Retreatement finallll/ dental implant courses

Retreatmentt
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INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education

INTRODUCTION

GOOD NEWS, BAD NEWS Dilemma
Good news - Hundreds of millions-salvaged
Bad news – tens of millions of failures According to
various articles---
Conventional treatment 85-94% success rate
10-15% failure rate.
Future of endodontics -- treatment of these failures !!!
Root canal anatomy – imp – branches –
furcally , laterally , apically as multiple exits

Characteristics of an ideal root canal filling :-Characteristics of an ideal root canal filling :-
• Three dimensional filling of entire root canal system asThree dimensional filling of entire root canal system as
• close to the cemento dential junction as possible.close to the cemento dential junction as possible.
• Min. amount of sealerMin. amount of sealer
• Dense radiographic appearance , without overDense radiographic appearance , without over
extensions or under filling in the presence of patentextensions or under filling in the presence of patent
canal.canal.
• Hermetic seal = sealed against the escape of air orHermetic seal = sealed against the escape of air or
made airtight by fusion or sealingmade airtight by fusion or sealing
CRITERIA for success of –CRITERIA for success of –
• Asymptomatic – able to function both sides equallyAsymptomatic – able to function both sides equally
• Healthy peridontiumHealthy peridontium
• Bone healing over a period of timeBone healing over a period of time
• Principles of rest. Excellence should satisfyPrinciples of rest. Excellence should satisfywww.indiandentalacademy.com

Causes of root canal failure ?
1.Reintroduced intraradicular microorganisms :-
Contaminated RC , dentinal tubules with MOs
or their byproducts – periradicular area – apical
periodontitis
Inadequate cleaning & shaping , obturation .
Ledge , broken instrument – persistence of
bacteria in the canal – pathologic disease –
polymicrobial or single species , predominantly
anaerobic , gram positive , E.faecalis .
If no obturating material at apex – fungi , candida
albicans are found.

2 . Extraradicular infection :-
•By extrusion of dentin chips , contamination with
over extended , infected endodontic instruments
or infected periodontal pocket .
•Actinomyces israeli and propionibacterium
propionicum can exist in PA tissues & may
prevent healing after RCT.
3. Foreign body reaction :-
•Cellulose fibers from paper points , over
extended obturation , sealer flush – loer
incidence of healing.
4. Cysts ;- 15 – 45 % cystic lesions in all PA
lesions

Crump described it as an Acronym
‘Poor Past’ which denotes :-
P erforation
O bliteration
O verfilled
R oot canal missed
P eriodontal disease
A ccess (improper)
S plit
T rauma .

Washington study
Apical percolation operative errors caseselection
63.5% 14.5% 22%
Incomplete obturation Root perforation Root resorption
Unfilled canal Gross overfilling Pdl problem
Broken instruments

Diagnosis of posttreatment disease :-
• Visual extraoral and intraoral and through PDL examination
• Visual – use magnification & illumination – fractures ,
occlusal facets , dentin exposure , recession , sinus tract ,
swelling , palpation , percussion ,sensitivity to heat &
cold ,
examination adj teeth
Radiographic examination :-
• Caries , defective rest , periodontal , quality of obturation ,
missed canals , broken instruments , peri radicular
pathology , perforation , fractures , resorption , & canal
anatomy
• Multiple radiographs in diff angulations , SLOB rule , bite
wing for bone height , sinus tract traced with GP ,
radiograph should be of sharp image .

Common errors during the diagnosis ofCommon errors during the diagnosis of
endodontic failureendodontic failure :-:-
Through examinationThrough examination
Pain of non odontogenic origin should bePain of non odontogenic origin should be
ruled out like neurogenic pain , MFD,TMDruled out like neurogenic pain , MFD,TMD
Odontogenic pain may be of nonOdontogenic pain may be of non
odontogenic origin –odontogenic origin –
Occlusal trauma , peridontallyOcclusal trauma , peridontally
involved vertical or oblique root fractureinvolved vertical or oblique root fracture

Criteria for case selection
Established failure Potential failure?
Coronal access Quality of filling
Unfeasible Feasible Unsatisfactory Satisfactory
Need for new restoration
Indicated Not indicated
Considerations
Surgery Retreatment Follow up No treatment

