ENDODONTIC RETREATMENT OF A MANDIBULAR FIRST MOLAR WITH
SYMPTOMATIC APICAL PERIODONTITIS: A CASE
REPORT*Martariwansyah*Mahasiswa Peserta Program Dokter Gigi
Spesialis Ilmu Konservasi Gigi Fakultas Kedokteran Gigi Universitas
Padjadjaran
Case Summary : A 24-year-young male patient complaining of
discomfort in his tooth #36, which had already been endodontically
treated one year ago. Six month later, a filling became looseand
got the temporary filling. After standing for a long, he began to
experience moderate pain at percussion especially when used
chewing. There was no sign of swelling or sinus. He never take any
medication to relieve the pain. Intra Oral examination found the
old cavity with the temporary filling (fig.1), Pulp sensitivity
test was negatif. At the mesial side was sensitive to percussion.
Periapical Radiographic analysis showed of tooth was periapical
lesion at mesial apical root (fig.2).Diagnosis : Tooth 36
previously treated; symptomatic apical periodontitis. Treatment
planning : Endodontic retreatment and placement of indirect onlay
composite Figure2. Periapical Radiographic analysis showed of tooth
was periapical lesion at mesial apical root ((July 3rd 2014Figure
1.the old cavity with the temporary filling (July 3trd 2014)
Removing Gutapherca : After giving local anaesthesia with
Xylocaine(Dentsply Maillefer) 2% with adrenaline (Epinephrine)
1:80,000 the tooth was isolated with rubber dam and clamp (Hygenic)
(Fig.3). The access cavity was refined with an Endo Access bur
number A0164 DM (Dentsply Maillefer) and Remnant restoration
material was removed. When exposing the pulp chamber floor, a lot
of debris, sealer and gutta-percha (GP) were observed. There was
appearance of two master cones in the mesial side (one mesio buccal
and one mesio lingual), and one in the distal side (fig.4). The
retreatment was done after removing the GP using Hand files
Instrument without solvent (fig 5.). GP was removed using light
apical pressure and passively rotated clockwise until the working
length with Hedstroem File Colorinox 25mm #25 (Dentsply Maillefer).
The pulp chamber was thoroughly rinsed with 2.5 % sodium
hypochlorite solution (NaOCl) . After removing GP on the distal and
mesial canals carefully examined using an endodontic probe. X-rays
are taken to verify that cleaning fiilling material completed.
(fig.6)
figure 4. Exposing the pulp chamber floor, a lot of debris,
sealer and gutta-percha were observedFigure3. the tooth #36 was
isolated with rubber dam and clamp (Hygenic)
Figure 6. X-rays are taken to verify that cleaning fiilling
material completed
Figure 5.Gutta-percha was removed using light apical pressure
and passively rotated clockwise until the working length was
reached with Hedstroem File Colorinox 25mm 25 (Dentsply
Maillefer)
Preparation : Instrumentation was performed again according to
the pre-enlargement technique, which preparing the middle-coronal
third with ProTaper Rotary Shaping File 19mm SX and subsequent
preparation of the apical third. The initial coronal preparation
was carried out with the ProTaper Next (PTN) (Dentsply Maillefer)
X1 file, which has a 0.17 tip size and a 4% taper. Using Glyde
(Dentsply Maillefer) as intracanal lubricants to aid preventing
blockage during cleaning and shaping (fig.11). The file was used in
a brushing motion to approximately two-thirds of the estimated
working length with frequent NaOCl irrigation. The file was
withdrawn from the canal frequently to clean the flutes and to
recapitulate with a #10 K-File to ensure canal patency was
maintained. Once the coronal preparation was completed, the working
length (WL) was gotten by electronic measurement with an apex
locator, ProPex PiXi (Dentsply Maillefer) (fig 7.) and Creating
smooth and reproducible apical glide path using PathFile(Dentsply
Maillefer) #16, #19 rotary instruments to the full WL
(fig.8).Taking the radiograph to confirm full WL (fig.9). Canal
preparation was continued to WL. the PTN X1 and X2 file with the
same brushing motion, again with regular irrigation and
recapitulation. The next stage was to gauge the apical diameter of
the canals and thus determine the finishing PTN (Dentsply
Maillefer) X3 file (fig.10) which has an ISO 30 tip size and 6%
taper. After shaping was completed, theEndoActivatorwas used to
agitate the 2,5 % NaOCl (fig.11). After rinsing out the NaOCl with
sterile water, the canals were irrigated withchlorhexidin (CHX) 0.2
% followed byGlyde (Dentsply Maillefer)) to remove smear layer
(fig12). All canals were dried with paper points (fig 13). Calcium
Hydroxide paste (Non setting) was placed into the canal with a
lentulo spiral paste carrier and the access cavity was closed with
ciprospad (Dentsply Maillefer) as temporary filling. The intracanal
dressing was changed weekly for two weeks. In the Final
appointment, the calcium hydroxide dressing was removed, the canals
were rinsed, and each of the three canals was gauged again using
hand K-files to confirm a full WL. The canals were irrigated again,
dried with sterile-paper points and taking a radiograph photo to
confirm fit of the master cone (fig.14). Once the master GP cone is
fit, the canals were obturated with GP master cones (X3, size 30)
(Dentsply Maillefer) and AH Plus Sealer (Dentsply Maillefer) using
the lateral condensation technique (fig.15 a.b). Access cavity was
sealed with SDRSmart Dentine Replacement (Dentsply Maillefer). When
the patient was reviewed after one week, there was not any
abnormality detected radiologically and clinically (fig.16).
