Understanding Success and Failure

Healing vs. Persistent Pathosis

by David B. Rosenberg, DDS, FICD, FACD

Retreatment: Why and When

Why retreat? The specialty of endodontics is fortunate to be able

to offer our patients the best that dentistry can pro-
Implants have eliminated the need for nonsurgical vide for them. We can predictably save teeth, and
endodontic retreatment. without any conflict of interest provide implant ser-
vices when appropriate. No other branch of den-
Implants have eliminated the need for apicoectomies. tistry can make this claim.

As the saying goes, “if you only have a hammer, When considering endodontic treatment or
everything is a nail.” retreatment versus an extraction some factors to con-
sider include:
As endodontists we have a complete set of tools, Is the tooth restorable?
along with the knowledge and experience to use them
to our patient’s advantage. We perform osseous sur- What function does this tooth provide?
gery, soft tissue surgery, and internal nonsurgical
restorative endodontic procedures. If we need to put What is the expected functional lifetime of the re-
a post in a tooth we can do that. If we need to put a sultant restoration?
titanium post in the bone we can do that also.
Are the patient’s desires and expectations realistic?
So why retreat a tooth? If it is in the patient’s best What are the number, types, and duration of the pro-
interests why not retreat it? Unless retreatment is a cedures required?
service that one can not provide.
What are the surgical risks and potential complica-
In deciding whether to extract or retain a tooth who tions?
is more qualified than an endodontist? Endodontists
successfully treat teeth that other practitioners con- Of course no treatment can claim 100% success.
demn. Only endodontists have the skills and experi- Endodontics has its limitations. Vertically fractured
ence necessary for successful endodontic treatment roots, nonrestorable teeth, and hopeless periodontaly
of complex cases. If the only treatment option a involved teeth should be extracted. Teeth that if re-
dentist or dental specialist can offer requires extract- tained may interfere with long term outcomes should
ing the tooth, is the patient being offered a treatment also be removed even if they can be treated. An
plan in their best interests or the providers? example of this would be trying to save a single
mandibular incisor where implants are being used
Of course the converse is also true. If the only ser- to restore the mandibular dentition.
vice you can offer for a failing tooth is a heroic at-
tempt at retreatment, are you able to provide for the Implants also have their limitations. Treatment in the
patients best interests? Not every tooth should have esthetic zone (the esthetic zone being wherever the
an attempt made at saving it when more predictable patient says it is) is a major concern. Often the im-
options exist. plant site needs to be developed with bone, or soft
tissue grafting for optimal esthetic results. Without
Endodontists perform some of the most complex a good recipient site for the implant, esthetics will
dental procedures. From conventional endo where be compromised.
we work within _ to 1/2mm tolerances, to placing
retrogrades in roots near vital structures in small Implants used to restore adjacent tooth extraction
spaces with challenging access requirements. Re- sites often present an esthetic challenge. Esthetic
placing a tooth with a titanium screw is a lot less results are significantly related to preservation of the
complicated than providing an endodontic service. papilla and its supporting bone. The papilla is present
when the interproximal crest of alveolar bone ex- toration must also be evaluated. This is a subjective
ists. This alveolar bone is resorbed when adjacent evaluation based in part on experience.
teeth are missing. Between adjacent implants there
is often no interproximal crest of alveolar bone that A thorough radiographic examination can make
provides for the scalloped appearance of the peri- evaluation of existing conditions more objective.
odontal tissues that form a papilla. Natural roots Radiographs angulated from the mesial and distal,
can have an esthetic advantage due to their ability to as well as straight on, are needed. Furcations can be
preserve the natural papilla. evaluated with a bitewing film. The bitewing films
can also be taken from more coronal and apical di-
Rationale for Retreatment rections. These different angles can help identify
When considering treating teeth with failing endo- missed canals, fractures, perforations, while also
dontic therapy, several options exist. They include evaluating the quality of the existing endodontics.
endodontic surgery, extraction, no treatment, or en-
dodontic retreatment. Most causes of endodontic failure are related to con-
taminated root canal spaces. There are several cat-
The patient’s chief complaint needs to be investi- egories of endodontic failure for which retreatment
gated. Postendodontic treatment complaints may is promising. They include:
include, sensitivity to; temperature, biting, pressure,
Missed canals (Figures 3, 4)
palpation, and recurrent sinus tracts.
Incomplete obturation (Figures 5, 6, 7)

