Nonsurgical endodontic retreatment II

Endodontic Retreatment Procedures

Access Through Full-Coverage or Preexisting Restorations

Removal of Existing Restorations

Removal of Canal Obstructions

Post and Core Removal

Removal of Gutta-Percha

Removal of Carrier-Based Gutta-Percha Obturators

Removal of Silver Cones (Points)

Removal of Soft and Hard Pastes

Removal of Calcifications

Root Canal Preparation in Retreatment

Irrigation in Retreatment

Obturation After Retreatment

Restorative Options

Follow-Up and Prognosis

Remove the old crown
in some cases, the restorative material may need to be completely cut through with high-
speed rotary instrument and then pried off with a narrow-ended tool

 If the crown is made out of gold or metal, then removal becomes even more difficult
because the material is harder to penetrate
Access Through Full-Coverage or Preexisting Restorations
Remove all the existing restorations

1.observe cracks or fractures

2.possibility of leakage

3. missed root canal

4.presence of recurrent caries
5.poor marginal adaptation of the crown

6.future restoration is possible or not

Removal of Canal Obstructions
Removals of canal obstructions are typically complex treatment situations that frequently
require extensive operator training and experience to manage

Canal obstructions include

 posts and cores

calcifications of the root canal system

 iatrogenic ledges

dentinal debris in the root canal system

 fractured instruments
When a fractured instrument is lodged beyond the curve and extrudes beyond the apical
foramen, a surgical approach should be considered

When an instrument fractures in the apical one third of the canal in a later stage of canal
instrumentation and if an excessive amount of tooth structure must be sacrificed to retrieve
it, the separate file should be incorporated as part of the filling material and scheduled for
periodic review
Ledge formation typically occur when stainless steel files are not properly precurved to
match the canal curvature

Root canal transportation and ledging can also occur during preparation if debris
accumulation is not consistently removed

A precurved #10 K file in the original pathway

Postoperative radiograph showing the root filling in the original canal beyond the ledge
Post and Core Removal
Depends on

the operator’s level of skill, experience, training, and instrumentation selection

type of core material (cast versus resin or amalgam)

the length and diameter of the prefabricated or cast post

post location and Post material type (metallic or nonmetallic)

Some posts may be difficult to remove if they are long, well fitted, or cemented with bonding
systems or resin cements

nonmetallic posts such as tooth colored zirconia or fiber posts may be difficult to differentiate
from the tooth structure

The first step in post removal is to section and remove incrementally the core material with

1. Carbide bur

2. Transmetal bur

3. Diamond bur

4. Zirconia-diamond bur
This procedure is best performed using illumination to help preserve adjacent tooth
structure

After core removal, any visible cement surrounding the post can be circumferentially
removed using fine ultrasonic tips

Screw posts can usually be loosened with ultrasonics applied to them in a counterclockwise
rotation and picked up with varioussized hemostats or small-tipped forceps or pliers
Potential Complications of Post Removal
Fracture of the tooth

leaving the tooth nonrestorable

Toot perforation

Post breakage

Inability to remove the post

ultrasonically generated heat damage to the periodontium, so it is recommended to use

Ultrasonic tips with water coolant
Removal of Gutta-Percha
 The gutta-percha Initially removed from coronal one third, middle one third finally
eliminated from apical one third

Gates-Glidden burs should probably be limited to the coronal portion of the canal

poorly compacted canal gutta-percha may remove easily using H file

excessive force must not be used because of the possible presence of apical root
resorption or poorly adapted gutta-percha root fillings, which may result in the
material extrusion
The procedures can be accomplished using hand and rotary instruments, ultrasonic
instruments, or solvents and generally requires a combination of these methods

The most efficient way to remove gutta-percha root fillings is to use ultrasonic and hand
instruments followed by rotary instruments

 if chloroform is used during the early stages of gutta-percha removal, more filling material
will most likely remain in the canal and may contribute to excess extrusion beyond the
apical foramen
Xylene, halothane, eucalyptol, eucalyptus oil, carbon disulfide, benzene, and orange oil can
also be used for this purpose

