DEPARTMENT OF CONSERVATIVE

DENTISTRY & ENDODONTICS

SEMINAR

ON

ENDODONTIC RETREATMENT

SUBMITTED BY

GAYATHRI .P
1ST YEAR MDS

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The term “success” and “failure” in endodontics must be defined more rigidly in

order to be meaningful. A clear definition and agreement of what constitutes a

“failure” following endodontic treatment does not exist between / among the

endodontist.

A question that should be asked of any discipline or technique in dentistry

is “what degree success should be expected”. Success in turn measured

longitudinally – long-range success as opposed to short term success. The

beautiful resin restoration turning into an ugly yellow in 1 yr is not an unqualified

success.

Clinician always are helpless in answering the questions like how

successful the success? What are the criteria for success? Comfort and function?

Radiographic? Histologic?

Since histologic criteria is impractical, one would have to go with comfort

and function and radiographic finding.

CLINICAL CRITERIA:

Many defines the successful results after endodontic therapy as retention of

treated tooth despite of persistence of radiographic regions of rarefaction. Often

conservative non-surgical treatment fails, but the tooth can still be retained by

surgical procedures like apical curettage, root resection, hemi section and root

amputation.

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 Such a clinical criteria of success are acceptable but perhaps the adequate

clinical function should be substituted for success. The use of adequate clinical

function is more realistic and satisfy the needs of the clinician if the retention of

tooth is the ultimate goal of endodontic therapy. Thus judged by the yardstick of

absence of clinical symptoms and tooth retention, endodontic therapy is successful

procedure in majority of cases.

RADIOGRAPHIC CRITERIA:

The criteria for endodontic failure are the development of the periapical

areas of rarefaction after endodontic treatment in cases where nothing was present

before the treatment was begum or persistence or increase in the size of area and

rarefaction after the completion of treatment.

Still other claim that the treatment cannot be considered as successful until

the periapical areas of rarefaction has been completely disappeared with possible

exception of slight thickening of PDL around excess fitting material.

A number of cases in which periapical radiolucency reduces in size but is

not disappeared completely and categorization and frequently placed in the

category of doubtful, uncertain, progressive repair category.

Defining the success or failing by using the radiographic aid is not certain

because of the variability in the evaluation by radiographic method. Biased

judgment by the different observers, difference in angulation and exposure of the

radiographs taken at different times gives variable results for success and failure.

Considerable variations exist in the incidence of success and failure reported by

various investigators.

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HISTOLOGIC CRITERIA:

When evaluating histologic criteria for failure, absence of chronic

inflammation and complete bone and periodontal ligament regeneration are

employed success rate are dramatically reduced.

Histology examination of 119 endodontically treated upper anterior teeth of

cadavers revealed the complete healing. Chronic inflammation apparently can

persist in periapical tissues for long periods of time without painful symptoms.

A parallel exist between the persistence of chronic inflammation following

operative manipulations and chronic periapical inflammation following

endodontic procedures. Following operative proceeding, pulp inflammation may

persist for many years. Frequently judged by the absence of pain or no positive

radiologic finding, neither the operator nor the patient is aware of phenomenon. In

other words the procedures have been successful clinically but histologially, a pulp

lesion is present.

The parallel in endodontics is also obvious. Following non-surgical

treatment complete healing of the majority of periapical lesions does not occur.

Granulomatous lesion have been formed in tissue sections of the periapical tissues

of painless, endodontically treated teeth which have been extracted.

To answer the question “How successful is endodontic therapy?” a study

was undertaken at the University of Washington School of Dentistry to evaluate

endodontically treated teeth to determine their rate of success. More important to

the study, the rate of failure was also established and the cause of failure were

carefully examined. Finally the entire discipline of endodontic therapy was

reexamined and definite improvements were made as a result. The improvements

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in treatment are reflected in improvement in success which increased to 94.45%

from a formed success rate of 91.10%.

The teeth included in the success group were those that demonstrated

decided periradicular improvement and those with continuing periradicular health.

The failures were made up to those teeth that initially demonstrated periradicular

damage and had not improved as well as those that had deteriorated since

treatment.

A group of Temple University reported 95.2% success rate at the end of 1

year. They found that teeth started with vital inflamed pulp had more success

(98.2%) than teeth with non-vital pulp (93.1%).

Distribution of failures of treated endodontic cases: Two-year recall by

frequency of occurrence:

Distribution of 104 endodontic failures 2 years following thera py when

assayed by frequency of occurrence, note that incomplete obturation accounts for almost

60% of all failures followed by root perforation.

Causes of failure No. of failures % failure

a) Incomplete obturation 61 58.66

b) Root perforation 10 9.61

c) External root resorption 8 7.7

d) Coexistent periodontal periradicular lesion 6 5.78

e) Canals grossly overfilled or over extended 4 3.85

f) Canal left unfilled 3 2.88

g) Developing apical cyst 3 2.88

h) Adjacent pulpless tooth 3 2.88

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i) Silver point inadvertently removed 2 192

j) Broken instrument 1 0.96

k) Accessory canal unfilled 1 0.96

l) Constant trauma 1 0.96

m) Peforation, nasal floor 1 0.96

Total failure 104 100.00

Distribution of failures of treated endodontic cases: Two-year recall by

category of causes of failure

Causes of failure No. of failures % failure

A Apical perforation total 66 63.46

Incomplete obtuation 61 58.66
Unfilled canal 3 2.88
Ag point inadvertently removed 2 1.92

B Operative Error – total 15 14.42

Root perforation 10 9.61
Canal grossly overfilled or overextended 4 3.85
Broken instrument 1 0.96

C Errors in case selection – total 23 22.12

External root resorption 8 7.70
Coexistent periodontal periradicular lesion 6 5.78
Developing apical cyst 3 2.88
Adjacent pulpless tooth 3 2.88
Accessory canal unfilled 1 0.96
Constant trauma 1 0.96
Perforation, nasal floor 1 0.96

Total 104 100.00

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TUNING OF ENDODONTIC FAILURES:

Failures in endodontically treated teeth occurs at various time intervals up

to 10 or more years after completion of treatment.

According to Seltzers majority of unsuccessfully treated teeth failed within

24 month of completion of treatment. Other failed up to 10 yrs later, a few cases

failed more than 10 yrs later.

According to Gahnen and Hanss and Engstrom emphasized that follow up

examination of endodontically treated teeth by radiograms should be done at least

4 to 5 years after the completion of the treatment and final evaluation of result is

made. However even such long term radiographic follow up examination are not

necessarily indicative of status of periapical tissue.

Radiographically healing was apparently delayed in the first 6 months in

teeth with areas of rarefaction. Actually repair was evidence histologically. At the

end of 2nd year there was a slightly higher % of healing.

In teeth without periapical areas of rarefaction the converse was true: that is

there was a higher % of failure at the end of 2 yrs as compared with the percentage

at 6 months.

Thus, for assessment of results, a 2 year follow up period is better than a 6

month follow up period in teeth without areas of rarefaction, but 6 month checkup

is adequate for evaluation of trends in teeth with areas of rarefaction.

Causes of Failures: (According to the Seltzers and Bender)

 Local

 Systemic

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  Local systems

Local:

a) Infection:-

Presence of infected necrotic pulp  continuous irritation to periapical

tissue failure. Even after thorough chemomechanical debridement and with

irrigants and antimicrobial agents the floors of root canal is reduced to a point

where there is only negative culture, however such negative culture do not

guarantee the stability of the canals.

It is possible to have healing of the periapical tissue despite of the presence

of microorganism. These finding of repair in the presence of infected root canals

stress the importance of such factors as host-parasite relationship, the virulence of

the microorganism and the ability of infected tissue to heal.

Ostrander claimed that some endodontic cases probably fail because of

strictly aseptic technique was not observed and new microbes were introduced

during the root canal treatment.

b) Poor Debridement:

- Untreated and inadequate debridment

- Not removal of smear layer

The best way removal of smear layer, 10 ml of 17% EDTA buffered to a

pH of 7.7 followed by 10ml of 5.25% NaOCl solution effective in removal of

smear layer and superficial debris.

Retreatment Non-surgical:

In the recent years the number of people seeking endodontic treatment has

dramatically increased because of publics choice of root canal treatment over tooth

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extraction. General dentists and endodontists are better trained because of

advances in technology. The growing use of endodontics can be described as

“Good news, bad news dilemma”.

The good news is that hundreds of millions of teeth are salvaged though

combination of endodontics, periodontics and restorative dentistry. The bad news

is that ten millions of teeth are endodontically failing for variety of reasons.

Many failures can be attributed to an abundance of misinformation and

misconception about endodontics. Additional failures occurs because clinicians

tends to resist changes, these practitioners hesitate to embrace the new

technologies, instruments and materials. Unfortunately, the accelerating rate of

change in the field of endodontics has left many dentists in the gap between

current training and new possibilities.

Criteria for success:

The healing capacity of endodontic lesion is dependent on many variables,

including diagnosis, complete access, identification of all orifices and canal

systems and use of concepts and techniques directed towards three-dimensional

(3D) cleaning, shaping and obturation. The standard for success could be defined

by four following criteria.

1) The patient should be asymptomatic and should be able to chew from both

the sides.

2) The periodontium should be healthy, including normal attachment

apparatus.

3) Radiographs should demonstrate healing or progressive bone fill over time.

