tic re treatment

8/8/2019 tic Re Treatment

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'Redo of a Root Canal'

or

Nonsurgical retreatment of endodontic therapy is

most commonly completed when nonsurgical

endodontic (root canal) therapy is unsuccessful.

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Some of the reasons are:

1. Leakage.

2. Incomplete Cleaning and Sealing 3. Improper healing: .

4. New problems in a successfully treated tooth

5. Incomplete Canal Debridement 6. Inadequate Gutta Percha Obturation

7. Improper Silver Points obturation

8. Removing Threaded Posts

9. Periodontal disease10. Missed canal

11. Split tooth

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Improper healing: Curved or narrow canals were not treated during the initial

treatment

Complicated canals went undetected during the initial treatment

The crown or restoration did not prevent saliva fromcontaminating the inside of the tooth.

New problems in a successfully

treated tooth New decay can expose a root canal filling material, causinginfection.

A cracked or loose filling or crown can expose the tooth to newinfection.

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Incomplete Canal Debridement

Failure to clean the entire root canal

system will often result in failure.

Incomplete treatment will leave pulpresidue that can serve as a reservoir for

bacteria that can initiate or perpetuate

periradicular lesions.

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Inadequate Gutta Percha Obturation

Inadequate gutta percha fills can be under

extended (too short), under filled (too thin),

or overextended (too long). leads to aninadequate seal, and incomplete

debridement of the canals. Organic

solvents, headstrom files or rotary devices

such as the GPX gutta removal kit can beused.

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Silver Points

Failures of silver points are usuallyassociated with leakage and corrosion.The inability of silver points to seal

irregular shaped canals allows leakage of the tissue fluids into the canal. Contact of these fluids with the silver point's result inthe formation of corrosive products such

as silver sulfates and silver carbonates,which can damage the periradicular tissues

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Steps in retreatment

Step 1: Removal of canal filling materials

Step 2: Post Removed

Step 3: Canal Filling Materials Removed and

Root canals Cleaned

Step 4: Retreatment Complete with Buildup

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Step 1: removal of canal filling materials

Step 1: build up

material from the

previous endodontic

therapy is removed. If a

post is present, it is

exposed for removal.A

microscope can be very

helpful during this part

of the procedure sinceit allows substaintially

better vision.

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Step 2: Post Removed

Step 2: Post andother intracanalobstructions are

removed. anultrasonichandpience may beused to vibrate thepostlose.Sometimesboth are used inmore challengingcases.

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Step 3: Canal Filling Materials Removed

and Root canals Cleaned

Step 3: The old root canal

filling material is removed

sometimes with organic

solvent.cleaning and

shaping of the canals is

done to the apex.

Irrigation is done to

dissolve and flush

debrie. X-rays are takenperiodically during the

cleaning process to check

if the instruments are

cleaning near the end of

the root. rxdentistry.net



Step 4: Retreatment Complete with

Buildup

Step 4: root canals arefilled with gutta perchawith cement/sealer to helpseal the canals to preventbacteria from

reentering. the accessopening in the crown isfilled with a build uprestoration aspictured. The restorationis matched for color if

possible.After endodontictreatment, X-rays aretaken to verify thatcleaning and filling of thecanals is close to the endof the root.

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Follow up : every 6 - 12 months (an abscess may

take 2 years to heal )

The resulting space inside the center

portion of the tooth is filled with

1. (gutta percha)

2. cement (zinc oxide + eugenol)

3. mineral trioxide aggregate (MTA)

4. plastic resin

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Retreatment can be :

1) non-surgical

2) surgical3) combination of both.

I am shall try to discuss the non surgical

phase of retreatment sequentially.

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CORON AL ASSEMBLY

W ORKING THROUGH THE EXISTING RESTORATION IS

CONSIDERED PROPER IF THE RESTORATION IS

FUNCTIONALLY DESIGNED , W ELL FITTING AND

ESTHETICALLY PLEASING.

F ACTORS THAT INFLUENCE THE REMOV AL ARE:

1. PREPARATION TYPE (retention features,design etc)

2. RESTORATION DESIGN AND STRENGTH

3. RESTORATIVE MATERIAL

4. CEMENTING AGENT : order in increasing strength

ZnOE-Polycarboxylate-Silicon Phosphate-

GIC-Resin modified GIC-Bonded Resins

5. TYPE OF REMOVAL DEVICE AVAILABLErxdentistry.net



CORONAL DISASSEMBLE

DEVI

CES

1. GRASPING INSTRUMENTS : APPLY INWARD

PRESSURE ON TWO OPPOSING HANDLES . E.g.