Even though they have been shown to be less effective at softening gutta-percha than
chloroform, the majority of those solvents do not pose a significant health risk to patients
Removal of Carrier-Based Gutta-Percha Obturators
 These devices have a central core of plastic, metal, or other dense material that is
coated with gutta-percha

Treatment begins by creating a pathway adjacent to the central core to allow an

instrument to engage the carrier

Soften the gutta-percha on the surface of the carrier with a heat source or solvent

 avoid placing the heated tip in contact with the dentin wall for long periods
Gutta-percha can also be softened using rotary instrumentation at higher speeds but it
should be limited to straight canals

Once a pathway has been created, single or multiple Hedstrom files can be used to engage
and remove the carrier (these strategies work better for plastic carriers)

 Metal carriers are more easily removed using modified hemostats, pliers, and ultrasonic
instruments
Removal of Silver Cones (Points)
 solvents, ultrasonic instruments, or hand files are used to create a space around the
exposed silver point

The coronal portion of a loosened cone extending from the pulp chamber can then be
grasped and pulled from the canal with specialized hemostats, modified or regular Steiglitz
forceps, needle holders, gold foil pliers, Caufield silver point retrievers, or splinter forceps
If the coronal portion of the cone is not present, one or more hand files can be used to
engage and extract the cone

 A Silver points that cannot be removed may necessitate surgical intervention

Removal of Soft and Hard Pastes

Soft pastes are easily removed utilizing hand or rotary instruments

 Copious irrigation and a crown-down preparation technique are recommended when

removing soft materials

 the coronal aspect of the hard paste is removed first with a bur or ultrasonic tip or with
files with hardened sharp points
Removal of Calcifications
Root canal calcifications are often noted radiographically

calcifications are managed using a combination of chelating agents, stiff hand files (e.g., C
and C+ files)

the curved portion of the canal can be carefully negotiated using various chelating agents
and lubricants

The canal may be enlarged, using the crown-down technique, with a combination of hand
files and NiTi rotary file systems

If the canal cannot be negotiated surgical intervention must be considered

Root Canal Preparation in Retreatment
factors should be consider during retreatment include

 the bulk of the root, root canal configuration as well as curvature, presence of danger
zones, and root surface depressions during root canal preparation

Crown-down preparation is the instrumentation method of choice for endodontic

 the possibility of iatrogenic accidents is significantly higher, particularly broken

instruments, when rotary instruments are used to remove root canal filling materials
The important steps in root canal instrumentation is to determine the working length

more emphasis on reshaping the root canal space might make the tooth susceptible to
future fracture

The advantage of endodontic retreatment in more than one visit is the benefit of
antibacterial activity of the medicaments

endodontic retreatment can be performed in one visit to prevent further recontamination

of the root canal space if there is no wiping exudate or no symptomatic apical periodontitis
Irrigation in Retreatment
the concentration of the irrigation solution and contact time, the needle penetration depth
are important factors that might affect biofilm removal

Both NaOCl and ethylenediaminetetraacetic acid (EDTA) could affect various types of biofilms
via dissolving biofilm matrix
Obturation after Retreatme
 use of NiTi spreaders for cold lateral compaction has been recommended as a result of
lower risk of inducing cracks compared with stainless steel spreaders

Thermafil exhibited promising long-term outcomes as a root canal obturation technique

Single-cone obturation technique with bioactive endodontic sealers has been introduced as
an option for obturating root canals; however, supporting investigations do not currently
share high levels of evidence
Restorative Options
the coronal restoration works as a ‘‘barrier’’

1.to prevent reinfection of the root canal system

2.to protect the tooth from root fracture

One recent study demonstrated that teeth restored with fiber posts yielded significantly
less tooth loss than teeth restored without a post, regardless of the presence or absence of
a full-coverage crown
Follow-Up Care Prognosis
An initial follow-up visit usually takes place at 6 months post-retreatment, and then yearly

follow-up visits should include a clinical evaluation of mobility, periodontal probing, and
palpation and percussion testing and radiographic examination

retreatment can have a high successful outcome that is comparable with primary root canal
therapy if the apical foramen can be negotiated and the cause of failure overcome

Negotiating the entire root canal length should help eradicate microorganisms, debris, and
previous filling materials from the root canal space