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C ASE REP ORT

Orthograde retreatment and apexification after unsuccessful endodontic treatment, retreatment and apicectomy
1 Department of Cariology, Restorative Sciences and Endodontics, University of Michigan Dental School, MI, USA; and 2Tokyo, Japan

C. M. Sedgley1 & R. Wagner2

Abstract
Sedgley CM, Wagner R. Orthograde retreatment and apexification after unsuccessful endodontic treatment, retreatment and apicectomy. International Endodontic Journal, 36, 780^786, 2003.

Aim To describe a case where a second orthograde retreatment was successful in the management of an infected mandibular right rst molar that previously had received both orthograde and retrograde treatments. Summary Periapical surgery is unlikely to be successful unless the root canal system has been adequately debrided and sealed. A case is described where orthograde endodontic treatment, retreatment and apicectomy were unsuccessful in the management of an infected mandibular right rst molar. The periapical radiolucency eventually disappeared following a second orthograde retreatment. The second retreatment included 12 months of intracanal calcium hydroxide placement to promote apexication, thus allowing subsequent controlled obturation with gutta percha and AH26. At a 5-year review following completion of treatment, the tooth remained asymptomatic and was in normal function. Key learning points  Orthograde retreatment is a treatment option to manage refractory lesions in teeth that have previously received endodontic treatment, retreatment and apicectomy.  Orthograde retreatment using long-term intracanal calcium hydroxide can help promote root-end closure of a resected apex. Keywords: apexication, apicectomy, case report, orthograde, retreatment.
Received 16 January 2003; accepted 23 June 2003

Introduction Under optimal conditions, success rates of 96 and 74% have been reported following orthograde endodontic treatment (Sjogren et al. 1990) and retreatment (Sundqvist et al. 1998), respectively. A lower success rate is expected when bacteria are not eliminated from

Correspondence: Dr Christine Sedgley, Department of Cariology, Restorative Sciences and Endodontics, University of Michigan Dental School, 1011 N. University Drive, Ann Arbor, MI 48109-1078, USA (Tel.: 1 734 647 4182; fax: 1 734 936 1597; e-mail: csedgley@umich.edu).

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the root canal system prior to obturation, a process made more difcult with single-visit treatment (Sjogren et al. 1997), which eliminates the antimicrobial benets of an inter appointment dressing such as calcium hydroxide. Healing of refractory cases may be prevented by bacteria colonizing the root apex and surrounding periapical tissues (Happonen et al. 1985, Sundqvist et al. 1998, Nair et al. 1999). With failure of orthograde endodontic retreatment, periapical surgery may be indicated (Lovdahl 1992), but without elimination of bacteria from the root canal system, complete healing following apical surgery is unlikely (Grung et al. 1990, Danin et al. 1999). This report describes a case where, following previous failure of orthograde endodontic treatment, retreatment and apicectomy, a second orthograde retreatment procedure, using a long-term intracanal calcium hydroxide both as an antimicrobial agent and to promote root-end closure of the resected apex, was performed, and the periapical radiolucency eventually disappeared. Report A 48-year-old Caucasian male patient presented complaining of persistent extraoral stula and episodes of intraoral swelling associated with the mandibular right rst molar (tooth 46). Medical history was noncontributory. A complete coronal coverage with a ceramic-metal crown had been provided for tooth 46, 10 years before. Eight years later, the tooth was diagnosed with pulpal necrosis, and orthograde endodontic treatment was provided by a general dental practitioner (preoperative radiograph, Fig. 1). However, as the mesial canals had been overprepared (Fig. 2), the patient attended an endodontist for orthograde endodontic retreatment. In a one-appointment procedure, the mesial canals were debrided and obturated with gutta percha and sealer (type unknown), and the occlusal access cavity made through the crown was restored with amalgam. At the time of retreatment, 6 months after the original treatment, a periradicular radiolucency associated with the mesial root apex was apparent (Fig. 3). Within 10 months of retreatment, right submandibular lymphadenopathy and intraoral swelling in the buccal sulcus, adjacent to the mesial root apex of tooth 46, developed. The patient attended an oral surgeon, who resected the mesial root apex and cold-burnished the exposed apical gutta percha. At a 6-week review, healing was uneventful. However, within 10 months of surgery, both an intraoral buccal sulcus swelling and extraoral stula had developed, at which time the patient attended for further care. On clinical examination, the tooth was slightly tender to percussion and exhibited normal mobility. Periodontal health was excellent, and probing depths were normal. Crown

Figure 1 Preoperative radiograph mandibular right rst molar, 27 months before presentation to author.

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Figure 2 Initial endodontic treatment, 26 months before presentation to author.

Figure 3 Immediate post-retreatment radiograph, 20 months before presentation to author.

margins appeared intact clinically and radiographically. The margins of the occlusal access amalgam restoration placed 20 months previously appeared intact clinically. A radiograph showed that there was a periradicular radiolucency associated with the mesial apex of tooth 46 and that the occlusal amalgam did not extend to the canal orices (Fig. 4). All surrounding mandibular and maxillary teeth were caries-free. An extraoral stula at the apical level of the

Figure 4 Ten months postsurgery and at time of presentation to the author. An extraoral stula and nonuctuant intraoral buccal swelling are present.