TRIDENT CROWN REMOVER , KY PLIERS ,

WYMANN CROWN GRIPPER

2. PERCUSSIVE INSTRUMENTS : IT DELIVERS AN

IMPACT EITHER DIRECTLY OR INDIRECTLY TO

THE RESTORATION OR THE PROSTHETIC DEVICE

. E.g. ULTRA SONIC ENERGYBY DENTSPLY

3. ACTIVE INSTRUMENTS : ACTIVELY ENGAGE AND

APPLY FORCE TO POTENTIALLY LIFT THE

PROSTHESIS THROUGH A WINDOW THAT WAS

MADE INTO THE RESTORATION E.g. METALIFT ,

KLINE CROWN REMOVERrxdentistry.net



metalift

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MISSED CAN AL

MISSED CANAL HOLDS TISSUE REMNANTS LEADING TO

INFECTION AND FAILURE

TEETH WHICH MAY HOLD ADDITIONAL CANALS

1. MAXILLARY CENTRAL (2 CANALS)

FIRS

T PM (THREE ROOTS

AND CANALS

)SECOND PM

FIRST MOLAR (2 CANALS IN MB ROOT)

SECOND MOLAR (2 CANALS IN MB ROOT)

2. MANDIBULAR INCISSORS (2 CANALS)PREMOLARS

1ST and 2nd MOLARS

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DIAGNOSING A MISSED CANAL

1. ANATOMIC FAMILIARITY ( COMMONEST CAUSE

OF FAILURE)2. RADIOGRAPHIC ANALYSIS ( BUCCAL OBJECT

RULE )

3. COMPUTERISED DIGITAL RADIOGRAPHY (CDR)

4. MAGNIFICATION GLASSES AND MICROSCOPES5. REASONABLY EXTRAVAGANT ACCESS CAVITIES

6. DYES like METHYLENE BLUE- it gets absorbed

into orifices

7. NaOCl ± CHAMPAGNE TEST ± BUBBLING DUE TOTISSUE IN MISSED CANAL

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Removal of gutta percha

For convenience the root canal is divided into apical , middle andcoronal third.

TECHNIQUES USED ARE:

1. ROTARY REMOV AL : 0.02 AND 0.06 NiTi FILES 1200-1500RPM

2. ULTR ASONIC : VIBR ATIONS THERMOSOFTEN THE GP3. HEAT REMOV AL : HEAT CARRIERS ARE AV AILABLE

4. HEAT + H-FILE : ALTERN ATE USE OF HEAT AND H-FILE

5. H-FILE + ORG ANIC SOLVENT : SOLVENTS LIKE:CHLOROFORM , XYLENE , EUCALYPTOL ,HALOTHANE , METHYL CHLOROFORM

6. P APER POINT AND ORG ANIC SOLVENT : P APER POINTS ABSORB TILL NOTHING IS VISIBLE ON THEM

WICKING ACTION OF PAPER

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Silver Points SILVER POINTS F AIL DUE TO CHRONIC LEAK AGE

DENTIST SHOULD KEEP IN MIND THAT THE APICAL 2-3mm IS

PREP ARED P AR ALLEL AND THE REST OF THE CAN AL IS FLARED.

STEPS AND TECHNIQUES:

1. ACCESS : PROPER ACCESS IS M ADE BY REMOVING THE CORE.

2. PLIERS REMOVAL :ST

IE

GL

ITZ

PL

IE

RS

A

RE

USED

US

ING³FULCRUM MECHANICS´

3. ULTRASONIC REMOVAL : CAN BE USED BOTH DIRECTLY AND INDIRECTLY

4. SOLVENTS & CHELATORS: M AY BE USED WITH SM ALL SIZED INSTRUMENTS

5. BY PASS THE INSTRUMENT &THEN REMOVE WITH H FILE.6. ULTRA SONIC + H FILE

7. WIRE LOOP TECHNIQUE : 26 G AUGE NEEDLE WITH INBUILT WIRE LOOP USED TO ENG AGE & REMOVE SILVER POINT.

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The degree of difficulty in removing silver points is

greatly impacted by two factors, : access

fit.

