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Nonsurgical retreatment of a postsurgical endodontic failure
0099-2399/84]1012-0577/$02.00/0 JOURNAL OF EklEXJDONTICS Copynght 9 1984 by The American Associationof Endodontists
Printed in U.S.A. Vow.. 10, No. 12, Dt~CEMBER1984
CASE REPORT Nonsurgical Retreatment of a Postsurgical Endodontic Failure Retratamiento no Quirurgico de un Fracaso Endodontico Post-quirurgico Donald J. Kleier, DMD
A 45-yr-old Caucasian woman was referred by her family dentist because of pain and periapical pathology associated with both her maxillary central incisors. The teeth had been endodontically treated and retrofill amalgams had been placed. Both teeth were diagnosed as postsurgical endodontic failures. The teeth were retreated nonsurgically. An 18-month recall examination showed normal soft tissue anatomy and an apparent decrease in the size of the periapical radiolucencies. Nonsurgical retreatment of postsurgical endodontic failures is an alternative to reoperation or extraction.
often patients undergo surgery for endodontic failures instead of nonsurgical retreatment. Patients are sometimes referred to an endodontist because of failing endodontic teeth which have already been treated surgically. Rud et al. (5) stated that cases which fail postsurgically should be reoperated or extracted but little has been published describing alternative treatment methods for postsurgical endodontic failures. This case reports nonsurgical retreatment of a postsurgical endodontic failure.
Una mujer cauc~,sica (blanca) de 45 a~os rue derivada por su dentista de cabecera debido a que presentaba dolor y patologia periapical en sus incisivos centrales superiores. Los dientes habian sido tratados endodonticamente y se habian colocado amalgamas retrogradas. En ambos dientes se diagnostico fracaso quir0irgico. Los dientes fueron retratados sin hacer cirugia. En un control a los 18 meses se observo anatomia normal de los tejidos blandos y una evidente disminucibn en el tama~o de la zona de radiolucidez periapical. El retratamiento no quirurgico despu(~s de un fracaso endodontico quir,',rgico es una alternativa ante una nueva cirugia o la extraccibn.
A 45-yr-old Caucasian woman was referred for an endodontic consultation by her family dentist with a chief complaint of pain and occasional swelling in the area of her maxillary central incisors. The patient reported that the crowns of both maxillary central incisors had been fractured approximately 1 yr previously in an automobile accident. Her teeth were treated endodontically and crowned shortly thereafter. Approximately 3 months later, the patient returned to her dentist complaining of episodic pain in her maxillary central incisors. The patient was then informed that periapical surgery was necessary to eleviate the pain and treatment was performed. The patient was then asymptomatic for approximately 6 months. After this time both centrals again became symptomatic. She again complained to her family dentist and was subsequently referred. The patient's medical history was unremarkable. Examination showed an actively draining sinus tract apical to the maxillary left central incisor. Both centrals were sensitive to percussion. The maxillary lateral incisors and canines responded normally to pulp vitality tests and were asymptomatic. Radiographic examination showed the right central was obturated with a silver
CASE REPORT
Surgical endodontic therapy is an accepted part of endodontic practice. Indications and contraindications for endodontic surgery, including retrofill amalgam procedures have been reported in the dental literature (13). An indication for surgery is failure of endodontically treated teeth. Block and Bushnell (4) stated that too 577
578
Kleier
FIG 1. Pretreatment radiograph showing maxillary right and left central incisor and periapical radiolucencies.
cone and the left central was obturated with guttapercha. Retrofill amalgams were present in the apices of both teeth. The gutta-percha in the left central was approximately 2 mm short of the retrofill amalgam. Both central incisors had periapical radiolucencies (Fig. 1). The patient was fearful of a second endodontic surgery and was considering extraction of both centrals. A nonsurgical approach to retreatment was explained including the possible need for a second surgery. The patient agree to undergo nonsurgical retreatment. Utilizing local anesthesia, both centrals were isolated with a rubber dam and access to the endodontic filling material was established. The silver cone in the maxillary right central was removed using the Hedstrom file technique (6). Moderate corrosion was noted on the apical half of the silver cone. The gutta-percha in the maxillary left central incisor was removed using the chloroform solvent technique (6). During instrumentation of the teeth, the retrofiU amalgams were probed to confirm their retention in the root apices (Fig. 2). A dry cotton pellet was sealed in each tooth with a zinc oxideeugenol temporary | cement and the patient was rescheduled for another appointment. One week later the patient returned and reported an improvement in her clinical symptoms. Examination showed initial healing of the sinus tract at the apex of
Journal of Endodontics
FIG 2. Periapical radiograph showing silver cone removed from the maxillary right central incisor. A Hedstrom file is used to probe the retrofill amalgam.