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resected mesial root exiting externally at the border of the mandible and a nonuctuant intraoral buccal swelling adjacent to tooth 46 were evident, although nonpurulent at the time of examination. The patient reported taking Penicillin VK when the extraoral stula drained, and had recently completed a course of antibiotics. A provisional diagnosis was made of chronic suppurative apical periodontitis, with extraoral stula associated with unsuccessful orthograde and retrograde endodontic treatment. The patient was keen to retain the intact crown and avoid a second surgical procedure. It was therefore decided to undertake a second orthograde retreatment with the aim of rst debriding and disinfecting the mesial canals, and then, in the event of a favourable tissue response, inducing apexication to allow eventual obturation without extrusion of material into the periapical tissues. The coronal amalgam and radiolucent resin-like material under the amalgam in the pulp chamber were removed to expose the gutta percha. There was no clinical evidence of coronal leakage. The gutta percha was debrided from the mesial canals using Gates Glidden burs, Hedstroem and K-les with chloroform and 5.25% sodium hypochlorite (Clorox, The Clorox Company, Oakland, California, USA) irrigation. The mesial apices were readily patent using size 90 les. Following further irrigation with a 15% EDTA solution (with 0.75% cetrimide; Largal Ultra, Specialites Septodont, Saint-Maur, France) and 5.25% sodium hypochlorite, an intracanal dressing of Ledermix paste (Lederle Pharmaceuticals, Wolfratshausen, Germany) was placed and sealed coronally with cotton wool pellets, Cavit (ESPE, Seefeld, Germany) and intermediate restorative material (IRM, Dentsply Caulk, Milford, DE, USA). At a 1-week review, the extraoral stula was no longer patent and intraoral swelling had reduced considerably. Retreatment of the distal canal as originally planned was deferred at this time. After irrigation with 15% EDTA and 5.25% sodium hypochlorite, the mesial canals were lled with calcium hydroxide-casein paste (Reogan Rapid, Vivadent, Schaan, Germany) using a lentulo spiral paste ller. The access cavity was sealed with zinc oxide eugenol cement and amalgam as an interim coronal seal resistant to occlusal forces to minimize the possibility of coronal leakage owing to marginal breakdown. At a 6-month review, the tooth was asymptomatic, the extraoral stula had healed and there was radiographic evidence of partial bone healing. The mesial canals were irrigated with 5.25% sodium hypochlorite and redressed with calcium hydroxide and sealed coronally, as previously described. Another 6 months later, there was radiographic evidence of further bone healing (Fig. 5) and clinical evidence of an apical hard-tissue barrier adequate for obturation. The mesial canals were irrigated with 15% EDTA and 5.25% sodium hypochlorite and obturated with gutta percha and AH26 (Dentsply DeTrey GmbH,

Figure 5 Twelve months after second orthograde retreatment commenced. The mesial roots have intracanal calcium hydroxide in place.

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Figure 6 Three-year review.

Figure 7 Five-year review.

Konstanz, Germany) using lateral condensation. The access cavity and coronal 3 mm of all canals were restored with a bonding agent (Resinomer; Bisco, Inc, Schaumberg, IL, USA) and amalgam. At 3-year (Fig. 6) and 5-year (Fig. 7) reviews since obturation, healing was evident and the tooth remained asymptomatic and in normal function. The crown had been replaced because of suspected mesial marginal leakage. Discussion This report describes a case where orthograde root canal treatment, retreatment and root apex resection were unsuccessful in the treatment of an infected mandibular right rst molar. The periapical radiolucency eventually disappeared following second orthograde retreatment, and the tooth remained functional and asymptomatic 5 years after obturation. Placement of intracanal calcium hydroxide for 12 months promoted root-end closure and allowed obturation without extrusion of material into the periapical tissues. Similarly, Marais (1998) described a maxillary rst molar that had received orthograde endodontic treatment and apicectomy, but presented with persistent pain a few months later. Orthograde retreatment resolved the symptoms, but the author did not provide details on the review period and management of the open apex created by the apicectomy. With the present case, the difculty in obtaining apical stops to enable controlled obturation was