Points that are accessible and loose are easily removed

by use of specialized forceps.

Binding and/or inaccessible points require the use of

more specialized equipment. Tight fitting silver pointsneed to be "loosened" before retrieval is attempted.

Ultrasonic devices, such as the EIE CT-4 ultrasonic tip,

are very useful for this purpose. Once the silver point is

loosened, it can be easily removed if accessible.

Roydent extractor system. This utilizes the use of

headstrom files that are worked along side the silver

point, and withdrawn in a single firm motion.

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ENDODONTIC PLIERS

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Endodontic forceps

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P ASTE REMOV AL

PASTES WERE USED ORIGINALLY FOR THOSE PATIENTS

WHO COULD NOT AFFROD CONVENTIONAL ENDO T/T

SET PASTES CAN BE : SOFT AND PENETRABLE

HARD AND IMPENETRABLE

TECHNIQUES:1. ULTRASONIC ENERGY : CPR3 , 4 and 5

2. HEAT

3. ROTARY INSTRUMENTS :

SS 0.02 TAPERED HAND FILES MMEKE PILOT HOLE

FOLLOWED BY NiTi FILES

4. SOLVENTS + FILES : REAGENTS ENDOSOLV ³R´ (RESIN)

ENDOSOLV ³E´ (EUGENATE)

5. SOLVENTS + PAPER POINTS

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POST REMOV AL KNOWLEDGE OF ROOT MORPHOLOGY , ROOT WALL THICKNESS

, LENGTH SHAPE AND CURVATURE IS A MUST

POST REMOVAL CAN BE INFLUENCED BY TYPE OF CEMENTINGAGENT ( DIFFICULT FOR RESIN CEMENTS)

POSTS CAN BE : METTALIC / NON METTALICPARALLEL / TAPEREDACTIVE / NON ACTIVESMOOTH / THREADED

ALL CIRCUMFERENTIAL RESTORATION MUST BE REMOVED

AROUND THE POST TECHNIQUES:

1. CPR ULTRASONIC S YSTEM( TITANIUM)

2. PRS KIT : REQUIRES STRAIGHT LINE ACCESS2-3 MM OF HEAD OF POST IS ALTERED BY PECKDRILLING MOTIONTUBULAR TAP APPLIED ON POST & REMOVED WITHSPECIAL PLIERS

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POST

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Removing Threaded Posts

If it is a threaded post , you can now place

either the wrench or a hemostat on the

post and thread it out of the root. If the

post is not moving, you can apply a thicker

ultrasonic tip directly to the post and let it

vibrate the post for several minutes. You

can even hold the post with a forceps andtouch the ultrasonic tip to the forceps and

hence the post

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POST REMOV AL SYSTEM

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CROWN POST

REMOVAL

ULTRASONIC

S YSTEM

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BROKEN INSTRUMENTS

REMOVAL INFLUENCED BY REMOVAL INFLUENCED BY

1. LENGTH

2. CROSS SECTIONAL DIAMETER

3. CURVATURE OF THE CANAL

4. INSTRUMENT MATERIAL: SS INSTRUMENTS DON¶T FR ACTURE LIKE NiTi INSTRUMENTS WHICH FR ACTURE DUE TO HEAT FROM ULTR ASONICS

DENTIST SHOULD KEEP IN MIND THE ORIGINAL MOTION IN W HICH INSTRUMENT BROKE

F ACTORS REQUIREDFOR INSTRUMENT PLACEMENT

: 1 CORON AL ACCESS

2 R ADICULAR ACCESS

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BEFORE REMOVING ANY INSTRUMENT OTHER ORIFICES

SHOULD BE COVERED TO PREVENT SLIPP AGE

TECHNIQUES:1. BYPASS WITH H FILE

2. ULTRASONIC + H FILE

3. WIRE LOOP TECHNIQUE : 26 GAUGE NEEDLE WITH

INBUILT WIRE LOOP USED TO ENGAGE & REMOVE SILVER

POINT4. IRS S YSTEM: Microtube has a 45 degree bevelled end.

Long part of the bevel placed on outer side of inst.

Instrument Is ³scooped up´.

wedge passed thru internal lumen to distal

end & instrument is engaged .