Perforations (Figures 8, 9)
When a patient complains of temperature sensitiv-
Coronal leakage (Figures 10, 11)
ity after endodontic therapy, their complaint is often
dismissed. Thermal testing should be performed to Missed Canals
see if their complaint is reproduced. If it is the endo- Angled radiographs can show missed canals in sev-
dontic treated tooth that responds, the presence of eral ways:
untreated pulp is suspected.
By observing that the obturation is not centered
in the canal. Since the root forms around the
When an endodontic treated and restored tooth that centrally located pulp, an eccentrically located
has been asymptomatic for years begins to become obturation may indicate additional untreated ca-
sensitive to biting, pressure, or palpation, endodon- nal space. (Figures 12, 13)
tic failure should be suspected. This is especially true
if no recent dentistry or trauma has taken place. Oc-
Observing the radiographic apex having a bi-
clusal adjustment and antibiotics will temporarily convex shape. Maxillary molar MB roots and
abate the symptoms but they will usually return re- mandibular molar distal roots with two canals
peatedly. As with virgin teeth exhibiting these symp- often exhibit this anatomical marker. (Figures
toms an endodontic abscess should be suspected. 14, 15, 16)
(Figures 1, 2)

Angled radiographs project superimposed roots
Patients are often aware of a “gum boil” that comes onto the film as described with the cone shift
and goes. When presenting for an exam the sinus rule, also called the buccal object rule, or the
tract may be difficult to see. Palpation in an apical SLOB rule. The result of angling the radiograph
to coronal direction on the buccal and lingual may is the identification of these otherwise superim-
result in exudate being expressed through the mu- posed roots. (Figures 17, 18)
cosa. The sinus tract may now be traced to its source.
Incomplete Obturation
Evaluation of the Existing Treatment: Radiograph Incomplete obturation is suspected when radiographs
interpretation in evaluation for retreatment show:
When retreatment is being considered the quality of
The radiopacity of the obturation is similar to
the previous endodontic therapy and subsequent res- dentin. When pulpal and dentinal debris are left
Figure 1 Upon a quick inspection the Figure 2 The patient’s symptoms were
endodontics in the first molar appears relieved after retreatment of the
adequate to outstanding. The patient previously under-treated canals, and
was persistently symptomatic. treatment of a previously missed
second MB canal. Almost all maxillary
molars have four canals.

Figure 4 This tooth was found to have Figure 3 The second premolar has a
three separate canals. radiolucency that extends from the
apex to the CEJ along the distal root
surface.

Figures 5-7 Without the use of the surgical operating microscope, retreatment of this central incisor would be extremely difficult.
With the microscope the apical bifurcation can be seen and managed.
Figure 8-9 A perforation with no communication to the oral cavity has a good
prognosis today. The post was removed and the perforation was repaired with MTA.
A new post and crown were placed and healing has occurred.

Figure 10 Endodontic surgery has Figure 11 Healing has occurred after

failed to resolve this extensively post removal, silver point removal,
treated first molar. The margins on the gutta percha removal, endodontic
crown are suspect. The leaking crown retreatment, and a new crown.
needs to be addressed if endodontic
retreatment is to succeed.

Figure 12-13 The obturation of the MB root on this first molar is eccentrically
positioned. When the root was retreated, a second MB canal was found.
Figure 14-16 This first premolar case illustrates the value of multiple angled preoperative views and the significance of lateral
canals. The outline of a second untreated canal can be seen on the second view. After the silver point is removed and the tooth
retreated, the anatomical complexity of this root canal is revealed.

Figure 17 The radiograph of the Figure 18 The presence of two canals Figure 19 Indistinct obturation as
lateral incisor reveals a deep concavity is demonstrated on the postoperative seen in this molar is cause for
on the root surface. The presence of radiograph. concern. After the crown was placed,
this concavity is often indicative of symptoms developed, necessitating
multiple canals within the root. endodontic retreatement.