4) The principles of restorative excellence should be satisfied.

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Non-surgical versus surgical retreatment:

Endodontic failures must be carefully evaluated so that a decision can be

made among non-surgical retreatment (NSRC7), surgical retreatment (SRC7) or

extraction.

Non-surgical root canal treatment is an endodontic procedure used to

remove materials from root canal space, and if present, correct deficiencies or

repair defects that are pathologic or iatrogenic in origin.

These disassembly and corrective procedures that allow the clinician to 3D

clean shape an pack the root anal system.

Factors influencing retreatment decisions:

As we know that the endodontic success depends on the multiple factors.

Clinicians should have a better understanding of biologic principles and greater

knowledge, appreciation and respect for root canal system anatomy and it plays in

success and failure.

Improved training, breakthrough techniques, new technologies and

attention to restorative excellence enable clinician to obtain superior results. The

various factors that influencing retreatment decisions are –

1) When should the retreatment be considered?

Some certain teeth exhibit inadequate endodontic treatment based on the

present day, however they may fulfill the success. These teeth may be watched

rather than retreated, unless the tooth has to receive a new restoration or lies

within the field of anticipated comprehensive dentistry.

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 If the tooth is symptomatic has periodontal disease that appears after the

secondary to endodontic cause or exhibits a radiographic lesion of endodontic

origin, then decision is to be made between the retreatment and extraction.

2) What does the patient wants?

It is profoundly important to understand patient wants, needs and overall

expectations from his oral health. The clinician needs to spend sufficient time with

patient to establish rapport and trust, and to fully explain the treatment options and

to discuss the possible outcomes of the treatment.

Then patient should be told for the treatment cost equipped with this

knowledge, patient can choose the treatment options that best fulfill their wishes.

Patient relations are enhanced with this approach because there are no surprises.

Sometimes patient wants treatment but due to physically or phychologically

enable to tolerate the time or uncertainty of same retreatment efforts. These

patients may be candidates for certain procedures.

3) Is the tooth is strategic:-

Clinician should look at the tooth carefully and should decide that whether

the tooth is essential. It is necessary to explore other treatment possibilities that

may be whatever reason better or more predictable. Consultation with other

specialists save time, energy, effort, cost and prognosis associated with treatment

alternatives.

4) Restorative evaluation:-

Fundamental to endodontic treatment is the ability to produce an

esthetically well designed and clinically functional restoration. Often broken down

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tooth should be recommended for crown lengthening procedures so that restorative

dentist can achieve ferrule effect and establish a healthy biologic width.

Certain teeth fracture after restoration of endodontically treated tooth

because clinicians rely too much on post and core to retain coronal restorations,

rather than having restoration margins gripping a 2 to 3mm collar of

circumferential tooth structure.

Endodontically crown lengthening addresses isolation issues, create pulp

chambers that retain solvents, irrigants and later if required inter-appointment

temporaries. The periodontal procedure of crown lengthening assists in placing

well defined margins, improves the accuracy in impression, enhance laboratory

procedures, allow in accurately fitting restorations and promote health of

attachment apparatus.

5) Periodontal Evaluation:-

Clinician should also evaluate the periodontal health. Endodontially failing

teeth should be examined for pocket depth, mobility, crown-to-root ratios, hard

and soft tissue defects and other anomalies that could preclude a healthy

attachment apparatus. Periodontal treatment can provide numerous treatment

modalities that in concert with other disciplines, can afford a more longitudinal

success.

6) Other Interdisciplinary Evaluation:

Most of the endodontically failing teeth can be successful. Treatment with

skill, experience and technologies that are present today. However the clinician

should not focus on the specific tooth, rather they should appreciate how this tooth

fits into a treatment plan that promotes oral health. The strategic nature of any

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tooth must be evaluated from a variety of dental disciplines, and clinician must

carefully analyze restorability, the periodontal condition, occlusion. The potential

for orthodontic extrusion or uprighting and the ability to perform successful

endodontic retreatment.

7) Chair time and cost:-

The chair time and cost associated with any procedure must be carefully

analyzed and understood by the clinician and completely communicated to the

patients with experience clinician will begin to appreciate the time required to

predictably and safely disassemble an endodontic failure and therefore to

determine the cost to the patient.

Philosophically, the combined fees of endodontic retreatment and

restorative procedure should be at least equal the alternative fee (i.e. NSRCT +

restorative alternative). Clinician need to quote an adequate “disassembly fee” its

compensate themselves for chair time often required to perform these endodontic

retreatment procedures.

8) Referral:-

Clinician should always remember the Hippocratic Oath “Do no harm

while doing good”, when evaluating teeth for endodontic retreament, a series of

challenges must be addressed to produce predictably successful outcome. Ethical

question arises as to whom best qualified to address these challenges and produce

the desired results. Clinician should treat patients as they would like to be treated

themselves. Therefore it is important to remember that at times referral is the most

ethical and prudent course of action.

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Coronal Disassembly:

Clinician typically access the pulp chamber through the existing restoration

if it is judged to be functionally designed, well fitting and esthetically pleasing.

Endodontically the decision to remove any restoration is based primarily on

whether additional access is required to facilitate disassembly or retreatment.

If the restoration is deemed inadequate or additional access is required, the

restoration should be sacrificed. However, on specific occasions it is desirable to

preserve and remove the existing restorative dentistry.

Factors influencing restorative removal:

The removal of restoration is dramatically enhanced when there is a

knowledge, respect and appreciation of the concept, and techniques used in

restorative and reconstructive dentistry. The safe dislodgement of restoration is

dependent on five factors.

1) Preparation type: Preparation vary in retention, depending on the total tooth

surface area of the tooth covered and height, diameter and degree of the

axial walls.

2) Restoration design and strength:- The design and ultimate strength of

restorative is dependent on its physical properties, thickness of material,

and the quality and technique of the lab technician.

3) Restorative material:- The composition varies from metal to various tooth

coloured materials. However these materials react to stress and strains

required during removal must be appreciated.

4) Cementing agent:- The retention of cements range from weak to strong

generally progressing from ZnO eugenol  polycarboxylate  silicon

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 phosphate  ZnPO4  GIC  resin modified glass ionomers  bonded

resin. Clearly the new generation of bonding materials in conjunction with

well designed and retentive preparations, has made restorative removal

more difficult.

5) Removal devices:- The safe and successful dislodgement of prosthetic

dentistry requires knowledge in the selection of the variety of devices.

Clinician needs to identify and become familiar to each device, its safe

application, effectiveness, limitations and costs.

Coronal Disassembly Devices:

Although there are many tools available for coronal disassembly, the

following represents the preferred instrument for the removal of restoration. The

tools used for disassebly have been divided into three categories.

a) Grasping

b) Percussive

A) Grasping:-

Hand instruments works by applying inward pressure on two opposing

handles. Increasing the handle pressure proportionally increases the instruments

ability to grip a restoration. The actual grasping instrument selected should protect

the restoration and provide to reduce the danger of slippage.

These grasping devices are best used in removing provisionalized dentistry

and include the trident crown placer/ remover, K.Y. Pliers, Wynman crown

grippers.

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B) Percussive instruments:-

In this device the prosthetic disassembly is done by selected and controlled

percussive removal forces. This family of the instruments delivers impact directly

to a restorative or indirectly to another securely engaged prosthetic removal

device. Although these devices are valuable removal instruments caution must be

exercised when considering the disassembly of tooth coloured restorative. E.g.

- Ultrasonic energy, peerless gown – A-Matie, and coronaflex

- Used to remove provisionalyzed and potentially definitely cemented

dentistry.

C) Acute Instruments:-

The instrument of this category actively engage a restorative, enabling a

specific dislodgement force to potentially lift off the prosthesis. These devices

require a small occlusal window to be cut through the restorative to facilitate the

mechanical action of the instrument.

Disadvantage is the making and repairing of the occlusal hole is

significantly offset by the advantage of saving the patient’s existing restorative

dentistry.

Advantage:- For the removal of the permanently placed restoration. E.g. K-line

crown remover, bridge remover.

Also straight access line can be achieved by sacrificing the restoration.

- No.2 and No.4 round diamond bur is used to remove the tooth coloured

restorative material.

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 - Transmetal bur tooth shaped bur to remove the as less vibration and used to

remove precious and non-precious metal alloys.

- No.2 and No.4 surgical length carbide bur to increase and access.

B) Missed Canals:

The causes of endodontic failure is multifaceted, but a statistically

significant percentage of failure are related to missed root canal systems. Missed

canals hold tissue and at times bacteria and related irritants that inevitably

contribute to clinical symptoms and lesions of endodontic origin.

Historically and still too often, surgical treatment has been directed toward

corking the end of the canal with the hopes that retrograde material will

incarcerate biologic irritants within root canal system over the life of the patient.

Although this clinical scenario occurs anecdotally, it is not nearly as predictable as

non-surgical retreatment.

Canal Anatomy:

Several tooth groups have roots that notoriously hold additional system.

 Maxillary central incisors – contain in canal or more extracanals

 Maxillary first bicuspid – broad roots buccal to lingual, although orifice is

common, ribbon shaped, clinician need to expect deep canal divisions or

multiple apical portals of exit.

 Maxillary first molar have an MB root that usually contains two root canal

systems that often times anatomically communicate via isthmus. This can be

identified by without microscope in and with microscope in 90%.

