RETREATMENT IN PERSISTENT APICAL

PERIODONTITIS
 Contents
Introduction
Endodontic success
Endodontic failure
Causes
Endodontic retreatment
Management of post treatment apical periodontitis
Non surgical endodontic retreatment
Conclusion
Reference
 Introduction
• Retention of natural teeth in an asymptomatic
condition  GOAL of endodontic therapy

• Lack of knowledge ,its poor application or break in

chain of proper procedures due to various causes 
FAILURE of endodontic treatment
• These failures can be attributable to
inadequacies in :
Diagnosis
Isolation
Access preparation
Cleaning and shaping
Obturation
Post space preparation
Instrument separation
Missed canals
Persistent infections
Iatrogenic events or re-infection of the root canal
system when the coronal seal is lost after
completion of root canal treatment
 ENDODONTIC SUCCESS
• Success should be determined on basis of defined criteria 
conclusions drawn by available resources that treatment was
well or badly performed are based on clinical and
radiographic criteria.

• Histological criteria will be defined in a second moment by

microscopic examination, when opportune and necessary.
EVALUATION OF ENDODONTIC SUCCESS
 CLINICAL CRITERIA
• According to Bender et al
– Absence of pain and swelling
– Disappearance of sinus tract
– No loss of function
– No evidence of soft tissue destruction, including probing defects
– Persistent findings like (swelling or sinus tract) indicates failures
 Success – defined by following criteria:
• Patient should be asymptomatic and be able to function
equally well on both sides
• The periodontium should be healthy, including a normal
attachment apparatus
• Radiographs should demonstrate healing or progressive bone
fill overtime
• Principles of restorative excellence should be satisfied.

• ( C.J.Ruddle )
 Radiographic Assessment

• Radiographic assessment is obligatory

• In cases with previous endodontic therapy, radiographs are useful in
– Evaluation of caries,defective restorations,periodontal health
– Quality of the obturation
– Existence of missed canals
– Impediments to instrumentation
– Periradicular pathosis
– Perforations,fractures,resorptions
– Canal anatomy

• Multiple angulated films should be used to determine endodontic etiologies

• CBCT:Untreated canals,root fractures,resorption
• Classified as
– Success
– Failure
– Questionable
• Success
– Absence of a radiographic resorptive apical lesion.
– A lesion present at the time of treatment has resolved
– Lesion not present at the time of treatment has not developed.

• So success is evident by an eliminated or non-developed area

of rarefaction after a post treatment interval of 1 to 4 years.
• Failure
– Persistence or development of radiographically evident pathosis.
– Radiolucent lesion that has enlarged, has persisted or has developed
since the treatment.

• Questionable
– A state of uncertainty Situation(radiolucent lesion)has neither become
worse not significantly improved
– A questionable status reverts to failure if the situation (non-resolution)
continues ,generally after a period of 1year.
 Histologic Examination

• Evidenced by reconstitution of periapical structures and an

absence of inflammation.

• Routine histologic evaluation of periapical tissues on patients is

impractical.

• Thus, clinical findings (signs and symptoms as well as radiographic

findings) are only means of assessing success and failure.
  ENDODONTIC FAILURE
• One of aspects responsible for adequate microbial control is
effective root canal preparation, achieved by adequate
cleaning and shaping.

• Goal of mechanical action of root canal instrumentation is

removal of contaminated material from main root canal.
• Irrigants are effective due to their antimicrobial properties,
solvent capacity and tissue tolerance.

• In addition to depth of their action, surface active volume

and capacity- surface tension are powerful allies.

• Associated with this stage, the intracanal dressing makes a

significant contribution to this antimicrobial process.
 FAILURES
• In the past, undesirable outcomes of endodontic therapy were
described as failures.

• Friedman states that “most patients can relate to the concept of

disease-treatment-healing, whereas failure, apart from being a negative
and relative term, does not imply the necessity to pursue treatment.”

• He has suggested using the term post treatment disease to describe those
cases that would previously have been referred to as treatment failures.

• Principles and practice of endodontics, ed 4, St. Louis, 2009.

• Considering endodontic microbiota present endodontic
infections can be divided into:

 Primary- infection observed in teeth not submitted to endodontic

treatment.
 Secondary- infection present in endodontically treated teeth.
 Persistent - an infectious process that does not respond positively to
endodontic treatment
Post treatment apical periodontitis
ETIOLOGY OF POST TREATMENT DISEASE

To effectively plan treatment, clinician may place

etiologic factors into four groups
1) Persistent or reintroduced intraradicular
microorganisms
2) Extraradicular infection
3) Foreign body reaction
4) True cysts

Essential Endodontology.Prevention and treatment of apical periodontitis ,2008

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 According to Nair et al
• Causes of microbial origin
• 1. Intra canal factors:
– a) Bacteria
– b) Fungi
• 2. Extracanal factor
– a) Actinomycosis
• Causes of non-microbial origin
• 1. Exogenous factor (foreign-body-reaction type)
a) filling material
b) paper tips
2. Endodgenous factor
a) Cyst
b) Cholesterol crystals
 INTRARADICULAR INFECTIONS
• Bacteria resisting effects of treatment usually located in areas of
difficult access by instruments and irrigants, and often in direct contact
with a source of nutrients from the periradicular tissues.

• Include the
– Apical part of the root canal
– Lateral canals,
– Apical ramifications,
–Isthmuses
–Dentinal tubules.
• Chances of a favourable outcome with root canal treatment
are significantly higher  infection is eradicated effectively
before root canal system is obturated.

