NON SURGICAL

ENDODONTIC
RETREATMENT

Presented by
Dr. Sayak Gupta
 DEFINIATION
 A procedure to remove root canal filling materials
from the tooth , revise the shape and oburate the
canals ,usually accomplished because the original
treatment appears inadequate or has failed or
because the root canal has been contaminated by
prolonged exposure of to the oral environment.

 Accor to American Association of Endodontist

 Etiology of retreatment
 Failure of root canal treatment is generally attributed
to either residual or resistant intraradicular
microrganisms surviving the chemomechanical
cleaning procedures or new microorganism
invading the canal via coronal microleakage, vertical
fracture of the tooth ,perforation or accessory canals
which communicate with the oral cavity.
 Indication for retreatment
 Presence of clinical signs(swelling,sinus,tenderness to
percussion )

 Enlargement of existing periradicular radiolucent lesion

associated with the tooth

 Development of new periradicular radiolucent lesion associated

with the tooth

 Persistence of periradicular radiolucent lesion associated with

the tooth which had root canal treatment four years ago or more
 Containdication
 RCT treated vertical fracture
 Poor peridontal status
 Nonrestorable teeth
 Access is difficult
 Patient with TMJ dislocation
 Resorption
 The Washington Study
 Two year recall analysis-
 Total population of 3,678 patient who could have
returned for 2 yrs,1229 actually did return, a recall
rate of 33.41%.There was a 91.10%success rate -104
failure of 1,067 cases. After these impovements,
arose to 94.45% :-9 failure of 162 cases
 Frequency of Occurrence
Cause of failure Number of failure Percentage of failure
Incomplete obturation 61 58.66
Root perforation 10 9.61
External root resorption 8 7.70
Coexistent periodontal 6 5.78
periradicular lesion
Overextented 4 3.85
Missed canal 3 2.88
Developing apical cyst 3 2.88
Silver point 2 1.92
Broken instrument 1 0.96
Accessory canal unfilled 1 0.96

Constant trauma 1 0.96

Perforation 1 0.96
Treatment Planning
 According to John S Rhodes(2006) following
are the various options for the management of
endodontic failures;

1. Review or do nothing
2. Root canal retreatment
3. Root end surgery
4. Extraction

J of Advanced Medical and Dental Sciences

Research
 Non Surgical Endodontic Retreatment

 Procedure of endodontic therapy-

1. Coronal access needs to be completed

2. All previous root filling materials need to be
removed
3. Canal obstruction must be managed
4. Impediments to achieve full working length
must be overcome.
 Coronal Access Cavity Preparation
 Retreatment access is called coronal
disassembly.

 Removal of the coronal restoration includes-

1. Full coverage restoration
2. Core build up materials
3. Post placed into the canal
 Removal of full coverage crown
Carbide bur such as transmetal bur.

Transmetal bur are recommended for

cutting crowns and bridges. The active
axial part is applied to the surface to
be cut with the moderate pressure.

To make the vertical cut through the

crown on the buccal aspect.
 Grasping instruments – applying inward
pressure on two opposing handle.

 Example-
1. K.Y pliers
2. Roydent bridge remover
3. Coronalflex kit
4. Crown A Matic
5. Kline crown remover
6. Richwil crown & bridge remover
 Post removal
 These are classified into two catagories-

1. Prefabricated posts- variety of shapes

(parallel sided or tapered),designs
(active,passive and acid-etched group) and
materials

2. Custom cast post

 Removal techniques-

The bulk of the core material around the post and within the
chamber can be removed with high speed handpiece using
cylindrical or tapered carbide or diamond burs. When majority
of the restorative materials is removed ,a less aggressive
instrument ,such as tapered bur in a slow speed handpeice or a
tapered midsized ultrasonic tip should be used to remove the
last of the embedded core material .This process is greatly
facilitated by use of magnification and illumination.
 Ultrasonic Vibration
 Ultrasonic energy produced will set up shock
waves in the solvent and make it penetrate
deeper into the canal spaces exerting a faster
solvent action on the cement.
 Another instrument consider for exposing and
loosening a post Roto-pro bur.