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 Maxillary second molars should be suspected of having a second canal in due

MB root until proven otherwise.

 Mandibular central incisors have broad roots facial to lingual and second more

lingual canal approximately 45% of the time. Access cavity should be carried

more lingual at the expense of cingulum.

 Mandibular premolar hold complex root canal system. The anatomic variation

include displaced orifice, deep divisions, loops and branches and multiple

portals of exist apically.

 Mandibular first molar and 2nd molar the clinician should of a groove between

MB and ML. the broad distal canal contains extra canals that may be separated

along its length or become contiguous after cleaning and shaping procedures.

Also DB and DC system becomes common, deep banching with multiple

apical portals of exit are normal.

 L-shaped canals in mandibular second molar

Armamentarium and Technique:

When one is from missed canals, the following concepts, armamentarium

and technique are most helpful.

a) Anatomic familiarly is essential before preparing the access cavity or

reentering a tooth that has been previously treated endodontically.

b) Radiographic analysis should be critical. Well angulated periapical films

should be taken with the directed straight on mesioblique and distoblique.

The technique gives 3D morphology of tooth. In the root canal treatment

where the endodontic treatment is performed. Obturation material has been

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 radiograhically as ‘centered’ within the canal regardless of the angulation

of the cone. Conversely if the obturation materials appears positioned

asymmetrically within the long axis of the root, a mixed canal should be

suspected.

Computerized digital radiography affords a variety of software features,

significantly enhancing radiographic diagnostic in identifying hidden, calcified or

untreated canals.

Vision is enhanced with magnification glasses, head lamps and

transilluminating devices. The dental operating microscope affords extraordinarily

light and magnification and it gives the clinician unsurpassed vision control, and

confidence in identifying or chasing extra canals.

Surgical length burs enhance direct vision by moving the head of the hand

piece further away from the occlusal table and improving the line of sight along

the shaft of the bur.

Access cavities should be prepared and expanded so that there smallest

dimensions are dilated by separation of the orifice on the pulpal floor and their

widest dimensions are at the occlusal table. The isthmus areas or developmental

grooves or both are firmly probed with an explorer in an effort to find a catch.

Piezoelectric ultrasonic in computation with innovative new CPR ultrasonic

instruments provide a breakthrough for exploring and identifying missed canals.

Ultrasonic systems eliminate the bulky head of the conventional hand piece, which

obstructs the vision.

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 The working end of the ultrasonic instrument is 10 times smaller than the

smallest round bur and their abrasive coatings allow them to send away dentin

when exploring for missed canals.

Micro openers are flexible stainless steel ISO sized hand instruments that

feature irgonomally designed offset handles. Micro openers have limited length

cutting blades that in conjunction with their 0.04 and 0.06 tapers, enhance tensile

strength, make it easier to locate, penetrate and perform initial canal enlargement

procedures.

Various dyes, like methylene blue, can be irrigated into the pulp chamber of

teeth to aid into diagnosis,

- Chamber is rinsed thoroughly

- Dried

- Visualized to see where the dye has been absorbed

- Dye has been absorbed in fins, orifices and isthmus areas (and it will road

map the anatomy).

NaOCl can aid in the diagnosis of missed or hidden canals by means of test.

After cleaning and shaping procedures, the access cavity is with NaOCl and the

solution is observed to see if bubbles are toward the occlusal table. A positive

bubble reaction signifies the sodium hypochlorite is either reacting with residual

tissue within a canal in treatment, reacting with missed canal, or reacting with a

residual chelator.

If discovered, missed canals can usually be 3-D cleaned shaped and placed.

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C) Removal of Obturation Materials:

1) Gutta-percha removal:

The relative difficulty in removing gutta-percha varies according to the

canals length, cross sectional dimensions and curvature. Regardless of the

technique, gutta-percha is best removed from the root canal in progressive manner

to prevent inadvertent displacement of irritants periapically.

Dividing the root into three parts – coronal 1/3 rd, middle 1/3rd and apical

1/3rd. The gutta-percha is initially removed from the coronal 1/34d. in canals that

are with straight and large canals, single cones can be removed at one times with

one instrument in one motion.

The various techniques of gutta-percha removal are:

1) Rotary removal:-

Nickel and titanium (0.04 and 0.06 tapered rotary files are the most

effective and efficient group of instrument for gutta-percha removal. Rotary

instruments should be removed cautiously from the underpreapared canals and

generally not selected for removing the gutta-percha that do not accept them

passively.

When removing the gutta-percha mentally divide the canal into thirds and

then select 20 or 30 approximately sized instruments that will fit passively within

these progressively smaller regions.

To soften and engage gutta-percha mechanically rotary instrument must

turn a the speed ranging between 1200 to 1500 rpm. The rotational speed selected

is based on the friction required to mechanically soften and effectively gutta-

percha coronally.

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2) Ultrasonic Removal:-

The piezoelectric ultrasonic system represents a useful technology to

rapidly eliminate gutta-percha. The energized instruments produce the heat that

thermosoften gutta-percha. The energized instruments produce heat and

thermosoften gutta-percha.

Specially designed ultrasonic instruments are carried into the canals that

have sufficient shape to receive them and will float gutta-percha coronally into

pulp chamber.

C) Heat removal:-

Traditionally a power source in conjunction with specific heat carrier

instruments such as 5004 Touch-N-Heat and system B used to thermosoften and

remove the bites of the gutta-percha from the root canal system. of the instrument

in the underprepared canals and around pathways of curvature. In larger canals

this method works good.

Technique:-

Actuate the instrument and make it red hot than plunge it in gutta-percha

(coronal aspect). The heat carrier is deactivated as it cools freeze a bite of gutta-

percha on its working end. Removal of instrument causes an attached bites of

gutta-percha.

D) Heat and Instrument Removal:

Another way to removal is the heat and hedstrom files hot instrument

placed into gutta-percha and immediately withdrawn to soften the material. Then

No.35, 40, 45, H files is selected and quickly but gently screws into the

thermosoftened mass. When gutta-percha cools, it will freeze on the flutes of the

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file. Especially good in those cases where gutta-percha extends beyond the

foramen.

File and chemical removal:

- Best option form removal of gutta-percha from small and curved canals.

- Chloroform is the reagent of choice and plays an important role in chemically

softening gutta-percha.

- Sequential technique the pulp chamber with chloroform select the appropriate

sized K-file selected and then gently picking in chemically softened gutta-

percha. Initially size 10 to 15 ss file is used to pick into gutta-percha occupying

the coronal 1/3rd of the canal.

- Frequent irrigation with chloroform in combination with picking action creates

a pilot hole and sufficient space for serial use of large files to remove gutta-

percha in the portion of the canal.

- This method continues until no gutta-percha seen on the flute.

- Only when the gutta-percha has removed from the coronal 1/3 rd the technique

is repeated to the middle 1/3rd and than to the apical 1/3rd.

- The progressive removal prevents the needless extrusion of chemically

softened gutta-percha periapically.

Paper point and chemical removal:

Gutta-percha and most are miscible in chloroform and once in solution, can

be absorbed and removed with appropriately sized paper points. Drying solvent

filled canals with paper points is known as wicking and is the always final step of

gutta-percha of removal.

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 The wicking action is essential in removal of residual gutta-percha and

sealer out of fins, and aberrations of root canal systems.

Technique:-

In this technique the root canal system is firstly flushed with chloroform

and the solution is then absorbed and removed with appropriately sized paper

points.

Paper points wick from peripheral to central and their use in this manner

liberates the residual gutta-percha and sealer from root canal systems.

Even when the points come out clean, white and the clinician should

assume residual gutta-percha and sealer are still present. At this point the chamber

is again flooded with chloroform now introduced with more “flushing action”. The

irrigating cannula is placed below the orifice and solvent is passively and

repeatedly irrigated than aspirated. This alternating method then aspirating creates

a vigorous back and forth turbulence that powerfully promotes the elimination of

root canal filling material.

After chloroform wicking procedures, the canal is liberally flushed with

70% isopropyl alcohol and wicked to further encourage the elimination of

chemically softened gutta-percha residues.

Silver Point Removal:

The relative ease of removing failing silver point is based on the fact that

chronic leakage greatly reduces the seal and hence lateral retention. Before a given

silver point retrieval is selected, it is useful to recall the canal preparation

prescribed for this method of obturation.

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 Typically the apical 2 to 3mm of canal was prepared relatively parallel and

then flared coronal to the apical zone. When clinician evaluate silver point failures

they should recognize that the silver point, the parallel the length, hope for a

coronally shaped canals and take advantage of this space discrepancy.

There are various techniques advocated to remove the silver points,

depending upon their varying lengths, diameters and position they occupy within

the root canal space.

Certain removal techniques evolved to address the silver points that bind in

unshaped canals over distance. Other techniques with large cross sectional

diameters finally other technique are necessary to remove the split cone or

intentionally sectioned silver point lying deep within root canal space.

A) Access:- Typically the coronal heads of silver cones are within pulp

chamber and are in cements, composites or amalgam cores. Access

preparation should be done so that to minimize the risk of inadvertently

foreshortening the silver points. Initial access with the surgical length

cutting tools subsequently ultrasonic instrument may be carefully used

within the pulp chamber to brush cut away the restorative materials and

progressively expose the silver point.