the maxillary left central incisor. Both centrals were obturated at this appointment with gutta-percha using a vertical condensation technique (7) (Fig. 3). The patient was referred to her family dentist for restoration of the teeth. Recall examination after 18 months showed normal attached gingiva and alveolar mucosa surrounding the restored maxillary central incisors. The sinus tract originally present had completely healed. Radiographic examination showed apparent reduction in the size of the radiolucent periapical lesions (Fig. 4). The patient reported she had been asymptomatic since her last visit. DISCUSSION This case demonstrates the need to identify the etiology of endodontic failure prior to surgical therapy. Rud et al. (8) concluded from their clinical investigation that the main reason for postsurgical failure was leakage of infectious or necrotic material from an unfilled portion of the root canal. This material either bypassed a retrofill amalgam or diffused through unfilled lateral canals. Placement of a retrofill amalgam is not a substitute for thorough canal instrumentation and obturation. Obstructions in the root canal space have been cited
Voh 10, No. 12, December 1984
Postsurgical Endodontic Failure
579
FIG 3. Immediate posttreatment radiograph showing gutta-percha vertically condensed against the retrofill amalgams.
FIG 4. Eighteen-month posttreatment radiograph showing reduction of pedapical radiolucencies.
as an indication for a retrofill amalgam (3). In a failing surgical case where a retrofill amalgam has been placed because of a canal obstruction, attempted removal of the obstruction should be considered. Several authors (9-12) have reviewed and introduced techniques for removing canal obstructions. If the obstruction can be removed, the retrofill amalgam is probed to demonstrate its retention in the root end. Amalgam which resists displacement can serve as a apical stop against which to condense gutta-percha. I have successfully retreated six cases in this manner within the past few years. If the amalgam is displaced from the root end, creation of a new apical stop may be impossible. When no apical stop exists endodontic surgery with retrofill amalgam placement is probably the treatment of choice, although calcium hydroxide therapy may be an alternative (13).
Dr. Kleier is associate professor, Endodontics, University of Colorado School of Dentistry, Denver, CO. Address requests for reprints to Dr. Donald J. Kleier, University of Colorado School of Dentistry, 4200 E. 9th Ave., Box C-284, Denver, CO 80262.
SUMMARY This report described nonsurgical retreatment of two maxillary central incisors that were considered to be postsurgical endodontic failures. Methods for canal retreatment were discussed. Nonsurgical retreatment is an alternative to reoperation or extraction of endodontic surgical failures.
References 1. Luebke RG, Glick DH, Ingle JI. Indications and contraindications for endodontic surgery. Oral Surg 1964;18:97-113. 2. Cohen S, Burns RC (eds.). Pathways of the pulp. 3rd ed. St. Louis: CV Mosby, 1984:613-42. 3. Arens DE, Adams WR, DeCastro RA (eds.). Endodontic surgery. Philadeiphia: Harper and Row, 1981:1-13. 4. Block RM, Bushell A. Retrograde amalgam procedure for mandibular posterior teeth. J Endodon 1982;8:107-12. 5. Rud J, Andreasen JO, Jensen JEM A follow-up study of 1000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:215-28. 6. Cohen S, Bums RC (eds.). Pathways of the pulp. 3rd ed. St. Louis: CV Mosby, 1984:291-2. 7. Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967;11:732-9. 8. Rud J, Andreasen JO, Jensen JEM A multivariate analysis of the influence of various factors upon healing after endodo~tic surgery. Int J Oral Surg 1972;1:258-71. 9. Sieraskii SM, Zillich R M Silver point retreatment: review and case report. J Endodon 1983;9:35-9. 10. Fors UGH. Berg J-O. A method for the removal of broken endodontic instruments from root canals. J Endodon 1983;9:156-9. 11. Weismen MI. The removal of difficult silver cones. J. Endodon 1983;9:210-1. 12. Roig-Greene JL. The retrival of foreign objects from root canals: a simple aid. J Endodon 1983;9:394-7. 13. Gerstein H (ed.). Techniques in clinical endodontics. Philadelphia: WB Saunders, 1983:185-7.