Figure 20-21 The original treatment terminated at a ledge that was created when the original path of the canal was not followed.
Upon retreatment the ledge was bypassed, allowing access and treatment of the original canal, which terminates with its foramen
centrally located in the periapical radiolucency.
 in the canal during obturation, the volume that Perforations should be suspected when radiographs
the more radiopaque obturation materials can reveal:
occupy is limited. The result is a diminished ra-
A radiolucency at the apical extent of a post.
diopacity of the obturated canal.

A furcal radiolucency exists adjacent to mini-

The radiopacity of the obturation becomes less mally remaining furcal tooth structure.
distinct in an apical direction. This is another
indication that significant debris may remain in
A sinus tract that traces to the furcation, or to
the canal. (Figure 19)
the mid root area where the external root sur-
face is concave (a strip perforation).

The obturation does not reach the PDL. Mesial,
distal, and straight on radiographs will show the
The Coronal Seal
most apical obturation level. If none of the ra-
The quality of the coronal seal can be evaluated ra-
diographs show obturation to the PDL it is rea-
sonable to assume that the obturation is short of diographically by examining for the following, as
the cavosurface of the canal. (Figures 20, 21) they can provide avenues for micro leakage:

Open margins

A vertical void (a black line) visible between
the obturation material and the canal wall. The
Recurrent decay
canal may be filled in terms of length, but in-
completely filled in three dimensions. This black
Voids parallel to posts
line could also indicate a vertical fracture.
If the etiology of the failure can be assigned to one

Evidence of endodontic surgery without retro- of these four categories there is reason to explore
grade placement retreatment as an option for the patient.

Evidence of endodontic surgery with retrograde Root Fractures

placement in the root, but not the canal. (Figure Fractures also create areas of persistent inflamma-
22) tion that may necessitate extraction. Fractures are
often difficult to see on radiographs. Sometimes their

The obturation does not seem to follow the curve presence is indicated when radiographs show:
of the root, or terminate in the center of the ra-
A vertical black line between the obturation
diolucency. This could indicate a ledge or per-
material and the root
foration. (Again, see Figures 20, 21)

A “halo” shaped radiolucency surrounding a

The presence of silver points.
root. (Not the typical circumscribed radiolucency
associated with a chronic apical abscess.)

The presence of separated instruments.

Perforations
Changing the vertical angulation of the central

Perforations create areas of persistent inflammation, ray may allow detection of horizontal fractures
and resolution of perforations depends to a large (usually caused by trauma). A radiograph should
extent on where they are located. The amount of be taken at a right angle to the long axis of the
supportive tooth structure remaining is also a criti- root, along with two additional views, one at 45
cal factor in the long-term success or failure of per- degrees toward the apex and one at 45 degrees
foration repair efforts. toward the crown.
Figure 22 These retrogrades may have Figure 23 The preoperative radio- Figure 24 The apex locator readings
esthetic value but are not sealing the graph of the second premolar sug- were suggestive of a perforation or
canals, as evidenced by the files gested the presence of a vertical root fracture. The radiograph shows the file
extending past them. fracture on the distal side of the root. in the fracture line. Irrigating this with
NaOCl would have been a major
iatrogenic mistake. When the apex
locator reading is aberrant, investigate
the cause before proceeding.

Figure 25 The second molar has silver

points perforating both mesial canals.
The first molar is fractured through the
furcation and decayed. The patient has
been asymptomatic for more than 20
years. Regaining access to the calcified
mesial canals apical to the perforation
is a challenge. Surgery or extraction
are more predictable treatment options
for the second molar.
The Clinical Exam is extensively restored, the dye can be placed in the
The Coronal Seal gingival sulcus. A spoon excavator or similar instru-
The integrity of the coronal restoration needs to be ment may than be used to reflect the soft tissue away
evaluated clinically and visually, as coronal leakage from the root. The root can be examined for a frac-
is a factor in endodontic failure. ture with magnification and fiber optics.