Above the orifice

B) Pliers Removal:- After completing access and fully exposing the part of

silver point confined the pulp chamber, a suitable grasping instrument such

as pliers is selected. The care should be taken not to needlessly foreshorten.

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 When grasping a silver point, rather than trying to pull it throughout of the

canal, the pliers is rotated using fulcrum mechanics and levered against the

restoration or tooth structure to enhance removal efforts.

Below the orifice:

C) Indirect ultrasonic:- When segment is below the orifice the CPR 3, 45

ultrasonic unit may be used. The CPR 3, 55 have parallel walls and provide

progressively longer lengths and smaller diameter.

The ultrasonic instrument is used to trephine circumferentially around the

obstruction, breaks the cement and safely expose much of silver points.

Caution:- The ultrasonic instruments are not used directly as silver points

because elemental silver is soft and rapidly erodes during mechanical

manipulation once the surrounding material is removed, ultrasonic energy

may be then transmitted directly on a grasping pliers to synergistically

enhance the retrieval efforts. This form of indirect ultrasonic

advantageously transfer energy along the silver point, breaks up material

deep within the canal and enhance removal efforts.

D) Files, solvents and chelators:

If the pliers and indirect ultrasonic fails the clinician should immediately

abort this approach and appreciate that silver points are perfectly round and root

canal systems are typically irregular in their cross-sectionals shapes. This

discrepancy between round silver and an irregularly shaped canal allow the use of

solvent and 10 or 15 ss file.

In solvent filled chamber, files are used laterally to silver points to break up

cements and undermine and loosen silver point for removal. In under prepared

26
canals, chelators are at times better than solvents by allowing the instrument to slip

and slide and work laterally to silver point.

If a space exists or can be created by between silver point and canal wall, a

35, 40 or 45 H file can be inserted into space. This is called Hedstron

Displacement technique. Powerfully promotes the removal process because

instruments the vake angle bites, engages and establishers a strong purchase on

any metallurgically soft silver points.

Microtube Removal points:

a) Microtube tap:- The post removal system contains smaller microtubule taps

that clinicians to mechanically tap, thread and engage the most coronal aspect

of any obstruction with diameter of 0.6 mm or greater.

These microtubular tap contains a reverse thread and engage an obstruction by

turning in a counterclockwise direction. They are generally used to engage

obstructions that extend into pulp chamber.

b) Microtube mechanics options:- In this removal method a microtube is placed

via the exposed coronal most part of obstruction. It is then passed down the

length of the tube until it engaged itself tightly between the obstruction and

internal lumen of microtube.

Carrier-based gutta-percha removal:

Carrier based obturators were originally metal and file like yet, over the

past several years they have been manufactured from easier to remove plastic

materials.

After careful access and complete circumferential exposure of the carrier, a

suitable grasping pliers is selected and a purchase is obtained on the carrier. The

27
relative tightness of the carrier within the canal then be tested using the plier.

Recognizing that the carrier is frozen in a hardened guttapercah enhance

successful removal in these cases.

 The carrier is grasped with the pliers and extrication is attempted using

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

 If enough canal shape exists, a CPR 3,4,5 or ultrasonic can be used

alongside the carrier to produce heat and thermosoften the gutta-percha.

The activated ultrasonic instrument is gently moved apically and carrier is

oftentimes displaced and out coronal.

 Indirect ultrasonics can be performed by grasping the exposed carrier with a

pliers and then placing an ultrasonic instrument against the pliers.

 Rotary instrumentation can be used to anger a plastic effectively and

efficiently from the canal. This should only be attempted if there is

sufficient space to passively accommodate the rotary instrument without

engaging lateral dentin.

 The IRS (Instrument Retrieval System) may considered in certain cases, to

remove a carrier. This method of removal is especially appropriate if the

core of the carrier is metal and has cutting flutes that are engaging lateral

dentin.

 Solvents will chemically soften the gutta-percha and allow small files to

work deeper, professionally undermining and loosening a carrier for

removal.

28
PASTE REMOVAL:

Originally, the intention for paste use was for those patients who could not

afford conventional endodontics and this modality of treatment was considered a

benevolent alternative to extraction. When evaluating a paste care for retreatment,

it is useful to clinically understand that paste can generally be divided into soft,

penetrable and removable versus hard, unpenetrable and at times unremovable.

Typically the paste used in soft within the canal and easily removed. But

the paste used in white colored used in Russia and reddish brown resin paste in

eastern Europe and pacific challenges in removal because they set up brick hard.

However, it is important because the method of placement, the coronal

portion of paste in the canal is most dense (The material is progressively less

dense moving apically).

In addition, retreatment of paste filled cases is often wrong with surprise

because clinician frequently encounter calcification, resorption and flare ups that

should be anticipated and communicated.

Techniques for removing the metallic silver points from the canals:-

1) Use of spoon excavators, explorers and retrivers:

A no.31 or 33 endodontic spoon excavator with sharp cutting edge will

often lift out a silver cone if the cone is fairly loose. If the end of the hook is bent

sufficiently, it can be initially hooked with fine no.17 explorer or silver point

retriever.

These instruments resemble spoon excavator with V-shaped notch

modification. These mode of action is a prying motion, similar to that of tin

29
extraction elevator. Solvents should be used before the practitioner attempts

removal of any silver cone that is firmly lodged in the canal.

2) Use of hedstrom files:-

The use of the solvent and fine instruments will often free up the removal

of coronal part of the silver cone. Once a pathway is negotiated, the file braiding

technique can be used. One or more H file usually No.20 and 25 range are placed

beside the silver cone as apically as possible and screwed into position until tight.

The screwing engages the soft silver metal yields a satisfactory purchase. If the H

files are twisted together, they can be simultaneously pulled out by hand or they

can be clamped by the surgical needle holder and levered against the incisal or

occlusal edge.

This technique may also be considered for the removal of sectional or burst

off silver cones in addition to plastic gutta-percha cone carrier. Since hedstrom

files will not enjoy stainless steel the technique will not work on broken files, or

even if they are fairly long and loose coronally.

Specialized Forceps:

Several specialized forceps for the removal of metallic objects have been

developed. All have narrow beaks that will extend into a reasonably conservative

access opening. The silver point forceps is a grooved needle-nosed pliers that is

often too bulky to use in small access openings. The bulkier portion of the forceps

can be ground away to permit better penetration into the orifice. However the fine

teeth of the instrument often slide off the metal object to be removed rather than

grasp it firmly. These problems can be overcome by use of perry gold foil pliers, a

peet splinter forceps or 3 ½ CVD mosquito forceps.

30
 These forceps are generally more useful because the taper one the beaks is

ore gradual, allowing freedom for beak separation and engagement of the metallic

object in deep access opening. The tips are not quite so delicate as the tips of

slightly forceps and are less likely to bend or slip under tension.

Massern Kit:

Kit contains a series of tubular traphing drills and two sizes of tubular

extractors (1.2 and 1.5mm). The principle of this technique is first to create a

space in the root canal around the coronal 2mm of the metallic.

Ultrasonic energy:- Ultrasonic instrument in conjunction with microscope afford

excellent control in removing paste from straight assay portion of the canal.

Specifically, the CPR 3, 4, 5 or zirconium nitride-coated ultrasonic instruments

may be used below the orifice to remove brick hard, resin type paste.

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

specially designed adapter that mounts as and is activated by the ultrasonic

handpiece.

Heat:- Certain resin pastes soften with heat. Heat carriers can be selected if this

modality of removal is chosen.

Rotary instruments:- SS 0.02 tapered hand files may be used to negotiate through

paste fillers. They create a pilot hole for safe ended rotary instrument and

effectively the toxic material coroanlly.

Dangerous but at times helpful is the use of end-cutting NiTi rotary

instruments to penetrate paste.

Solvents and Handfiles:- Endosolve ‘R’ and Endosolve ‘E’ can be useful in

chemically softening hard paste. “R” designates the choice for the removal of resin

31
based pasts and ‘E’ is the solution for elimination of eugenol based paste. These

segments can be placed interappointment against a paste type material via paper

points or cotton pellets to promote shrinkage and facilitate subsequent removal.

Microdebriders:- After removing the paste fillers and cleaning and shaping the

canal, the remaining pastes still be noted within the irregularities of the root canal

preparation.

Microdebriders are specially designed instrument to precisely remove

residual paste material from a root canal system. The microdebriders have

ergonomically designed offset handles. These SS instruments enhance vision, they

have diameter of 0.20 and 0.30 mm and available in 0.02 tapers with 16 mm of

efficient H-type cutting blade.

Solvent and paper points:- After paste removal, paper point wicking in the

presence of specific paste solvents is important to further remove and liberate

materials from irregularities.

Blocks, ledges and apical transportations:

Failure to respect and appreciation the biologic and mechanical objectives

of cleaning and shaping increases frustration and predispose to needless

complications such as blocks, apical transportation and potentially perforations.

Occasionally blocks ledges and apical transportation occur and are

clinically encountered. Perhaps the most powerful unsaid method to negotiate

blocked canals, bypass ledges and manage apical transportation is the attitude “I

will” which requires determination, perseverance and patience.

32
Technique of managing blocks:

 When encountered with blocked canal, tooth is flooded with NaOCl.

 Well angulated radiographs are observed and the root curvature and apical

pathology.

 The clinician should appreciate that disease flows a root canal system occur in

coronal to apical direction and the connection should be made that lesions of

endodontic origin from adjacent to portal of exit.

