ENDODONTIC

RETREATMENT (1)
Dr. Rasha Ahmed Abou Samra
The Glossary of Endodontic Terms published by the American
Asssociation of Endodontists gives retreatment the following
definition:
RETREATMENT:
A procedure to remove root canal filling materials from the tooth
followed by:
 Cleaning.
 Shaping.
 Obturating the root canals.
Such a definition seems to be over simplistic and restrictive,
because in many situations, retreatment is indicated when there
is no root canal filling to remove.

Such is the case when a failure results from a missed canal

during initial treatment. A more precise definition involving all
situations was needed.
CARR defined endodontic retreatment as:

A procedure that is performed on a tooth that previously has

had attempted definitive treatment and now requires further
treatment to ensure a successful result.
 Retreatment Vs. Initial Treatment
In terms of objectives, there is no difference between initial
treatment and retreatment.

In both situations, microorganisms must be eradicated from the

root canal system through:

 Shaping canals and 3-D cleaning.

 Filling and sealing the endodontic space.

 Retreatment Vs. Initial Treatment
INITIAL TREATMENT CASES

It must be appreciated that, in both straightforward and complex

initial treatment cases, all root canal systems are patent and
anatomic complexities can, in most instances, be overcome by a
skillful practitioner.
 Retreatment Vs. Initial Treatment
RETREATMENT CASES

 In contrast, the original canal patency is oftentimes lost or

severely compromised in the retreatment situation.

 Further, most of the teeth to be retreated have already been

restored, further compounding the retreatment challenges.
Retreatment is indicated on the mandibular first and second molars.
A. In contrast to the second molar, many coronal and intracanal obstacles are present on the
first molar.
B. A post-operative radiograph demonstrates the two treatments completed.
A. Radiograph of a mandibular left second molar reveals a poorly-fitting bridge, canals holding
a silver point and paste, and evidence of furcal and apical pathoses.
B. Ten-year recall radiograph shows the importance of three-dimensional endodontics and
restorative excellence.
 When providing root canal
treatment using today’s
techniques the clinician expects
excellent success rates.

 Initial root canal therapy,

however, does not always result
in healing for a multitude of
reasons.
 Criteria for endodontic success:
1. The treated tooth is asymptomatic & functional.

2. Healthy periodontium.

3. Soft tissue appears normal & responds normally to manual examination

4. Radiographically:

 No periapical pathosis develops after treatment.

 Pre-existing lesion heals.

 No new apical lesion develops during follow-up.

A: Extensive lesion in the region of the mesial root of tooth 36.
B: Completed root canal filling.
C: Follow-up radiograph 1 year later. Significant, but yet incomplete healing.
The periodontal ligament space appears to be widened. The tooth was symptom-free.
 Endodontic Failure
Endodontic Failure has been defined in some studies as a recurrence of
clinical symptoms along with the presence of a periapical radiolucency.

 An endodontically treated tooth should be evaluated clinically as well as

radiographically for its root canal treatment to be deemed successful.

 Patient should be scheduled for follow ups to ascertain that the treatment is
a success and the tooth in question is functional.
 How to identify a failed case?
1. Swelling /persistent pain / resorption/ mobility/ the
treated tooth is symptomatic.

2. Incomplete or deficient existing root canal treatment.

3. Procedural errors (perforations, ledges, separated

Poor obturation
file,….) with periapical
infection
4. Non-healing periapical lesions.

5. New apical lesion develops during follow-up.

 The causes of the initial endodontic treatment failure can
include inability of the procedure to eradicate bacteria.
 Failure to adequately disinfect the root canal system may result
in failure of the endodontic treatment.
 Bacteria may persist after initial treatment as a result of areas
that were inaccessible to instrumentation and irrigation.
 Enlarged lesion
Symptomatic

A. Radiograph indicating presence of asymptomatic persistent apical periodontitis 7 years

after initial treatment. The patient elected no treatment at that time.
B. Six-year follow-up. Lesion has enlarged and the tooth has become symptomatic.
 INCOMPLETE OBTURATION
Periapical radiograph of the maxillary left
first molar is showing the presence of
apical pathosis.
A patient has had sensitivity to palpation
and percussion.
Recently the American Association of Endodontists has proposed the
following alternatives to the terms “success” and “failure”:
• Healed: Functional, asymptomatic teeth with no or minimal radiographic
periradicular pathosis.
• Nonhealed: Nonfunctional, symptomatic teeth with or without radiographic
periradicular pathosis.
• Healing: Teeth with periradicular pathosis that are asymptomatic and
functional.
• Functional: A treated tooth or root that is serving its intended purpose in the
dentition.
 Determination of success or failure may be difficult because of the nature
and complexity of the periapical healing process itself and as a result of
difficulties in observation.

