Non-surgical Retreatment

Endodontic failure must be evaluated so that a decision can be made among

nonsurgical retreatment surgical retreatment, or extraction.
Nonsurgical retreatment is a procedure to remove materials from the root canal,
address or repair defects , followed by cleaning, shaping and root canal obturation.
Surgical retreatment involves the surgical radical elimination of the periradicular
pathology, better preceded by conventional retreatment if applicable.
Steps of retreatment
I. Coronal disassembly
II. Establish access to the root canal system
III. Removal of canal obstructions and management of canal impediments.
IV. Cleaning, shaping and obturation

I.Coronal disassembly
Regaining access involves either:
• Removal of existing restoration
• Gaining access through existing restoration
Removal of existing coronal restoration is mandatory in case of secondary caries
,poor marginal adaptation or presence of post and core, otherwise it’s a compromise
between removal of restoration or gaining access through.
Advantage of gaining access through the restoration:
1. Better isolation
2. Easier rubber dam placement
3. Maintenance of form, function and esthetics.
4. No cost of replacement.
Disadvantages:
1. Reduced visibility and accessibility
2. Complicate the procedure of repairing errors
3. Risk of microbial infection through undetected poorly adapted margins
Decision to remove the restoration is considered simple in case of amalgam or
composite fillings. However, in cases of full coverage restorations, the issue is more
complicated
Removal of crown can be achieved by :
• the use of different types of crown removers taking care of the remaining
underlying tooth structure.
• Sectioning with diamond bur if porcelain is involved, and transmetal or
carbide fissure bur for cutting through metal crowns.
II.Establish access to the root canal system
Removal of canal contents:
• Post and core
• Root canal filling material
o Silver points
o Gutta Percha & Resilon
o Paste filling material
Removal of post and core:
All core material should be removed with maximum conservation remaining tooth
structure. This can be facilitated by using magnification devices and small sized
burs.
Removal of posts can be achieved by:
• Complete removal of core material
• Ultrasonic vibration all around the post
• Use of haemostat for gripping the post
• Use of special tools designed for post removal
Removal of filling materials:
Filling materials are either
• Silver points
• Gutta percha
• Resilon
• Carrier based
 • Paste

Removal of silver points

• Using micro-forceps if the head of the point accessible for gripping
• Use of ultrasonic vibration
• Partial bypassing and engagement using H files
• Using hypodermic needle tightly fitting over the silver point with
cyanoacrylate adhesive
• Using special instrument removal device.

Gutta Percha removal & Resilon

Gutta percha can be removed mechanically, chemically , thermally or combination
• Mechanical removal:
o Hand instruments
o Rotary instrumentation
Appropriate sized H files are used too engage gutta percha within the canal ( not the
canal dentin).
Gates glidden burs can be used to remove the coronal portion of gutta percha
Special rotary instrument designed for retreatment can be used according to their
manufacturers’ instructions eg. Protaper retreatment and R Endo systems

Chemically
Solvents are used for dissolving the gutta percha e.g.
• Chloroform
• Eucalyptol
• Halothane
Thermally
A hot instrument is inserted into the Gutta-perch to soften the material e.g heat
carriers or ultrasonics followed by insertion of H files.
Carrier based gutta percha
Filling removal can be achieved via the aid of ultrasonics, solvents and rotary
instruments

Paste removal
Hard pastes can be managed by using ultrasonics and/or solvents.

III.Removal of canal obstructions and management of canal impediments.

*Managing ledged canal:

Ledges are bypassed using K file #10 or #15. The apical 2-3 mm of the file is
precurved in a sharp curve to the same direction the expected curvature of the canal
and a unidirection rubber stop is oriented to guide the file curvature within the canal.
The precurved file is proceeded apically in a trial of negotiating the after-ledge
portion of the canal until re-establishing patency.
Once bypassed, the file moved in a filing motion ensuring the tip of the file is apical
to the ledge. The procedure is repeated with the successive file in the same manner
until the ledge is nearly unnoticeable.

*Managing of separated instruments:

Management of the separated instrument is affected by many factors including:
• Material of the separated instrument
• Position within the canal
• Size of the separated fragment
• Curvature of the affected root
• Accessibility & visibility of the tooth
• Remaining dentin thickness
If the coronal tip of the separated fragment is accessible for grasping, thin haemostat
or Stieglitz pliers can be used for grasping or the use of special kits like Massermann
extractor.

If it is not accessible for grasping;

• Staging platform around the coronal tip of the separated fragment is created
using modified Gates-Glidden bur
• Suitable sized ultrasonic tips can be used to induce vibration of the fragment,
beside its minor cutting action of the surrounding dentin. Ultrasonic tips are
used in a counterclockwise direction to aid in disengagement of the locked
fragment.
• After being partially loose, the fragment can be then special instrument
retrieval kits like IRS or Massermann kit.
• If it is not possible to remove the lodged fragment, attempts should be made
to bypass it using K file #10 or #15 and copious irrigation.

*management of perforations:
Perforation may be pathologic or iatrogenic communications between the root canal
space and the attachment apparatus.
• Pathologic by resorption and caries
• Iatrogenic during root canal therapy.
Perforation repair may be performed either nonsurgically by approaching the defect
through the canal, or surgically by using an external approach.
Non surgical perforation repair:
- The defect is flushed using sterile saline and cleaned to remove any contaminated
dentin surrounding the perforation.
- Hemostasis should be done using collagen, or calcium sulfate, or calcium
hydroxide.
- A small cotton pellet should be placed over the entrance of the canals to prevent
its blocking.
- the repair material is manipulated according to the manufacturers’ instructions
 and carried in a small amalgam carrier or special dispensing tools designed for
that purpose. Then it is condensed with small condenser or plugger.

Bioceramics, specially Mineral trioxide aggregate (MTA) are nowadays the material
of choice in terms of their tolerance of moisture and sealing ability. Other materials
have been used of the management of perforation such as Amalgam, Glass ionomer,
EBA, and composite.

After completion of retreatment procedures, canals are adequately prepared,

obturated and left for follow up.