report. Endodontology. 2024;36(2):181-187. doi:10.4103/endo.endo_133_23.
12. Lee SM, Kwak JD, Ruch A, Kratchman SI, Karabucak B, Kohli MR. Three-dimensional assessment of healing variability after endodontic microsurgery using the bone lid technique: a case series. J Endod. 2026;52(1):141-148. doi:10.1016/j.joen.2025.09.006.
13. Abella Sans F, Barragan Montes J, Zbozen T, Suresh N, Dharmarajan L, Dummer PMH, et al. Minimally invasive vertical incision subperiosteal tunnelling technique for targeted endodontic surgery: technical overview and a case report. Int Endod J. 2025;58(11):1799-1805. doi:10.1111/iej.70014.
14. Mahendran K, Mohamed Hussain MA, Maloor SA, Saminathan K. Guided endodontic surgery: case series. Indian J Dent Res. 2023;34(1):94-97. doi:10.4103/ijdr.ijdr_462_20.
15. Mora-Carabali M, Contreras A, Rodriguez P, Zamora I, Rodriguez M. Tomographic, microbiological and histological characterization of secondary apical periodontitis: case series. Braz Dent J. 2023;34(1):123-132. doi:10.1590/0103-6440202304590.
16. Safi C, Kohli MR, Kratchman SI, Setzer FC, Karabucak B. Outcome of endodontic microsurgery using mineral trioxide aggregate or root repair material as root-end filling material: a randomized controlled trial with cone-beam computed tomographic evaluation. J Endod. 2019;45(7):831-839. doi:10.1016/j.joen.2019.03.014.
17. Zhou W, Zheng Q, Tan X, Song D, Zhang L, Huang D. Comparison of mineral trioxide aggregate and iRoot BP Plus root repair material as root-end filling materials in endodontic microsurgery: a prospective randomized controlled study. J Endod. 2017;43(1):1-6. doi:10.1016/j.joen.2016.10.010.
18. Dong X, Su Q, Li W, Yang J, Song D, Yang J, et al. The outcome of combined use of iRoot BP Plus and iRoot SP for root-end filling in endodontic microsurgery: a randomized controlled trial. Clin Oral Investig. 2024;28(3):188. doi:10.1007/s00784-024-05569-7.
19. Salah HM, Hashem AAR, Mustafa T, Soliman AH, Khallaf M, Haddadeen H. The impact of root end filling material type and the application of bone graft on healing of periapical tissues after endodontic microsurgery: a clinical randomized controlled trial. Sci Rep. 2024;14(1):25378. doi:10.1038/s41598-024-66033-w.
20. Attar-Attar L, Bernabeu-Mira JC, Cervera-Ballester J, Penarrocha-Diago M, Penarrocha-Diago M. Systematic review of surgical regenerative treatment for apicomarginal lesions in periapical surgery. Med Oral Patol Oral Cir Bucal. 2024;29(3):e416-e422. doi:10.4317/medoral.26405.
2. Huang S, Chen NN, Yu VSH, Lim HA, Lui JN. Long-term success and survival of endodontic microsurgery. J Endod. 2020;46(2):149-157.e4. doi:10.1016/j.joen.2019.10.022.
3. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature - Part 1: comparison of traditional root-end surgery and endodontic microsurgery. J Endod. 2010;36(11):1757-1765. doi:10.1016/j.joen.2010.08.007.
4. Gliga A, Imre M, Grandini S, Marruganti C, Gaeta C, Bodnar D, et al. The limitations of periapical X-ray assessment in endodontic diagnosis: a systematic review. J Clin Med. 2023;12(14):4647. doi:10.3390/jcm12144647.
5. Thakur V, Kaul R. Apicoectomy: a review of clinical concepts and techniques. J Oral Res Rev. 2025;17(1):77-82. doi:10.4103/jorr.jorr_14_24.
6. Soesilo D, Pangabdian F, Wijaya YH, Puspita S. Apicoectomy for periapical lesion treatment after post endodontic failure on first maxillary premolar (case study). Asian J Dent Health Sci. 2023;3(1):1-4. doi:10.22270/ajdhs.v3i1.38.
7. Lara Munoz AG, Chavez Mestanza EA, Buitron Recalde MR, Lara Munoz AG. Clinical case report of non-surgical and surgical endodontic treatment (apicoectomy). Salud Cienc Tecnol. 2024;4:536. doi:10.56294/saludcyt2024.536.