 Many asymptomatic endodontically treated teeth demonstrate varying

degrees of apical lesions radiographically.

 The clinician must judge whether a tooth is on a pathway to success or to

failure and then decide together with the patient the proper course of
treatment if indicated.
For endodontically treated teeth with previously vital pulps and
no preexisting apical lesion:
• The tooth remains asymptomatic
• No periapical pathosis develops after treatment.
Success
• New symptoms.
• The appearance of a periapical lesion.
Failure
For a tooth with a diagnosis of pulp necrosis:

• If the tooth remains asymptomatic.

• Pre-existing apical periodontitis heals.
Success • No new apical lesion develops during follow-up.

• The presence of symptoms.

• Enlarging lesion.
Failure • A new lesion.
The causes of post-treatment disease.
1. Intraradicular microorganisms.

2. Extraradicular infection.

3. Foreign body reaction.

4. True cysts.
Causes of endodontic treatment failure:

1) Lack of tooth isolation during

root canal therapy.
2) Inadequate cleaning, shaping,
Periapical radiograph of
and irrigation. mandibular second molar is
showing incomplete obturation
3) Incomplete obturation. and large periapical pathosis.
 Causes of endodontic treatment failure:

4) Anatomic variations in the root

canal anatomy went undetected
in the first procedure.
5) Root canal obstructions,
(A) Poorly shaped and obturated first mandibular
including calcifications, can bicuspid, note only one canal is treated.
also be a problem. (B) Retreatment reveals missed second canal.
Causes of endodontic treatment failure:

6) Missed canals.
7) Overextension of root filling materials.
8) Procedural errors can negatively affect the
treatment outcome:
 Perforations.
 Canal transportation.
 Fractured instruments.
 Ledge formation.
Causes of endodontic treatment failure:

9) Loss of coronal seal (missing coronal

restoration)

Coronal microleakage and recurrent decay can

expose the root canal filling material to bacteria
leading to reestablishment of root canal infection
Suspected coronal
after initial treatment which may also lead to leakage of bacteria.

progression of disease.
Causes of endodontic treatment failure:

10) Initial treatment may be compromised by long-term use of

temporary materials before placement of definitive restorations.
11) Necrotic tissues remaining in the root canal either through failure
to identify all the canals or treating canals shorter than the
working length.
Causes of endodontic treatment failure:

12) Extra-radicular infection: Bacterial cells can invade the

periradicular tissues either by:
a) Direct spread of infection from the root canal space.

b) Via contaminated periodontal pockets that communicate with the apical area.

c) Extrusion of infected dentin chips.

d) By contamination with overextended, infected endodontic instruments.

Causes of endodontic treatment failure:

13) Foreign body reaction: the presence of foreign material in the

periradicular area causing inflammatory response.

14) Vertical root fracture(VRF), traumatic injuries, periodontal disease,

excessive removal of tooth structure (predisposing teeth to fracture) may
lead to treatment failure.
 Vertical root fractures (VRF)

Typical J-shape lesion along the mesial Exploratory surgery may be needed to
root surface of the mesial root in a first confirm the presence of vertical root
mandibular molar. Note that two metallic fracture in some cases .
posts are present in the mesial root.
 Diagnosis and Retreatment Options

Diagnosis of a tooth in need of endodontic retreatment should be

based on:
1. Clinical signs and symptoms: (Palpation and percussion
sensitivity- Localized swelling)
2. Radiographic Examination: Periapical radiographs and when
necessary, cone beam computed tomography (CBCT).
CBCT images reveal more periapical lesions compared with the two-
dimensional conventional radiographic techniques.
 Diagnosis and Retreatment Options
Periapical radiographs should be taken in two different horizontal
angles to evaluate:
a) The quality of obturation.
b) Crestal bone level.
c) Presence of missed root canals.
d) Procedural errors.
e) Resorptions.
f) Lateral or periapical radiolucent lesions
 transportation
perforation ???