• If microorganisms persist in root canal at time of root filling or

if they penetrate into canal after filling  higher risk that the
treatment will fail

- (Byström et al. 1987, Sjögren et al.1997).

Bacteria entombed by root filling usually die or are prevented
from gaining access to periradicular tissues.

Some bacterial species - survive for relatively long periods,

deriving residues of nutrients from tissue remnants and dead
cells.

If root canal filling fails complete seal, seepage of tissue

fluids can provide substrate for bacterial growth.

If growing bacteria reach a significant number and gain access

to periradicular lesion, they can continue to inflame
periradicular tissues.
•Microbiota associated with failed cases differs
markedly from that reported in untreated teeth
(primary root canal infection).

•T.denticola, P.alactolyticus, T.forsythia,

P.gingivalis, T. socranskii, P.endodontalis.

•Fungi are not found.

JOE 2008; 34(11), 1296

•Reduction of Gram-negative organisms following endodontic treatment and
subsequent proportional increase of Gram- positives facultatives.

•Streptococci ( Streptococcus mitis, Streptocoocus gordonii, streptococcus

anginosus, Streptococcus sanguinis and streptococuus oralis), Parvimonas
micra, Actinomyces species, Propionobacter species, Pseudoramibacter
alactolyticus, lactobacilli, E faecalis.
•Persistent infections are the major cause of post-treatment apical
periodontitis does not prevent secondary infections due to coronal
leakage.

•Cross-sectional studies indicate that the best outcome is achieved in

teeth with adequate root canal fillings associated with adequate
coronal restorations.

•It is advisable to treat the tooth as a continuum, placing a well-

adapted permanent coronal restoration as soon as possible after
finishing root canal treatment.

J Endod 2013; 39: 600–604.

Risk of reinfection is dependent on quality of root filling
and coronal seal

CORONAL
SEAL
(Saunders & Saunders 1994).
 EXTRA RADICULAR CAUSE
•Extraradicular infection may be associated with chronic
inflammation and lead to endodontic treatment failure.

•By defending themselves against the action of the

complement system, avoiding destruction by phagocytes,
causing immunosuppression, changing antigenic coats, and
inducing proteolysis of antibody molecules (Siqueira 1997).
•The extraradicular infectious process can be dependent on or independent of the
intraradicular infection.

•Dependent infection- maintained by constant proliferation and invasion of the

periradicular tissues by bacteria present in intraradicular infection.

•Cannot sustain itself without the intraradicular component.

•Independent infections - that are no longer fostered by an intraradicular infection and as

such may not respond to adequate root canal treatment.

• Endodontic Topics 2003; 6: 78–95.

•One of the most significant mechanisms of evasion from the host
defence system is the microbial arrangement in a biofilm.

•A biofilm can be defined as a microbial population attached to an

organic or inorganic substrate, surrounded by microbial extracellular
products, which form an intermicrobial matrix
• (Costerton et al )

•Biofilm formation is a step-wise procedure ,its formation occurs in

the presence of microorganisms, fluid and solid surface.
•Organized in biofilms, microorganisms show higher resistance to
both antimicrobial agents and host defence mechanisms when
compared with planktonic cells.

• (Costerton et al 1987, 1994, Gilbert et al. 1997).

 •By examining teeth refractory to root canal treatment, Tronstad
et al. (1990) reported the occurrence of bacterial biofilms
adjacent to the apical foramen and bacterial colonies located
inside periradicular granulomas.
-

- Int Endod J, 2001; 34, 1–10

•The major consideration regarding treatment of periradicular
biofilms is that the clinician cannot detect a biofilm in any
particular clinical case.

•Theoretically, microbiological sample could inform the clinician

if the root canal is bacteria free or if there are persistent
intracanal microorganisms
•Once root canal samples yield negative cultures, the canal is
obturated. If subsequent healing does not occur, then one may
suspect extraradicular infection.

•It is well known that intracanal disinfection procedures or

systemically administrated antibiotics can not easily affect
bacteria located outside the apical foramen.
•The placement of endodontic medicaments into the periradicular
tissues in order to eliminate microorganisms and to decompose
periradicular biofilms does not appear to be an adequate procedure.

• First, it is currently difficult or even impossible to clinically

diagnose extraradicular infections.

• Secondly, most endodontic medicaments are cytotoxic and/or may

have their antimicrobial effects neutralized after apical extrusion.
•The development of a nonsurgical strategy to combat
biofilms appears questionable.

•Therefore, extraradicular infections, if present, must

be treated by means of periradicular surgery.
So far, there is no clear evidence that an extraradicular infection
can exist as a self-sustained process independent of the
intraradicular infection.
J Endod 2008; 34: 1124–1129
Ricucci et al. evaluated several treated teeth with post-treatment
apical periodontitis and could not detect any case of independent
extraradicular infection.
J Endod 2009; 35: 493–502.
Non-microbial cause – fact or myth?
Endogenous causes include cholesterol crystals and true cysts,
Exogenous causes comprise foreign-body reactions to apically
extruded filling materials, paper points or food.
J Endod 2009; 35: 493–
502.
In most of these cases it is very difficult to rule out the
concomitant presence of infection as the cause of disease.
Therefore, the participation of non-microbial factors as the
exclusive cause of treatment failure has still to be consistently
proven.
•Disease associated with overfilled root canals is generally caused
by a
– Concomitant infection in cases where a proper apical seal is
missing, Favouring nutrient supply to residual bacteria in the
canal,
– or when infected dentinal debris are projected extraradicularly as
a result of previous overinstrumentation.