Printed in U.S.A. Vow.. 10, No. 12, Dt~CEMBER1984
CASE REPORT Nonsurgical Retreatment of a Postsurgical Endodontic Failure Retratamiento no Quirurgico de un Fracaso Endodontico Post-quirurgico Donald J. Kleier, DMD
A 45-yr-old Caucasian woman was referred by her family dentist because of pain and periapical pathology associated with both her maxillary central incisors. The teeth had been endodontically treated and retrofill amalgams had been placed. Both teeth were diagnosed as postsurgical endodontic failures. The teeth were retreated nonsurgically. An 18-month recall examination showed normal soft tissue anatomy and an apparent decrease in the size of the periapical radiolucencies. Nonsurgical retreatment of postsurgical endodontic failures is an alternative to reoperation or extraction.
often patients undergo surgery for endodontic failures instead of nonsurgical retreatment. Patients are sometimes referred to an endodontist because of failing endodontic teeth which have already been treated surgically. Rud et al. (5) stated that cases which fail postsurgically should be reoperated or extracted but little has been published describing alternative treatment methods for postsurgical endodontic failures. This case reports nonsurgical retreatment of a postsurgical endodontic failure.
Una mujer cauc~,sica (blanca) de 45 a~os rue derivada por su dentista de cabecera debido a que presentaba dolor y patologia periapical en sus incisivos centrales superiores. Los dientes habian sido tratados endodonticamente y se habian colocado amalgamas retrogradas. En ambos dientes se diagnostico fracaso quir0irgico. Los dientes fueron retratados sin hacer cirugia. En un control a los 18 meses se observo anatomia normal de los tejidos blandos y una evidente disminucibn en el tama~o de la zona de radiolucidez periapical. El retratamiento no quirurgico despu(~s de un fracaso endodontico quir,',rgico es una alternativa ante una nueva cirugia o la extraccibn.
A 45-yr-old Caucasian woman was referred for an endodontic consultation by her family dentist with a chief complaint of pain and occasional swelling in the area of her maxillary central incisors. The patient reported that the crowns of both maxillary central incisors had been fractured approximately 1 yr previously in an automobile accident. Her teeth were treated endodontically and crowned shortly thereafter. Approximately 3 months later, the patient returned to her dentist complaining of episodic pain in her maxillary central incisors. The patient was then informed that periapical surgery was necessary to eleviate the pain and treatment was performed. The patient was then asymptomatic for approximately 6 months. After this time both centrals again became symptomatic. She again complained to her family dentist and was subsequently referred. The patient's medical history was unremarkable. Examination showed an actively draining sinus tract apical to the maxillary left central incisor. Both centrals were sensitive to percussion. The maxillary lateral incisors and canines responded normally to pulp vitality tests and were asymptomatic. Radiographic examination showed the right central was obturated with a silver
CASE REPORT
Surgical endodontic therapy is an accepted part of endodontic practice. Indications and contraindications for endodontic surgery, including retrofill amalgam procedures have been reported in the dental literature (13). An indication for surgery is failure of endodontically treated teeth. Block and Bushnell (4) stated that too 577
578
Kleier
FIG 1. Pretreatment radiograph showing maxillary right and left central incisor and periapical radiolucencies.
cone and the left central was obturated with guttapercha. Retrofill amalgams were present in the apices of both teeth. The gutta-percha in the left central was approximately 2 mm short of the retrofill amalgam. Both central incisors had periapical radiolucencies (Fig. 1). The patient was fearful of a second endodontic surgery and was considering extraction of both centrals. A nonsurgical approach to retreatment was explained including the possible need for a second surgery. The patient agree to undergo nonsurgical retreatment. Utilizing local anesthesia, both centrals were isolated with a rubber dam and access to the endodontic filling material was established. The silver cone in the maxillary right central was removed using the Hedstrom file technique (6). Moderate corrosion was noted on the apical half of the silver cone. The gutta-percha in the maxillary left central incisor was removed using the chloroform solvent technique (6). During instrumentation of the teeth, the retrofiU amalgams were probed to confirm their retention in the root apices (Fig. 2). A dry cotton pellet was sealed in each tooth with a zinc oxideeugenol temporary | cement and the patient was rescheduled for another appointment. One week later the patient returned and reported an improvement in her clinical symptoms. Examination showed initial healing of the sinus tract at the apex of
Journal of Endodontics
FIG 2. Periapical radiograph showing silver cone removed from the maxillary right central incisor. A Hedstrom file is used to probe the retrofill amalgam.
