Endodontic Topics 2016, 34, 64–89 © 2016 John Wiley & Sons A/S.

All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

Non-surgical retreatment of teeth

with persisting apical periodontitis
following apicoectomy: decision
making, treatment strategies and
problems, and case reports
€
MICHAEL H ULSMANN & GABRIEL TULUS

In the endodontic literature, only a few studies and case reports can be found demonstrating and further
discussing non-surgical treatment of failed apicoectomies. As a second apicoectomy has a limited success rate,
non-surgical retreatment should be discussed as an additional treatment option before extraction is considered.
Depending on the reason for treatment failure or for persistence or development of apical periodontitis, and
depending on the presence or absence and the type of retrofilling, treatment strategies need to be adapted to
the specific clinical scenario. It is the aim of this review to describe a strategy for non-surgical orthograde
retreatment of previously apicected teeth with persisting apical periodontitis, to review the literature that may
be helpful to discuss such cases, to develop an individual treatment plan, to discuss several specific aspects of
treatment, and to present different clinical cases.

Received 3 July 2016; accepted 16 July 2016.

Introduction In a review, Friedman (4) demonstrated that the

Apicoectomy frequently is performed in cases of
failed non-surgical endodontic therapy. The primary
aim of endodontic surgery is not the elimination of
intraradicular infection from the entire root canal but
the removal of bacteria from the apical part of the root
by removing this part completely and by preventing
access for surviving microorganisms to the
periradicular tissue by the placement of a retrograde
filling (1–3). Although not recommended,
apicoectomy frequently is limited to surgical removal
of the root tip without previous sufficient retreatment
(Fig. 1a) and (re)disinfection of the root canal system.
Without proper disinfection, the placement of a
retrograde filling is unlikely to result in periapical
healing (Fig. 1b).
mean success rates from published studies for
endodontic surgery are as high as 58.9% without and
79.6% with pre-surgical retreatment of the root canal
filling. In a systematic review, Torabinejad et al. (5)
reported a success rate for apical surgery of 77.8%
2–4 years postoperatively and of 71.8% after 4–6
years. Six years after surgery, the success rate dropped
even further to 62.9%. In a review and meta-analysis
of the data published in clinical studies, Tsesis et al.
(6) identified 11 studies with contemporary
treatment techniques using a microscope and placing
a root-end filling with MTA and reported a success
rate of 91.6%. Another meta-analysis by Setzer et al.
(7) included the data from 21 papers evaluating
success rates for traditional surgical techniques and 9
articles on contemporary endodontic microsurgery.

64

Figure 1. (a) Apicoectomy and retrograde obturation in insufficiently prepared, disinfected, and obturated roots
resulting in persisting apical pathosis. (b) Insufficient disinfection and obturation without placement of a
retrograde filling resulting in failure of apicoectomy.
The authors reported a success rate of 59% for the
traditional and of 94% for the modern microsurgical
techniques using dental operating microscopes,
microsurgical techniques, and retrograde obturation
using MTA. These data indicate that in a number of
cases of non-successful apical surgery, further
treatment is necessary and indicated.
Reasons for failure of apical surgery
The main reasons for failure of endodontic surgery
as summarized by Saunders (2) are:
• Persistent microbial contamination of the root canal
system or recontamination via coronal leakage.
If the microorganisms remaining and surviving in
the root canal system or recontaminating the root
canal manage to multiply to a sufficient number and
to gain access to the periradicular tissues, a periapical
inflammation can be initiated or may persist. This is
possible in apicected roots with and without a
retrograde root-end filling as, in both cases, additional
apical leakage may be present. In a prospective study
on apical resurgery in 24 of 54 cases (44.4%) without
a retrofilling, failure occurred after primary
apicoectomy (8). So far, no information is available on
the microbiological aspects of persisting disease after
apical surgery. It can be presumed that the microbial
flora is identical or at least similar to that of failed
primary treatment, dominated by Gram-positive
Non-surgical retreatmet after apicoectomy
organisms such as Enterococcus faecalis (9–11), but
final proof still is missing.
In these cases and even if a retrograde filling has been
placed, non-surgical retreatment can be considered
since improved disinfection during retreatment can be
achieved, which will stimulate apical healing.
• Extraradicular infection.
In cases of extraradicular infection, which cannot
be diagnosed without a biopsy, orthograde
retreatment without additional surgical intervention
directly addressing the infected extraradicular tissues,
does not present a promising treatment modality. To
our knowledge, no data are available on the incidence
of extraradicular infection following apicoectomy.
• Inability to seal the root canal system from the
periradicular tissues.
Under the operating dental microscope, Von Arx
et al. (12) observed a high frequency of gaps
between the root canal filling and the adjacent
dentinal wall (83.3% in 168 apicected roots)
(Fig. 2). If proper sealing without such leakage can
be achieved during non-surgical retreatment, success
in terms of healing of apical periodontitis may occur.
A further problem will occur in roots that were
apicected using the traditional technique with an
acute bevel. In these cases, many dentinal tubules
have been exposed and connect the root canal to the
periradicular tissues (3). It may be difficult or even
impossible to seal these tubules from the
65
H€
ulsmann & Tulus
A Orthograde retreatment may be successful in cases
B already been due to missed canals (14). In two
Figure 2. (a) Persisting periradicular lesion 2 years
after apicoectomy with retrograde filling. (b) Following
extraction of the tooth, a large gap between the root
canal wall and the retrofilling becomes visible. It seems
questionable whether proper disinfection of the root
and subsequent healing in such cases can be achieved
without removal of the retrofilling.
periradicular tissues and prevent further bacterial
leakage via these connections. As determination of
an adequate working length will be difficult in these
cases, non-surgical retreatment should be discussed
critically, but still may remain a treatment option.
• Anatomical problems and anomalies preventing
sufficient disinfection and obturation.
Frequent anatomical problems include the presence
of an irregular root canal diameter or a narrow isthmus
between two root canals (3). These isthmi have been
found in 83% of mesial and 36% of distal roots in first
mandibular molars (13). In a clinical study, the
presence of isthmi was identified as the reason for
failure in 3 of 54 cases of failed apicoectomy (8).
Undiagnosed irregularities result in incomplete
preparation and obturation of the root canal; in
consequence, apical leakage will appear or persist.
66
of identification, preparation, and disinfection
followed by tight obturation of such irregularities.
• Poor surgical techniques (2).
Among the problems associated with surgical (and
also non-surgical) techniques, untreated root canals
and misalignment of retrograde preparation and root
axis will be found (2).
Missed root canals have been responsible for
treatment failure after apicoectomy in 4 of 54 roots
(8). It should be considered that failure of primary
treatment in a certain number of cases will have
clinical studies, Wolcott et al. (15,16) demonstrated
that MB2 in maxillary molars was detected in only
59% of maxillary molars during initial treatment, but
in 67% during retreatment. Recently, in a
retrospective evaluation of CBCTs of endodontically
treated molars and premolars, the overall incidence
of untreated root canals was reported as 23.04% (17).
As apicoectomy frequently is performed without
previous revision of the root canal treatment, it can be
expected that this problem of untreated root canals
will pertain and also contribute to surgical failures. In
these cases, surgical retreatment alone will result in
apical closure of a missed canal, if detected, but
proper disinfection requires a non-surgical approach.
If a previously missed root canal can be detected
via a coronal access, the root canal can be prepared,
disinfected, and obturated:
▪ to its natural apical terminus, if not yet
resected. The root canal can be treated as
recommended for primary treatment of
infected root canals;
▪ to the resected but not prepared, not
disinfected, and not obturated apical endpoint.
MTA will be the apical obturation material of
choice; or
▪ to the most coronal level of the retrograde
obturation if the apical part of the root canal
has already been sealed during apicoectomy of
the root.
• Divergence between the axis of the retrograde
cavity and the root axis or insufficient depth of the
retrograde cavity (< 3 mm) were detected in 20 of
54 cases (37%) of surgical failure (8). It must be
considered whether these technical deficiencies can
be overcome by non-surgical retreatment alone or
whether a combined treatment would be preferred.