 When blocked canal shortest file is choose which goes to the working length.

Shorter instruments provide more stiffness and move the clinicians fingers to

the tip of the instrument resulting in greater tactile control.

 It should be noted that the canals are more curved than the roots they are in.

 As such a number 10 file is precurved to simulate the curvature of the canal

and unidirectional rubber stop is oriented to match the file curvature.

An attempt is made to slide the instrument into the canal:-

- If this unsuccessful the canal should be enlarged, irrigate and overcurve the file

to facilitate moving it to the length.

- If an obstruction is encountered the precurved file is directed in a picking

motion.

- Clinician should use very short amplitude light to negotiate the canal terminus

short pecking strokes ensure safety, irrigants deeper and increase the

possibility of canal negotiation.

- The handle of the file with a tip engated should never be rotated excessively

because it can produce loads leading to the separation of the instrument.

33
- If apical extent of file sticks or engages, then motion is minimal back and forth.

- If no.10 file begins to move apically, it may allow useful to used smaller

instrument with diameter 0.08 and 0.06mm.

- Depending on the severity of the blockage, these efforts often allow the

clinician to reach the foramen passively and establish potency.

If no progress is made after diligent effort over a time frame of

approximately 3min, then sodium hypochlorite is removed and root canal is

replaced by viscous chelator. Then same technique is done that it takes few

minutes to work the chelator deep into the canal and benefit from its desirable

attributes.

If no.10 file sticks and engages into debris, then a smaller instrument such

as no.1 file is at times useful.

When instrument travels to length, its tip is gently moved to and minutely.

Pushing the instrument to the length carries more chelator deeper into the canal,

places more debris into the suspension and lubricates files so it will slide to length.

The clinician continues with short light amplitude push and pull stroke and

the file gently and subtly over a range of 1 to 2mm. when the instrument moves

freely, slightly longer 2 to 3mm amplitude strokes are taken. Finally strokes of 3 to

4mm are used until the file can glide to the terminus with ease and predictability.

There are clinical where the previously mentioned technique have been

carefully attempted but either the file is not progressing apically or not tracking

the pathway of physiologic canal.

34
What to do next requires a thoughtful?

If the patient is asymptomatic, periodontics is healthy and there is no lesion

of endodontic origin, then preparation is finished at the level of obstruction. The

patient is informed of this less than ideal outcome and frequent important periodic

recalls.

If the blocked canal is not negotiable and if clinical symptoms, periodontal

breakdown. The 3D packing of the canal is required. Also importance of recalls.

Endodontic Perforations:

Perforation represents the pathologic or iatrogenic communication between

the root canal space and the attachment apparatus. The causes of the perforations

are resorptive defects, caries or iatrogenic events that occur during endodontic

treatment.

Regardless of the cause, a perforation is an invasion into the supporting

structure that initially loss of attachment and inflammation ultimately this may

compromise the prognosis of the tooth. Perforations at or below the crest of bone

certainly pose a serious threat to otherwise favorable endodontic prognosis.

Perforation at or below the crest of the bone certainly pose a serious threat

to an otherwise favorable endodontic prognosis.

Considerations influencing perforation repair:

The 4 dimensions of perforation: Treating clinicians must identify the four

dimensions of a perforation and understand how each of these entities critically

affects treatment selection and prognosis.

35
 Microscopes, paper points, electronic apex locators, such as root Zn and

diagnostic radiopaque contrast solution such as solution are useful in determining

the level, location and extent of perforation and potential for successful

management.

The 4 dimensions of perforations are:-

1) Level:-

Perforation occur in coronal, middle and apical 1/3 rd of roots. Furcal

perforations have similar considerations as coronal 1/3rd perfor. Perforations at this

level threatens the sulcular attachment and pose different treatment challenges

then more apically occurring perforations. In general more apical the perforation,

more favorable the prognosis.

2) Location:-

Perforations occur circumferentially on buccal, lingual, mesial and distal

aspects of roots. The location of perforation is not so important when non-surgical

treatment is selected, however the position is critical and may preclude surgical

access.

3) Size:-

Perforation size greatly affects the clinicians ability to establish a hermetic

seal. The area of a circular perforation can be mathematically described. Therefore

doubling the perforation size with any bur or instrument increases the surface area

to seal fourfold.

4) Time:-

Regardless of the cause the perforation should be repaired as early as

possible to discourage further loss of attachment and prevent sulcular breakdown.

36
Chronic perforations exhibit loss of sulcular attachment and pose treatment

challenges that potentially escalate to surgical correction.

Periodontal Condition:-

Teeth that have been perforated should be examined thoroughly.

Specifically the sulci of these teeth must be thoroughly probed. If the attachment

apparatus is intact without pocketing is critical and treatment is ideally directed

towards non-surgically repairing defects. If there is a periodontal breakdown with

resultant loss of attachment, interdisciplinary consultation (including orthodontic,

periodontic and endodontic condition) and restorative should guide treatment

planning, sequencing and prognosis.

Esthetics:-

Perforation in anterior region can be definitely impart esthetics, patients

that exhibit high lip line can be esthetically compromised by soft tissue defects,

such as clefts, recessions a discrepancies in the microgingival dimension of the

crown when compared with adjacent teeth.

Vision:-

Magnification glasses, headlamps and transilluminating devices facilitate

vision and are important adjuncts in addressing perforations. The dental operating

microscope has dramatically improved vision.

Treatment sequence:-

When there is perforation and canal is open but not been optimally shaped,

the perforation defect should be repaired before proceeding with definitive

endodontic treatment. If the perforation is not repaired first, the clinician will be

37
unable to control bleeding into the canal, confine irrigation or achieve a controlled

hydraulic pack.

However any given perforated canal should be optimally enlarged and

prepared to improve access to defects to increase and to minimize post-repair

instrumentation.

To maintain the patiency of the canal a gutta-percha segment cotton pellet

or collagen can be placed apical to the defect to prevent canal blockage during the

perforate repair procedure.

Caution must be exercised not to the perforation repair during subsequent

disassembly, canal preparation and obturation procedure.

Materials used for perforation repair:-

Many perforation defects exhibit massive bleeding upon reentry. A

clinician must be familiar with few haemostatic agents and materials that can

predictably arrest bleeding.

A dry field enhance vision while creating an environment for predictable

placement of restoration agent. Ca(OH)2 is syringed into the canal, hydraulically

moved place and allowed to canal and defect for 4 to 5 or longer. The Ca (OH) 2 is

then flushed from field using NaOcl. Two or 3 placements of Ca(OH) 2 usually

begin to control bleeding. If he haemostasis is not achieved the Ca(OH) 2 is

advantageously left in the canal till the future appointment.

Other materials through which we can achieve haemostasis is collagen,

calcium sulfate, freeze-dried bone and MTA. Other also exist but are not used

38
because of the cost, ease of handling and placement. Ironically the ferric sulfate

leaves a coagulum behind that they promote bacterial growth.

Barrier Materials:

- Resorbable

- Non-resorbable

Barrier helps to produce a dry filled and also an internal matrix or back stop

to condense restorative materials against.

Resorbable barrier:- Internal bleeding into the tooth must be managed this is

accomplished by passive or resorbable non-surgically through the access cavity.

Resorbable barrier materials are intended to be placed in the bone, not left

within tooth structure. The barrier should confirm to the anatomy of the furcation

or root surface involved.

1) Collagen materials such as Colla cote/ collatape:-

- Excellent property provides a complete haemostasis

- Biocompatible supportive of new tissue growth

- Resorbable in 10 to 14 days

- Based on the size of defect and available access, pieces of collacote are cut

to appropriate sizes and carried into access cavity.

- Material is placed incrementally into the osseous defect until a solid barrier

corresponding to cavosurface of the root is established.

- Collagen barrier widely used within conjunction with amalgam, super, and

other non-bonded restorative material.

39
 - Never used with adhesion dentistry because it absorb moisture and will

contaminate the restoration.

2) Calcium sulfate such as Capset:- Can be used as a barrier and haemostatic agent

in perforation management. It creates a tamponade effect – mechanically plugging

the vascular channels once it is set.

- Biocompatible

- Resorbable in 2 to 4 weeks

- Syringed though the tooth into the osseous defect using a microtubule

delivery system.

- During the placement it will fill the portion of the osseous defect and

portion of space within the root defect.

- Calcium sulfate sets brick hard and easily sanded flush to the external root

surface with selected ultrasonic finishing instruments.

- UFI are coated for sanding, scaled to work deep within the root canal space

and their port technologies dispense irrigant precisely into the field of

action.

- Calcium sulfate is the barrier of choice when using the wet bonding.

B) Non-resorbable barriers:

- MTA exhibits excellent tissue biocompatibility and can be used both non-

resorbable barrier and restorative material.

- Many clinical applications and represents an extraordinary breakthrough for

managing radicular repairs.

40
 - MTA is the barrier of choice when there is potential moisture

contamination or when there are restrictions in technical access and

visibility.

- MTA with the internal mature concepts the resorbable collagen matrix is

placed which act as the seal for the MTA.

Restoration:-

The various restorative used should be biocompatible, non-resorbable,

esthetically pleasing and that provides complete seal. The material commonly

employed are – amalgam, super-EBA resin cement, composite bonded

restorations, Ca phosphate cement and MTA.