the maxillary left central incisor. Both centrals were obturated at this appointment with gutta-percha using a vertical condensation technique (7) (Fig. 3). The patient was referred to her family dentist for restoration of the teeth. Recall examination after 18 months showed normal attached gingiva and alveolar mucosa surrounding the restored maxillary central incisors. The sinus tract originally present had completely healed. Radiographic examination showed apparent reduction in the size of the radiolucent periapical lesions (Fig. 4). The patient reported she had been asymptomatic since her last visit. DISCUSSION This case demonstrates the need to identify the etiology of endodontic failure prior to surgical therapy. Rud et al. (8) concluded from their clinical investigation that the main reason for postsurgical failure was leakage of infectious or necrotic material from an unfilled portion of the root canal. This material either bypassed a retrofill amalgam or diffused through unfilled lateral canals. Placement of a retrofill amalgam is not a substitute for thorough canal instrumentation and obturation. Obstructions in the root canal space have been cited
Voh 10, No. 12, December 1984
Postsurgical Endodontic Failure
579
FIG 3. Immediate posttreatment radiograph showing gutta-percha vertically condensed against the retrofill amalgams.
FIG 4. Eighteen-month posttreatment radiograph showing reduction of pedapical radiolucencies.
as an indication for a retrofill amalgam (3). In a failing surgical case where a retrofill amalgam has been placed because of a canal obstruction, attempted removal of the obstruction should be considered. Several authors (9-12) have reviewed and introduced techniques for removing canal obstructions. If the obstruction can be removed, the retrofill amalgam is probed to demonstrate its retention in the root end. Amalgam which resists displacement can serve as a apical stop against which to condense gutta-percha. I have successfully retreated six cases in this manner within the past few years. If the amalgam is displaced from the root end, creation of a new apical stop may be impossible. When no apical stop exists endodontic surgery with retrofill amalgam placement is probably the treatment of choice, although calcium hydroxide therapy may be an alternative (13).
Dr. Kleier is associate professor, Endodontics, University of Colorado School of Dentistry, Denver, CO. Address requests for reprints to Dr. Donald J. Kleier, University of Colorado School of Dentistry, 4200 E. 9th Ave., Box C-284, Denver, CO 80262.
SUMMARY This report described nonsurgical retreatment of two maxillary central incisors that were considered to be postsurgical endodontic failures. Methods for canal retreatment were discussed. Nonsurgical retreatment is an alternative to reoperation or extraction of endodontic surgical failures.
References 1. Luebke RG, Glick DH, Ingle JI. Indications and contraindications for endodontic surgery. Oral Surg 1964;18:97-113. 2. Cohen S, Burns RC (eds.). Pathways of the pulp. 3rd ed. St. Louis: CV Mosby, 1984:613-42. 3. Arens DE, Adams WR, DeCastro RA (eds.). Endodontic surgery. Philadeiphia: Harper and Row, 1981:1-13. 4. Block RM, Bushell A. Retrograde amalgam procedure for mandibular posterior teeth. J Endodon 1982;8:107-12. 5. Rud J, Andreasen JO, Jensen JEM A follow-up study of 1000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:215-28. 6. Cohen S, Bums RC (eds.). Pathways of the pulp. 3rd ed. St. Louis: CV Mosby, 1984:291-2. 7. Schilder H. Filling root canals in three dimensions. Dent Clin North Am 1967;11:732-9. 8. Rud J, Andreasen JO, Jensen JEM A multivariate analysis of the influence of various factors upon healing after endodo~tic surgery. Int J Oral Surg 1972;1:258-71. 9. Sieraskii SM, Zillich R M Silver point retreatment: review and case report. J Endodon 1983;9:35-9. 10. Fors UGH. Berg J-O. A method for the removal of broken endodontic instruments from root canals. J Endodon 1983;9:156-9. 11. Weismen MI. The removal of difficult silver cones. J. Endodon 1983;9:210-1. 12. Roig-Greene JL. The retrival of foreign objects from root canals: a simple aid. J Endodon 1983;9:394-7. 13. Gerstein H (ed.). Techniques in clinical endodontics. Philadelphia: WB Saunders, 1983:185-7.