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overcome by long-term placement of calcium hydroxide, known to stimulate calcic barriers (Heithersay 1975) and exert an antimicrobial action (Stevens & Grossman 1983). Alternatively, after interim treatment with an antibacterial agent, mineral trioxide aggregate (MTA) could be considered for use as an apical plug, with an advantage being the speed at which the treatment can be completed (Giuliani et al. 2002). With the present case, another approach could have been preparation of apical stops using larger les, followed by obturation. However, preparation of apical stops beyond the existing size 90 was not considered an appropriate option for an already structurally compromised tooth. In addition, if an apical bevel had been placed during root resection, then enlargement of the canals to prepare apical stops could have zipped the root-end orices, ultimately further complicating the obturation procedure. The unsuccessful healing outcome despite adoption of an accepted treatment sequence (Lovdahl 1992) supports previous reports of the difculties in adequately debriding and disinfecting the root canal system in a single visit without the benet of interim antibacterial dressings (Sjogren et al. 1997). In addition, it is reasonable to suggest that an apicectomy in the presence of suppurative apical periodontitis might have a better prognosis in combination with root-end debridement and retrolling rather than cold burnishing of gutta percha alone. Retreatment of the distal canal, whilst originally planned, was not undertaken owing to the prompt response to mesial root treatment. Six years after commencing treatment, both distal and mesial root periradicular tissues appear healthy. The healing response to initial debridement of the mesial canals alone was rapid with longstanding symptoms resolving within 1 week. Ledermix, the intracanal dressing placed for the initial 1-week period, contains steroids and tetracyclines, which may have interfered with the production or action of macrophage-derived destructive mediators (Metzger 2000). In addition, the combined use of EDTA and sodium hypochlorite has been shown to possess more effective antibacterial action than exposure to sodium hypochlorite alone (Bystrom & Sundqvist 1985, Abbott et al. 1991). Interestingly, Molander et al. (1998) reported that bacterial growth from samples taken from the canals of root-lled teeth with apical periodontitis undergoing retreatment was signicantly inhibited when chloroform was used to dissolve gutta percha. At the time of initial presentation to the author, there was no purulent drainage and thus no microbiological samples were obtained. However, species identied in refractory endodontic lesions include Actinomyces israelii and Arachnia propionica (Happonen et al. 1985, Sjogren et al. 1988), and intracanal monoinfections of predominately Gram-positive organisms have been associated with failed endodontically treated teeth (Sundqvist et al. 1998), with Enterococcus species being the predominant species recovered (Molander et al. 1998, Sundqvist et al. 1998). Conclusions The present case supports previous reports that periapical surgery is unlikely to be successful unless the root canals have been adequately debrided and sealed (Grung et al. 1990, Danin et al. 1999). Orthograde retreatment using long-term intracanal calcium hydroxide both as an antimicrobial agent and to promote apexication of a resected apex could be considered as a treatment option for refractory lesions in teeth that have undergone apicectomy. Disclaimer Whilst this article has been subjected to Editorial review, the opinions expressed, unless specically indicated, are those of the author. The views expressed do not necessarily

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represent best practice, or the views of the IEJ Editorial Board, or of its afliated Specialist Societies. References
Abbott PV, Heijkoop PS, Cardaci SC, Hume WR, Heithersay GS (1991) An SEM study of the effects of different irrigation sequences and ultrasonics. International Endodontic Journal 24, 30816. Bystrom A, Sundqvist G (1985) The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. International Endodontic Journal 18, 3540. Danin J, Linder LE, Lundqvist G, Ohlsson L, Ramskold LO, Stromberg T (1999) Outcomes of periradicular surgery on cases with apical pathosis and untreated canals. Oral Surgery, Oral Medicine and Oral Pathology 87, 22732. Giuliani V, Baccetti T, Pace R, Pagavino G (2002) The use of MTA in teeth with necrotic pulps and open apices. Dental Traumatology 18, 21721. Grung B, Molven O, Halse A (1990) Periapical surgery in a Norwegian county hospital: follow-up ndings of 477 teeth. Journal of Endodontics 16, 4117. Happonen R-P, Soderling E, Viander M, Linko-Kettunen L, Pelliniemi LJ (1985) Immunocytochemical demonstration of Actinomyces species and Arachnia propionica in periapical infections. Journal of Oral Pathology 14, 40513. Heithersay GS (1975) Calcium hydroxide in the treatment of pulpless teeth with associated pathology. Journal of the British Endodontics Society 8, 7493. Lovdahl PE (1992) Endodontic retreatment. Dental Clinics of North America 36, 47390. Marais JT (1998) Failure of apicectomy surgery and successful endodontic retreatment. Journal of the Dental Association of South Africa 53, 1320. Metzger Z (2000) Macrophages in periapical lesions. Endodontics and Dental Traumatology 16, 18. Molander A, Reit C, Dahlen G, Kvist T (1998) Microbiological status of root-lled teeth with apical periodontitis. International Endodontic Journal 31, 17. Nair PN, Sjogren U, Figdor D, Sundqvist G (1999) Persistent periapical radiolucencies of root-lled human teeth, failed endodontic treatments, and periapical scars. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 87, 61727. Sjogren U, Happonen RP, Kahnberg KE, Sundqvist G (1988) Survival of Arachnia propionica in periapical tissue. International Endodontic Journal 21, 27782. Sjogren U, Hagglund B, Sundqvist G, Wing K (1990) Factors affecting the long-term results of endodontic treatment. Journal of Endodontics 16, 498504. Sjogren U, Figdor D, Persson S, Sundqvist G (1997) Inuence of infection at the time of root lling on the outcome of endodontic treatment of teeth with apical periodontitis. International Endodontic Journal 30, 297306. Stevens RH, Grossman LI (1983) Evaluation of the antimicrobial potential of calcium hydroxide as an intracanal medicament. Journal of Endodontics 9, 3724. Sundqvist G, Figdor D, Persson S, Sjogren U (1998) Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment. Oral Surgery, Oral Medicine and Oral Pathology 85, 8693.

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