• In a number of clinical cases, dentinal cracks and
microfractures, originating from the use of rotary
instruments or ultrasonics for preparation of the
retrograde cavity, lead to communication
between apical tissues and the root canal. It has
been reported repeatedly that such cracks or
microcracks can be initiated during each step of
endodontic treatment and may or may not
develop into incomplete fractures of a root (18).
Due to bacterial leakage, apical healing cannot be
achieved.
An evaluation of 168 consecutive cases of apical
surgery (12) reported craze lines and cracks in 9.5%
of the apicected root surfaces in 168 roots.
These cases with apical cracks and microfractures
will probably not respond positively to non-surgical
or surgical retreatment as closure or repair of such
fractures and cracks will not be possible.
Treatment options in cases of failed
apicoectomy
In cases of failed apical surgery, several treatment
options need to be discussed (2):
• Extraction of the tooth with or without
placement of a dental implant.
• Resurgery with or without previous or
simultaneous retreatment of the coronal part of
the root canal.
• Non-surgical retreatment with or without
removal of a retrograde filling.
Extraction
Extraction of the already apicected tooth with a high
degree of probability will remove the origin and cause
of periradicular inflammation. However, the loss of
the natural tooth is associated with a number of
different problems, the discussion of which is far
beyond the scope and limits of this paper. The reader
is referred to a review by Zitzmann et al. (19).
Apical resurgery
In a systematic review of the literature, Peterson &
Gutmann (20) collected 8 studies reporting the
success rates of apical resurgery. The weighted
average outcome of primary endodontic surgery
Non-surgical retreatmet after apicoectomy
reported in these publications was 64.2% for success,
25.7% for uncertain, and 15.7% for unsuccessful
outcomes. The weighted average after 1 year for
resurgery from those studies was 35.7% for success,
with 26.3% for uncertain and 38% for unsuccessful
outcomes. As the postoperative time period plays an
important role in healing and outcomes, it should be
considered that a number of uncertain cases will heal
and finally be successful as well, increasing the total
success rate to a maximum of 62.0%. This may make
resurgery a preferable treatment option for the
patient. Nevertheless, the authors point out that
surgery failure may be related to problems not
responding positively to resurgery. Finally, these 8
studies should be interpreted with utmost caution as
they have been published up to 30 years ago and do
not represent modern (micro)surgical treatment
techniques including the use of the dental
microscope or MTA as the retrograde obturation
material. In a 5-year longitudinal comparative study
of 162 cases of apical surgery and 69 cases of
resurgery, Gagliani et al. (21) reported success rates
of 86% for surgery and 59% for resurgery. As
demonstrated, the success for primary apical surgery
may decrease over time (5). Nevertheless, resurgery
allows direct inspection of the root tip and
identification and treatment of cracks and
microfractures as well as of previously undetected
isthmi or lateral canals, which is not possible during
non-surgical retreatment of failed surgical cases.
An increased success rate for resurgery has been
reported by Song et al. (8), who used a
contemporary microsurgical technique including the
use of a dental operating microscope, ultrasonic
retro-tips, and retrograde obturation with MTA or
Super-EBA. Out of 42 recalled patients (2-year recall
rate 77.8%), 39 were rated as a success, resulting in a
success rate of 92.9%.
Non-surgical retreatment after
failure of apical surgery
Although not infrequently performed by specialized
endodontists, non-surgical retreatment of failed
apicoectomy has not gained much attention in the
endodontic literature, which mainly consists of case
reports. This basically means there are reports on
successful treatments, whereas failed attempts are
67
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ulsmann & Tulus
only infrequently published, resulting in a
considerable bias and possible overestimation of
healing rates.
The “open apex concept”
It might be debated whether non-surgical retreatment
of apicected roots shows more similarities either to
the treatment of teeth with open apices or to
iatrogenic perforation repairs. The diameter of the
apical opening may be comparable to cases with
immature roots, but no remnants of Hertwig’s
epithelial root sheath should be expected to be
present in the periapical tissue as this will disappear
after tooth development, leaving only agglomerations
of cells (cell rests of Malassez) (22). Whether this
makes classical apexification procedures a less
promising approach is controversial and the role of
Hertwig’s epithelial root sheath still has not been fully
clarified. Several case reports (23–29) have been
published demonstrating successful apexification even
after apicoectomy, which probably means any kind of
apical hard tissue barrier after intracanal medication
with calcium hydroxide. Ohara & Torabinejad (30)
reported on apical closure after application of a
calcium hydroxide dressing in an immature tooth that
had undergone only apical curettage. Cvek (31)
described this type of apical barrier as a layer of
coagulated and later calcified tissue with adjacent layers
of cement-like tissue. He stated that the ability of the
periodontal tissues to form hard tissue obviously is not
related to the stage of tooth development and root
formation. Remnants of pulp tissue, although
inflamed, and periapical connective tissue have also
been discussed as the origin of hard tissue (30).
In contrast to immature roots, the most apical
part of the root in apicected teeth will be thicker
and less prone to fracture. As in most cases of
perforation, an inflammation is present in the
adjacent tissue and the presence of an extraradicular
biofilm cannot be excluded. Regardless, proper
intracanal disinfection and tight closure of the apical
opening with a biocompatible material are
mandatory for all of these clinical scenarios.
Thus, an actual concept for treatment could be
based on an “open apex concept” and should
consider the use of modern armamentarium and
materials and include different treatment scenarios
for different preoperative conditions.
68
Diagnosis and treatment planning
Thorough diagnosis should be performed as usual.
Some focus should be placed on scars from previous
endodontic surgery, amalgam tattoos as sequelae
from amalgam retrofillings, the presence of a sinus
tract, and tenderness to percussion and apical
palpation. Sulcular probing should exclude
fistulation via the periodontal space due to a vertical
root fracture.
The radiograph will provide the examiner with
information on the homogeneity, length, and quality
of the root canal filling; the presence or absence of a
retrograde root-end filling; as well as its location,
length, and shape. Dental cements and amalgam
usually can be distinguished with a high degree of
certainty as well as metal materials such as silver
cones. Metallic sectional posts (titanium or other
metals) have also been used for apical obturation
during apicoectomy; as well, it has been suggested
to extend such posts beyond the root tip into the
periapical tissues as a kind of transapical fixation or
endodontic implant (32) (Fig. 3).
In some cases the geometry and location of the
retrofilling can give valuable information on the
angle and location of the apicoectomy (Fig. 4). If
the apical level of the root filling or retrofilling
shows rectangular angles and appears at the same
level as the most apical part of the root, the
resection level will be more horizontal than if a
rectangular filling presents with some distance from
the tip of the root. A rounded contour of the root
filling can be interpreted as a result of post-resection
obturation. The diameter of the retrofilling in relation
to the diameter of the root canal preoperatively can
already indicate whether non-surgical removal of the
retrofilling seems possible and reasonable. An unusual
shape of the retrofilling in the radiograph can be the
result of anatomical structures such as an isthmus.
Depending on the radiographic diagnosis of root
anatomy and the presence, location, and
radiographical shape of a retrograde root-end filling, a
decision needs to be made on whether non-surgical
retreatment appears to be possible, reasonable, and
promising and whether an attempt at the removal of a
retrofilling should or could be made with a reasonable
chance of success. It should be kept in mind that
failure to remove the root-end filling still leaves the
option of resurgery or extraction and only infrequently
 Non-surgical retreatmet after apicoectomy

A B C D

Figure 3. (a) Radiopacity suggests a small-sized cementum retrofilling in an unfilled root canal. The diameter of the
retrofilling seems to be larger than the diameter of the root canal, which could make orthograde removal very
difficult and carry a high risk of pushing the filling into the periapical tissues. The tooth shows apical and marginal
periodontitis. Preservation of the tooth should be discussed critically and replacement by an implant regarded as a
valid treatment option. (b) Radiopacity suggests an amalgam retrograde root-end filling. In the distal root, the
contours of the root end apical to the retrofilling is indicative of a beveled resection. In the mesial root, the
amalgam seems to connect two previous apical foramina and an isthmus. The shape of the amalgam filling also
demonstrates an angulation of the apicoectomy. Regarding the size of the retrofilling, only thin root walls will be
present most apically. If not already present, there will be some risk of cracks and fractures if retreatment is
considered. (c) The root canal has been obturated using a sectional (silver) cone technique. (d) Radiograph of an
apicected maxillary incisor demonstrating obturation with a sectional (silver) cone technique. The apical part of the
cone after placement obviously has been shortened and “burnished” onto the surface of the root tip. As this might
result in some retention, orthograde removal of the cone could be difficult if not impossible.