“Retreatment is defined as a procedure to remove root
canal filling materials from the tooth and again clean,
shape and obturate the canals.
“Non surgical retreatment is an endodontic
treatment procedure used to remove materials from
the root canal space and, if present,address
deficiencies or repair defects that arepathologic or
iatrogenic in origin. These disassembly and
corrective procedures then allow the clinician to 3-D
clean, shape, and pack the root canal system.”
- C.J.Ruddle

Objective of retreatment :-
Return the tooth to function and comfort
and to allow the supporting structures
to repair completely.
Classification of retreatment :-
1. Discontinued treatment by prior
dentist
2. Incomplete treatment
3. Complete but inadequate treatment
4. Complete and apparently adequate
treatment , but with a questionable
long-term prognosis.

Treatment planning:Treatment planning:
Do nothing – observeDo nothing – observe
ExtractionExtraction
NSRCTNSRCT
SRCTSRCT
LEAKAGE ?LEAKAGE ?
Inadequate cleaning , shaping & obturation ,Inadequate cleaning , shaping & obturation ,
iatrogenic events , or reinfection –iatrogenic events , or reinfection –
when coronal seal is lostwhen coronal seal is lost
Rationale for retreatment is toRationale for retreatment is to removeremove the rootthe root
canal space as a source of irritationcanal space as a source of irritation

Gaining Access to Root Canals
Coronal Restoration
Post & Core
Gaining Access to the Apex
Retain
Remove
Remove
Retrieve
penetrate
Pastes & cements
Consistency
Penetrate Remove Drill out
Solids
Coronal free ends
Canal cross section
Location & accessibility
Pull Out Bypass Devices
Semisolids
Condensation, shape of the root
Obturation length
Dissolve Remove Pull Out
Quality of restoration
Prosthetic Demand
Type, Size of Post
Crown Prep's
Multirooted Teeth

Factors considered during retreatment.
• Coronal restorations
• Radicular restorstions

Coronal restorationsCoronal restorations
Factors influencing Restorative removal:Factors influencing Restorative removal:
• Preparation type – retention – surfacePreparation type – retention – surface
area, taper & diameter.area, taper & diameter.
• Restoration design & strength –Restoration design & strength –
thickness & quality of restoration.thickness & quality of restoration.
• Rest. material - composition, reactionRest. material - composition, reaction
to stress & strain.to stress & strain.
• Cementing agent – weak or strongCementing agent – weak or strong

Removal devicesRemoval devices
Grasping instrumentsGrasping instruments
Appling inward pressure on two opposing
handles
Handle pressure α instrument ability to grip
restoration
Trident crown Placer/ remover
K.Y. Pliers
Wynman Crown Gripper
Removing provisional restorations

Percussive instrumentsPercussive instruments
Selective and controlled percussive removal forceSelective and controlled percussive removal force
Deliver impact directly to restoration or indirectly toDeliver impact directly to restoration or indirectly to
another securely engaged prosthetic removal deviceanother securely engaged prosthetic removal device
CoronaflexCoronaflex
Ultrasonic EnergyUltrasonic Energy
Peerless Crown - A -MaticPeerless Crown - A -Matic
For provisional & definitive restorationFor provisional & definitive restoration

Active Instruments:Active Instruments:
• Actively engage a restoration, enabling aActively engage a restoration, enabling a
specific dislodgement force to potentially liftspecific dislodgement force to potentially lift
off the prosthesis.off the prosthesis.
• Requires a small occlusal window to facilitateRequires a small occlusal window to facilitate
mechanical action of the instrument.mechanical action of the instrument.
MetaliftMetalift
Kline Crown RemoverKline Crown Remover
Higa Bridge RemoverHiga Bridge Remover