 There are three shape are available all of which are six
sided, noncutting tapered bur that are used in a
highspeed handpiece around the circumference of the
post .

 The vibration created when the non cutting flutes

come in contact with the post decrease the retention of
the post facilitating its removal.
 Post Removal Kits are

1. Gonon post removing system,

2. Thomas Screw post removal kit
3. Ruddle post removal system
4. Eggler post remover
 Gyro Tip bur has been designed for the specific
purpose of removing fiber reinforced
composite post.

 These drills consist of a heat generating tip

designed to soften the matrix that bind the
fibers within the fiber reinforced post.
 Complications of post removal
 Fractured tooth
 Tooth perforation
 Post breakage
 Inability to remove the post
 An additional concern is ultrasonically
generated heat damage to the periodontium.
 Gutta Percha Removal
 Initially removed from the canal in the coronal one
third ,then the middle one third and the final eliminated
from the apical one third.

 Following methods are used

1. H files
2. Gutta percha solvent
3. Rotary instrument
4. Specialized rotary instrument designed for retreatment
5. Heat transfer device
6. Soft tissue laser
 Overextended gutta percha removal can be
attempted by inserting a new hedstrom files
into the extruded apical fragments of root
filling, using a gentle clockwise rotation to a
depth of 0.5 to 1 mm beyond the apical
constriction. The file is then slowly and firmly
withdrawn with no rotation removing the over
extended material.
 Gutta percha solvents are

1. Eucalyptol oil
2. Halothane
3. Turpentine
4. Xylene
5. Orange wood oil
 Rotary removal
 Gates glidden drills
 Profiles a mechnical push pull
quarter turn file system.

Specialized rotary instrument

designed for retreatment-
1. Protaper universal retreatment
2. R Endo(micro-mega)
3. M two Retreatment
 Protaper Universal Retreatment kit

 D1 FILE: 30/0.09 NiTi fileof16mm:coronal third

 D2FILE:25/0.08 NiTi file of 18mm:middle third
 D3 FILE:20/0.07 NiTi fileof 22mm:apical third

 R-ENDO(micro-mega)

 Made up from a round blank

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

 s-shaped cross section

 2 instrument with cutting tips designed to
reach the apex.
 Mtwo R15/0.05
 Mtwo r 25/0.05
 Heat transfer devices
 Heat carrier tips-
1. System B
2. Endotec
3. Endo twin
4. Touch n heat
5. Down Pak
 Carrier based gutta percha removal
 There are two type of carriers found in these
system : metal and plastic

 Metal carriers are fluted

 Plastic carriers are smooth sided
 Silver point removal
 Steiglitz pliers 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 pliers is rotated using
fulcrum mechanics and levered
against the restoration or tooth
structure to enhance removal efforts.
 Caufield silver point retrievers 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

 Caufield silver point retrievers are available in the

three sizes 25,35,50
 Braided file technique-
1. Using hedstrom files

2. Sealer is dissolved

3. Files are negotiated as apical as possible in two and three areas

around the silver point

4. Space surrounding the silver point are carefully instrumented upto

size 15.

5. Then small H files are gently screwed in as far as possible apically

6. The flute design of H files allows for better engagement into the
silver point

7. Files are then twisted together and pulled out through the access
 Paste removal
Soft setting paste can be removed using the normal endodontic instrument
preferably using crown down technique

Hard setting cement like resin cements can be first softened using solvent like xylene
,eucalyptol etc and then using endodontic files. Ultra sonic endodontic devices can
also be used to break down the paste by vibration and thus facilitate their removal.

Following method can be employed to remove paste for retreatment cases

1. Use of heat employed for some resin paste for softening them
2. Use of ultra sonic energy is employed to remove brick hard resin type paste
3. Some time chemicals like Endosolv R (resin based paste) and Endosolv E (zinc
oxide and eugenol) are employed for hard paste
4. Use of microdebriders is done to remove remenants of paste materials
5. Rotary instruments are also used for removal of paste.
 Biocalex6.9(currently known as Endocal 10) is
a hard setting calcium oxide paste
 Removal of the separated instrument
 A very common cause for instrument separation is improper use
which included overuse or not discarding an instrument and
replacing it with a new when needed.