A B C

Figure 4. (a) The root canal has been obturated with a metal cone, probably a silver cone. The rectangular apical
contours of the cone indicate the level of the apicoectomy, which seems to be not or only slightly beveled. (b)
Preoperative radiograph of an apicected maxillary incisor presenting with acute pain, demonstrating insufficient
obturation (probably a single-cone filling with excessive amounts of sealer) without a retrofilling. The radiograph
suggests an extremely oblique level of apicoectomy. (c) The 6-month recall demonstrates intact periapical contours.
The MTA likely partially extends beyond the level of the resection.

will worsen the situation. Good radiographical

quality of the obturation may hint at extraradicular
causes of persisting periapical inflammation.
Resurgery in such cases may be considered the
treatment option with a higher chance for a
successful outcome.
The optimal and most promising treatment
strategy must be evaluated individually for each
tooth (Fig. 5).
Access cavity
An access cavity needs to be prepared that allows
complete removal of all filling material from the pulp
chamber, which subsequently has to be searched
meticulously for additional root canal orifices that
may have been missed during previous non-surgical
and surgical treatment (28,33) (Fig. 6). To facilitate
further treatment, the size and location of the access

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H€
ulsmann & Tulus

Figure 5. Decision strategy for teeth with failing

apicoectomy.

cavity should allow direct visualization of the

apicected root apex through the dental microscope
in the majority of cases.
C

Apicoectomy without retrograde

filling
In cases without a retrograde obturation, removal of
the filling material, mostly gutta-percha and a sealer,
should be performed as described for non-surgical
retreatment (34,35). Great care must be taken to
prevent apical extrusion of any foreign material
(filling material, dentin chips, irrigants), which can
induce or sustain a periapical inflammation (36). The
use of a solvent should be avoided, at least during
removal of the most apical part of the root canal, in
order to prevent apical extrusion of dissolved gutta-
percha remnants. A crown-down or step-down
approach seems to be favorable. Modern systems and
devices for deep application and suction of an irrigant
(Stropko irrigator and air blower: Vista Dental
Products, Racine, WI, USA; EndoVac: Discus Dental,
Culver City, CA, USA) can be helpful. Suction from
the most apical part of the root canal can easily be
performed by mounting a thin and flexible irrigation
needle into the adapter of the saliva ejector.
Apicoectomy with retrograde filling
In cases of failed apicoectomy with a retrograde
filling, a decision must be made as to whether or not
to remove the retrograde filling. From the literature
Figure 6. (a) Preoperative radiograph of an apicected
maxillary molar. (b) Length determination radiograph:
a missed root canal was detected in the mesial-buccal
root. (c) The 2-year follow-up shows good apical
healing.
there is no evidence on the superiority of one of
these modalities, so the decision needs to be made
on a case-by-case risk-versus-benefit basis.
Removal of the filling material will allow improved
disinfection of the resected root canal and placement
of uncontaminated filling material. However,
removal also increases the risk of apical extrusion of
the remaining filling material, bacteria, irrigants, and
new obturation material. Additionally, the attempt at
removal can result in further weakening of the most
apical root structures including formation or
perpetuation of existing cracks and microfractures.
Also, it must be considered that some retrograde

70

filling materials such as amalgam fillings will be
difficult to remove.
Non-removal may leave contaminated filling
material and prevent sufficient disinfection, namely
of the interface between obturation material and
root dentin. Leaving the retrofill or remnants of the
root-end filling may not improve the tightness of the
apical obturation, but carries a lower risk of apical
extrusion of filling materials and irrigants into the
periapical tissues. To our knowledge there are still
no studies reporting chances and risks of orthograde
removal of different retrograde filling materials from
a resection site.
Removal of retrograde fillings
Failure of an apicoectomy may occur due to bacterial
leakage via dentinal tubules at the resection site or as
a result of leakage of a retrograde obturation. Exact
differential diagnosis will be impossible in a clinical
situation. Wu & Wesselink (37) argued that
microorganisms remaining in the apical part of an
instrumented and obturated root canal and even
beyond the apical constriction may present one
major reason for endodontic failure, which has been
demonstrated in several studies (38–41), and that
therefore instrumentation and disinfection to the
(major) apical foramen would seem necessary. It
should be presumed that the obturation material is
contaminated to an unknown extent, making the
removal of the retrofilling desirable, thus allowing
subsequent disinfection of the most apical part of
the apicected root. Ng et al. (42) reported the
results of a prospective study on factors affecting
endodontic treatment and retreatment outcomes.
The main factors for success were achievement of
apical patency and instrumentation and irrigation as
near as possible to the apical root canal terminus.
This data would suggest removal of the retrofilling
whenever this looks promising in order to achieve
apical patency and to enhance apical disinfection.
A great variety of materials have been
recommended for retrograde obturation: amalgam,
zinc oxide–eugenol cements, reinforced zinc oxide–
eugenol cements (namely IRM and Super-EBA),
MTA, glass ionomer cements, composite resin,
compomers, Diaket, gold foil, and Retroplast (1,43).
In the majority of cases, most likely a type of
cement has been used for the retrograde root filling.
Non-surgical retreatmet after apicoectomy
Following removal of the coronal root filling
material, direct inspection through the dental
microscope and probing with endodontic
instruments (i.e. Micro-opener, Dentsply, Ballaigues,
Switzerland; endodontic spreaders) may provide
some information on the consistency of the root-end
obturation material. Zinc phosphate cement, glass
ionomer cement, Super-EBA, amalgam, and
comparable materials will be impenetrable for
endodontic instruments and solvents will not be
helpful in dissolution. Removal can be attempted
using a fine ultrasonic tip under direct visual control
by trying to disintegrate the cement. This will occur
when the ultrasonic energy exceeds the cohesive
energy of the filling material. Great care must be
taken not to push the filling material into the apical
tissues. Pirani et al. (44) attempted to remove Retro
TC (an MTA cement not commercially available),
Intermediate Restorative Material (IRM, Dentsply),
and Vitrebond (3M ESPE, St. Paul, USA) from
retrograde cavities in a retrograde approach. They
used ultrasonic tips designed for retrograde
preparation for no longer than 60 seconds to avoid
microcracks in the roots. None of the materials
could be removed predictably. Retro TC was
removed significantly better than Vitrebond. No
differences were found between the other two
materials, but in most cases the retrograde filling
material could not be removed completely. Due to
its clearly higher bond strength to dentin, the
removal of Vitrebond presented more difficulties.
Many specimens showed a smear layer on exposed
dentin and cracks developed in four roots. Some
specimens showed irregular diameters indicating
hard tissue loss due to ultrasonic energy. Boutsioukis
et al. (45) investigated in vitro the orthograde
removal of MTA used as a root filling material with
and without an additional gutta-percha cone.
Comparing two removal techniques, rotary nickel–
titanium instruments were not able to penetrate the
MTA filling, whereas the use of a finger spreader
mounted in an ultrasonic unit allowed penetration,
but in no case resulted in complete removal of
MTA. Remnants of filling material were detected in
all specimens and in 7 of 15 root canals patency
could not be regained. The authors reported that in
preliminary tests it was not possible to advance H-
files into the MTA, which is in contrast to a study
by Young et al. (46), who were able to remove
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ulsmann & Tulus
MTA by threading a size 25 Flexofile into the
cement.
Ultrasonics
The use of ultrasound in endodontics in general and
in retreatment in particular has been reviewed by
Plotino et al. (47). It has been demonstrated
repeatedly in case reports that the removal of hard
pastes and cements from the root canal can be
achieved by ultrasonic vibration (48–52). Until now
there is no clinical evidence as to which type of
ultrasonic tip is best suited for that purpose. In a
case series, Krupp (53) demonstrated the successful
removal of cementum retrofillings using size 30
ultrasonic tips with low energy.
When selecting the armamentarium as well as the
treatment mode, the time necessary for removal of
the retrograde filling as well as the rise in
temperature, development of microcracks and
fractures of the root canal walls, marginal chipping
at the resection site, and the amount of loss of
root dentin need to be considered. An increase
in the number of cracks has been described
following retrograde preparation using ultrasonic
tips (54–56).
Madarati et al. (57) measured the temperature rise
at the outside of the root during removal of
separated instruments using CPR ultrasonic tips
(Obtura Spartan, Fenton, USA) at different power
settings, which may be comparable to removal of a
retrograde filling. Using high power levels, a
temperature rise of up to 17.5°C occurred. Hashem
(58) reported an increase of temperature at the
external root surface of up to 14°C after 2 minutes’
use of ultrasound for the removal of a broken
instrument. Larger instruments induced a higher rise
in temperature than smaller tips. In other studies on
ultrasonic post removal or ultrasonic removal of
fractured instruments, external temperatures were
measured up to more than 50°C (57,59,60). The
authors concluded that working at high power
settings should be avoided due to the high risk of
thermal damage to the periodontal ligament and
bone. Using an endodontic file size 25 with
intermittent irrigation of 1 mL NaOCl (25°C) every
30 seconds, the external temperature was lower than
40°C; continuous irrigation resulted in an external
temperature of only 32°C (61).
72
Removal of the retrograde filling material under
continuous flow of an irrigant will reduce the
increase in temperature as demonstrated for the
removal of intracanal posts (59,60) but does not
allow working under direct view of a microscope.
Nevertheless, frequent and copious irrigation is
mandatory for disinfection as well as the removal of
already disintegrated cement.
Solvents
It has been demonstrated that different root-end filling
materials (IRM, a ZnO–eugenol cement; ProRoot, an
MTA cement; Superseal, an EBA cement) show low
solubility when immersed in water (62). There was no
difference in the solubility of amalgam, Super-EBA,
and MTA in water (63). Ketac Endo, a glass ionomer
root canal sealer, showed more chemical disintegration
in water than AH 26, Tubli-Seal (64), and Diaket (65).
Ketac Endo had a lower solubility in chloroform and
halothane than Apexit, AH Plus, and Tubli-Seal EWT
(66) root canal sealers. There are some investigations
on the solubility of endodontic sealers and the effect of
solvents on those (64–66), but little is known about
the effect of solvents on the hardness of commonly
used retrograde fillings materials. Xylene causes a
significant reduction in the hardness of IRM after a 5-
minute contact time; chloroform after only 1 minute’s
contact (67). After 5 minutes of treatment with
chloroform, the IRM specimens (10 x 5 x 3 mm) had
completely dissolved. Martos et al. (68) reported that
one of two zinc oxide–eugenol sealers (Intrafill)
showed a higher solubility against orange oil than the
second ZnO–eugenol sealer (Endofill) whereas reverse
results were found for xylol after 2 and 10 minutes of
exposure time. The authors did not present any
explanation for these contradicting results, which may
be due to the different composition of these two
sealers. Whitworth & Boursin (66) reported a 62.5%
weight loss of Tubli-Seal EWT after 10 minutes of
exposure to chloroform, compared to only 5.2% for
halothane. A ZnO–eugenol sealer showed higher
solubility against EDTA after 10 minutes than against
NaOCl 2.5% and 10% (69). Whether the results can be
transferred to zinc oxide–eugenol containing
retrofillings must remain speculative.
In several studies, MTA has been shown to have a
very low solubility (70–72). Also, the use of chelator
irrigants such as EDTA or MTAD (Dentsply/