Importance of taking preoperative periapical radiograph with different angles.

(A) Mandibular left second molar shows broken instruments in one of the mesial root
canals.
(B) Different horizontal angle of the same tooth shows a possibility of root canal
transportation as well as perforation in the same root
 Importance of taking preoperative periapical radiograph with different angles.
(A) Periapical radiography of the maxillary left first molar when taken from distal
resulted in superimposition of the distobuccal root over the palatal root.
(B) Taking the radiograph with a different horizontal angle shows broken instrument
in the distobuccal root.
 Diagnosis and Retreatment Options
An investigation by Torabinejad et al. showed that 20% of the
teeth with a history of root canal therapy that had no visible
radiographic periapical lesions exhibited periapical
radiolucencies >1 mm in size when evaluated by CBCT.
They recommended further follow-up of the case to determine
the true nature of these radiolucencies.
The cautioned clinicians not to consider all these lesions as
treatment failures because the radiolucency might be:
1) Persistent periapical disease.
2) A previous lesion in its healing phase.
3) Fibrous scar tissue: some patients will present asymptomatic,
yet may exhibit a periapical radiolucency that may, in fact,
be healing by scar tissue formation.
 An example of following-up a case that shows periapical lesion in CBCT image.
(A) Presence of a large periapical lesion around the maxillary left lateral incisor.
(B) Root canal treatment of the lateral incisor.
(C) Periapical healing 2 years after the treatment.
(D) CBCT shows the presence of a radiolucency around the maxillary lateral incisor in axial view of the
tooth that was treated 2 years ago.
No treatment should be performed for this case because the patient is symptom free and the follow-up
radiograph showed healing compared with the preoperative radiograph.
For endodontic retreatment purposes CBCT could be ordered if:
(A) Conventional two-dimensional radiography (periapical) did not provide

enough information regarding the reason(s) for failure in a tooth that

previously received endodontic treatment.

(B) Conventional two-dimensional radiography (periapical) shows the

possibility of complex root canal anatomy in a tooth with a history of
endodontic therapy.

(C) There is possibility of mishaps and overlooked root canal(s) that are not

adequately detected by conventional two-dimensional radiography

 (A) Conventional two-dimensional radiography (periapical) did not provide enough
information regarding the reason(s) for failure in a tooth that previously received endodontic
treatment

Maxillary left second premolar received root canal therapy 2 years ago; however, the patient
complained of pain and sensitivity on percussion and palpation since the treatment visit.
The CBCT image in coronal view showed apical perforation in the buccal root.
(B) Conventional two-dimensional radiography (periapical) shows the
possibility of complex root canal anatomy in a tooth with a history of
endodontic therapy.

(A and B) Periapical radiography showed

possibility of a complex root canal anatomy
in mandibular left first molar.
(C) CBCT image in axial view showed that
the distolingual canal had been overlooked
(white arrow).
(D) The tooth received endodontic
retreatment.
 (C) There is possibility of mishaps and overlooked root canal(s) that are not adequately
detected by conventional two-dimensional radiography

Trifurcation
perforation.