The choice of restorative repair material is based on the technical access to

the defect, the ability to control moisture and esthetic consideration.

Techniques for Repairing Perforation:-

1) Management of coronal 1/3rd or furcal perforation:

The major difference between coronal 1/3 rd and furcal floor perforations is

the shape of the resultant root defects. Mechanical perforations at the furcal area

are rounded and at the coronal 1/3rd are ovoid by nature of occurrence.

Isolate the perforation site –

- If the perforation is just occurred mechanically, it is cleaned. In this situation if

haemostasis is present the defect can be immediately repaired.

- If the perforation is chronic and exhibits microleakage, it needs to be cleaned

and prepared receiving the restorative material.

41
- Ultrasonic instruments are ideal for preparing perforation sites because of there

geometries, coatings and technologies.

- In coronal 1/3rd where esthetic consideration CaSO4 with the adhesion dentistry

is generally used.

- Historically amalgam and more recently super-EBA have been used for the

coronal 1/3rd perforation. Presently MTA is rapidly becoming the barrier and

restorative of choice for repairing non-esthetic coronal 1/3rd defects.

2) Management of Perforation in Middle 1/3rd:

Iatrogenic perforations in middle 1/3rd are generally caused by endodontic

files, drill or misdirected posts. By nature of occurrence defects are ovoid in shape

and typically represents larger surface area to seal. In multirooted teeth

perforations in furcal areas are termed as furcal strips.

Middle 1/3rd have the same technical considerations as the coronal 1/3 rd,

except clinician is now dealing with the defects that are more deeper and from the

access cavity.

The factors that must be addressed to successfully treat these more apically

positioned perforations are haemostasis, access, use of the technique and selection

of best material in challenging environment.

When managing deeper defects the vision is enhanced by direct access, by

this can compromise some of the tooth structure irreversibly. Generally the

perforations that occur by overjealous instrumentation does not require shaping

that is they are sterile and do not require modification using micro instrumentation

procedure.

42
 In middle 1/3rd perforations with small defects if the bleeding can be dried

and arrested the perforations can then be sealed and repaired during 3-D

obturation.

If the defect is large there is moisture or if the canal cannot be definitely

dried, the perforation must be first repaired before 3D obturation. It is wise to

prepare the canal before initializing the perforation repair procedures. A prepared

canal will facilitate access to the defect and minimize postrepair instrumentation.

To prevent the obstruction of root canal space during the repair procedures,

any readily material is placed in the canal and apical to the defect before the

perforation is repaired.

Management of perforations in the apical one third:

Perforations occurring in the apical 1/3 rd of roots primarily result from

breakdown that occur during cleaning and shaping procedures. Blocks and ledges

invite deep perforations and result from inadequate irrigation, inappropriate

instrumentation and failure to maintain patency.

The perforations at the apical 1/3 rd procedures frustration to the clinician

due to decreased access. However, it is generally best for clinician to first attempt

non-surgical retreatment to enhance the existing endodontic treatment. The

clinician should attempt to negotiate the physiologic terminus with the concepts,

instruments and techniques.

The file is gently worked to negotiate the physiologic pathway established

patency, and the way for the next successively lager instrument. The next

43
sequentially layer precurved file is then inserted and carried apical to the

perforation but not necessarily to the length.

The holding file the pathway of the true canal and prevents it from being

blocked during subsequent repair. It is the material for choice if the dry

environment and access are not possible. To prevent the bolding file from being

frozen is sea of MTA as it hardens, the instrument is grasped with pliers and

moved up and down in short 1 to 2 mm amplitude strokes.

A radiograph should be taken to confirm the position of the MTA and the

quality of the repair. A wet cotton pellet is placed within the pulp chamber against

the MTA, the tooth is provisionalized and the patient is dismissed.

Techniques for managing ledges:

An internal transportation of canal is termed a ledge. Often ledges result

when clinicians work short of length and get blocked, using the stiff instruments.

Many ledges are by passed by using the same technique described for

block. Once the tip of the file is apical to the ledge, it is moved in and out of the

canal using very short push and pull movements with emphasis on staying apical

to the defect.

When the file moves freely, slightly longer push and pull strokes reduce the

ledge and confirm the presence or absence of internal canal irregularities. If the

file is sliding easily, it is turned upon withdrawal because this motion will tend to

straighten the apical 1/3rd of SS file and allow it to rasp, smooth or eliminate the

ledge.

44
 During these procedures, the clinician should try to keep the file coronal to

the apical foramen. When the ledge can be predictably bypassed, efforts are

directed toward establishing patency with no.10 file gently passing a 0.02 tapered

no.10 file 1mm through the foramen increases its diameter to 0.12mm.

A breakthrough in the ledge management is the use of greater taper (GT)

with hand files. The major advantage of using 91 files to remove a ledge is Do

diameters are 0.20 mm, their maximum flute diameter is 1.00 mm and their tapers

are 3 to 4 times conventional 0.02 tapered files.

It should not be introduced into the canal until the ledge has been bypassed,

the canal is negotiated, and patency established. After bypassing the ledge and

negotiating the canal up to and if necessary a no.20 file creates a pilot hole so that

tip of 97 file can passively follow the slide path. The NiTi G7 instrument must be

precurved with endo bender pliers.

To successfully precurve a NiTi instrument the working end of the G7 file

is securely grasped between the jaws of the fill binder and handle is pulled through

a radius of between 180 to 270.

NiTi has memory and efforts to bend it must be exaggerated so that when

the instrument is released from the pliers it will have the desired curvature in its

apical extent. The orientational rubber stop is placed on the instrument and then

turned to match the direction of the apically curved gutta-percha file.

Gutta-percha hand files are used in the crown down manner, big to small.

An appropriately tapered gutta-percha then carried into the canal and the rubber

stop is oriented so that the instruments precurved working end can bypass and

more apical to the ledge.

45
 After the gutta-percha file is used number 10 files is used to check if the

ledge has been either reduced or eliminated.

In the instance when the ledge cannot be removed filling the master cone

gutta-percha can be challenging. In these cases the master cone is trimmed so that

its terminal diameter equals to Do diameter of the file that was at length.

The cone is then precurved to simulate the curvature of the canal and the

radicular portion is placed on the dappen dish of 70% isopropyl alcohol. When the

master cone is removed the rigidity has been increased significantly.

Techniques for managing apical transportation:-

Moving the position of canal physiologic terminus to new iatrogenic

location in the external root surface equal to transportation of the foramen. If the

transportation has occurred the canal exhibits the reverse and fails to provide

resistance to gutta-percha. This leads to incomplete obturation.

Type 1:- Minor movement of physiologic foramen to new iatrogenic location.

In this instance clinician try to create a positive apical canal. Generating

shape coronal to the foramen removal of the dentin and can lead to steep

perforation. If sufficient residual dentin maintained the canal is 3D shaped,

cleaned and packed.

Type II:- Moderate movement of the physiologic foramen to new iatrogenic

location.

More reverse architecture exhibited

Creating the weakening and perforation

Barrier – MTA

46
Technique:-

- MTA mixed with anaesthetic solution or sterile to heavy, cake like

consistency.

- Carried to the orifice with microtube carrying device, such as customized

spinal tap needle or on the side of west perforation repair instruments.

- Gently and waxed down through non-standardized gutta-percha or flexible

plugger.

- In straighter canals gutta-percha can be vibrated, moved into defect by CPR3, 4

or 5. It should be activated at the lower energy.

- If repairing the defect apical to the canal curvature a 4 to 5mm column of MTA

is first shepherd around the curvature with flexible gutta-percha plugger.

- A precurved no.15 or no.20 SS file is then carried around the canal curvature

into the MTA. Indirect ultrasonic with CPR-1 tip used on the shaft of the file.

The vibratory energy will encourage MTA to slump, move and adapt to the

configuration of the canal laterally.

- A dense 4 to 5 mm zone of MTA in the apical extent of canal should be

confirmed radiographically.

- Moistened cotton is placed against the MTA and temporary filling.

Type III: Severe movement of the physiologic foramen to new iatrogenic location

of the external root surface.

In this situation the terminal extent of the canal is 10 badly mutilated that

barrier technique is not feasible have 3D obturation is not possible.

If the tooth with type III transportation has to be salvaged, it requires

obturation as best as possible with follow-up of corrective surgery.

47
 Draw back if MTA is used perforate

Perforation repair when to start the treatment

Post Removal:

It is common for clinician to encounter endodontically teeth that contain

posts. The post is removed in two instances when endodontic treatment is failing,

the need arises to remove a post to facilitate successful non-surgical retreatment;

when restoration needs require the removal of existing post to improve design,

mechanics or esthetics of a new restoration significantly.

Factors influencing post removal:

a) The most critical factors required in successful post removal are operator

judgment, training and experience as well as using the best technology and

techniques.

b) Clinician must also have knowledge and respect for anatomy of teeth and the

variations found in them.

c) It is important to know each root’s morphology, including external concavities,

root wall thickness, length, shape curvature of the canal. This information can

be obtained from well angulated pre-operative radiograph. Films also assist the

clinician in visual, the length, diameter, direction of the post and its in the pulp

chamber.

d) Post removal also influenced by post type and cementing agent. Post can be

into parallel versus tapered, actively engaged versus non-actively retained,

metallic versus new non-metallic. Post retained with the classic cements (e.g.

zinc phosphate) can generally be removed however posts bonded into root

48
 canal space with material like composite resin or glass ionomers are

substantially more difficult to remove.

e) Other important factors that impart post removal are the available interocclusal

space, existing restorations and whether the position of coronal most aspect of

the post is supracrestal or subcrestal.

f) Post removal becomes ore challenging moving from anterior to posterior teeth.

g) The difficulty in removing post substantially increases in furcated teeth

containing multiple posts joined coronally with single or multiple interlocking.

h) When evaluating a tooth for post-removal, the clinician must weigh risk versus

benefit. An example the titanium post have radiodensity similar to the gutta-

percha when viewed radiographically.