DeTrey) has been considered to decrease the
hardness of MTA (73). After 5 minutes, MTAD
caused a slightly higher removal of MTA and a
rougher surface than EDTA, but only minor volume
reductions could be measured and the differences
were not significant. The authors calculated that it
would take 32 hours to resolve a 2-mm-thick layer
of MTA. Therefore it seems questionable whether
solvents might be of any relevance for the removal
of larger amounts of cement, i.e. a retrograde filling of
3 mm or more in length. Using scanning electron
microscopy and energy dispersive x-ray spectroscopy,
Lee et al. (74) demonstrated that MTA loses its
crystalline structure and that its microhardness is
significantly reduced after contact with EDTA during
setting time. This is due to disruption of the
hydration process. A mixture of MTA and 2%
chlorhexidine (CHX) resulted in a reduced MTA
compressive strength (75). In both studies, the effect
was determined during the setting of MTA, thus not
allowing conclusions on the effect of the solvents on
already set MTA. Nevertheless, Holt et al. (75)
reported an extreme brittleness of MTA after mixture
with CHX, which might facilitate removal. Kayahan et
al. (76) demonstrated a lower compressive strength
and microhardness for MTA after acid etching with
37% phosphoric acid than for unetched controls.
Carbonic acid was able to significantly reduce surface
hardness of set white MTA 1 and 21 days after
mixing, whereas chlorhexidine showed a significant
effect only 1 day after application. EDTA did not
show any effect at all after 1 and 21 days (77).
To our knowledge, only a few case reports,
including 15 clinical cases, have been published to
date on non-surgical retreatment of failed
apicectomies including removal of retrograde
obturation material (29,53,78–81). Fava (29)
retreated a maxillary second bicuspid with a
retrograde filling, probably a cement filling. After
removal of the coronal filling material, the root canal
was irrigated and dressed with calcium hydroxide. As
this did not result in closure of the fistula, the
retrograde filling material was intentionally pushed
through the foramen into the periapical tissues in
order to disinfect the most apical part of the root
canal and place the calcium hydroxide in direct
contact with the exposed dentinal tubules and the
periapical tissues. The fistula closed and the tooth
was re-obturated with gutta-percha and sealer. The
Non-surgical retreatmet after apicoectomy
2-year recall demonstrated excellent apical healing.
The filling material was not resorbed during that
interval but did not show any signs of inflammation
radiographically. Herrmann (78) presented two cases
of non-surgical retreatment after failed apical surgery
including removal of the retrograde obturation
material (probably cement) with ultrasound (UT
ultrasonic tips, EIE2, San Diego, CA, USA) and
suctioning with microcannules (EndoEze, Ultradent,
Salt Lake City, UT, USA) but did not report the
technique of removal of the retrograde filling in
detail. Both cases in the 3- and 2-year controls
showed complete apical healing, although in one
case the apical root filling material could not be
removed completely. St€ ockl (82) and Nordmeyer &
H€ulsmann (80) also could not completely remove
the retrograde filling material using ultrasonics
(ProUltra tips, Dentsply).
Soares et al. (79) reported on two cases of failing
apicectomies with retrograde amalgam fillings. Root
canal treatment was repeated without removal of the
retro-fillings and calcium hydroxide was placed as a
dressing, but in both cases sinus tracks persisted.
Finally, the amalgam fillings using large K-files (ISO
60 and ISO 80) were pushed out of the root into the
periradicular lesions and calcium hydroxide placed as a
dressing. In time (10 days in the first case), the
amalgam was transported through the sinus tracts
into the oral cavity. Healing of the lesions advanced
and the symptoms as well as the fistulas disappeared,
which was confirmed in 42- and 65-month recalls.
The authors presumed that failure of apicoectomy as
well as of the initial attempts at non-surgical
retreatment might be due to bacterial contamination
of the interface between the root canal wall and the
retrograde filling, which can be sufficiently disinfected
only after removal of the amalgam. The treatment
technique chosen in these two cases inhibits the risk
of persisting periapical inflammation due to
contaminated debris inside the lesion. However, it can
be speculated that the immune system might have had
better opportunities to eradicate infection around the
amalgam as well as in the most apical part of the roots
after removal of the fillings.
Non-removal of retrograde filling
In some case reports, no attempt was undertaken to
remove the retrograde filling. The filling material
73
H€
ulsmann & Tulus
was removed from the coronal part of the root canal
until the retrograde filling material was reached. The
root canals were disinfected using different irrigation
regimens; in some cases, calcium hydroxide was used
as an additional temporary dressing.
A similar procedure has been proposed for
retreatment cases in which solid filling materials
could not be removed or bypassed (83). In cases of
the preoperative presence of a lesion, a significantly
lower success rate should be expected if no access to
the apical tissues can be achieved and infected
material remains inside the root canal.
Determination of working length
There are no studies clarifying the optimal working
length in the non-surgical retreatment of root-end
resected teeth. Apical extrusion of irrigants, bacteria,
and filling material due to over-instrumentation
should be avoided, as well as insufficient disinfection
and incomplete re-obturation due to underestimation
of root length. Nevertheless, it should be kept in
mind that both can occur at any selected retreatment
length.
The determination of the endodontic retreatment
length may present some major difficulties as the
level and angle of the resection cannot be determined
exactly on the radiograph. If a decision is made not to
remove the retrograde filling or if attempts at removal
have been undertaken but failed to pass beyond the
coronal extension of the retrograde filling, this will
mark the maximum penetration depth for re-
preparation, irrigants, medication, and re-obturation.
In apicected roots without a retrograde filling, the
apical constriction has been removed during
apicoectomy, resulting in an open apex with unknown
diameter and unknown angle of the bevel.
In an ex vivo study, El Ayouti et al. (84)
investigated the accuracy of three electronic apex
locators (Root ZX, Morita, Tokyo, Japan; Raypex 4,
VDW, M€ unich, Germany; ApexPointer, MicroMega,
Besancßon, France) in locating the apical terminus of
root-end resected teeth. All three apex locators were
used with a stainless steel file ISO size 15 and
showed acceptable accuracy and located the apical
terminus within 1 mm in 90%, 74%, and 71% of the
cases, respectively. No over-instrumentation occurred
with the Root ZX, but it did in 4% of the cases with
the other devices. Accuracy was influenced by the size
74
of the root canal at the apical terminus, with larger
sizes resulting in an underestimation of the root
length. Uzun et al. (85) investigated the measuring
accuracy of two apex-locating handpieces in apicected
roots in vitro (Tri Auto ZX, Morita, Kyoto, Japan;
TCM Endo V, Nouvag, Goldach, Switzerland). In
both devices, the Auto Reverse Function (ARL)
started past the resected root length (RL) (approx.
0.3 mm for the Tri Auto ZX and 1.3 mm for the
TCM V). The electronic measurement (EL) of the
devices (without rotary motion) was 0.3 mm shorter
than the RL for the Tri Auto ZX and 0.01 mm longer
than RL for the TCM V. The authors suggest that the
over-instrumentation with the Auto Reverse Function
is caused by the time elapsed between the electronic
measurement of the apical terminus and the stop
function of the motor’s rotation and recommended
the use of apex locators for determination of working
length only in the length-measuring mode without
file rotation.
Using electronic apex locators in teeth with
incomplete apex formation has been shown to be
inaccurate when using apex locators of the first
generations measuring electric resistance (86,87). In
35 teeth with incomplete root formation, Baggett
et al. (88) investigated the accuracy of endodontic
working length determination using absorbent paper
points. In 95% of the cases, tactile determination of
the apical terminus was within 1 mm of the
radiographically determined length. Whether the
presence of dentinal cracks and incomplete fractures
influences the accuracy of electronic length
determination has not yet been investigated.
In a review, Kim & Lee (89) reported conflicting
results on electronic working length determination
in teeth with apical resorption ranging from 62% to
96.2% accuracy (both with  0.5 mm tolerance).
In many cases, the most apical level of the root
canal can be visualized through the dental
microscope, regardless of whether this is a retrograde
filling or vital periradicular tissue. In such cases, the
value of a radiograph for length determination may be
controversial as it will not present additional
information. Nevertheless, a length determination
radiograph, although with limited reliability, may be
important for documentation and legal issues.
El Ayouti et al. (90) described the use of a size 25
K-file with the tip (0.5–1 mm) bent to a 90° angle.
The pre-bent tip is used to circumferentially probe

