Endodontic Retreatment In Case Of Failure-Case Report

Ruxandra Mărgărit1), Oana Cella Andrei 2)

1)
Department of Restorative Odontotherapy, Faculty of Dentistry, „Carol Davila”
University of Medicine and Pharmacy, Bucharest
2)
Department of Removable Prosthodontics, Faculty of Dentistry, „Carol
Davila” University of Medicine and Pharmacy, Bucharest

Corresponding author: Ruxandra Mǎrgǎrit, Phone +40747-440.013, e-mail:

ruxandra.margarit@gmail.com
ENDODONTIC RETREATMENT IN CASE OF FAILURE-CASE REPORT
(Abstract)
In medical practice, clinicians come across an increased number of endodontic
treatments which, like other dental treatments can fail. The increase of endodontic
treatment consequently resulted in the increase of the number of their failures, and their
management presenting complex and significant endodontic problems. Endodontic
retreatment of a failure is required by the increased desire to preserve the tooth on the
dental arch, preventing the need for dental extraction that may have adverse
consequences in terms of functional and psychological effect on patients. This article
presents two clinical cases that required endodontic retreatment in order to avoid
complications that could occur, and could lead to the need for extraction as the final
result. Considering that the teeth in question have a special importance, one being one of
the mandibular first molars and the other-an upper central incisor,with physiognomic
role, we resorted to their endodontic retreatment and we’ve covered them with porcelain
fused to metal crowns.
Keywords: endodontic failure, retreatment, incomplete obturation, crown.

Introduction:
Endodontic retreatment is a procedure which is done on a tooth previously
endodontically treated, but whose current condition requires further endodontic treatment
to achieve a successful result.
Despite the fact that the success rate of endodontic treatment is high, each
clinician must be prepared to endodontically retreat the endocanalicular system, if initial
treatment failes (1).
Several specialists showed that 30-50% of their clinical work is represented by
endodontic retreatments.
Endodontic retreatment repeats steps of root canal treatment by coronary
approach, its objective being the cleaning of the canals of irritating agents, most of them
beeing microorganisms, which have survived the previous treatment or have infiltrated
after therapy. Therefore, endodontic retreatment is consistent with the biological rationale
of the root canal therapy and is preferable whenever possible.

Caese report::
CASE 1 L.O. patient, a woman, showed up in the dental office complaining of pain in the
right mandibular arch. Following clinical and radiological examination, it was noted that

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in the right mandibular region, at the level of 4.5 and 4.7 tooth, there were present two
decays that required resolution only by the preparation of simple cavities filled with
restorative materials. But the radiological exam showed us that, at the level of 4.6, an
incorrectly performed endodontic treatment due to the root canal filling being incomplete
(Fig. 1), but fortunately, has not revealed the presence of periapical pathology. Although
mesial root of the tooth shows a slight curvature, suggesting a cause of endodontic
treatment failure, distal root is common. Across all three canals the endodontic treatment
was incomplete. We started by removing the coronary filling using a high speed spherical
bur. Penetration holes into root canals were highlighted and we have performed the
removing of their material fillings. Canal filling material was removed and infected root
canals were disinfected using antiseptic and medicinal substances. Initially, we’ve
resorted to a temporary root canal filling and the distal canal was filled with no problems.
In an attempt to perform the treatment of the two mesial canals, their curvature
constituted an obstacle. The direction of mesio-lingual canal was detected by radiological
examination using a reference needle (Fig. 2), ultimately being successful in achieving
endodontic retreatment despite the root curvature (Fig. 3), using a material based on
calcium hydroxide. As a final coronal restoration a porcelain fused to metal crown was
made that restores the integrity of the mandibular arch (Fig. 4,5,6). Endodontic
retreatment done on time allowed remission of clinical symptoms and also prevented the
occurrence of periodontal complications. The first mandibular molar, which is an
important tooth, has been saved successfully.