Following this, a indirect onlay composite was cemented using
SmartCem2 (Dentsply Maillefer) (fig.17 a, b). Finaly, taking
radiograph for confirm the cementing onlay.(fig.18). One week
observation after the treatment was done (fig.19)
Figure 8. Creating smooth and reproducible apical glide path
using PathFile(Dentsply Maillefer) #16, #19 rotary instruments to
the full working length
Figure 7. The working length was gotten by electronic
measurement with an apex locator, ProPex PiXi (Dentsply
Maillefer)
Figure 10. Determining the finishing ProTaper Next (Dentsply
Maillefer) X3 fileFigure 9. Taking the radiograph to confirm full
working length
Figure 11. theEndoActivatorwas used to agitate the 2,5 %
NaOCl
Figure 12. Glyde (Dentsply Maillefer))as lubricant and chelating
agent to remove smear layer
Figure13. All canals were dried with paper points
Figure 14. taking a radiograph photo to confirm fit of the
master cone (Sept 22nd 2014).
Figure. 15 a. The canals were obturated with gutta-percha master
cones (X3, size 30) (Dentsply Maillefer) and AH Plus Sealer
(Dentsply Maillefer) using the lateral condensation
techniqueFigure15b. obturated canal
Figure 16. Taking a radiograph to evaluate obturation (Sept 22nd
2014).Figure.17 a. a indirect onlay composite was cemented using
SmartCem2 (Dentsply Maillefer). Lateral view
Figure 18. Taking a final radiograph to evaluate cementing (Sept
29th 2014).Figure.17 b. indirect onlay composite was cemented using
SmartCem2 (Dentsply Maillefer). Occlusal View
Figure 18.b. One week observation after the treatment was done
(lingual view) (Oct 10th 2014
Figure 18.a. One week observation after the treatment was done
(occlusal view) (Oct 10th 2014
DiscussionThe conventional retreatment is always the first
treatment option in the cases of endodontic failure 1,2. Endodontic
treatment failure has been associated to persistent infection of
canals: unsatisfactory shaping or cleaning procedures, incomplete
root canal filling, iatrogenic errors or leakage of
temporary/post-endodontic restorations are common factors that may
impair an acceptable microorganisms eradication3. Furthermore,
Inadequate obturation of the root canal invites failure as surely
as does inadequate filling of a coronal cavity4. For this case, the
endodontic failure was caused breakdown coronal sealing.
Recontamination of the root canal system by coronal leakage will
occur through: sealer dissolution by saliva; percolation of saliva
in the interface between sealer and root canal walls (particularly
if smear layer is present) and/or between sealer and gutta-percha5.
Microorganisms penetrate into the canal after filling, there is a
higher risk that the treatment will fail 6,7. How high the risk of
reinfection will be is dependent on the quality of the root filling
and the coronal seal 8.If the root canal had been unsealed at some
point during the treatment, enteric bacteria are found more
frequently than in canals with an adequate seal between the
appointments. Pinheiro et al. reported a significant positive
relationship between the absence of a coronal restoration and the
presence of streptococcus spp. And candida spp. in the root canal
9. In 2004, Adib et al.attempted to identify the bacterial flora in
root-filled teeth with persistent periapical lesions and a history
of coronal leakage. They found the predominant group of bacteria
was Gram-positive facultative anaerobes of which staphylococci
followed by streptococci and enterococci were the most prevalent.