Radicular restorations
Paste removal
Endosolve ‘E’ tetra chloroethylene
Endosolve ‘R’ formamid , phenylethylic alcohol
Rotary removalRotary removal
Heat and instrument removalHeat and instrument removal
Ultrasonic removal ( less effective when used in combinationUltrasonic removal ( less effective when used in combination
with Chloroform )with Chloroform ) (Robert W. landely et al )(Robert W. landely et al )
File and chemical removal (most effective when used inFile and chemical removal (most effective when used in
combination with Chloroform )combination with Chloroform ) (Robert W. landely et al)(Robert W. landely et al)
Paper point and chemical removalPaper point and chemical removal wicking & flushingwicking & flushing
Micro- debriders: ISO 20 and 30 instruments, 0.02 taper 16mmMicro- debriders: ISO 20 and 30 instruments, 0.02 taper 16mm
H- file cutting blades , off- set handleH- file cutting blades , off- set handle
Fulcrum & leverage technique( Thermafil obturation removal )Fulcrum & leverage technique( Thermafil obturation removal )
Success rate of retreatment ranges from 69-86%Success rate of retreatment ranges from 69-86% (fobi G.M et al)(fobi G.M et al)

Chloroform
Methyl chloroform
Carbon tetra chloride
Xylene
Carbon disulfide
Eucalyptol oil
Halothane
Rectified white
turpentine
Orange wood oil
Anise oil
Castor oil
oil of citronella
Cottton seed oil
Guaiacol
Oil of hemlock
Levender oil
Oil of melaieuca
Peppermint oil
Sassafras oil
Thyme oil
Oil of white pine
Oil of wintergreen
Semi solid obturations
Chemical Removal of GP

Chloroform:
Most effective
Evaporates rapidly
Potential carcinogenic ??
Xylene:
Highly toxic
Evaporates too slowly
As an intra-canal medicament
Dissolving effect less than chloroform
Eucalyptol:
Less irritating than chloroform
Antibacterial
Least effective GP solvent
Orange wood oil Contraindicated – over extended fillings

Among various solvents i.e Rectified whiteAmong various solvents i.e Rectified white
Turpentine, oil of melaleuca , Eucalyptol , White pin oil, & pineTurpentine, oil of melaleuca , Eucalyptol , White pin oil, & pine
needle oil with chloroform - all solvents dissilved GP 50% in 15needle oil with chloroform - all solvents dissilved GP 50% in 15
mins at 37°cmins at 37°c
Rectified white Turpentine completely dissolvedRectified white Turpentine completely dissolved
(Kaplowitz et al )
Alternate to Chloroform – heated instru. , Eucalyptol (heatAlternate to Chloroform – heated instru. , Eucalyptol (heat
potentiate solvent) , sonics , ultrasonics & GGpotentiate solvent) , sonics , ultrasonics & GG
(Zakariasen KL et al)
Ultrasonics retreatment performed effectively in root canalsretreatment performed effectively in root canals
obturated with GP and Ketac – Endoobturated with GP and Ketac – Endo
(S.Friedman et al)
In over extruded GP canals the file should be extended 0.5-In over extruded GP canals the file should be extended 0.5-
1mm beyond the apex for removing GP1mm beyond the apex for removing GP
(Zvi Metzger et al)
Canal finder system is not superior to hand instrumentationCanal finder system is not superior to hand instrumentation
(N.Imura et al)

1. Anise oil , 2. Eucalyptol , 3. Castor oil ,4. oil of citronella ,
5. Cottton seed oil , 6. Guaiacol , 7. Oil of hemlock ,
8. Levender oil , 8. Oil of melaieuca , 9. Orange oil ,
10. Peppermint oil , 11. Rectified Turpentine oil , 12.
Sassafras oil , 13. Thyme oil ,14. Oil of white pine , 15. Oil of
wintergreen were compared with CHLOROFORM
Among all these Rectified Turpentine oil was significantly more
effective in dissolving GP than other essential oils.
No statistical diff. b/w CHLOROFORM & Rectified Turpentine
oil (Kaplowitz et al)
Negligible risk to the patients when Chloroform , Xylene ,
Halothane is used (Michel J. et al)
Enamel , dentine hardness decreases when Chloroform ,
Xylene , Halothane is used , and is directly praportional to the
exposure time ((Jacob .s et al)