(A) The maxillary right first molar with inadequate root canal therapy showed a possibility
of mishap during access cavity preparation.
(B) CBCT images in coronal showed trifurcation perforation.
It would be wise to precisely evaluate each case by clinical
and radiographic examinations and, if necessary, refer the
patient to a periodontist or a prosthodontist to make sure that
the tooth is restorable and to assess the need for crown
lengthening in order to place a suitable full-coverage
restoration after endodontic retreatment. This consultation
may be as simple as a brief conversation or even referral of the
patient, but a second opinion is extremely useful in these
situations.
Indications for Nonsurgical Endodontic Retreatment
(A) Retreatment is considered the primary procedural option
when the tooth exhibits:
1. Inadequate initial root canal treatment.
2. Palpation and percussion sensitivity.
3. Localized swelling.
4. Recurrent caries.
5. Leaky provisional restorations.
6. Substandard or missing coronal restorations.
Indications for Nonsurgical Endodontic Retreatment
(B) Radiographic evaluation may show:
1. The presence of untreated canals.
2. Poor canal obturation with voids.
3. Separated instruments.
4. Recurrent caries.
5. Defective restorations with open margins that can
potentially contribute to failure of the endodontic
treatment.
In most instances, nonsurgical root canal retreatment is the
first treatment of choice for:
 Overcoming a non-healing outcome of a previous root canal
treatment.
 Correcting a previous inadequate endodontic treatment with
no clinical and radiographic signs of failure.
In addition to performing endodontic retreatment for the failed cases. In
some instances, endodontic retreatment should be performed for teeth
with inadequate root canal therapy despite the absence of clinical signs
or symptoms and radiographic pathosis.

1) The fracture of the preexisting restoration (loss of coronal seal).

2) Retreatments are indicated in teeth with poorly sealed canals when a

complex treatment planning involving periodontics and prosthodontics is
scheduled (these cases should be considered as potential failures).
If a new restoration is scheduled in case of inadequate root canal therapy despite the
absence of clinical signs or symptoms and radiographic pathosis, these cases should be
considered as potential failures and retreatment should be considered prudent.

A. Retreatments are indicated in teeth with poorly sealed canals when a complex
treatment planning involving periodontics and prosthodontics is scheduled.
B. 12-year follow-up radiograph after retreatments and final restoration.
A major factor to determine the requirement for nonsurgical
retreatment is the restorability of the tooth after the necessary
removal of pre-existing restorative materials.
Additional tooth structure may be lost during caries
elimination and removal of post and core materials.
 A. Limited visibility and access
with crown present.
B. Enhanced visibility and
access after removal of the
crown.

The restorability decision often requires comprehensive

disassembly of preexisting restorations, removal of caries and
evaluation of the remaining root canal system.
Contraindications for Nonsurgical Endodontic Retreatment
1. Non restorable tooth.
2. The presence of extensive periodontal involvement that
weakens tooth support.
3. The presence of problematic coronal or radicular fractures.

Patients who are not motivated to save the natural tooth are
poor candidates for retreatment.
Treatment Planning for Nonsurgical Retreatment

There is no unique treatment plan for all the teeth with

a history of endodontic therapy and non-healing
periapical lesions.

Each case should be evaluated individually.

 Risks and Benefits of Retreatment
Nonsurgical root canal retreatment procedures have potential
risks as:
1. Fracture of a porcelain crown during the access procedure.
2. Iatrogenic challenges may arise such as:
a) Extensive removal of tooth structure.
b) Canal transportation.
c) Creation of ledges, or perforations.
d) The separation of an instrument is also possible, which may
impede the ability to completely remove obturation materials.
These complications potentially affect the retreatment outcome
 Risks and Benefits of Retreatment

The benefits of retreatment include:

1. The preservation and retention of the patient’s natural tooth.
2. The avoidance of more extensive clinical treatment and costs.
The treatment options in endodontics, when previous
root canal therapy is showing signs of failure:
1) Nonsurgical root canal retreatment.
2) Surgical endodontics.
3) Possible extraction followed by placement of an implant.
Nonsurgical endodontic retreatment is usually preferred
to other treatment options because the procedure is less
invasive than:
» Surgical endodontics

» Extraction and replacement with implant.

THE SURGICAL OPTIONS MAY INCLUDE:

1. Periradicular curettage.
2. Apical root resection.
3. Root amputation.
4. Hemisection.
If the cause of the post-treatment disease is either:
1. Persistent extraradicular infection.
2. Foreign body reaction.
3. The presence of a true cyst.
Then nonsurgical root canal therapy has little likelihood of allowing healing
to occur, and surgical methods should be employed.

If there has been a previous procedural complication such as:

 A ledge that cannot be bypassed.
 A separated instrument that cannot be removed.
Then surgery may become a better option.
The goals of nonsurgical endodontic retreatment are to remove
materials from the root canal space and if present, address deficiencies
or repair defects that are pathologic or iatrogenic in origin.
Thank you