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WIRE LOOP TECH

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NiTi FILES

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M ASSER AN KIT FOR BROKEN

INSTRUMENT REMOV AL

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Blocked canalBlocked canal FIRST FLOOD THE CANAL WITH NaOCl SHORTER AND SMALLER FILES ARE USED TO REACH THE

WORKING LENGTH SINCE THEY ARE STIFFER AND PROVIDE

TACTILE CONTROL. ( SS FILE No10 ).

SHORT AMPLITUDE , LIGHT & PECKING STROKES ARE USED

CHELATING AGENT ( EDTA ) USED

PROGRESSIVELY STROKE AMPLITUDE SHOULD BE

INCREASED

LAST OPTION IS : SURGERY , REIMPLANTATION ,

EXTRACTION.

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Ledges

A LEDGE IS AN INTERNAL TRANSPORATATION OF THE

CANAL FORMED W HEN W E W ORK SHORT OF THE

W ORKING LENGTH

TECHNIQUES

1. SMALL SS FILES USED TO NEGOTIATE THE LEDGE2. GREATER TAPER NiTi FILE (0.2 mm DIA)

3. PRECURVED NiTi FILES : After negotiating the ledge file rotated

in CW direction subsequently removing the ledge.

4. FILES WITH CHELATING AGENTS

5. PRECURVED GP POINT WITH ISOPROPYL ALCOHOL 75%: alcohol causes hardening of GP

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apical transportations

AN APICAL TR ANSPORTATION IS MOVING THE CAN AL¶S

PHYSIOLOGICAL TERMINUS TO A DIFFERENT POSITION.

FOR AMIN AL ZIPS,RIPS OR TEARS ARE CAUSED BY

CARRYING PROGRESSIVELY LARGER AND STIFFER IN

LENGTH.

M AY RESULT IN OVER EXTENSION OF GP AND F AILURE

TYPES AND MANAGEMENT:

TYPE-1 : MINOR TRANSPORTATION: M AY WEAKEN THE ROOT.

³W AIT AND W ATCH´

TYPE-2 : MODERATE DISTANCE TRANSPORTATION.

MINER AL TRIOXIDE AGGRETATE

TYPE-3 : SEVERE DISTANCE TRANSPORTATION.

CORRECTIVE SURGERY.rxdentistry.net



ENDODONTIC PERFOR ATIONS

PERFORATIONS ARE PATHOLOGIC OR IATROGENIC

COMMUNICAT

ION

SBETWEEN ROOT CANAL

SPACE ANDPERIODONTIUM.

FACTORS INFLUENCING REPAIR

1. LEVEL : CORONAL / MIDDLE / APICAL

2. LOCATION : BUCCAL / LINGUAL / MESIAL / DISTAL

3. SIZE .

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M ATERI ALS USED FOR REP AIR:

HEMOSTATICS : CALCIUM HYDROXIDE SYRINGED ( SETS IN 5min)

2-3 TIMES APPLICATION FOLLOWED BY NaOCl IRRIG ATION.

2. BARRIER MATERIALS : RESORB ABLE

NON RESORB ABLE

a) RESORBABLE : - COLLAGEN (14 days ) hemostasis in 5mins

- CALCIUM SULPHATE ( 2 - 4 weeks )

b) NON-RESORBABLE : MTA ( EXCELLENT IN MOISTURE )

RESIN CEMENTS

AM ALG AM

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MANAGEMENT OF CORONAL ONE-THIRD PEDFORATION:

1. CALCIUM SULPHATE BARRIER

2. AMALGAM

3. MTA4. EBA RESIN CEMENT

MANAGEMENT OF MIDDLE ONE-THIRD PEDFORATION:

IF CLEAN AND DRY FIELD CAN BE MAINTAINED THEN WE MAYUSE MOST AVAILABLE MATERIA.

# IN PRESENCE OF MOISTURE , MTA IS THE BEST CHOICE

MANAGEMENT OF APICAL ONE-THIRD PEDFORATION:

LEDGES MAY LEAD TO APICAL PERFORATION.

1. THUS REMOVE THE LEDGE SEAL THE PERFORATION WITHMTA WHILE KEEPING A SMALL FILE IN THE CANAL WITHTO AND FRO STROKES TO MAINTAIN PATENCY

2. APICOCECTOMY AND RETROGRADE FILLING

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MTA

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THANK YOU

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tic re treatment

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