the root canal walls and to detect the apical terminus
of root dentin in teeth with open apices. This may
be a helpful technique especially in apicected roots
with a severely beveled resection surface. In an
in vitro study, the authors determined the accuracy
of this probing technique to be 97% (0.5 mm) in
detecting the most apical terminus of the root.
Nevertheless, it remains to be clarified whether the
most apical or the most coronal level of the
resection plane represents the optimal treatment
length.
Preparation and disinfection
The aim of re-preparation is to clean as much space
of the root canal system as possible, which includes
preparation of previously undetected and unprepared
root canals, enlargement of isthmi, and preparation
of previously unprepared parts of the root canal wall.
Basically, the rules for retreatment of roots which
not have undergone apicoectomy apply.
The endodontic literature does not present any
evidence-based information or other useful data on
the optimal irrigation regime for non-surgical
retreatment of failed apicoectomies. Additionally, no
information is available on the microbiota colonizing
root canals following unsuccessful endodontic
surgery. If coronal leakage can be identified as a
reason for failure, the presence of E. faecalis and
fungi should be expected as demonstrated frequently
in failed primary treatment (11). The disinfection
protocol should be defined accordingly.
Due to the wide-open apex after removing the
filling material and, if indicated, the retrograde
filling material, there is a high risk of extrusion of
irrigants into the periapical tissue. The problems of
irrigation mishaps and the severe sequelae of such
incidents have been reviewed in detail in a previous
issue of this journal (91). The literature does not
show any preference concerning the concentration of
sodium hypochlorite for disinfection of immature
teeth or teeth with open apices or apical resorption.
Basically, irrigation should be performed as described
for non-surgical retreatment of failed primary
endodontic treatment, including irrigation with 2%
chlorhexidine to eradicate bacterial species that have
survived the previous treatment approach (92).
Even highly concentrated sodium hypochlorite can
be safely used as an irrigant without danger of
Non-surgical retreatmet after apicoectomy
irrigation mishaps during removal of the coronal
filling material until the root-end filling is partly
removed. It seems reasonable to disinfect the
coronal parts of the root canal intensively before
removal of the retrofilling is started as this will
reduce the risk of apical extrusion of bacteria.
Following removal of the root filling or the
retrograde filling, bleeding may occur from the
inflamed periradicular tissues, thereby not allowing
sufficient inspection of the root canal and the apical
tissues and hindering root canal obturation. Tulus
(93,94) achieved hemostasis from apical bleeding
using a laser; the type of the laser was not specified.
Whether the use of ferric-(III)-sulfate, frequently
and successfully used for hemostasis in pulpotomy in
primary teeth (95,96), or comparable hemostyptic
substances can be recommended has not yet been
proven.
Recently, a new approach, the “apexum
procedure,” has been suggested by Metzger et al.
(97,98). This technique aims at modification and
improvement of healing kinetics by minimally invasive
destruction and removal of inflamed periradicular
tissue, which is first “minced” by rotary instruments
and then washed out and suctioned from the lesion.
The chronic lesion shall be converted into new
granulation tissue, thus promoting tissue repair. In
animal experiments (97) and an in vivo clinical trial
(98), this technique showed significantly enhanced
healing kinetics with no noticeable adverse events
occurring. The large apical opening following
apicoectomy may facilitate the use of this technique.
Whether the “apexum procedure” can be helpful in
the treatment of extraradicular infection has yet to be
elucidated.
Re-obturation
Basically, the material for re-obturation of the apical
part of the root canal should show the same
properties as a retrograde filling material: good
sealing ability, high biocompatibility, no shrinkage,
low solubility, and ease of application.
MTA has been suggested as a filling material in
the endodontic treatment of immature teeth with
incomplete root formation as an alternative to
classical apexification using calcium hydroxide (99).
As remnants of Hertwig’s epithelial sheet should not
be expected to be present after apicoectomy, MTA
75
H€
ulsmann & Tulus
seems to be the preferable material for apical closure.
MTA already has been widely used for retrograde
obturation during apicoectomy (100,101) and has
been shown to have excellent biocompatibility. The
literature on MTA has recently been excessively
reviewed (70–72). New types of bioceramic
materials, namely Biodentine (Septodont, Fausse-
sur-mer, France), Totalfill (Brasseler, Savannah, GA,
USA), and others have just been introduced but
reliable information and data on their clinical use are
still missing (102).
Giuliani et al. (99) reported on the treatment of
three incisors with open apices and necrotic pulps.
Following preparation and irrigation with 3% NaOCl
and medication with calcium hydroxide for 1 week,
the apical 4 mm of the root canals were filled with
MTA under the dental operating microscope. No
further compaction with ultrasonics was performed.
All three cases were rated to be successful after 1
year. In a case series, the same group of authors
demonstrated successful treatment outcomes after
placing apical MTA plugs in 10 out of 11 teeth with
immature roots (103). A prospective study on
single-visit apexification using MTA revealed a
success rate of 77% (33/43 teeth) (104).
Witherspoon & Gutmann (105) treated 144
immature teeth with MTA as an apical plug in one
or two appointments. 78 teeth were checked after a
mean time of 19.4 months (54% recall). Of the
treated teeth, 93.5% (single visit) and 90.5%
(multiple visits) had healed. Only 6 of these 78 teeth
(7.7%) presented with persisting disease,
demonstrating high success rates for both strategies.
Holden et al. (106) reported a success rate of 85%
(17/20 teeth) for the apical barrier technique with
MTA plugs in the treatment of teeth with immature
apices. In a study by Sarris et al. (107), who treated
17 non-vital permanent incisors with immature roots
using MTA, the clinical success rate was 94.1% and
the radiographical success rate 76.5%. In a
retrospective analysis of 78 teeth with open apices
due to apical resorption or excessive apical
enlargement that were treated with MTA, 84%
healed (recall rate 72%) (108). A medication with
calcium hydroxide significantly improved the
adaptation of an MTA apical plug (109); therefore, a
two-visit approach may be considered. In a long-
term study on perforation repair using MTA, all 16
teeth healed (110). In another study on the
76
treatment outcomes of root perforation repair with
MTA, 18 out of 21 teeth (86%) healed (111). The
low number of cases in these clinical studies should
indicate cautious interpretation of the results.
The thickness of the apical MTA plug should not
be less than 4 mm (112–114). It is recommended to
compact the MTA with an ultrasonic impulse onto
the plugger (113). Of course, this procedure carries
a certain risk of unintentional extrusion of MTA into
the periradicular tissues. Another research group
(115) could not confirm the superiority of
ultrasound-assisted placement of MTA compared to
manual compaction. They described more voids and
poorer adaptation to the root canal wall following
the use of ultrasound. Higher condensation pressure
results in fewer voids but in significantly reduced
surface hardness as the space for intracrystalline
water, which is necessary for MTA hardening, is
reduced by pressure (116). An internal matrix, as
discussed later, can be helpful to avoid or at least
limit such overfills.
Tahan et al. (117) presented a case with
unintentional excessive apical extrusion of MTA in a
tooth with incomplete root formation, large apical
periodontitis, and a fistula. Despite this incident, the
tooth remained symptom-free and the sinus tract
had closed at the 2-week recall. The 1-year recall
demonstrated complete healing of the periradicular
lesion, although the MTA was not resorbed. No
signs of inflammation were visible around the
surplus material. Experimental studies have
demonstrated that MTA, when in contact with vital
tissue, is not resorbed but surrounded by newly
developed hard tissue (118). Mente et al. (108)
could not detect a negative impact on the success
rate of overfilled MTA in the treatment of teeth with
open apical foramina. In an animal study, Shabahang
et al. (119) demonstrated a small band of calcified
tissue around apically extruded MTA.
Matrix concepts
The “internal matrix concept” for perforation repair
was first described by Lemon (120). He defined
three requirements for successful non-surgical
perforation repair: hermetical seal of the defect with
a non-resorbable biocompatible material, no
contamination of the material by hemorrhage, and
prevention of over- or underfilling. He suggested