What is the effect of retreatment on the canal enlagement inWhat is the effect of retreatment on the canal enlagement in
curved canals ?
< 20 ° curvature the apical area the enlargement is more whencurvature the apical area the enlargement is more when
compared with coronal or middle.compared with coronal or middle.
>23 ° curvature the canals showed 30 – 85 % enlargement incurvature the canals showed 30 – 85 % enlargement in
apical areaapical area (Lisa R, wilcox et al)
Canal cleanliness is best achieved with Roths sealer followed byCanal cleanliness is best achieved with Roths sealer followed by
AH26 and Ketac - EndoAH26 and Ketac - Endo
(Shimon Friedman et al)
Thermofill is best removed by using ultrasonics and rotaryThermofill is best removed by using ultrasonics and rotary
instrumentation than Chloroforminstrumentation than Chloroform
(Lisa R, wilcox et al)

Solid obturating material removal
Silver point removal
“Chronic leakage greatly reduces the seal, and hence lateral retention.”
Access
Indirect ultrasonics
Files , solvents & chelators
Steiglitz pliers,
Peet splinter forceps

POST DISASSEMBLY
Factors influencing post removal
Post type – parallel / tapered, active / passive
Cementing agent
Techniques for post removal
Rotosonic vibration
Ultrasonic vibration
Mechanical devices

Rotosonic preparation
Regular tip Roto - Pro bur
Six faced bur * 2,00,000 rpm 1.2million/ min 20,000/ sec
Inexpensive method counterclockwise direction 2-3 minutes
To expose coronal end of post
Muller bur
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Ultrasonic vibration
“10 minute rule”
CPR – Zirconium nitride coated tips
Coronal area Deeper area
Preferable to do in DRY field
Dampens tip movement & performance
Small diameter tips prone for weakening
Undesirable aerosol formation
Impaired vision www.indiandentalacademy.comwww.indiandentalacademy.com

Lateral vibration with 2 tips simultaneously
(Takakazu yoshida et al)
Use of ultrasonic tips designed for post vibration and
maximization of audible sound level during treatment plays a
imp role in effectiveness & efficacy of posts
(Eric B Dixon et al)
Sonic instruments are not useful in removal of the posts – 3,6.3
kHz , ultrasonics with 25,30,35 kHz are effective in post remova
(Buoncristiani et al)
MB2 in 1st molar 71 - 77%,2nd molar 59 -65% plays an imp role
in retreatment cases
(James Wolcott et al)

Broken instrument removal
coronoradicular acces
Gates glidden circumferential ‘staging platform’
After bypassing the broken instrument with k file ,
the file is mounted on an ultrasonic handpiece
for loosening & retreival of broken instruments
(Camillo D arcangelo et al)

Wire loop technique
Tube and glue (Cancellier Extractor kit):
0.5, 0.6, 0.7, 0.8 mm outer diameter
Masserann kit
1.2 to 1.5mm diameter, generally for anterior teeth
Spinal tap needle:
19-23 gauge, with metal insert plunger / H- file
Endo extractor

LOSS OF WORKING LENGTH
Blockage of canal system:-
Blockage is an obstruction in a previously patent
canal system that prevents access to the apical
constriction or apical stop.
Causes :-
Dentin chips.
Tissue debris
Restorative material
cotton pellets.
Paper points.
Broken instruments

Solution
Removal of caries and unsupported
toothstructure.
Access walls should be flared occlusally.
Ledges should be removed.
Temporary restoration should be removed.
Copious irrigation.
Never skip the file sizes.
Recapitulation
Avoid excessive pressure.
Precurve the instrument
Use chelating agent

Ledging (internal transportation)
Its an artificially created irregularity on the Surface of the
root canal wall that prevents the placement of the
instrument to the apex.
Causes :-
Failure to precurve the instrument.
Application of excessive apical pressure
Recognition:Recognition:
Instrument no longer reaches the entire working length.
Loss of normal tactile sensation of canal binding in
the lumen. (Feeling of tip hitting a solid wall).
Radiograph with instrument in place. ( instrument
tip pointing away from the lumen of the canal)

Prevention:
Accurate interpretation of the diagnostic
radiograph - Curvatures length and size.
Correction:
Precurve & do not force the instr.
Instruments with non cutting tips.
Frequent irrigation & recapitulation
Use chelating agent