• B Dent J.; 2014;216 (6); 305-311

Procedural errors and post-treatment disease
•The major problem with a procedural accident arising during
chemomechanical procedures is when it prevents or makes it difficult
for the clinician to properly disinfect the apical part of the root canal.

•Such as-
– Missing canal, Fractured
instrument, Ledge
– Perforation
– Overfilling
 Treatment Plan
• Patient harbouring true endodontic posttreatment disease has four
basic options for treatment :

• Do nothing
• Extract the tooth
• Nonsurgical retreatment
• Surgical retreatment

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Endodontic retreatment
 DEFINITION
• A procedure to remove root canal filling materials from the
tooth , followed by cleaning ,shaping and obturating the canals.

- AAE
• Nonsurgical retreatment is an endodontic treatment
procedure used to remove materials from the root
canal space and, if present, address deficiencies or
repair defects that are pathologic or iatrogenic in
origin.

- (C.J.Ruddle)
 Endodontically treated tooth

Evaluation of treatment results

Established failure Potential failure

Feasibility of coronal access Evaluation of obturation quality

unfeasible Feasible Unsatisfactory Satisfactory

Needs new restoration

Needed Not needed

Surgery Retreatment new restoration Follow up Follow up

MANAGEMENT OF POST-TREATMENT APICAL
PERIODONTITIS
•Teeth with post-treatment apical periodontitis can be
managed by either nonsurgical endodontic retreatment
or periradicular surgery, some teeth are extracted, but
many remain untreated in spite of the evident pathosis.
•These two approaches differ significantly in rationale –

– Retreatment is an attempt to eliminate root canal infection,

whereas apical surgery is an attempt to enclose the infection
within canal.

– To foster confidence and appropriate management, definitive

criteria are required to select cases for extraction, retreatment
or apical surge
 CASE SELECTION
•Diagnosis.
– Presence or absence of disease is determined
according to clinical and radiographic findings.

•Assessment of outcome of root canal treatment

– Should be assessed atleast after 1 year and
subsequently as required.
•Favorable outcome:
– Absence of pain, swelling and other symptoms, no sinus
tract,
– No loss of function.
– Radiological- normal periodontal ligament space around the
root.

– Quality guidelines European Society of Endodontology IEJ,39, 921–930, 2006

•Uncertain outcome:

– Lesion has remained the same size or has only diminished in size.
In this situation it is advised to assess the lesion further until it
has resolved or for a minimum period of 4 years.

– If a lesion persists after 4 years the root canal treatment is usually

– Considered to be associated with post-treatment disease.

• Unfavorable outcome:
• The tooth is associated with signs and symptoms of Infection.
• A radiologically visible lesion has appeared subsequent to treatment
or a pre-existing lesion has increased in size.
• A lesion has remained the same size or has only diminished in size
during the 4-year assessment period.
• Signs of continuing root resorption are present.

• In these situations it is advised that the tooth requires

further treatment.
•Non-endodontic disease or a healing process should be
carefully considered as a differential diagnosis .

– The case history is reviewed,

– Noting previous radiographs when available.
– Past symptoms.
– Time elapsed since previous treatment and
– Previous attempts at retreatment or apical surgery
•In the past, it was the clinician's responsibility to select and
then provide the most appropriate treatment.

•Currently, it is the patient who selects the treatment.

•The clinician's responsibility is to communicate the

information and thus facilitate the patient's decision making
process, and to provide the selected treatment.
Patient Considerations
People's attitudes towards disease and necessity of treatment
differ significantly

Int Endodod J 1998: 31: 358-63.

 Tooth Considerations

Site of infection-
For root canal infection prognosis is best with retreatment.
For periapical (extraradicular) infection independent of the root
canal flora, prognosis is best with apical surgery.
In contrast, when a vertical crack or fracture is present,
prognosis is
hopeless with both procedures .
Differential diagnosis is required, therefore, to establish the likely
site of infection.
Typical manifestation of periapical actinomycosis - one or more
sinus tracts, and that of vertical crack/ fracture - isolated, narrow
defect along the root
Root canal complexities
The potential of retreatment to
capacitate healing is actualised mainly
when root canal patency can be regained
throughout.
Feasibility of overcoming these
complexities must be
assessed.
Perforation
Perforation of the pulp chamber or root comprises a
pathway of infection and impairs the prognosis.
Retreatment in conjunction with internal repair of the
perforation is warranted to curtail the infection.
when healing appears unlikely or does not occur, surgery
may be required, including external repair of the
perforation and possibly an attempt at guided tissue
regeneration.
.
Restorative, periodontal and aesthetic factors.
Teeth considered to have hopeless restorative or periodontal
prognosis should be extracted.
With compromised periodontal support, surgery may result in an
unfavourable crown-root ratio; therefore, retreatment is selected
 Clinicians considerations
• Clinicians vary with regards to-

• Capability- Procedure that can be performed best by the

attending clinician is selected,

• Armamentarium- The instruments required to perform either

procedure are available, that procedure is selected.

• Time availability- In specific circumstances (remote areas, community

clinics) an excessive practice load prevents a clinician from undertaking
a lengthy retreatment of one complex case, surgery is selected
 Previous Treatment Attempts
• If a previous retreatment or apical surgery procedure did not result
in healing, the quality of the treatment provided should be
accessed.

• If it is considered that the initial case selection was appropriate

but the quality can be significantly improved, the same procedure
is selected again.

• Otherwise, the alternative procedure is selected, considering that it

may better address the site of the infection and capacitate healing
Prevention of potential disease
Endodontically treated teeth may appear to be free of any signs
of disease and yet harbor microorganisms in the canal.