the use of hydroxyapatite to create a matrix that can
prevent overfilling and allows proper compaction of
the repair material into the perforation. Bargholz
(121) reported on the use of resorbable collagen
compacted outside the perforation and thus creating
a semi-solid matrix against which MTA can be
pressed. As the pressure necessary for the application
of MTA is not as high as for amalgam, gutta-percha,
or other repair materials, the consistency of collagen
is sufficient to create an “artificial floor” that
prevents overfilling. The material will be resorbed,
allowing bone and tissue to grow in its place and
provide close contact with the highly biocompatible
MTA. Additionally, the use of freeze-dried bone,
demineralized bone, calcium sulfate, and other
materials for the internal matrix have been discussed
(120,122).
A case has been presented by Ruddle (123), who
removed a fractured instrument extending through
the resection site into the periapical tissues using
ultrasonics, placed barriers (no details on the
material used), and re-obturated three previously
resected main root canals with a warm obturation
technique.
The use of an internal matrix could be considered
when placement of an MTA plug does not seem
feasible and obturation material that needs to be
inserted or compacted with higher pressure is
preferred, or in cases with extremely large apical
openings with a high risk of overfill. Nevertheless,
there is no scientific evidence for a final
recommendation.
Indications and contraindications
At present, there are no clearly defined and
evidence-based criteria nor any useful data from
short- or long-term recall studies concerning
indications and contraindications for non-surgical
retreatment of failed apicoectomies. On the basis of
current knowledge, a strategy mainly should be
based on the reasons for failure of endodontic
surgery treatment as outlined by Saunders (2):
• Persistent microbial contamination of the root
canal system or recontamination via coronal
leakage.
These cases may be treated successfully by non-
surgical retreatment following removal of the
obturation material and proper disinfection of the
Non-surgical retreatmet after apicoectomy
root canal system. Whether removal of a retrofilling
is necessary and possible must be decided on a case-
by-case basis. Contamination of the gaps around a
retrofilling might prevent successful healing, so
removal of the retrofill should be attempted if
possible.
• Extraradicular infection.
If an extraradicular infection and/or an
extraradicular biofilm are present, non-surgical
treatment likely will not promote healing of a
periradicular lesion. This also may be the case if
contaminated retrofillings are pushed into the
periradicular tissue, thus initiating or sustaining an
extraradicular infection.
• Inability to seal the root canal system from the
periradicular tissues.
If proper obturation cannot be achieved, a non-
surgical attempt at retreatment does not look very
promising. Even a material such as MTA, which has
been demonstrated to show excellent sealing ability
as a retrofilling or in cases with wide-open apical
foramina or incomplete root formation, will not be
able to solve all clinical situations.
• Anatomical problems and anomalies preventing
sufficient disinfection and obturation.
Anatomical problems that are difficult to handle
include splitting of a root canal above the resection
level or curved root canals preventing inspection of
the most apical part of the apicected root. If an
isthmus is present, it should carefully be enlarged
using fine ultrasonic tips to allow proper disinfection
and obturation.
• Poor surgical techniques.
This includes teeth with an incorrect angle of
resection or with incomplete resection of the root
tip. An extremely beveled apical surface will be
difficult to disinfect using a non-surgical approach.
Determination of an optimal working length and an
adequate apical level of obturation can present
additional technical problems. An insufficient
retrofilling in some cases likely cannot be
(completely) removed, leaving contaminated areas
inside the root around the filling material.
• Dentinal cracks and microfractures.
Teeth with apical cracks and microfractures will
probably not respond positively to non-surgical or
surgical retreatment as closure or repair of such
fractures and cracks is not possible.
• Missed root canals.
77
H€
ulsmann & Tulus
If the missed root canal can be detected via an
orthograde access cavity preparation, (re)disinfection
of all root canals may offer a reasonable prognosis
for successful healing. It must remain speculative
whether the absence or presence of a retrograde
filling in the previously detected root canal(s) and
removal or non-removal of such a retrofilling
influences the prognosis if all of the root canals are
detected and properly instrumented.
Success rates
Analysis of case reports on non-surgical retreatment
of failed apicoectomies reveals that, in many cases
(19/63), only healing or progressive repair is
reported and only a few cases (24/63 teeth) have
been interpreted by the authors and operators as
being completely successful (Table 1) (26–
30,33,35,53,79–81,93,94,123–125,128–142). For
11 cases, no outcome data have been reported. Only
11 failures have been reported so far, which mainly
is due to a publication bias, favoring publication of
successful treatment. It should be noted that limited
short-term data are available at present and long-
term recall studies are still missing. These data
approximately represent the success rates as reported
in two contemporary investigations (143,144).
Recently, Ng et al. (145) published the results of
a prospective study on factors affecting the success
of non-surgical root canal treatment and
retreatment. Among the factors identified to
correspond with retreatment success were the
presence or absence and size of a periapical lesion,
presence or absence of a sinus tract, achievement of
patency at the canal terminus, and extension of
cleaning the root canal as close as possible to its
apical terminus. It should be expected that these
factors will also play an important role in the success
or failure of non-surgical retreatment after failed
apicoectomies.
To date, only three studies have been published
on the success rates for non-surgical retreatment of
teeth with persisting apical inflammation following
apicoectomy (143,144,146). Caliskan (146) non-
surgically retreated 11 surgically treated teeth with
apical lesions ranging in size from 2 to 11 mm in
diameter using calcium hydroxide as an
interappointment medicament and cold lateral
compaction of gutta-percha and Diaket (Espe,
78
Seefeld, Germany) as the sealer (surgical group).
Teeth were controlled after 2–8 years. 75
endodontically treated teeth with comparably sized
lesions were retreated and served as the control
group. The success rate in terms of complete healing
was 45.5% (5/11 teeth) for the surgical group with
2 uncertain cases (18.2%) and 4 failing cases
(36.3%). In the control group, the success rate for
lesions < 5 mm was 68.3% (28/41) and 58.8% (20/
34 teeth) for lesions > 5 mm. Incomplete healing
occurred in 12.2% and 14.7%, failure in 19.5% and
26.5%, respectively. It should be mentioned that
these figures of course are valid only for the specific
treatment technique of that study, including calcium
hydroxide medication, irrigation with 5.25% sodium
hypochlorite, use of chloroform as a solvent, in some
cases drainage by incision, and obturation using cold
lateral compaction. No mention has been made on
the use of a dental operating microscope, devices for
electronic determination of working length, or
ultrasonics for activation of the irrigant. MTA was
not used at that time for apical closure, but in 5
teeth of the surgical group, apexification with
calcium hydroxide was performed as the size of the
apical opening exceeded size 90. No information has
been included as to whether any teeth of the surgical
group presented with a retrograde filling and
whether the treatment mode was modified in these
cases. Thus, the value of the reported success rates
seems limited. The second study by Mente et al.
(143) comprised 25 cases, 23 of which were
followed for at least 1 year. Treatment was
performed using the dental operating microscope
and MTA as the material for the retrofilling. The
success rate was reported to be 87% (20 teeth), with
3 cases (13%) rated as failures. Incomplete healing,
termed as scar tissue, was considered to be a success.
Tulus et al. (144) presented the results of a
retrospective study on 86 consecutive cases (68.6%)
of non-surgical retreatment of teeth presenting with
persisting periapical inflammation following
apicoectomy. 59 of these teeth were recalled and
controlled radiographically approximately 1–2 years
after retreatment (median 20 months). All of the
teeth had been treated by an experienced
endodontist in private dental practice. Two groups
with primary endodontic treatment or retreatment
performed by the same endodontist during the same
time period served as control groups. In that study,
 Table 1: Survey and summary of case reports on non-surgical retreatment following unsuccessful apicoectomy

