Nonsurgical retreatment

Successful

Asymptomatic

Periodontium should be healthy

Radiographs should demonstrate healing

Principals of restorative excellence should be satisfied

Non surgical treatment
Procedure to remove root canal filling materials from the tooth, revise the shape and
obturete the canal

Usually accomplished because the original treatment appears inadequate or has failed or
because the root canal has been contaminated by prolonged exposure to oral environment
Indications for nonsurgical retreatment

1.A patient presents with a tooth that has had inadequate initial root canal treatment,

with a history of painful symptoms that either have not changed or have worsened since the

initial treatment
2.The pain may be spontaneous but most often is initiated by chewing or biting pressure
3.There may have been a history of episodes of facial swelling or swelling in muco buccal fold
4.Recurrent caries

5.leaky provisional restorations

6.missing corona restorations

7.The patient may also present with an apical lesion that was not present at the time of initial
treatment or the enlargement of a preexisting apical radiolucency
Contraindications for nonsurgical retreatment
1.If the tooth is deemed to be nonrestorable, then retreatment is contraindicated
2.If the crown-to-root ratio is compromised and excessive mobility is present as a result of
chronic periodontal disease, then retreatment is contraindicated
3.situations where the root canal space may no longer be accessible as a result of root canal
calcifications or the presence of large, well-fitting post and core restorations

These cases would require periradicular endodontic surgical treatment to attempt to resolve
the non-healing lesion if the tooth is to be retained
4.In cases of separated instruments that cannot be bypassed or retrieved that result in a
nonhealing situation, apical surgery is the choice rather than attempting another
nonsurgical retreatment

5.The same applies to ledges that cannot be bypassed, perforation defects not amenable to
nonsurgical repair, and root canals that have been transported and the original root canal
space cannot be negotiated
Etiology of posttreatment disease
1.Persistent or reintroduced intraradicular microorganisms

2.Extraradicular infection

3.True cysts
`1.Persistent or reintroduced intraradicular microorganisms
is the major cause of posttreatment disease

root canal space and dentinal tubules are contaminated

pathogens can contact the periradicular tissue

apical periodontitis

Inadequate cleaning and shaping

Inadequate obturation

Inadequate final restoration

Iatrogenic procedural errors
poor access cavity design
untreated canals
 treating canal short
Contamination of an initially sterile root canal during treatment
canals that are poorly cleaned and obturated
complications of instrumentation
Ledges
 perforations
separated instruments
overextensions of root filling materials
2.Extraradicular infection
bacterial cells can invade the periradicular tissues by
direct spread of infection from the root canal space

extrusion of infected dentin chips

via contaminated periodontal pockets that communicate with the apical area
contamination with overextended

infected endodontic instruments

Actinomyces israelii and Propioni bacterium propionicum ( periapical tissues)

3.True cysts
 Cysts form in the periradicular tissues due to the presence of chronic inflammation
Types of periapical cysts
the periapical true cyst

the periapical pocket cyst

True cysts have a contained cavity or lumen within acontinuous epithelial lining

pocket cysts, the lumen is open to the root canal of the affected tooth

True cysts, due to their self-sustaining nature, probably do not heal following nonsurgical
endodontic therapy and usually require surgical enucleation
Diagnosis and Retreatment Options
be based on clinical signs and symptoms, radiographic and, when necessary,
tomographic interpretations

Radiographs should be clear image and include the tooth and surrounding tissues

Bitewing radiographs are useful in determining

1.interproximal caries

2.periodontal bone loss

3.recurrent decay under restorations and faulty restorations

All sinus tracts should traced with a cone of gutta-percha followed by a radiograph to
localize their origin
Periapical radiographs should be taken in two different horizontal angles to
evaluate

the quality of obturation

crestal bone

level, presence of missed root canals

procedural errors

Resorptions

 lateral or periapical radiolucent lesions

Mandibular left second molar shows broken instruments in one of the mesial root canals

Different horizontal angle of the same tooth shows a possibility of root canal transportation
as well as perforation in the same root
Periapical radiography of the maxillary left first molar when taken from distal resulted in
superimposition of the distobuccal root over the palatal root

 Taking the radiograph with a different horizontal angle shows broken instrument in the
distobuccal root
as a result of the fracture of the preexisting restoration, leakage, or unacceptable
esthetics, endodontic retreatment should be performed for teeth with inadequate root
canal therapy despite the absence of clinical signs or symptoms and radiographic
pathosis
Poorly treated mandibular molar with insufficient preparation and obturation

After retreatment showing well-prepared canals and a well-condensed obturation

Clinical view of tooth in showing a metal bridge

On removal of the bridge, the premolar shows a poor coronal restoration
Maxillary premolar with a short post and poor endodontic therapy

After retreatment, placement of post, resin composite core and a new bridge
cone-beam computed tomography (CBCT)
visualize the tooth and surrounding structures in three dimensions

allows the clinician to determine the true size extent, and position of periapical resorptive
lesions

giving information about

tooth fractures

missed canals

root canal anatomy

the nature of the alveolar bone topography around teeth

Factors to evaluate periodontal assessment
If the probing in excess of 3 mm to 4 mm, then the cause should be thoroughly evaluated

Is the defect of endodontic or periodontal origin?

Wide, broad pockets are generally periodontal lesions

Narrow probing defects with single-point probing are generally lesions of endodontic origin
or in some cases caused by vertical root fracture

Mobility measurements should be recorded and noted

Factors to be evaluated prior to deciding treatment options
1.Case history
Early radiographs

Time since previous treatment

Symptoms in the past

Previous endodontic treatment

2.Clinical situation

Symptoms at present

Possibility of restoration

Periodontal condition

3.Anatomy

Untreated root canals

Form of root canals

4.Root canal filling

Length of filling

Condensation of material

Type of material

5.Factors reducing chances of success

Broken instrument

Perforation

Ledge

External root resorption

Quality of endodontic treatment

Level of obturation – under filling/overfilling

Number of canals filled

Radiodensity of obturation

Amount of canal preparation

Symmetry of canals within the root space

Treatment Planning for Nonsurgical Retreatment
Important factors in this respect include

cost-effectiveness of the treatment

periodontal status

the remaining tooth structure after removing all caries and preexisting restorations

restorability of the tooth

 the need for crown lengthening in order to place a suitable full-coverage restoration

 esthetic and functional conditions