The success rate of endodontic surgery has shown significant improvement over the past two decades. To this day, many clinicians consider endodontic surgery as the last resort for saving endodontically treated teeth and often present the outcome as guarded to the patients. If the need for endodontic surgery is combined with a compromised periodontal or restorative condition, extraction is often recommended and implant placement is advocated. In this presentation, we will discuss the best evidence available regarding micro-surgical endodontics and factors contributing to its long term success. We will also present new considerations in dealing with complicated surgical cases to restore the supporting structure and provide a predictable outcome.