The factors that may affect emergence of post-treatment

endodontic disease are listed below:
 The adequacy of the coronal seal;
 The adequacy of the root filling
 The need for a new restoration
When both the root filling and the coronal seal are suspect, and a
new restoration is needed.
In these cases retreatment is indicated, as it offers the benefit of
preventing post treatment disease.

When a new restoration is not needed and only the root filling is
suspect, emergence of post-treatment disease is less likely, and
retreatment offers a lesser or no benefit.
In these cases only follow-up is indicated; retreatment, and
associated possible complications, can be avoided.

Endodontic Topics 2002, 1, 54–78

NONSURGICAL ENDODONTIC
RETREATMENT
PRIMARY GOAL: REGAIN
ACCESS TO THE
PERIAPICAL AREA
(ENDOTREATED TOOTH)
• Principals of endodontic therapy followed : completion of case
• Coronal access needs to be completed
• All previous root-filling materials need to be removed
• Canal obstructions must be managed
• Impediments to achieving full working length must be overcome

• Cleaning and shaping procedures : for effective obturation and case

completion
 Coronal Disassembly
• Retreatment access is called coronal disassembly

• Removal of the coronal restoration includes

• Full coverage restoration
• Core build-up material
• Post placed into the canal

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• Advised to remove the existing coronal restoration if it has
• Poor marginal adapatation
• Secondary caries
• To avoid procedural errors
• To maintain form, function and esthetics
• Re-access to the pulp chamber through the existing
restoration
• If it is judged to be functionally designed, well fitting and
esthetically pleasing.

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• Removal is based on whether additional access is required
to facilitate disassembly and retreatment.
• Preparation type
• Restoration design and strength
• Restorative material used
• Cementing agents
• Removal device
• Coronal disassembly devices:

1. Grasping instruments

2. Percussive instruments

3. Active instruments

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 Grasping instruments
• Appling inward pressure on two opposing handles
• Proportionally increases the instrument’s ability
to grip a restoration.
• Strong purchase while reducing dangerous
slippage.
Handle pressure α Instrument ability to grip restoration

• E.g.:
• Trident crown Placer/ remover
• K.Y. Pliers
• Wynman Crown Gripper
• Provisional restorations
 Percussive instruments
• Selective and controlled percussive removal force

• Deliver impact directly to restoration or indirectly to another

securely engaged prosthetic removal device

• Eg:
• Ultrasonic Energy
• Crown- A-Matic (Peerless)
• Coronaflex

• Removal of provisional & definitive restoration

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 Active instruments
• Actively engage a restoration, enabling a specific dislodgement
force to potentially lift off the prosthesis.
• Requires a small occlusal window to facilitate mechanical action of
the instrument.
• Creates a lifting force : separating crown & preparation
• E.g:
• Metalift
• Kline Crown Remover
• Higa Bridge Remover

38
 Post Removal
• Factors influencing post removal
• Operator judgment

• Training & Experience

• Technique & devices

• Post type - parallel/ tapered, active/ passive

• Cementing agent

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Steps:
Core restorative material is removed

A less aggressive instrument, such as a tapered bur in a slow-speed

handpiece or a tapered, midsized ultrasonic tip, should be used to remove
the last of the embedding core material.
• Magnification and illumination

Minimal restorative material remaining, smaller sized

ultrasonic instrument should be used
• To minimize the risk of removing unnecessary tooth structure
• Thinning of the post. 4
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• Techniques for post removal :

• Ultrasonic vibration

• Rotosonic vibration

• Mechanical devices

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 Ultrasonic vibration
• Piezo electric ultrasonic systems in conjuction with specific
instruments.

• Instrument at the interface between the post and the tooth (the
cement line)

• Constantly moved around the circumference of the post

• Disrupt the cement structure along the post/canal wall
interface and decrease post retention
• Tip should be removed from the access every 10 to 15 seconds
• To allow the use of an air/water syringe
• To clean the area of debris
• To reduce temperature produced that could potentially
cause damage to peri radicular tissues.
• Area around the post may be flooded with a solvent (chloroform)
prior to activating the ultrasonic instrument
• Dissolve the cement around the post

• Ultrasonic energy produced will set up shock waves in the solvent

and make it penetrate deeper into the canal space, exerting a faster
solvent action on the cement

43
• Heat generation with ultrasonic vibration
may help to decrease retention of resin
cemented posts.
(Garido et al 2004)

• Concern for heat generated periodontal

ligament damage.
(Swartz et al 2004)
 Rotosonic vibration
• Rotosonics is a method to potentially loosen and remove a fully
exposed post.
• The regular tip Roto-pro Bur (Ellman International, Hewlett, NY) is a
high-speed, friction grip bur whose six sides utilize six edges which
when rotated in one revolution produce six vibrations per revolution.
• Rotated at 200,000 rpm, it produces 1.2 million vibrations per
minute.

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 Mechanical Devices
• If retention reduction does not remove the post, some form of vice is
needed to pull the post from its preparation.
• Gonon post removing system

• Effective instrument for removing

parallel or tapered, nonactive
preformed posts

• Kit utilizes a hollow trephine bur aligned

with the long axis of the post and placed
over its exposed end
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 Fractured
post in a
lower
incisor Trephine bur
milling
the post

Ultrasonic
exposure of
the post Extraction device
tapping a
thread onto
the post
Domer bur creating a
shape that the trephine
bur can engage
Vice applied. Turning the 4
screw on the vice opens the 6
jaws, creating the extraction
force.
• This method is effective because
• All the force is applied to the bond between
the tooth and the post, ideally in the long
axis of the root.
• Drawbacks:

• Size of the vice that can make access in the molar region
and between crowded lower incisors difficult.