Apical periodontitis Retrograde Retrofilling Obturation

Authors Year Ref. Tooth clinical symptoms filling removed material Recall Healing Remarks
Stewart 1975 (26) 31 ap. period. no gp & sealer not reported not reported
41 ap. period. no gp & sealer not reported not reported
Kleier 1984 (124) 11 ap. period. amalgam no gp 18 months healing
21 ap. period. amalgam no gp 18 months healing
West & Lieb 1985 (27) 11 ap. period. no gp 1 year healing
Weiger 1992 (125) 22 ap. period. no gp 1 year healing
Ohara & 1992 (30) 32 ap. period. no gp not reported not reported treatment following
Torabinejad apical curettage
Chalfin 1993 (28) 34 ap. period. yes no gp 1 year healing add. root canal detected
15 ap. period. amalgam no gp 1 year healing add. root canal detected
26 ap. period. 2 x yes no gp 6 months healing only treatment of MB2
Moisewitsch 1998 (126) 12 ap. period. amalgam no gp & Roth’s 1 year healing
& Trope sealer
DeCleen 1999 (127) 26 ap. period. amalgam no not reported not reported not reported add. root canal detected
Fava 2001 (29) 15 ap. period. yes yes gp & Sealapex 27 months healed retrofill intent. pushed
through foramen
Friedman 2002 (128) 24 ap. period. amalgam no not reported 6 months healing
Sedgley 2003 (129) 46 ap. period. no gp & AH 26 5 years healed only 2 mesial r.c. were
& Wagner apicected and retreated
Ruddle 2004 (33) 16 ap. period. no not reported not reported healing add. root canal detected
Wong 2004 (130) 31 ap. period. no not reported not reported not reported
41 ap. period. no not reported not reported
Roda & 2006 (131) 15 ap.period. yes no not reported 1 year healed add. root canal detected
Gettleman
Tulus 2007 (93) 45 ap. period. no MTA 3 years healed
Herrmann 2007 (132) 11 ap. period. yes yes MTA 39 months healing
45 ap. period. yes yes MTA 23 months healing
Appel & 2007 (133) 21 clin. sympt. amalgam yes MTA not reported not reported
H€
ulsmann
B€
uttel 2008 (134) 11 ap. period. yes no Thermafil 2 months failure add. apicectomy
12 ap. period. yes Thermafil 2 months failure add. apicectomy
Tulus 2008 (94) 25 ap. period. no MTA 18 months healed

79
Non-surgical retreatmet after apicoectomy
80
H€

Table 1. Continued

Apical periodontitis Retrograde Retrofilling Obturation

Authors Year Ref. Tooth clinical symptoms filling removed material Recall Healing Remarks
St€
ockl 2008 (135) 34 ap. period. yes yes gp & AH plus 28 months healing add. root canal detected
ulsmann & Tulus

add. apicectomy
Kusgoz et al. 2009 (136) 32 ap. period. no MTA 30 months healed
Soares et al. 2009 (79) 22 ap. period. amalgam yes gp & sealer 42 months healing retrofills pushed through
12 ap. period. amalgam yes not reported 65 months healed foramen, dislodgement
of retrofills via fistulas
Bargholz et al. 2009 (35) 26 ap. period. amalgam no not reported 3 years healed add. root canal detected
Ree 2009 (137) 26 clin. sympt. amalgam no not reported 1 year healed add. root canal detected
12 clin. sympt. yes yes MTA not reported not reported
11 no silver cone yes MTA not reported not reported
Ruddle 2009 (123) 43 ap. period. amalgam lost into not reported 2 years healing
perirad. tissue
25 ap. period. amalgam no not reported 1 year healing
Noetzel 2010 (138) 21 ap. period. no gp & sealer 4 years healed
Pannkuk 2011 (81) 21 clin. sympt. amalgam yes MTA 3 years healed
11 ap. period. amalgam yes MTA 5 years healed
15 ap. period. amalgam yes MTA 5.5 years healing
11 no amalgam yes MTA 1 year healed
Nordmeyer & 2011 (80) 35 ap. period. yes yes MTA healed
H€ulsmann
Krupp 2011 (53) 11 ap. period. no no MTA not reported
21 ap. period. yes yes MTA not reported
26 ap. period. yes yes MTA 6 months healing
46 no yes yes MTA 8 months healed
21 ap. period. yes yes MTA not reported
25 ap. period. yes yes MTA 6 months healing
 Table 1. Continued

Apical periodontitis Retrograde Retrofilling Obturation

Authors Year Ref. Tooth clinical symptoms filling removed material Recall Healing Remarks
Appel 2011 (139) 36 ap. period. no MTA 3 years healed
16 ap. period. no MTA 2 years healed
17 ap. period. no MTA 1 year healed
46 ap. period. no MTA 1 year healed
46 ap. period. amalgam no MTA 2 years healed
Drebenstedt et al. 2011 (140) 21 ap. period. no failure extraction
32 ap. period. yes preop dislodged failure extraction
into apical tissues
24 ap. period. no failure extraction
11 ap. period. no failure extraction
15 ap. period. no failure extraction
Tripp 2015 (141) 15 ap. period. no MTA 1 year healed
Br€
usehaber 2016 (142) 16 ap. period. no MTA 3 years healed
14 ap. period. yes pal: no bucc: yes MTA 1 year healed
46 ap. period. yes no 2 years healed
Total 66 cases 12 failures 11 not reported 24 healed 19 healing

N.B. This survey is not the result of a systematical review.

