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CASE REPORT

Edit and Undo the filling step: A review on non surgical endodontic
retreatment measures to retrieve gutta-percha from the filled root canal
system
Dubey A1, Avinash A2, Sheetal Mujoo3
1. Reader, Department of Pedodontics & Preventive dentistry, Rungta College of Dental Sciences, Bhilai
(C.G), India.
2. Senior Lecturer, Department of Pedodontics & Preventive dentistry, Rungta College of Dental
Sciences, Bhilai (C.G), India.
3. P.G. student, Department of Oral Medicine and Radiology, Rungta College of Dental Sciences, Bhilai
(C.G), India.
Corresponding Address:
Dr. Alok Dubey,
Reader, Department of Pedodontics & Preventive dentistry,
Rungta College of Dental Sciences,
Kohka- Kurud road, Bhilai-490024 (C.G).
Tel: +918827865566
Email: dentistalok@yahoo.co.in
Abstract:
Over the years, non surgical endodontic retreatment has replaced apical surgery as the treatment of choice for the causes of endodontic therapy failure. The
recognition of persistent infection as the main cause of such failure has highlightened the need for procedures for cleaning and disinfecting the entire root
canal system. This paper reviews the measures employed to remove root canal filling material, efficacy of different methods and factors governing the
success of retreatment.
Key words: Gutta-percha removal, Endodontic retreatment, Pro Taper Universal system

Introduction:
Residual necrotic tissue or bacteria beneath gutta-percha
(GP) or sealer can be responsible for periapical
inflammation or pain. Thus, the main objective of non
surgical endodontic retreatment is to remove all material
filling the root canal and regain access to apical foramen1.
Materials used to obturate root canal:
There are four commonly encountered obturating materials
found in root canals. These materials are GP, carrier-based
obturators, silver points and paste fillers. The effective
removal of an obturating material requires utilizing the
most proven methods from the past in conjunction with
presently developed techniques2.
GP is the most widely used and accepted root filling
material. GP is usually used as a core filling material, in
combination with a sealer or cement as a luting agent.
Hence in majority of retreatment cases, the most commonly
encountered root filling material is likely to be GP3. This
review will be focusing mainly on GP as the obturating
material and the methods employed to retrieve back the
same.
Planning for endodontic retreatment:
Before commencing with any treatment, it is profoundly
important to consider all interdisciplinary treatment options
in terms of time, cost, prognosis and potential for patient
satisfaction. Endodontic failure must be evaluated, so a
decision can be made among non surgical endodontic
retreatment, surgical retreatment, or extraction 2. In general,
non surgical endodontic retreatment of previously filled

root canals has priority to surgical intervention for the


management of endodontic failures4.
Removal techniques are dependent upon canal size,
anatomy, canal third, quality of condensation, time since
obturation, quantity of GP present and whether the existing
GP is over or under extended relative to apical foramen5.
Methods employed to remove GP:
Removal of GP can be effected with endodontic hand files,
ultrasonic instruments or engine driven rotary files with or
without the aid of solvents. Heat and solvents have been used
to soften GP and facilitate its removal6.
Use of rotary instruments in non surgical endodontic
retreatment:
Rotary Ni-Ti instruments have been proposed for the
removal of filling materials from the root canal walls and
various studies have reported their efficacy, cleaning ability
and safety7. Mechanized removal of existing root filling has
greatly affected the efficiency of the process by reducing the
time required to accomplish this initial tedious stage of
retreatment. Nevertheless, these instruments should be used
with caution as they may transport or straighten the canals8.
Use of Pro Taper Universal system:
Pro Taper Universal system is specially designed for
retreatment. The system is effective in removing root filling
material with the time required for removing the bulk of the
material significantly reduced, compared with manual
procedures. It includes shaping, finishing and retreatment
instruments. The retreatment instruments; D1, D2, D3 are
designed for removing filling materials from the coronal,

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middle and apical portion of the canals respectively6,8.