Their results also showed a polymicrobial flora existed (with the
number of species recovered per tooth ranging from six to 41
species) when the canal was poorly root filled 10. In addition, In
the root canals of teeth with technically inadequate root fillings
and asymptomatic periapical lesions, but with an acceptable coronal
restoration, one or more obligate anaerobes are usually found and
the situation is similar to the infected but previously untreated
teeth 11,13 Symptomatic Apical Periodontitis represents
inflammation, usually of the apical periodontium, producing
clinical symptoms involving a painful response to biting and/or
percussion or palpation. This may or may not be accompanied by
radiographic changes (i.e.depending upon the stage of the disease,
there may be normal width of the periodontal ligament or there may
be a periapical radiolucency). Severe pain to percussion and/or
palpation is highly indicative of a degenerating pulp and root
canal treatment is needed 14.Root canal retreatment aims to
eliminate or to substantially reduce the microbial load from the
root canal to enable effective cleaning, shaping and filling of the
root canal system 15 . This procedure can uncover residual necrotic
tissues or bacteria that may be responsible for persistent
periapical inflammation, and allow further cleaning and refilling
of the root canal system 16. The relative difficulty in removing
gutta percha varies according to the obturation technique
previously employed and further influenced by the canals length,
cross sectional dimension, curvature and internal configuration.
Dividing the root into thirds, gutta percha may be initially
removed from the canal in the coronal one-third, then the middle
one-third, and finally eliminated from the apical one-third 17.
Various instruments have been used for gutta-percha (GP) removal,
including endodontic hand files, enginedriven rotary files,
ultrasonic tips and files, and heat carrying instruments. Chemicals
are sometimes used as solvents 18, 19 . Removal of GP using hand
files with or without solvents is time-consuming, especially when
the filling materials are well condensed 20. Gutta-percha is
usually removed with Hedstrom files alone or in combination with
Gates Glidden drills (GGdrills) with or without solvents 21.
Remaining filling debris has been assessed by radiography 16.In the
present case report, endodontic retreatment was necessary because
of the presence of periapical lesion, as a consequence of an
improper former root canal therapy performed one year ago. Removal
of sealer and gutta-percha from inadequately prepared and filled
root canal systems is essential in root canal retreatment because
it is likely to uncover remaining necrotic tissue or bacteria that
may be responsible for periapical inflammation and posttreatment
disease 22. Removal of GP using hand files without solvents because
from the radiographic analysis the proper root canal obturation is
inadequate in this case. Gutta-percha from the distolingual,
mesiobuccal and mesiolingual canal was removed with Hedstroem hand
files instruments for retreatment under copious irrigation with
sodium hypochlorite and EDTA solution. An important method to
remove gutta percha, especially when the canal has been
overextended vertically and underfilled laterally, is to utilize
the hedstroem displacement technique. The gutta percha is first
thermosoftened with heat and then a 15, 20, or 25 hedstroem file is
passively rotated clockwise into this mass. Let the gutta percha
cool and harden within the blades, and upon withdrawing the
hedstroem file, oftentimes the entire mass of gutta percha will be
removed as well 17, 22. Finishing of the root canal with
cemomechanical preparation was done by using some irrigants and
ProTaperNext files. The retreatment was performed in this case in
two appointments. Between the two appointments, calcium hydroxide
was placed as medication in the root canals for two weeks, in order
to kill the microorganisms undestroyed by the irrigation protocol
and neutralize remaining microorganisms in the root canal 23. In
this case, a postoperative radiographic was taken to evaluate the
quality of the performed endodontic retreatment and to confirm the
presence of three canals in relation to mandibular left first
molar.In summary, the microorganisms causing the initial infection
persisted in poorly treated root-filled teeth with periapical
lesions. In theory, if these root canals are retreated adequately
under a strict treatment regimen, the success rate should be as
good as endodontic treatment of the previously untreated teeth with
apical periodontitis.
Reference1. Lopes HP, Siqueira JF Jr., Elias CN. Retratamento
endodntico. In: Lopes HP, Siqueira JF Jr. Endodontia: biologia e
tcnica. Rio de Janeiro: Guanabara Koogan; 2004. p. 727-85.2.
