Conventional endodontic therapy is successful approximately 80–85% of the time. Many of these failures will occur after one year. The presence of continued pain, drainage, mobility or an increasing size of a radiolucent area are some of the indications to treat the case surgically. Since many of these cases may have had final restorations placed by the dentist, the salvage of these cases is of importance to the patient. Advances in periapical surgery have included the use of ultrasonic root end preparation. With the use of these piezoelectric devices, a more controlled apical preparation can be achieved. Additionally, isthmus areas between canals can be appropriately prepared and sealed. The precision afforded with these devices reduces the chances for a malpositioned fill and a more successful outcome.