• If the extraction force applied is not directed in the long axis

of the root, root fracture may occur
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• Other Post Removal Systems
(PRS) :

• Thomas Screw Post

Removal Kit
• Ruddle Post Removal
System
• Universal Post Remover
• JS Post Extractor
• Post Puller (Eggler Post
Remover)
 Removal Of Fibre Posts

• Ultrasonic / gonon kit : none works for fibre post removal

• Use of a high-speed bur to channel down through the post may result
in a high rate of root perforation.

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• A new bur Gyrotip has been designed for the specific
purpose of removing fiber-reinforced composite
posts.

• Drills consist of a heat generating tip designed to

soften the matrix that binds the fibers within the
fiber-reinforced post.
• Fibers within the post are parallel, which assists the axial
travel of the drill through the center of the post.

• Fluted zone of the drill allows the fibers to be safely

removed, creating access to the root canal filling.

• Above the fluted zone, a layer of plasma bonded silica

carbide reduces the heat generation

• This abrasive zone also provides for a straight-line access 5

0
preparation and facilitates the placement of a new post
• Ceramic and Zirconium posts : Impossible to retrieve.

• They are more fragile than metal posts, and though ceramic posts
may be removed by grinding them away with a bur.
• High risk of root perforation
• Zirconium has a hardness approaching that of diamond and cannot
be removed by this method.
• Removal of a fractured zirconia post by ultrasonic vibration
has been found to cause temperature rise of the post and on the
root surface
• Great white Z bur (SS White) : For Zirconia Posts

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 Potential Complications of Post Removal
• Fracture of the tooth, leaving the tooth nonrestorable

• Toot perforation

• Post breakage

• Inability to remove the post

• An additional concern is ultrasonically generated heat damage

to the periodontium.

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 Gutta Percha Removal
• Initially removed from the canal in the coronal one third, then the
middle one third and finally eliminated from apical one third.

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• Following methods or combination of methods are used.
• K-files or H-files
• Gutta-percha solvent
• Combination of paper points and gutta-percha solvent
• Rotary instruments
• Specialized rotary instruments designed for retreatment
• Heat transfer devices
• Soft tissue laser
 K & H files

• Allows for a gross removal of gutta-percha especially

from large canals, which are poorly compacted allowing
files to bypass the obturating material and ‘bite’ into
the mass
• Micro-debriders (Dentsply Maillefer) are small files
having 90-degree bend at the working end and an
attached handle.
• It may also be used to substitute standard K-files and H-
files. 5
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 Solvents
• Chloroform
• Methyl
chloroform
• Eucalyptol oil
• Halothane
• Turpentine
• Xylene
• Orange wood
oil
• Chloroform
• Proven to be most successful
• Evaporates rapidly
• Potential carcinogenicity
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• Eucalyptol:
• Less irritating than chloroform
• Antibacterial
• Least effective GP solvent

• Xylene:
• Highly toxic
• Evaporates too slowly
• Dissolving effect less than chloroform

• Orange wood oil:

• Contraindicated – over extended fillings

• Halothane:
5
• Longer time for dissolving than chloroform
6
 Rotary Removal
• Gates Glidden Drill and Peeso Reamer

• GPX Gutta-percha Remover (Prestige Dental)

• Specially designed file

• Slowspeed handpiece.
• Plasticizes by frictional heat and facilitates its removal
by its H-file like flute design.
• ISO 25–50 5
• Recently introduced NiTi GPX -curved canals 7
5
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• NiTi Rotary instruments

• Advantage of removing gutta-percha as well as shaping the

root canals in an under-prepared tooth, simultaneously.

• Several studies carried out for comparing the gutta-percha

removal efficacy of rotary with the hand instrumentation,
have shown both techniques to be almost equally effective

• The use of rotary devices in retreatment should be

followed by hand instrumentation. 5
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• NiTi Rotary Instruments

• Rotary : Reach the whole working length easily

• Plasticize through frictional heat.
• Hand instruments : refine and complete the removal.

• Recommended to be used at rotational speed of 3-4 times

more than that for routine cleaning and shaping.

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Specialized Rotary Instruments Designed for Retreatment

• ProTaper Universal Retreatment Kit (Dentsply)

• D1 File : 30/0.09 NiTi file (one white ring) of 16 mm : Coronal

third
• D2 File : 25/0.08 NiTi file (two white rings) of 18 mm : Middle third
• D3 File : 20/0.07 NiTi file (three white rings) of 22 mm : Apical
third

• R-Endo (Micro-Mega)

• Made up from a round blank

• Cross-section is characterized by three equally spaced cutting
edges.
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• Speed of 300-400 rpm along with gutta percha solvent.
• Series of six files named as Rm, Re, R1, R2, R3 and Rs
Mtwo Retreatment Kit (Sweden and Martina)

• S-shaped cross-section

• 2 instruments with cutting tips designed to reach the apex.

• Mtwo R 15/.05
• Mtwo R 25/.05

• Advantage of shaping the root canal in an under-prepared

tooth, simultaneously.
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Heat Transfer Devices
• Heat Carrier Tips

• System B
• Endotec
• EndoTwinn
• Touch’NHet
• DownPak

63
• Heat generated on the tip : soften guttapercha mass.

• More effective in well prepared canals.