 The following guidelines for when to discard and replace

instruments are:-

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

flutes
2. Excessive use has caused instrument bending or crimping
3. Excessive bending or pre-curving
4. Accidental bending occurs during file usage
5. Corrosion is noted on the instrument
 Ultrasonic instrument moved lightly around the
obstruction

 This will remove the dentin and around the

obstruction

 Gently wedging the energized tip between the file

and canal wall thereby, removing the instruments

 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
 Microtubes Devices
 Instrument Retrieval System
 Microtubes is inserted into the canal and the
long part of its bevelled end is oriented to the
outer wall of the canal to scoop up the head
of the broken instrument.

 The insert wedge is placed through open end

of microtubes and passed down its internal
lumen until it contact the broken obstruction.

 The broken instrument is secured by turning

the insert wedge handle screw in a clockwise
rotation.
 Wire loop & tube removal method
 25 gauge dental injection needle
 0.14mm diameter steel ligature wire

 Needle is cut to remove the bevelled end

 Both end 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 the
pull the wire loop up and tighten it around the
obstruction

 Complete assembly is withdrawn from the

canal
Other methods are-

1. Endoextractor
2.
3. Masserann kit

4. Extractor system

5. Separated
instrument retrieval
system
 Specially for use with microscopes are-
1. Cancellier instrument
2. Mounce extractor
 Management of Canal Impediments
 Iatrogenic mishaps resulting from
1. Vigorous instrumentation short of the
appropriate working length
2. Failure to confirm apical patency regularly
during the instrumentation
Causes-
Blocked canal
Ledge formation
 Blocked canal
 Well angulated radiographs
 Coronal portion of the canal should be enlarged
,to enhance tactile sensation

 Removal cervical and middle third obstruction

in the canal space

 Canal should be flooded with irrigant, and

instrumentation upto the level of the
impediment should be accomplished using non
end cutting instrument

 Precurved 8 and 10 no files used in pecking

motion.
1. Small amount of EDTA lubricant on a fine
instrument and introduce into the canal. Use a
gentle watch winding motion along with the
copious irrigation of the canal.
2. Excessive pressure and rotation of intracanal
instruments must be avoided.
•
 Ledge formation

 A deviation from the original canal curvature

without communicating with the periodontal
ligament resulting in a procedural errors is
termed ledge formation or ledging.
Treatment and prevention

1. To negotiate a ledge, choose a smaller no file

2. Give a small bend at the tip of the instrument and penetrate
the file carefully into the canal
3. When the file moves freely it may be turned clockwise upon
withdrawal to rasp, reduce,smooth or eliminate the ledge.
4. Use flexible NiTi files
5. Use sequential filing
6. Frequent irrigation and recapitulation during biological
mechanical preparation.
 Perforation
Etiology:
 Creating a ledge in the canal wall during the

initial preparation and perforating through the

side of the root at the point of obstruction
 Using too large or too long instrument and

either perforating directly through the apical

foramen
 Barrier materials for perforation repair
Materials-
 Collagen materials
 Calcium sulphate
 MTA (mineral trioxide aggregate)
 Other restoratives(amalgam, super EBA resin

cement ,composite restorative material,

Calcium phosphate cement
 Location of perforation –

 Coronal one third

 Middle one third
 Apical one third
 MANAGEMENT
 MTA has many advantages over other restorative materials when used for perforation
repair:

 This material seals well even when the cavity preparation is contaminated with blood.

 It is very biocompatible.

 Rarely eliciting any response from the periradicular tissue and the cementum like
material has been consistently shown to grow directly on the material after the
placement

 MTA has also been shown to have a high degree of clinically favorable long trem
outcomes when used as a perforation repair material
 The main disadvantage of the MTA is the long
time required for setting that makes the this
material inappropriate for transgingival defects
such as those associated with cervical
resorption
THANK YOU !