Fig.1. Incompete root canal filling -4.6 Fig.2. Needle pointing false path -4.6

Fig.3. Final endodontic retreatment -4.6 Fig.4. Coronary restoration- intermediate

aspect -4.6

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Fig.5. Coronary restoration-final aspect-4.6 Fig.6.- Coronary restoration-final aspect

CASE 2 A similar case of failure of endodontic treatment, is the one of T.L. patient,
female, who when she came in the dental office was complainig of pain in the right upper
incisor-1.1 (Fig. 7). After radiological examination (Fig. 8a) we can see an incomplete
root canal filling, what is the cause of patient’s symptoms. During the stages of root canal
treatment, the removing of material fillings was performed and endodontic retreatment
was done thoroughly, the final result beeing illustrated in Figure 8b). As coronal
restoration, as in the previous case, a physiognomic porcelain fused to metal crown was
done (Fig.9, 10). As a result, we prevented the loss of this front tooth, which is very
important in the patient's physiognomy. Following endodontic retreatment, after a period
of monitoring, there was a reduction in periapical lesion size.

Fig.7. Initial aspect -1.1 Fig.8a. Incomplete filling -1.1

Fig.8b. Final endodontic retreatment -1.1

Fig.9. Coronary restoration-intermediate Fig.10. Coronary restoration-final aspect

aspect -1.1 -1.1

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Discussions:
As said by Mao Tse Tung, “The foundation of success is failure”.
In situations when we diagnose a failure of initial endodontic treatment, there are
three possible variants of solving the existing problem. The first and most indicated
solution is represented by endodontic retreatment. The second option is represented by
apical surgery followed by retrograde sealing of the root canal, while the last option,
which is not desirable, is represented by dental extraction. The latter is necessary if the
first two options can not be achieved.
The first option- non-surgical endodontic retreatment is preferable in case of
endodontic treatment failures, when gaining acces to the root canals is possible. During
endodontic retreatment we should do cleaning, shaping, and three-dimensional filling,
with an inert filling material in all previously obturated root canals.
Some studies conducted over time, showed the presence of persistent apical
periodontitis in case of endodontically treated teeth, in a proportion of 45% (2,3). The
cause of persistent apical periodontitis is represented mainly by microorganisms that have
survived primary endodontic treatment. This problem can be resolved by orthograde
endodontic retreatment (4). During the stages of endodontic retreatment, the total
removing of root filling materials is essential, so it will be possible to eliminate all
residual microorganisms and to create favorable conditions for periradicular healing (5).
Studies were done on the success rate of endodontic retreatment, looking at the
presence or absence of periapical lesions. Holland and colleagues have analyzed
seventeen such studies (6). The conclusion is that, in case of periradicular lesions’s
absence, the success rate is higher, while in the cases where lesions were present, the
success rate varies from a minimum of 31 , 8% to a maximum of 85%.
Friedman et al. (7) show a success rate of 100% for the endodontic retreatment of
cases without periapical lesions, which suggests that in cases where infection is not
present, and retreatment is done by skilled clinicians, success rate can be very high. Also
Sjogren and colleagues (8), performing endodontic retreatments on 173 roots in the
absence of periapical lesions, obtained a success rate of 98%. If the periapical lesion is
present before starting endodontic retreatment, the success rate can be estimated at not
more than 70% (7).
The second approach, apical surgery, tries to block microorganisms within the
canal, through its apical seal. Leaving debris and microorganisms into the root canals is
contrary to biological reasoning. Thus, surgery is a secondary alternative if endodontic
retreatment is not feasible, or is contraindicated, or has failed probably due to
microorganisms that invaded the periapical tissue.
If in a given situation the tooth is impossible to restore, the extraction will be
recommended and an alternative replacement will be examined.
As a conclusion, it is very difficult to define failure of endodontic treatment. A
clear and precise definition of what success or failure is, can be said that there was not
among clinicians (9).

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