Zipping / Elliptication:
Apical Zip: “ An elliptical shape formed in the apicalApical Zip: “ An elliptical shape formed in the apical
foramen during the preparation of a curved canal when theforamen during the preparation of a curved canal when the
file extends through the apical foramen and subsequentlyfile extends through the apical foramen and subsequently
transports the outer wall”.transports the outer wall”.
Causes:
Failure to precurve files.Failure to precurve files.
Rotation of instr. in curved canals.Rotation of instr. in curved canals.
Use of large stiff instr. in curved canalsUse of large stiff instr. in curved canals.

Elbow:
When a file precurved / not is rotated in aWhen a file precurved / not is rotated in a
curved canal ,an elbow forms coronally tocurved canal ,an elbow forms coronally to
the elliptically shaped apical seatthe elliptically shaped apical seat.
Prevention:
• Precurve the files.Precurve the files.
• Remove the flutes in strategic areas.Remove the flutes in strategic areas.
• Anti curvature / reverse filing.Anti curvature / reverse filing.

Apical transportation (external transportation)(external transportation)
Physiologic terminus to iatrogenic terminusPhysiologic terminus to iatrogenic terminus
Reversed apical architecture & no apicalReversed apical architecture & no apical
resistance leads to poor filling - vertically overresistance leads to poor filling - vertically over
extended but internally underfilledextended but internally underfilled
Type I :- MinorMinor movement of physiologic foramenmovement of physiologic foramen
Shape coronal to foramenShape coronal to foramen
Type II :- ModerateModerate movement of physiologic foramen , Reversedmovement of physiologic foramen , Reversed
apical architectureapical architecture
Barrier to control bleeding & MTABarrier to control bleeding & MTA
Type III:- SevereSevere movement of physio.foramenmovement of physio.foramen
Obturation & followed by surgeryObturation & followed by surgery

Missed canals
Anatomic familiarity
Radiographic Analysis
Magnification devices
Transillumination
Piezoelectric Ultrasonic devices
Micro openers
Dyes
Champagne Test

Apical Root Perforation:
Perforations in the apical segment of the root canal.
Causes:
Transportation of the apical portion of the canal.Transportation of the apical portion of the canal.
Inaccurate working length determination and overInaccurate working length determination and over
instrumentation.instrumentation.
Tear drop shaped transported apical foramen.(Zip)Tear drop shaped transported apical foramen.(Zip)

Midroot Perforations:
Tend to occur mostly in curved canals,
Ledges
Strip Perforations
Recognition:
Similar to apical perforation..
Sudden complaint or hemorrhage
Confirmed by paper points or radiographs.

Cervical Root Perforation:
During process of locating and widening of root canals .
Inappropriate use of Gates Glidden Drills.
Recognition:
Sudden appearance of blood from Pdl. Lig Space.
Electronic apex locators
Rinsing and blot drying and direct visualization.
Use of loupes, endoscopes or microscopes
enhances vision and recognition of this
mishap.

The Four Dimensions
Level:
Coronal middle apical
Furcal perforations – Coronal one-third
perforations.
Cervical perforations threaten the sulcular
attachment and pose different treatment
challenges than more apical perforations.
“ The More Apical The Perforation.. The More
Favourable The Prognosis”

Location
Circumferentially on mesial , distal , buccal &
lingual aspects of root
Location is not so imp when NSRCT is selected
Position is imp and this may preclude to sugical
approach
Size
Greatly affects the hermetic seal
Circular shaped ∏r2 > surface area to seal fourfold
Time
Should be repaired as early as possible
Loss of attachment & sulcular breakdown

Periodontal condition
Perforated teeth must be examine carefully for
pocket – no pocket ideal for NSRCT
Pocket present – interdisciplinary consultation
is needed
Esthetics
In anterior teeth – best adhesive material
should be given – but these materials discolor –
may cause tooth discoloration , soft tissue
tattoos and may compromise esthetics