• Alternatively, hand spreaders can also be used in similar

manner, however, amount of heat transferred to these
instruments is not consistent.
• Ultrasonics

• Piezoelectic ultrasonic system, produces

heat that thermo softens GP

• It will float coronally into the pulp chamber

• Tips available for ultrasonic

• Condensation of GP or specialized re-
treatment tips
Soft Tissue Lasers

• The studies, conducted on effectiveness of the Nd: YAG laser for removal of
gutta- percha, have shown that it is capable of softening gutta-percha.

• Lower settings (100 mJ, 15 Hz, 1.5 W)

• Fairly clean root canals, but an incompleteeliminationof
gutta-percha from dentinal walls.
• Increased power levels (100 mJ, 20 Hz, 2 W)
• More effective on the canal walls, cleaning them better

• The addition of solvents have not shown any improvement in their efficiency
in terms of time required for removal of GP. 65
• Paper point and chemical removal

• Drying solvent filled canals with paper points is known as “wicking”

• It is always the final step of gutta percha removal.

• Wicking action removes residual gutta percha end sealer out of fins, cul de
sac and aberrations of the root canal.

• Wicking takes place by pulling dissolved materials from periapical 66

to central.
 Carrier Based gutta percha
removal
• After careful access and complete circumferential exposure of
carrier a suitable grasping pliers is selected and a purchase is obtained
on the carrier.

• Carrier is grasped with the pliers and extrication is attempted using

fulcrum mechanics, rather than a straight pull out of tooth.

• If enough canal space exists, a 4 or 5 ultrasonic instrument can be used

along side carrier to produce heat and thermosoften the G.P.
67
 Silver Point Removal
• Easily removed : chronic leakage greatly reduces the seal and
hence lateral retention.

• The coronal heads of silver points are within pulp chambers

and are entombed in cements, composites or amalgam cores.

• Initial access with high speed surgical-length cutting tools.

• Subsequently, ultrasonic instruments may be carefully used within the pulp

chamber to brush cut away restorative materials and progressively expose the
silver point.
68
• Pliers removal

• Stieglitz Plier used gently pull to confirm its relative tightness.

• When grasping a silver point, rather than trying to pull it straight out
of the canal the plier is rotated using fulcrum mechanics and levered
against the restoration or tooth structure to enhance removal
efforts.

• Indirect Ultra Sonic

• Used when a segment of silver point is encountered below the orifice

and space is restricted. 69
• Indirect Ultra Sonic

• Care must be used so that ultrasonic instruments are not used directly on silver
points because elemental silver is soft and rapidly erodes during mechanical
manipulation.

• Once the surrounding material is removed, ultrasonic energy then may be

transmitted on a grasping plier to synergistically enhance the retrieval efforts.

7
0
Braided file technique

• Using Hedstrom files

• Sealer is dissolved
• Files are negotiated as apically as possibly in two to three areas around the
silver point.
• The spaces surrounding the silver point are carefully instrumented to size
15.

• Then small Hedstrom files are gently screwed in as far as

possible apically.
• The flute design of Hedstrom file allows for better
engagement into the silver point.
• Files are then twisted together and pulled out through
the access.
• Caufield silver point retrievers

• When not much of the silver point exposed in the chamber, the clinician can
attempt to remove it using the Caufield silver point retrievers (Integra Miltex).

• Instrument is a spoon with a groove in the tip that can engage the exposed end
of the silver point so it may be elevated from the canal or possibly elevated to
the point where it may be grasped by forceps.

• Available in three sizes:

• 25, 35 and 50
7
2
 Paste Removal
• When evaluating a paste case for retreatment, it is useful to clinically
understand that the coronal portion of the paste in the canal is most dense (the
material is progressively less dense moving apically).

• Ultrasonic energy
• Ultrasonic instruments in conjunction with the microscope, afford excellent
control in removing paste from the straight portions of a canal.

• To remove paste apical to a canal curvature, precurved file is attached to a

specially designed adapter that mounts on and is activated by the ultrasonic 73

hand piece.
• Rotary instruments
• Stainless steel O.O2 tapered hand files to negotiate through paste fillers.
• These files can potentially create a pilot hole for safe ended, Ni Ti
rotary instruments to follow.

• Solvents and Hand Files

• Reagents like Endosolv ‘R’ and Endoslov ‘E’ can be helpful in
chemically softening hard paste.
• These reagents can be placed interappointment.
74
• Micro debriders
• To precisely remove residual paste materials
• Offset handles, 0.02 tapers with 16mm of efficient hedstrom
type cutting blades.

• Solvents and paper points

• After paste removal, paper point wicking in the presence of specific
paste solvents is important

75
 Broken Instrument
Removal
• Incidence of hand instrument separation has been
reported to be 0.25% and for rotary instruments it ranges
from 1.68% to 2.4%.
(Iqbal et al
2006)

• A common cause for instrument separation is improper

use.
• Overuse and not discarding an instrument and replacing it with a new one
76
when needed.
List of guidelines for when to discard and replace instruments

1. Flaws, such as shiny areas or unwinding, are detected on the flutes

2. Excessive use has caused instrument bending or crimping

• NiTi instruments : tend to fracture without warning
• Constant monitoring of usage is critical

3. Excessive bending or precurving has been necessary

4. Accidental bending occurs during file use.
5. Corrosion is noted on the instrument.
6. Compacting instruments have defective tips or have been
excessively heated. 77
 Factors influencing broken instrument removal:

1. Cross sectional diameter of the canal

2. Length of the canal
3. Root morphology – thickness of dentin and the depth of external concavities.
4. Curvature of the canal
• Straight portion of canal : removed usually.
• Around canal curvature : removal is possible if the access if established to
its most coronal extent.
• Apical to curvature : removal may not be possible.
5. Type of material that obstructs the canal
• SS files do not fracture during removal
• NiTi breaks again because of heat build up caused by ultrasonic devices. 78
Technique for broken instruments removal