Open margins on coronal restorations can be revealed Apex locator readings that are aberrantly short should
by the production of bubbles when apical pressure be compared with a measurement film. The apex
is applied to the occlusal surface. Use of an explorer locator reading could be due to a fracture or perfora-
and mobility testing is also required. tion. (Figures 23, 24)

Periodontal Evaluation. Observation of multiple sinus tracts that trace to the

Periodontal disease may be misdiagnosed as an en- same root often occurs when the fracture separates
dodontic failure. The opposite is also true. The clini- the root in half, creating buccal and lingual sinus
cal exam needs to include periodontal probing of the tracts.
entire tooth including any furcations. Ideally the
entire quadrant should be probed. When the general Past History of the Tooth
periodontal health is good, finding an isolated deep Information on the technique used during the initial
periodontal defect that is narrow in a horizontal di- endodontic treatment may be difficult to obtain. It
rection may actually be a draining sinus tract. Peri- could be useful to know if irrigants were used. The
odontal defects that are wider coronally than apicaly type of irrigants and how they were used could also
are more indicative of fractures or periodontal pa- be useful. The importance of using NaOCl and EDTA
thosis. to produce as clean a canal as possible has been well
established. If a less than ideal protocol was fol-
Perforations lowed during the original treatment, retreatment may
Perforations that can be probed through the sulcus result in healing.
have an unfavorable prognosis. This is because re-
attachment of the periodontal fibers and regenera- Prognosis
tion of the alveolar bone is compromised. Due to When all the information required to diagnose the
salivary contamination a persistent supraosseous, etiology of the endodontic failure is analyzed a prog-
subgingival inflamed pocket will remain. nosis for retreatment can be offered.

Perforations that are in 5 or 6 walled bony defects A Poor prognosis is given for:
have an excellent prognosis when repaired with
Vertical root fractures with probing depths that
MTA. are markedly greater than immediately adjacent
sites. This indicates that the fracture, in addition
Fracture Identification to being subgingival extends infraosseously. This
Fiber optic transillumination when applicable is an bone is expected to eventually be lost due to
excellent diagnostic aide for fracture identification. bacterial infection of the fracture.
A fracture is indicated when the light transmission
is halted at a darkened interface. This interface is
Furcation perforations with a sulcular commu-
where the fracture line exists. Crowns and large res- nication.
torations can limit the usefulness of fiber optic tran-
sillumination.
Apical third perforations in roots with abrupt
apical curvature. It can be very difficult to re-
Staining with a dye such as methylene blue will also enter the natural canal to complete the endodon-
help elucidate the fracture. The stain can be used in tics in this situation. Surgery is usually a more
conjunction with transillumination. When the tooth predictable approach here. (Figure 25)
A Good prognosis can be given failures with an eti-
When the natural root and the bone it preserves
ology of: is the best option.

Separated instruments

When the decision is made to retain the tooth,

Silver points retreatment addresses more of the apical
anatomy than surgery.

Perforations coronal to the periodontal attach-
ment
Infraosseous perforations that don’t communi-
cate through the sulcus can be addressed in a

Root perforations in the coronal to middle third more conservative fashion from a coronal ap-
without sulcular communication (5 or 6 walled proach than a surgical approach.
defects)
When discussing a comprehensive treatment plan,
patients should be made aware of the status of their

Apicoectomies without retrogrades placed
existing endodontic treatments. Asymptomatic teeth
with questionable endodontics should be considered

Retrogrades placed in the root but not in the ca-
for retreatment prior to completion of their compre-
nal
hensive treatment plan. Before proceeding with
retreatment, the potential need for additional proce-

Missed canals
dures needs to be assessed. New restorations, crown
lengthening or other periodontal needs should be

Incomplete obturation
explained to the patient in order for an informed
decision to be made. When pre-existing endodontic

Coronal leakage pathosis or teeth with questionable endodontic treat-
ment become symptomatic shortly after overall treat-
Deciding Upon Endodontic Retreatment ment has been completed, patient doctor relations
As described previously, there are several factors that can be strained. This is especially true if the patients
make endodontic retreatment the preferred method were not informed ahead of time of the findings from
for treating endodontic failures, they include: their comprehensive exams.