The clinician should take care that a root can be structurally weakened,

perforated or fractured during any phase of retreatment ranging from radicular

dissamenable to subsequent shaping and filing procedures.

Techniques for Access:

Successful post removal requires sufficient access so all restorative material

from the pulp chamber should be eliminated. Clinicians often times access the

pulp through an existing restoration if it is judged to be functionally designed, well

filling and esthetically pleasing.

If the restoration is deemed inadequate and additional access is required

then the restoration is sacrificed. Coronal disassembly improves access, vision and

retreatment efforts.

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 When a post removal procedure are performed through an existing

restoration then the high speed rotary cutting tools are utilized to prepare lingual

or occlusal window, section and eliminate the core and create a straight line access

into the pulp chamber.

The # 2 and # 9 round bur diamonds in conjunction with water are used

more safely brush cut through tooth colored restorative such as porcelain.

Transmetal bur is bur of choice for cutting metal because of raw tooth

configuration of its blades reduces unwanted vibration when cutting various types

of precious and non-precious metals.

Surgical length #2 and #4 carbide round burs provide extended reach that

improves access and vision into the pulp chamber. Surgical length tapered

diamonds are advantageously used with light brushing motion to refine, smooth

and flare the axial walls and finish all aspects of access preparation. These cutting

tools remove the greatest bulk of restorative materials that commonly various post

head configuration.

Access refinement:

Piezoelectric technology in conjunction with ultrasonic instruments provide

important advantages when performing access refinement procedures. Ultrasonic

instruments are used for the access refinement. Small profile ultrasonic

instruments continuous and improved vision into field. On the contrary a rotating

bur in dental handpiece is oftentimes difficult to see because small sized head

often blocks the time of sight.

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 Contra angled, parallel sided and abrasively coated stainless ultrasonic

instruments enhance access, vision and cutting precision when progressively away

various materials.

Thinner and more parallel sided ultrasonic instruments are designed to

work in smaller spaces that is between the post and axial wall. The CPR-2

ultrasonic instrument is used in full intensity within the pulp chamber to eliminate

the remaining core materials circumferential to the post.

The smaller parallel sided CPR 3, 4 and 5 ultrasonic instruments are more

and should be used in the low intensity. These instruments are designed to work in

the small restricted and confined spaces.

If space is severely restricted within the field of operation CPR 6,7, 8

titanium ultrasonic instrument can be selected and used on low intensity. These

instruments provide clinician thinner diameters and longer lengths. The CPRs may

be used to safely brush and sculpt away the materials that upon elimination,

undermine the stability of the post.

All non-surgical ultrasonic work should be performed ‘dry’ to optimize

vision. When ultrasonic work is performed in a wet field, the debris that are

generated quickly accumulates and becomes a slurry of mud.

The assistant advantageously used the ‘Stropho three way adaptor with

white tip to direct and control continuous stream of air into the field. This clinical

action strives to blow out debris and importantly allows clinician to maintain

visual contact at all times on the energized tip of the instrument.

Water post technology in non-surgical ultrasonic instrument is contraindicated for

four important reasons:-

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 a) Water flowing through an ultrasonic instrument dampens movement and

decreases tip performance.

b) Small diameter ultrasonic instruments are weakened and more predispose

to expensive breakage when they are for internal water flow.

c) There is an undesirable aerosol effect regardless of where the water part is

positioned on ultrasonic instrument.

d) Water in combination with dentinal dust, creates mud, lost vision and

thereby increases the potential for iatrogenic outcomes.

Techniques for post-removal:

A) Rotosonic vibration:-

Rotosonic is a straight forward method of potentially loosen and remove

fully exposed post. The regular tip, Roto-Pro bur is a speed, friction grip bur

whose six faces are joined by six edges and when rotated one revolution, its edges

produces six vibration per revolution.

When the instrument is rotated at 200,000 rpm, it produces 1.2 million

vibrations per min, or 20,000 vibration per second. The instrument provides an

inexpensive method to remove certain posts. The bur is kept in intimate contact

with the obstruction and generally carried counterclockwise (CCW) around the

post.

B) Ultrasonic Energy:

If rotosonic efforts are unsuccessful, the clinician should select a specific

ultrasonic instrument such as CPR-1 because its superb energy transfer will

dislodge most posts.

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 The CPR-1 has a ball at its working end, which is kept in intimate contact

with the post to maximize energy transfer. The instrument is used in full intensity

and is moved around the post circumferentially and up and down along is exposed

length.

Experience suggest that after removing all circumferential restorative

materials, the majority of post can be safely and successfully removed in

approximately 10 minutes or less using the CPR-1. However certain posts resist

removal even after ultrasonic efforts using the 10 minute rule.

C) The PRS/ Mechanical Option:

A number of different devices have been designed to mechanically remove

a post. Many devices like post-puller (Brassler, USA) have limited success

because they frequently require excessive removal of tooth structure the root

fracture, ledges and perforations.

The post (EFDN) represents a definite improvement over earlier in that it is

less invasive and has enjoyed good success but for a variety of reasons by limited

number of clinician.

PRS (Post removal system by Endo) was developed to provide significant

improvement in simplicity, versatility and sizing during the post-removal

procedures.

The PRS is designed to mechanically engage and remove different kinds of

post types or other intracanal obstructions whose cross-sectional diameter are 0.60

mm or greater.

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 The PRS kit contains extracting pliers, a transmetal bur, five trephines of

interdiameter, five corresponding taps whose interdiameter ranges from 0.60 to

1.60 mm, a torque bar, and selection of rubber bumbers.

Mechanism:-

- Straight line access

- Complete circumferential visualization of post within the preparation

- A transmetal bur is used to round or taper coronal most part of aspect of post

of the post head will serve to effectively guide the subsequent inst over the

post.

- A drop of chelator such as RC Prep, or is then placed on the head of the post to

act as the lubricant to facilitate the machining process.

- To ensure circumferential the largest trephine that just engages the post is

selected. The latch type trephines should rotate approximately 15,000 rpm in

direction in a slow speed high torque hand piece.

- The trephine should be used in dulling motion to maintain rpm and keep the

head of he post cooler so it does not work harden and become more difficult to

machine. The trephine is to machine down 2 to 3mm length of most coronal

aspect of exposed post.

- If the chosen trephine fits passively, then a sequentially smaller size trephine is

selected to ensure proper circumferential melting.

- Generally, the trephine used for machining the post dictates the subsequent

selection of corresponding sized tubular tap. An opposite sized rubber bumper

is selected and inserted over the distal end of the tap. The rubber bumper

54
 serves to cushion, evenly distributed loads and protect the tooth during the

removal procedure.

- The tubular tap is pushed against the head of the milled down post and is

manually turned CCW to form threads. Firm apical pressure and small quarter

turn CCW motion will generally draw-down and securely engage the tap to the

post.

- The tap should be screwed over the post as little as the 1mm optimally or

maximum 3mm. caution should be exercised so that tap is not drawn down too

far over the post because maximum internal depth is 4mm. If the tap bottom

out against the post head, it can predispose to stripping the threads breaking the

wall of the tap, or shearing off obstruction inside the of the tap.

- When the tubular tap has engaged the post the protective rubber bumper is

pushed down onto the biting surface of the tooth.

- The post removal pliers are then selected and the extracting jaws are mounted

onto the tubular tap. The instrument is held securely with one hand, while the

fingers of the other hand begin opening the jaws by turning the screw know

CW. As the jaws slowly begins to open, increasing pressure will be noted on

the screw knob.

- Further utilizing the removal method, the clinician should visually confirm the

post being safely withdrawn along the long axis of the root canal.

- If turning a screw knob is increasingly difficult clinician should either hesitate

for a few second before continuing or use indirect ultrasonic technique to

vibrate on the post-engaged tubular lip. This enhances the screw knob to turn

further and thus potent adjunct to successful post removal.

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- Clinician also encounter threaded posts. The PRS is specifically designed to

address this scenario because each tubular tap turns CCW rotate. The post head

is milled down. In instances where threaded post are encountered the use of

extracting pliers are contraindicated. Typically the clinician back the post out

of the canal using CCW rotation.

BROKEN INSTRUMENT REMOVAL:

When instrument breaks it immediately frustration despair and anxiety. In

fact the broken instrument dilemma has caused such emotional distress that this

event is frequently referred to as “separated” or “disarticulated” file.

Today separated instruments can usually be retrieved because of

technologies advancement, ultrasonic instrumentation and microtube delivery

method.

The microscopes fulfill the age-old “If you can see it you can probably

remove it”. In combination the microscopes and ultrasonic instrumentation have

driven microsonic technique.

FACTORS INFLUENCING BROKEN INSTRUMENT REMOVAL:

- Depends on diameter, length and position of the obstruction within the canal.