Coronal Access

Radicular access

Creating a staging platform

1. Coronal access
• Done with high speed, friction grip surgical
length burs

2. Radicular access
• Hand files, and GG drills used
• GG drills maximize visibility coronal to the
obstruction

79
3. Create staging platform
• Modified GG is used.
• Cutting the bud of GG perpendicular to its long axis at its maximum C-S
diameter.
• This creates a small staging platform that facilitates the introduction of
ultrasonic instruments
.
• Ultrasonic instrument moved lightly in a CCW direction around the obstruction

• This will remove the dentin and trephines around the obstruction

• Gently, wedging the energized tip between the file and canal wall will
remove the instrument

• Deeper in the canal the obstruction is, the longer and thinner an ultrasonic tip must be.

• Thin tips must be used on very low power settings to prevent tip breakage

80
MICROTUBE DEVICES

• Instrument Retrieval System (IRS)

• Small staging platform : Further reduced by ultrasonics untilenough of the

separated instrument is exposed to retrieve.

• Microtube is inserted into the canal and the long part of its beveled end is
oriented to the outer wall of the canal to scoop up the head of the broken
instrument.

8
1
• The insert wedge is placed through open end of microtube and passed down its
internal lumen until it contacts the broken obstruction.

• The broken instrument is secured by turning the insert wedges handle screw in a
clockwise rotation.

82
Wire Loop & Tube Removal Method :
25-gauge dental injection needle, 0.14-mm-diameter steel ligature
wire.

Needle is cut to remove the beveled end

Both ends of the wire are then passed through the needle from the
injection end until they slide out of the hub end, creating a wire
loop

Once the loop has passed around the object to be retrieved, a small
hemostat is used to pull the wire loop up and tighten it around the
obstruction

8
3
Complete assembly is withdrawn from the canal.
• Other Methods:

• Endo Extractor (Brasseler USA)

• Masserann Kit (Medidenta International)

• Extractor System (Roydent)

• Separated Instrument Retrieval System

(SIRS)

84
• Specifically for use with Microscopes :

• Cancellier instrument (Sybron

Endo)

• Mounce extractor (Sybron Endo)

85
 Management of Canal Impediments
• Iatrogenic mishaps resulting from
• Vigorous instrumentation short of the appropriate working
length
• Failure to confirm apical patency regularly during
instrumentation.

• Includes:
• Blocked canals
• Ledge Formation
Managing Blocked canals
Well -angulated radiographs

Coronal portion of the canal should be enlarged

• To enhance tactile sensation
• Remove cervical and middle third obstructions in the canal space

Canal should be flooded with irrigant, and instrumentation to the level of the
impediment should be accomplished using non-end-cutting instruments

87
Precurved #8 or #10 file used in pecking motion
• Determine if there are any “sticky” spots that could be the entrance to a blocked
canal.
• Directional rubber stop should be used
• Very short amplitude, light pecking strokes to be used
• Short amplitudes - ensure safety, carry
irrigant deeper and increase the possibility of
canal negotiation

• File's handle whose tip is engaged, should never be

excessively rotated.

8
8
• Frequent evacuation of the irrigant and using a lubricant, such as RC
prep.

• Risk of deviating from the original canal path, creating a ledge, and
ultimately a false canal leading to zip perforation.
• Working radiograph taken when some apical progress made
• Occasionally, clinical situations arise where the
aforementioned techniques have been carefully attempted, but
either the file is not progressing apically or is not maintaining
the true pathway of the canal.

• If the tooth is asymptomatic and symptoms are not masked by

a pharmaceutical agent, and if the periodontium is healthy
and there are no lesions of endodontic origin, then the
preparation may be finished to the level of the obstruction and
obturated.
8
9
 Ledge Formation
• An artificially created irregularity on the surface of the root canal wall that prevents the
placement of instruments to the apex of an otherwise patent canal.

• A deviation from the original canal curvature without communication with the
PDL, resulting in a procedural error is termed ledge formation or ledging.
(JOE, 33, 2007)

9
0
Recognition of a Ledge

• Root canal instrument can no longer be inserted into

canal to full working length.

• Loss of tactile sensation of the tip of the instrument binding

in the lumen.

• Instrument point hitting against a solid wall

• Radiograph with instrument in place.

9
1
Management :

• Locating the ledge

• Irrigate, smaller instruments are preferred.
• No. 10 or 15 with a distal curve at the tip can be used
• Pointed towards the wall opposite to the ledge
• “Tear shaped” silicone stops can be used.
• Watch-winding motion
• If resistance is felt, retract slightly, rotate and advance
again,until it bypasses and reach apically.
• Confirmed with a radiograph

• If ledge cannot be bypassed, then clean, shape and obturate till obstruction.
9
2
Prevention of Ledge :

• Proper examination of the diagnostic

radiographs.
• Awareness of canal morphology
• Frequent recapitulation and irrigation
• Precurving the instrument and not forcing it.
• Using instruments with not cutting tip
• Using NiTi files in case of curved canals
• Modified instruments:
• Flex R files
• Safety Hedstrom files
• Flexofile 93
 Endodontic Perforation
• Perforations in all locations can be caused by 2 main errors:

1. Creating a ledge in the canal wall during initial preparation and perforating through
the side of the root at the point of obstructions / root curvature.

2. Using too large or too long an instrument and either perforating directly through the
apical foramen or wearing a hole in the lateral surface of the root by over
instrumentation.