81
Non-surgical retreatmet after apicoectomy
H€
ulsmann & Tulus

complete healing was achieved in 64.7% (41/59) of
the teeth with previous apicoectomy, an additional
11.8% showed signs of healing, and 23.5% were
classified as failures. Success rates for primary
treatment (n=66 teeth) were 75.8%, 59.4% for teeth
presenting with apical lesions, and 16.7% classified as
failures. In the retreatment group (49 teeth),
successful treatment was achieved in 77.6% (38/49)
of the teeth, with 22.5% failures. For teeth with
periapical lesions, the success rate was 64.3%. The
differences between the groups were not statistically
significant (Pearson’s chi-square test, P<0.05).
Case reports
Case 1
A 54-year-old male patient presented with clinical
symptoms on his maxillary right lateral incisor
(Fig. 7). Under the dental operating microscope, the
gutta-percha root filling was removed (Fig. 7b);
working length was determined electronically and
confirmed by a radiograph. The root canal was
carefully disinfected (EDTA 17%, NaOCl 1%, and
CHX 2%) and, following a 2-week dressing with
calcium hydroxide, was obturated with gutta-percha
and AH Plus (Dentsply, Konstanz, Germany) as a
sealer. During obturation, a slight extrusion of sealer
occurred. The 2-year follow-up presents with a
slightly widened periodontal space around the
surplus filling material (Fig. 7d).
Case 2
A 32-year-old male patient presented with
symptomatic apical periodontitis on tooth 35, which
had been apicected and obturated with retrograde
root-end filling of dental cementum (Fig. 8a). Most
of the cement was removed using an ultrasonic tip
(ProUltra, Dentsply). The radiograph demonstrated
incomplete removal of the retrofilling and an apical
splitting of the root canal (Fig. 8b). Following
placement of an apical matrix of collagen, which was
pushed through the apical opening into the
periapical space, the root canal was obturated with
MTA. The 3.5-year recall revealed complete
radiographic resolution of the radiolucency; the
tooth clinically was asymptomatic (Fig. 8c).
Case 3
A 48-year-old woman presented with frequent pain
episodes on her already apicected second maxillary
bicuspid. The radiograph showed a poor obturation
with silver cones and a large apical lesion. The root
filling was removed followed by thorough

A B C D

Figure 7. (a) Symptomatic apical periodontitis in an apiceted maxillary incisor. The radiograph suggests that an
apicoectomy has been performed on an insufficiently treated tooth without previous retreatment. (b) The root
filling material has been removed with some sealer still adhering to the root canal wall. No extrusion of filling
material is visible. Electronic determination of working length resulted in close relationship of the file tip to the
resection level. (c) Postobturation control demonstrating apical extrusion of MTA. (d) The 2-year recall shows
some MTA extruded into the periapical tissue. Good healing is evident with a widened periodontal space around
the extruded material. The tooth is clinically asymptomatic.

82
 Non-surgical retreatmet after apicoectomy

disinfection. Resorbable collagen was introduced
into the lesion and Totalfill (FKG, La Chaux-de-
Fonds, Switzerland) placed against this matrix in the
apical part of the root canal. Good healing was
observed at the 1-year follow-up (Fig. 9).
Case 4
A 46-year-old female patient presented with acute
symptoms on tooth 32. The tooth was mobile,
tender to percussion, and palpation was painful. It
showed a slightly increased probing depth circularly
around the tooth. The patient reported repeated
fistulation and swelling of the gingiva. The root had
been apicected several years before, which was
confirmed by scars in the buccal gingiva. The
radiograph revealed apical periodontitis on the
apicected tooth with the retrofilling being separated
from the root tip (Fig. 10). Following preparation
of an access cavity and removal of the gutta-percha
under the dental operating microscope using
Hedstroem files, pus discharged from the
periradicular tissue. Using microsuction, the exudate
was aspired and an attempt was undertaken to
remove the loosened retrofilling with a gauge 27
blunt needle. Under the microscope, the large apical
opening could be inspected with no visible signs of
root fracture. The lost retrofilling could not be
visualized. Working length was established both
radiographically and electronically. The root canal
was carefully irrigated with copious amounts of
CHX (2%) and NaOCl (1%). Finally, the irrigation
needle again was extruded through the large apical
opening of the root and the periapex was irrigated
with saline. Calcium hydroxide was placed as an
intracanal medicament and the tooth was
temporarily sealed. The patient was asymptomatic
for some weeks but then presented with buccal
swelling and tenderness to palpation and percussion.
After reopening the tooth, pus discharged,
confirming the diagnosis of an acute apical abscess.
Disinfection was repeated using the same protocol as
at the first appointment and the patient again was
asymptomatic for some weeks. After 6 months of
repeated disinfection and recurrent swelling or
fistulation, the tooth was extracted. As the tooth was

A B C

Figure 8. (a) Preoperative radiograph demonstrating a periapical lesion on an apicected tooth with a retrograde
filling (probably dental cement). (b) Incomplete removal of the cement with an ultrasonic tip. The localization of
the instrument tip suggests a splitting of the main root canal. (c) Following placement of an external matrix of
resorbable collagen (Kollagen-Resorb, Resorba, Nuremberg, Germany), the root canal was obturated using MTA.
The 3.5-year recall radiograph demonstrates excellent apical healing. Courtesy of Dr. Nordmeyer, Berlin, Germany.

A B C D

Figure 9. (a) The second maxillary bicuspid is poorly obturated with a silver cone, gutta-percha, and sealer and is
associated with a large inflammatory lesion. (b) Placement of resorbable collagen into the periapical lesion. (c)
Obturation of the apical part of the root canal with MTA. (d) The 1-year recall demonstrates good apical healing.

83
H€
ulsmann & Tulus

not saved by the oral surgeon, no inspection for Case 5

possible reasons of treatment failure could be
The patient presented with symptomatic apical
performed.
periodontitis on his left maxillary lateral incisor,
which had been apicected 3 years ago. The
preoperative radiograph suggests an extremely
beveled resection plane (Fig. 11a) and coronal
restoration with a customized post. Following
removal of the post with ultrasonics and of the root
filling material, working length was determined
electronically and verified by a radiograph. The
radiograph demonstrated over-instrumentation after
electronic measurement (Fig. 11b). The root canal
was disinfected and obturated with a plug of MTA
(Fig. 11c). The 1-year recall demonstrates
incomplete healing, which may be due to the
inability to properly disinfect the apical root surface
(Fig. 11d).

Figure 10. Displacement of the retrofilling into the
periradicular tissues. Non-surgical retreatment was not
successful in this case. The tooth was extracted following
repeated apical abscess on demand of the patient.
Case 6
A 13-year-old boy had been treated by his dentist
for pulp necrosis in his left maxillary central incisor
following a dental trauma. According to the dentist’s
report, the treatment had included root canal
treatment, obturation with sealer and a metal post,
and apicoectomy (Fig. 12a). The boy presented with
pain and swelling on tooth 21. A diagnosis was
made of acute apical abscess. Following removal of

A B C D

Figure 11. (a) A maxillary lateral incisor presenting with symptomatic apical periodontitis on an apicected tooth. A
metal post has been placed coronally. The preoperative radiograph suggests an extremely beveled resection plane.
(b) Following removal of the post and the filling material, working length was determined electronically and
radiographically. (c) The root canal was disinfected and obturated with a plug of MTA. The radiograph shows a
homogeneous apical MTA plug. The coronal part of the root was obturated some days later with an adhesively
cemented fiber post. (d) The 1-year recall demonstrates incomplete healing, which may be due to the inability to
properly disinfect the apical root surface.

84
 Non-surgical retreatmet after apicoectomy

A B the post, pus discharged from the root canal

(Fig. 12b). The root canal was disinfected using
NaOCl (1%) and CHX (2%) and medicated with
calcium hydroxide. Although this procedure was
repeated several times, fistulation persisted. Finally, a
CBCT demonstrated nearly complete bone loss on
the buccal aspect of the root and incomplete
resection of the root tip (Fig. 12c-d). The CBCT
suggested that a hole had been drilled into the root
tip, resulting in a complex anatomy that could not
be disinfected properly during retreatment. The
tooth was extracted.
C
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