Use of MTwo and R- Endo system:
MTwo retreatment files and R- Endo are Ni-Ti instruments
specially designed for removal of filling material. They
have found to be more effective and faster than hand files9.
Use of Safe Sider and Endo-Express reciprocating
System:
Safe Sider is an instrument with unique design and mode of
action. These non circular instruments are operated using
Endo-Express reciprocating hand- piece and have a non
interrupted flat design that results in adjacent indentations,
where the flat side meets the interrupted flutes. Even though
this instrument was not originally designed for retreatment,
it was hypothesized that its special design might potentially
be beneficial for effective removal of root filling material, as
it might engage the material and dislodge it from the canal
walls via a reciprocating motion8.
Use of Ultrasound:
A single cone or poorly condensed GP root filling may be
removed using ultrasound. A small size endosonic file may
suffice as it not used to physically engage the root filling.
The technique relies primarily on a combination of
irrigation and ultrasonic vibration to loosen the root filling
allowing it to be floated passively out of the canal3.
Use of Lasers:
Nd YAP and Nd YAG laser have been tried for removal of
GP and fractured files. There is wide spread concern
regarding the heat generated with lasers and being
transferred to bone and the surrounding tissues. Further
research to establish safety parameters is required prior to
lasers being recommended for clinical use to remove root
filling materials3.
Use of hand instruments:
Historically, and contemporarily, techniques used to remove
root filling material have included the use of K-Files and
Hedstrom files. H-files are effective in loosely condensed
GP. It may be possible to insert H file along side of the GP
root filling but not the canal wall. The H file is rotated
quarter-turn clock wise to further ensure engagement with
GP root filling and when the file is withdrawn from the
canal, it should pull out the loose root filling material. While
K-type files may also be used, Hedstrom files are
particularly effective as configuration of the file consists of
a series of intersecting cones with elevated cutting edges,
allowing better engagement of root filling. If the root filling
is overextended, removal using hand files may be successful
if it consists of a single cone or poorly condensed GP. This
technique is less likely to be effective if the GP root filling is
well condensed3.
Use of Solvents:
Sealers used in conjunction with GP may remain
inaccessible to mechanical removal when they are in
anatomic ramifications. In such cases, solvents are
necessary for the thorough cleaning of filling material or
debris and effective disinfection of the root canal system.
Removal of filling is greatly simplified by use of solvents11.
Studies on solvents evaluating their solvent capacity have
found Xiliol as best solvent while Eucalyptol, chloroform,
orange oil had similar results12.
Hybrid Technique:
Use of rotary devices in endodontic retreatment should be
followed by hand instrumentation to achieve optimal
cleanliness of root canal walls. Rotary instrumentation
plasticizes GP through frictional heat, it enables reaching
the apical third easily and quickly. So, rotary instruments

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can be used for quick removal of GP and then hand


instruments can be used to refine and complete the removal6.
Time taken to remove the root fillings:
Retreatment is more time consuming compared with initial
root canal treatment. Removal of GP using hand files with or
without solvent requires a mean time of 1.5 to 10.8 minutes.
The main benefit of using rotary instrument over
conventional hand instrument for removal of root files is
reduced time taken to achieve filling removal. This is more
appropriate in case of well condensed canals3,13.
Use of operating microscope:
Endodontic procedures are nearly always performed in areas
of limited access and reduced visibility. The combination of
magnification and better illumination offered by operating
microscope has made it an indispensible piece of equipment.
It is essentially helpful in retreatment cases as improved
vision and enhanced illumination would aid the removal of
root filling material. Magnifying binocular loupes combined
with fiber optic light may also be used but compared with an
operating microscope; the former combination is more
cumbersome. Unlike loupes, the operating microscope also
offers a range of magnification3.
Complications and risks associated with retreatment:
The main risk, when removing root filling material include
perforation, blockages, loss of working length, ledging and
fracture of the removal instrument. Early studies on GP
removal using a variety of different Ni-Ti file systems
reported a higher risk of instrument fracture when compared
with hand instrumentation. Later studies have reported that
fractures are rare3.
Conclusion:
The main goal of non surgical endodontic retreatment is to
gain access to the apical foramen by complete removal of the
root canal filling material, thereby achieving sufficient
cleaning and shaping of the root canal system and final proper
obturation14. Many options are available for the operator in
removing GP from root canal system. A combination of both
hand and rotary instrumentation is found to be effective in
well compacted canals while manual instrumentation is
beneficial in loosely condensed Gutta-percha. Specially
designed Ni-Ti instruments for removal of filling material
and Pro Taper Universal system have considerably reduced
the treatment time and have been found to be effective in
retrieving the GP6,9.
References:
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rotary NiTi instruments in removing gutta-percha from
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2. Ruddle CJ. Nonsurgical endodontic retreatment. J Calif
Dent Assoc. 2004; 32(6):474-84.
3. Henry Fergus Duncan & Bun San Chong. Removal of
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4. Paik S, Sechrist C, Torabinejad M. Levels of evidence
for the outcome of endodontic retreatment. J Endod.
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5. Mounce R. Current concepts in gutta-percha removal in
endodontic retreatment. New York State Dent J. 2004;
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6. Bhat SV, Suvarna N, Shetty KHN, Varma KR.
Comparison of efficiency of gutta percha removal in
retreatment using protaper retreatment files, RaCe
instruments with and without H files- an ex vivo
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Edit and Undo the filling step: A review on non surgical endodontic retreatment measures to retrieve gutta-percha from the filled root canal system

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12. Aguiar CM, Lima GAC, Bernart FD, Camara AC.


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