94
 Factors influencing repair
Considerations influencing perforation repair:
1. Level
2. Location
3. Extend of perforation
4. Potential for successful management

• Level:
• Coronal / furcation perforation : threaten sulcular epithelium
• In general, more apical the perforation, more favourable the
prognosis

95
• Location:
• Can occur circumferentially on the buccal, lingual, mesial and
distal aspects of roots.
• Location of the perforation is not so important when non-surgical
treatment is selected.
• Position is critical and may preclude surgical access if this
approach is considered.

96
• Extend & Size of Perforation:
• Size greatly affects the clinician’s ability to establish a hermetic
seal.
• The area of a circular shaped perforation can be mathematically
described as r2.
• Therefore doubling the perforation size with any bur or
instrument increases the surface area to seal four-fold.
• Time:
• Regardless of the cause, a perforation should be repaired as soon as
possible to discourage further loss of attachment and prevent sulcular
breakdown.

• Esthetics:
• Perforations in the anterior region can definitely impact esthetics.
• Tooth colored restorativesare chosen and selected from the best
materials currently available in adhesive dentistry.
97
• Periodontal condition :
• If the attachmentapparatus is intact without pocketing,timing is critical
and the treatment is ideally directed toward non-surgically repairing the
defect.

• Decision should be made for periodontal breakdown teeth, to go for surgical or

non- surgical or both together.

• Longstanding defect with periodontal lesion: surgery with guided tissue

regeneration
• Most cases, nonsurgical retreatment and internal perforation repair prior to
98
surgery will be beneficial to the treatment outcome.
 Management
• Difficulty of the repair : Level of perforation

• Furcal floor of a multirooted tooth or in the

coronal one third of a straight canal (access)
• Considered to be easily accessible

• Middle one third (strip or post perforations) :

Difficulty increases
• Apical one third (instrumentation errors)
• Predictable repair
• Frequently, apical surgery will be
needed. 99
 Barrier Materials For Perforation
Repair
• Barriers help produce a ‘‘dry field’’ and also provide an internal matrix or ‘‘back stop’’
against which to condense restorative materials.

• Absorbable
• Collagen materials (colla cote)
• Calcium sulfate (cap set)

• Non-Absorbable
• MTA
• Other restoratives (amalgam, super EBA resin cement, composite restoratives, calcium
phosphate cement)
100
 Management of
Coronal Third
• Hemostatics to control bleeding.
• Small area : sealed from inside the tooth
• Large area : seal from inside, then surgical repair

• Where esthetics is a concern, a calcium sulfate barrier along with composite restoration
is generally used.
• Super EBA have been used when esthetics not an issue.

• Presently MTA is restorative of choice because of its many desirable attributes.

101
 Management of Middle Third
• By nature of occurrence, these defects are ovoid in shape and typically
represent relatively large surface area to seal.

• Access to midroot perforation is most often difficult, and repair is not

predictable.

• Successful repair depends upon the adequacy of the seal established by

the repair material.

• The repair should be immediate, to protect the perforated site from

saliva and other contaminants.

• Barrier material of choice is MTA.

1 2
0
 Management of Apical
Third
• Overinstumentation :
• Re-establish the WL and enlarge with larger instrument.
• Apical barrier: Ca(OH)2, MTA, Dentin Chips,
Hydroxyapatite

• Apical Perforation :
• Negotiate
• Perforation site as the new apical opening and obturation is done to seal of the
foramen 103
• Surgery is necessary, if a lesion present apically
 Management of Apical Third
• Surgical Approach:
• A combined intracoronal and surgical approach involves repairing the defect
intracoronally, then reflecting a surgical flap to remove the inevitable
overextension of the repair material from the periodontal space.

• In case of failing furcation

repairs,
• Bicuspidation
• Hemi-Section
can be considered as treatment
• Intentional Replantation
options.
104
 Heat generation during treatment
procedures
• Several procedures in endodontic therapy that generate heat
• Greatest risk with Non-surgical retreatment
• Use of heat to soften canal filling materials
• Use of ultrasonics to dislodge posts and separated instruments

• Can potentially generate enough heat to raise the temperature of the external root surface by
10° C or more.

• Temperature elevations of the periodontal ligament in excess of 10° C can cause damage to
the attachment apparatus. 105
(Eriksson et al 1983, Saunders et al
1989,1990)
• Accepted that the heat-induced damage to periradicular tissues
during the usage of ultrasound energy for post removal is Time
Dependent.

• Study has showed that ultrasonic vibration for post removal

without coolant can cause root surface temperature increases
approaching 10° C in as little as 15 seconds.
(Dominici et al 2005)

10
6
 Recommendations for the use of ultrasound energy during the removal of canal
obstructions :

• Use ultrasonic tips with water ports whenever possible

• If ultrasound device does not have tips with waterports, have your
assistant use a continuous water/saline irrigation during usage.

• Take frequent breaks to let the tooth cool down.

• Avoid using the ultrasound on the high power setting.

107
 Conclusion
• Posttreatment endodontic disease does not preclude saving the involved tooth.

• In fact, the majority of these teeth can be returned to health and long-term
function by current retreatment procedures.

• In most instances the retreatment option provides the greatest advantage to the
patient because there is no replacement that functions as well as a natural tooth.

• Armed with the information in the preceding section, appropriate armamentaria,

and the desire to do what is best for the patient, the clinician will provide the
foundation for long- term restorative success. 108
 Reference
• Pathways of the Pulp – Cohen

• Textbook of Endodontics – Ingle

• Endodontic practice - Grossman