- Depends on the anatomy including diameter, length and curvature of the canal.

- Depends on the root morphology, including the circumferential diameter and

thickness of dentin and depth of an external concavity. If the 1/3 rd of the overall

length of the instrument is exposed it can usually be removed.

- Depends on the site where the instrument has broken, i.e. instrument that lies in

the straightway portion can be removed easily separated instrument that lie

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 partially around the canal although more difficult can. If the broken instrument

segment is apical to the curvature of the canal and safe access cannot be

established, the removal is not possible and in presence of signs and symptoms,

surgery or an extraction.

- Depends on the type of the material compromising an obstruction. Stainless

steel files tend to be easier to remove they do not fracture during the removal

process. NiTi instrument may break again during the ultrasonic removal are

knowledge, training and competency. Perhaps the most important factor central

to the successful instrument removal are knowledge, and competing.

Coronal and radicular access:

1) Different horizontally angulated preoperative radiographs.

2) Coronal access is accomplished by speed friction grip, surgical length burs

selected to create a straight line access to all the orifices special attention

should be towards the axial walls.

3) Radicular access is the second step required in the successful removal of

broken instrument.

Clinician experience suggests that majority of broken separate towards their

terminal extent at between D2, D4 and D5. Files mostly frequently break in the

apical 3 to 5mm because this is the region where a canal usually exhibits its

greatest degree of curvature. Even if the file breaks at the working length, position

of head of the instrument typically lies at the function of middle and apical one

third.

To create a safe radicular access (i.e. flare the canal coronal to the

obstruction) initially use hand files, small to large, coronal to the obstruction.

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 Hand files provides sufficient safe to safely instrument gates glidden. GG

are rotated at the spee of the 750 rpm and safely used with brushing motion to

create a tapered shape and maximize vision.

Creating a platform:

When canal is optimally staped microsonics is used as first option to

remove the broken instrument. At times when ultrasonics is used, its activated lips

does not have enough space, lateral to the broken file segment, to initiate

trephining.

If more lateral space is required, then the bud of GG is modified to create a

circumferential staging platform. The staging platform is made by selecting GG

drill whose maximum cross section diameter is slightly larger than visualized

instrument. The bud is altered by cutting it perpendicular to the long axis at its

maximum cross section diameter.

The modified GG is rotated at the speed of 350 rpm and directed apically

until it lightly contact the more coronal aspect of the instrument. Thus facilitating

the use of ultrasonic.

Technique for removing broken instrument:

1) Ultrasonic technique:-

Piezoelectric ultrasonic technology is used which should provide a broad

range of power, precise adjustment within the lower settings and electrical

feedback to regulate amplitude and safe tip movement.

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 Ultrasonic instrument should have contra angled design to provide access

and parallel sides walls to create a straight line and zirconium nitride coating to

precisely sand away dentin during trephine procedure.

The tip of ultrasonic instrument is kept in intimate contact against the

typically activated with the lower power setting. All ultrasonic work below the

orifice is conducted. Dry to enhance vision, a stropko three way adapter with an

appropriate tip to direct continuous strain of air to blow out dentinal dust is used.

The selected ultrasonic instrument is moved lightly in a CCW direction,

except when removing a file that has left handed thread in that case direction will

be CW.

Gently wedging the energized tip between the tapered file and canal wall

often times causes instrument to jump out of the canal. If the instrument lies deep

that long length and small diameter ultrasonic instrument are used.

On occasion, after creating an excellent coronal and radicular access,

performing the excellent ultrasonic trephining, the instrument does not come out

of the canal.

Further it may be unsafe to continue trephining around a broken instrument

because of lack of resin and anatomical restriction. In these cases the instrument

has to be bypass.

To maximize efficiency and success the handles from SS file is removed

and SS file is then inserted into dense called file. File adapter threads into

ultrasonic hand piece. This technique is of useful when root is thin or a portion of

file apical to canal curvature.

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 Even when loose, the angle formed between the coronally flared canal and

the head of the broken instrument often times preclude removal. This is best

managed by microtube removal.

Microtubes removal method:

They require excessive removal of the dentin. For clinician, the critical

when considering microtube removal methods is not the inside diameter but the

outside diameter which how deep it can be safely introduced into the canal.

The following represents the removal method.

1) Anchor:

In this method an appropriate sized microtube is selected and wire is passed

through it and looped at the one end and passed back through the tube. This loop

can potentially lasso a coronally exposed obstruction and when successful and

removes the instrument by pushing the tube apically and simultaneously pulling

the wire ends coronally.

2) Tube and Glue:- The canceilliu extractor kit (Sybron Endo)

- Contains four different size microtubes with outside diameter

approximately 0.50, 0.60, 0.70 and 0.80 mm.

- An abrasively coated ultrasonic instrument is used to trephine around the

instrument and typically expose 3mm coronal part of the obstruction.

- A microtube is prefit and made ensure that its internal diameter just fit over

the coronally exposed obstruction. The prefit microtube is now bonded to

the obstruction with an adhesive called core pastes.

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 - The microtubes are safely scaled for progressively deeper placement into

canals of post roots.

- The removal method is quiet effective for non-fluted broken instrument or

when there is difficulty a separated file that is loose.

3) Tap and Thread:-

The post removal system contains five microtubular taps. The smallest PRS

tap has the outside diameter of 1.50mm and internal form threads and

mechanically engages the most coronal aspect of the obstruction whose diameter

is 0.60 mm or greater.

4) Spinal tap needle:-

A spinal tap needle (Ranfac) in conjunction with its metal insert plunger or

another technique advocated to remove broken instruments. The microtube sizes

that are clinically relevant are 19, 21 and 23 gauze needles corresponding to

outside tube diameters of approximately 1.00, 0.80 and 0.60 mm.

Because of their unique to engages, smaller sized instrument and files are

selected and inserted into the coronal most aspect of the microtube. The h-file is

then passed down the length of the tube until it wedges tightly between the

obstruction and internal lumen of the tube.

However, because ZSO files tapers 0.32 mm over 16 mm of cutting blades,

the taper of file oftentimes restricts the placement through a smaller sized parallel

microtube. In this instance, the STN’s metal insert plunger must be used.

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5) Instrument removal system:-

The instrument removal kit (iRS) (Dentsply Tulsa Dental) provides another

method for the removal of the broken instrument, and other intracanal obstructions

such as silver points, carrier-based obturators.

The iRS is indicated when ultrasonic efforts prone to be unsuccessful and

may be used to remove broken instruments that are lodged in straight away

portions of the root or partially around the canal curvature.

There are two types of instruments:-

a) Black instrument

b) Red any yellow instrument

Black instrument:- The black instrument has outside diameter of 1.00mm and

designed to working coronal 1/3rd of the large canals.

Red and yellow have outside diameter of 0.80 and 0.60mm and can be placed

deeper into more narrow canals.

Each complete instrument is comprised of color coordinated microtube and

screw wedge.

Each microtube has a small-sized plastic handle to enhance vision during

placement and side window to improve mechanics and 45 beveled end to scoop

up the coronal end of a broken instrument.

Each screw wedge has a knurled metal handle, a left handed screw

mechanism proximally and a solid cylinder.

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Mechanism of removal of instrument with iRS:

- Straight coronal and radicular access is required to subsequently visualize the

coronal most part broken instrument.

- Ultrasonic instrument are used to circumferentially expose 2 to 3mm of

separated file. However ultrasonic instrument can only circumferentially

trephine sand away dentin and expose the portion of obstruction that lies

straight away portion of the canal.

- An iRS microtube is then selected that can passively slide through the pre-

enlarged canal and drop over exposed broken instrument.

- In a curved canal of the NiTi file will always lie against the outer wall. In these

instances the microtube is inserted into the canal with the beveled end oriented

to the outer wall of the canal to “scrap up” the head of the broken instrument

and guide it into the microtube.

- The obstruction is engaged by gently turning the screw wedge handle CCW.

- A few degrees of rotation will serve to tighten wedge and oftentimes displace

the head of the obstruction through the microtube window.

- If any given color coded screw wedge is unable to achieve a strong hold on the

obstructive, then another color coded screw wedge may be chosen to improve

engagement and successful removal.

- The obstructive can be potentially and remove by rotating the microtube and

screw wedge assembly CCW.

- If difficulty is encountered when rotating the microtube and screw wedge

assembly CCW, then proceed with limited CW rotation of 3 to 5, which will

promote staying engaged, followed by turning the assembly CCW.

- This repeated reciprocating handle motion will serve to loosen and facilitate

the removal process.

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REFERENCES :

1. Cohen.S, Hargreaves KM. Pathways of the pulp 10th edition.

2. John S Rhodes. Advanced Endodontics Clinical Retreatment and Surgery

1st edn. Taylor & Francis 2006

3. Carr GB. Microscopes in endodontics. Journal of the Californian Dental

Association

1992; 20: 55–61.

4. Hülsmann M, Schinkel I. Influence of several factors on the success or failure

of removal of fractured instruments from the root canal. Endodontics and Dental

Traumatology 1999; 15: 252–258.

5. Ward JR, Parashos P, Messer HH. Evaluation of an ultrasonic technique to

remove fractured rotary nickel-titanium instruments from root canals: an experi-

mental study. Journal of Endodontics 2003; 29: 756–763.

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