Instrumental removal system:
Indicated when other methods including ultrasonics not
efective
Composed of variously sized microtubes and insert wedges
that are scaled to fit and work deep in the canal.
Microtubes have a small handle to enhance vision
Tip has a 45-degree bevelled end and cut out window.
Black – 1.0mm
Red – 0.8mm
Yellow – 0.6mm www.indiandentalacademy.com

Innovative uses of hypodermic needles in retreatment cases:-
1st use1st use - To- To enlargeenlarge canal orifices by using sharp point as a handcanal orifices by using sharp point as a hand
drilldrill
2nd use2nd use – Can be used as a trephen to gain access– Can be used as a trephen to gain access
Tip can be shortened with aTip can be shortened with a bur , ditchbur , ditch with ultrasonics may bewith ultrasonics may be
needed sometimes to gain accessneeded sometimes to gain access
ClockwiseClockwise cutting and screws in ,cutting and screws in , anticlockanticlock rotation removal ofrotation removal of
instrumentinstrument
Second instrumentSecond instrument introducedintroduced within needle lumen to wedgewithin needle lumen to wedge
instrumentinstrument ((ingle & Bakland et al)ingle & Bakland et al)
• use cyanoacrylate to lute the broken instrument.use cyanoacrylate to lute the broken instrument.
Rowe et alRowe et al
Trepan bur and special excavator glued with cyanoacrylate.Trepan bur and special excavator glued with cyanoacrylate.
Spriggs et alSpriggs et al
Roughening the lumen with explirer or small bur.Roughening the lumen with explirer or small bur. Johnson et al-Johnson et al-
Settting of glue is accelerated by acrylic monomer,waterSettting of glue is accelerated by acrylic monomer,waterwww.indiandentalacademy.com

Materials Used In Perforation Repair:
Hemostatics:
A dry field – Enhances vision
Predictable environment for repair
CaOH loaded into canal with syringe – remain for 4-5
Minutes – flushed away by using NaOCl , 2 – 3 times
Usually needed to control bleeding – if bleeding not
Controlled leave CaOH til the next appointment
Eg. Calcium Hydroxide
Collagen
Freeze Dried Bone
Mineral trioxide aggregate.
Ferric sulfate contraindicated as it leaves back a
coagulum- Promoting bacterial growth and
compromises the seal & jeopardizing prognosis

Barrier materials:
For controlled placement of restorative materials.
They provide - A dry field,
An internal matrix
Resorbable Barriers:
Is nonsurgically passed through the access cavity and
Internally through the defect into a 3 walled osseous defect.
Confirms to the anatomy of the furcation /bone.
Collagen material eg Collacote
Biocompatible , Enhances new tissue growth , resorbable
in10– 14 days and left in situ – hemostatis achieved in 2 - 5
mins after packing inside the canal – contraindicated as a
barrier –absorbs moisture and contaminate the rest.

Calcium Sulphate; Capset
Can be used both as a barrier and hemostatic
material
Mechanically plugging the vascular channels after
setting
Biocompatible , doesn’t promote inflammation ,and
bioresrbable in 2-4 weeks
Can be deliverd into the canal through the microtube
If it sets inside the canal removed by using ultrasonic
finishing instrument
Is the material of choice when the restorative
material is wet bonding – MTA

Non Resorbable Barriers:
MTA exhibits excellent Biocompatibility.
Can be used as both a non resorbable barrier and a
restorative.
Material of choice in moisture contamination and
restrictions in technical access and visibility.
Restoratives:
Choice of rest. Material is based on technical access ,
ability to mosture control & esthetic needs
Amalgam , Super EBA , resin cement , Composite ,
Calcium phosphate cement

Management Of Root Perforations:
Perforation at or below the bony crest do significantly
affect
an otherwise favourable endodontic prognosis.
Considerations Influencing perforation Repair:
Microscopes, Paper points , Electronic apex locators
and a diagnostic radio opaque contrast solution
( Ruddle Soln ) are useful in determining the four
dimensions