8. Wang HH, Lam C, Myneni SR. Resolution of a cystic endodontic-periodontal lesion utilizing combined apicoectomy and guided tissue regeneration: a case report. Clin Adv Periodontics. 2022;12(2):94-100. doi:10.1002/cap.10149.
9. Hashem Q. Healing of extensive through-and-through periradicular lesion using apicoectomy without bone grafting: a case report with 3-year recall. Case Rep Dent. 2025;2025(1):7225338. doi:10.1155/crid/7225338.
10. Rajic VB, Mikus T, Gabric D, Vuletic M, Verzak Z. Bone tissue reparation and regeneration using bioactive material in endodontic surgery: a case report. Lijec Vjesn. 2023;145(5-6):216-220. doi:10.26800/lv-145-5-6-6.
11. Manishaa B, Sajjan GS, Kinariwala N, Madhu Varma KM, Ponnada N, Bagu SV. Endodontic dynamic navigation for precise apical microsurgery: case report. Endodontology. 2024;36(2):181-187. doi:10.4103/endo.endo_133_23.
12. Lee SM, Kwak JD, Ruch A, Kratchman SI, Karabucak B, Kohli MR. Three-dimensional assessment of healing variability after endodontic microsurgery using the bone lid technique: a case series. J Endod. 2026;52(1):141-148. doi:10.1016/j.joen.2025.09.006.
13. Abella Sans F, Barragan Montes J, Zbozen T, Suresh N, Dharmarajan L, Dummer PMH, et al. Minimally invasive vertical incision subperiosteal tunnelling technique for targeted endodontic surgery: technical overview and a case report. Int Endod J. 2025;58(11):1799-1805. doi:10.1111/iej.70014.
14. Mahendran K, Mohamed Hussain MA, Maloor SA, Saminathan K. Guided endodontic surgery: case series. Indian J Dent Res. 2023;34(1):94-97. doi:10.4103/ijdr.ijdr_462_20.
15. Mora-Carabali M, Contreras A, Rodriguez P, Zamora I, Rodriguez M. Tomographic, microbiological and histological characterization of secondary apical periodontitis: case series. Braz Dent J. 2023;34(1):123-132. doi:10.1590/0103-6440202304590.
16. Safi C, Kohli MR, Kratchman SI, Setzer FC, Karabucak B. Outcome of endodontic microsurgery using mineral trioxide aggregate or root repair material as root-end filling material: a randomized controlled trial with cone-beam computed tomographic evaluation. J Endod. 2019;45(7):831-839. doi:10.1016/j.joen.2019.03.014.
17. Zhou W, Zheng Q, Tan X, Song D, Zhang L, Huang D. Comparison of mineral trioxide aggregate and iRoot BP Plus root repair material as root-end filling materials in endodontic microsurgery: a prospective randomized controlled study. J Endod. 2017;43(1):1-6. doi:10.1016/j.joen.2016.10.010.
18. Dong X, Su Q, Li W, Yang J, Song D, Yang J, et al. The outcome of combined use of iRoot BP Plus and iRoot SP for root-end filling in endodontic microsurgery: a randomized controlled trial. Clin Oral Investig. 2024;28(3):188. doi:10.1007/s00784-024-05569-7.
19. Salah HM, Hashem AAR, Mustafa T, Soliman AH, Khallaf M, Haddadeen H. The impact of root end filling material type and the application of bone graft on healing of periapical tissues after endodontic microsurgery: a clinical randomized controlled trial. Sci Rep. 2024;14(1):25378. doi:10.1038/s41598-024-66033-w.
20. Attar-Attar L, Bernabeu-Mira JC, Cervera-Ballester J, Penarrocha-Diago M, Penarrocha-Diago M. Systematic review of surgical regenerative treatment for apicomarginal lesions in periapical surgery. Med Oral Patol Oral Cir Bucal. 2024;29(3):e416-e422. doi:10.4317/medoral.26405.
| Files | ||
| Issue | Vol 13, No 3 (Summer 2026) | |
| Section | Case Report(s) | |
| Keywords | ||
| Apicoectomy; Cone-beam computed tomography; Endodontic microsurgery; Post-treatment apical periodontitis; Root-end filling. | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Mirzaei A, Esmaeelpour P, Panjtanian SA. Endodontic Microsurgery for Post-Treatment Apical Periodontitis: A Case Series. J Craniomaxillofac Res. 2026;13(3):371-380.