Moiseiwitsch JR, Trope M. Nonsurgical root canal therapy treatment
with apparent indications for root-end surgery. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 1998;86(3):335-40.3. Ricucci D,
Siqueira Jr JF. Recurrent apical periodontitis and late endodontic
treatment failure related to coronal leakage: a case report. J
Endod 2011;37(8):11715.4. Schilder H, D.D.S.Filling Root Canals in
Three Dimensions.JOE Volume 32, Number 4, April 20065.Siqueira JF
Jr, Ras IN, Lopes HP, Uzeda M (1999) Coronal leakage of two root
canal sealers containing calcium hydroxide after exposure to human
saliva. Journal of Endodontics 25, 146.6. Bystrm A, Happonen R-P,
Sjgren U, Sundqvist G (1987)Healing of periapical lesions of
pulpless teeth after endodontic treatment with controlled asepsis.
Endodontics and Dental Traumatology 3 , 5863.7. Sjgren U, Figdor D,
Persson S, Sundqvist G (1997) Influence of infection at the time of
root filling on the outcome of endodontic treatment of teeth with
apical periodontitis.International Endodontic Journal 30, 297306.8
Saunders WP, Saunders EM (1994) Coronal leakage as a causeof
failure in root canal therapy: a review.Endodontics
DentalTraumatology 10, 10589. Pinheiro ET, Gomes BP, Ferraz CC,
Sousa EL, Teixeira FB, Souza-Filho FJ. Microorganisms from canals
of root-filled teeth with periapical lesions. Int Endod J 2003; 36:
11110. Adib V, Spratt D, Ng YL, Gulabivala K. Cultivable microbial
flora associated with persistent periapical disease and coronal
leakage after root canal treatment: a preliminary study. Int Endod
J 2004; 37: 54251.11. Cheung GS, Ho MW. Microbial flora of root
canal-treated teeth associated with asymptomatic periapical
radiolucent lesions. Oral Microbiol Immunol 2001; 16: 3327.12.
Peciuliene V, Balciuniene I, Eriksen HM, Haapasalo M. Isolation of
Enterococcus faecalis in previously root-filled canals in a
Lithuanian population. J Endod 2000; 26: 5935.13. Sundqvist G,
Figdor D, Persson S, Sjogren U. Microbiologic analysis of teeth
with failed endodontic treatment and the outcome of conservative
re-treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998; 85: 8693.14.American Association of Endodontists.Endodontic
Diagnosis. ENDODONTICS: Colleagues for Excellence.2013;9-1415.
Stabholz A, Friedman S (1988) Endodontic retreatment-case selection
and technique. Part 2. Treatment planning for retreatment. Journal
of Endodontics 14, 60714.16. Schirrmeister JF, Hermanns P, Meyer
KM, Goetz F, Hellwig E (2006d) Detectability of residual Epiphany
and gutta-percha after root canal retreatment using a dental
operating microscope and radiographs-an ex vivo study.
International Endodontic Journal 39, 55865.17. Ruddle CJ:
Nonsurgical endodontic retreatment. Cda journal, 2004;418. Wilcox
LR, Krell KV, Madison S, Rittman B (1987) Endodontic retreatment;
evaluation of gutta-percha and sealer removaland canal
reinstrumentation. Journal of Endodontics 13, 4537.19. Lewis R,
Block R (1988) Management of endodontic failures. Oral Surgery,
Oral Medicine and Oral Pathology 66, 711121.20. Sae-Lim V,
Rajamanickam I, Lim BK, Lee HL (2000) Effectiveness of ProFile.04
taper rotary instruments in21.Dalton BC, Orstavik D, Phillips C,
Pettiette M, Trope M (1998 Nov) Bacterial reduction with
nickel-titanium rotary instrumentation. J Endod.; 24(11):763-7.22.
Friedman S, Stabholz A, Tamse A. Endodontic retreatment-case
selection and technique. Part 3: retreatment techniques. J Endod.
1990;16:543-4923. Soares JA, Leonardo MR, Tanomaru Filho M, Silva
LAB, Ito IY. Effect of biomechanical preparation and calcium
hydroxide pastes on the anti-sepsis of root canal systems in dogs.
Journal of Applied Oral Science 13, 93-1009