Techniques for repairing perfotation :-Techniques for repairing perfotation :-
Management of coronal one third and furcal perforationsManagement of coronal one third and furcal perforations
Shape - furcalShape - furcal - bur- bur - round (furcal strips )- round (furcal strips )
- coronal 3rd - instrumentation - oval shape- coronal 3rd - instrumentation - oval shape
Immediate - hemostats and restoreImmediate - hemostats and restore
Chronic - clean and next appointment restoreChronic - clean and next appointment restore
Ultrasonic finishing instru. Ideal for preparingUltrasonic finishing instru. Ideal for preparing
perforation sitesperforation sites
Coronal 3rd – esthetics needed- calsium sulfate barrierCoronal 3rd – esthetics needed- calsium sulfate barrier
& adhesive rest. MTA& adhesive rest. MTA
In post – amalgam , super EBAIn post – amalgam , super EBA

Middle thirds :-Middle thirds :-
With mech. Instrumentation, GG , rotary instru.With mech. Instrumentation, GG , rotary instru.
And misdirected postsAnd misdirected posts
Oval , large sizeOval , large size
Fresh perfo.can be immediately doneFresh perfo.can be immediately done
Chronic - clean and next appointment restoreChronic - clean and next appointment restore
Hemostats for control of bleedingHemostats for control of bleeding
1st enlarge the canal > Access to the site ,1st enlarge the canal > Access to the site ,
visualization & < post repair instrumentationvisualization & < post repair instrumentation
When repairing its imp to maintain theWhen repairing its imp to maintain the
physiologic pathway of the canal by apicallyphysiologic pathway of the canal by apically
placing paper point , cotton or GPplacing paper point , cotton or GP
MTA is the choice of materialMTA is the choice of material

Apical thirds :-Apical thirds :-
Occur during BMPOccur during BMP
Blocks , ledges are common in apical perfo.Blocks , ledges are common in apical perfo.
First management of blocks & ledges should beFirst management of blocks & ledges should be
done canal pathway should be traceddone canal pathway should be traced
Next place a file into canal (holding file) & cutNext place a file into canal (holding file) & cut
above the occlusal level . Then vibrate MTAabove the occlusal level . Then vibrate MTA
into the canal and perforation defect , place wetinto the canal and perforation defect , place wet
cotton and close dressingcotton and close dressing
Next visit remove the holding file & completeNext visit remove the holding file & complete
the obturation by using GPthe obturation by using GP
If NSRT is not possible SRT is the choice ofIf NSRT is not possible SRT is the choice of
treatmenttreatment www.indiandentalacademy.com

echnique of MTA placement into the canal :-
n curved canals :-
Mix MTA - heavy (cake like) consistency – small
amount introduced into canal by using microtube
carrying device , 18 or 20 gauge spinal needle or West
Perf Repair instruments
hen MTA is gently tamped and coaxed down the
canal to app. length using customized , non standard
GP cone as a flexible plugger.
n straight canals :-
MTA is vibrated by using ultrasonic activator
instrument with lowest energy – wave like motion for
moving and adapting the cement – place wet cottonwww.indiandentalacademy.com

Mechanical devices
Masserann kit Post puller
Gonon post extractor Post Removal System (PRS) Kit
Extracting pliers
Transmetal bur
Five trephines
Tubular taps
Torque bar
Rubber bumpers

Post removal in multi posts present , by
sectioning into three parts and removed

Post removal by using
ultrasonic

Conclusion :-Conclusion :-
In the future of endodontics retreatment will definitelyIn the future of endodontics retreatment will definitely
grow significantly. variety of retreatment techniquesgrow significantly. variety of retreatment techniques
exist . However, all failure cases are not successfulexist . However, all failure cases are not successful
with NSRCT.with NSRCT.
Clinicians need to weigh risk versus benefitClinicians need to weigh risk versus benefit
and recognize that surgery or extraction might be inand recognize that surgery or extraction might be in
the patient’s best interest.the patient’s best interest.
As the health of the attachment apparatusAs the health of the attachment apparatus
around endodontically treated teeth is good , thearound endodontically treated teeth is good , the
naturally retained root will serve like a dental implant.naturally retained root will serve like a dental implant.
Properly performed, endodontic treatment is theProperly performed, endodontic treatment is the
corner stone of restorative and reconstructive dentistrycorner stone of restorative and reconstructive dentistrywww.indiandentalacademy.com

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