Causes of non healing endodontic treatment

Treatment options Indications

Contraindications
Risks and benefits Procedures for Retreatment Post Treatment Flare Ups References

 Failure to eliminate micro organisms during treatment Reintroduction of micro organisms after treatment By coronal micro leakage Inadequate cleaning and shaping Inadequate obturation Root canal calcifications Procedural accidents Ledge formation Canal transportation Separation of instruments

 Non surgical treatments

Root end surgeries Extraction

Intentional replantation

 Tooth with root canal therapy Pain either not changed or have worsen Pain is spontaneous but often initiated on biting History of facial swellings Clinical findings Swelling Percussion and palpation sensitivity Draining sinus Radiographic findings Recurrent caries Missed canal or poor obturation or inadequate working length

 Recurrent caries Compromising tooth structure Crown to root ratio is less and significant mobility Lack of patients motivation and oral hygiene maintenance Inaccessible canals as a result of Root calcifications Large well fitting post and core restorations Separated instruments or ledges that cannot be by passed or

retrieved Vertical root fractures Apical transportation or perforation

 Risks Fracture of crown or root Thinning, weakening and perforation of root canal Creation of ledges Separation of instruments Loosening of well fitted crowns Benefits Retention of natural tooth to get form & function Decreases the need of expensive prosthetic appliance

 Removal of ; Restoration canal obstruction Post and Cores Calcification Ledges Instruments fractures Gutta Percha Carrier Based GP Obturators Silver cones

 Coronal restorations should be removed Have favorable access to remove

Post Cores Obturation material

If there is evidence of micro leakage and recurrent caries In case of amalgam or composite

If crown has poor marginal seal or recurrent caries

If cosmetic crown is in place and well fitted then access

through the crown instead of removing it

 There are four major obstruction Post and core restoration Root canal calcification Ledges Separated root canal instrument Risk and benefit should be assessed and then attempted to

by pass or remove them

 Factors influencing post removal Trained endodontist Availability of technology Factors regarding post Length Diameter Design Cementing agent used

 PROCEDURE Step I

Remove core material Ultra sonic energy is utilized circumferentially to loosen it Hemostats are used to remove the loosen post or unscrew Special post removal kits

Step II

Step III

Step IV

 Post that are fracture beneath the pulp floor

can be removed with masserann kit Precaution should be taken to avoid root perforations

 If post retention is not reduced then following post puller

system can be can be used i.e 1. Thomas screw post removal system 2. Gonon post removal system 3. Ruddle post removal system Regardless of the method used it is important not to leave any post cement in the apical area of the root canal system

a. Perforation of roots
b. c.

d.

Fracture of tooth Post breakage Damage of periodontium by ultrasonic energy/heat

 Visualization of the area By the use of illumination Magnifying with the operating microscope A combination of Stiff hand files Chelating agents Ultra sonic tips To remove the calcified barrier and gain access to the root

canal

 Ultra sonic tips are used in the straight portion only Curved canals Hand files are bend and used with chelating agent Once calcification is removed Canal is prepared in crown down manner Using GATE GLIDDEN Hand files Nickel titanium rotary files If cannot be removed then surgery or extraction are the

choices

 Ledges are usually formed during cleaning and shaping

Common with stainless steal hand files They have good memory Tend to straighten out in curved canals But incidence has now reduced due to Niti files

These files remain in the centre of canal and are flexible

 Procedure Obstruction coronal to the ledge is removed Coronal portion of the canal is opened in a crown down fashion Ledge is visualized Ultimate goal is to bypass the ledge

Small size stiff precurved file is used Once the file is beyond the ledge use circumferential filling technique to remove obstruction Proceed from smaller files to larger files until ledge is removed Once removed apical portion of canal is cleaned & shaped

 Factors influencing successful removal Skilled and experienced practitioner Length of instrument Location of instrument Size of instrument

 Troughing with metallic burs

Ultrasonic instruments Gates Glidden burs

Peeso reamers
Masserann kit Specialized forceps

Cancellier tube

 If present above the curve Higher success If present apical to the curve Poor prognosis Because of increased chances of

Transportation Perforation Fragmentation of additional instruments

 Step I Gain access to instrument and visualization Using GG, ultra sonic tips, small neck burs or hand files Step II By pass the instrument Engage it with braiding file technique and pulled coronally Other technique is by using ultra sonic tips to dislodge it

or breaking it into smaller fragments and then irrigated

 Step I Access and visualization Step II Staging of the fractured instruments Accomplished by

Modified GG, rotary or burs

This creates a space for smaller instrument

Step III Engage the instrument and remove

 Other techniques Micro tube with cyanoacrylate glue to engage and remove If cannot be removed then surgery or extraction are

the options

 Instruments used Gate glidden Hand files

Reamers Hedstrom files

Rotary files

Heat Pluggers Ultra sonic tips

Solvents

Combination of above

Solvents used Chloroform Methyl chloroform Xylene Eucalyptol Tetrachloroethylene (Endosolv E) Formamid (Endosolv E) Rectified terpentine d-limonene (Hemo-De)

 Canals may be obturated with GP coated onto a central

metal or plastic core Removal of them utilizes a combination of techniques

Soften the gutta percha With solvents Hand files Heated pluggers Rotary tapered files

Removal of the core Braided file technique Engaging files

 Coronal restoration removed

Solvent and files are used to create space Braided file technique is used to remove silver cones

Other special instrument used to grasp points are; Caufield silver point retrievers Gold foil pliers Splinter forceps Hemostats Needle sleeves or micro tubes with cyanoacrylate glue

 Flare ups
Final coronal restorations Follow up visits

Prognosis

 Occur more frequently in retreated teeth

Preventions Material removal and instrumentation techniques should be selected that minimize the extrusion of debris And micro organism beyond apical foramen Use of irrigants frequently Crown down technique so debris removed coronally Intra canal medicaments in initial visit and in between appointment

 Retreated teeth require proper restoration

Objective is protection of tooth Prevention of coronal leakage

 Should be scheduled to Ensure tooth has restored Clinical symptoms have disappeared Radiographic healing If cause of initial failure was found then Then follow up visit occur at 6 months and then 1 year If cause was not found then Follow up at 3 months is warranted

 Most recent reports Published in 2004

It showed data from teeth restored 20 to 27 years before In report 95.5% teeth have normal radiographs after retreatmetn

A study is needed to find prognosis of current retreatment

cases

 Endodontics Principles and practice 4th edition Mahmoud torabinejad Chapter 19 Endodontics Vol 2 Arnaldo Castelucci Www.google.com images