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April 2001The Nonsurgical Retreatment Option - Disassembly

Fig.1 - As the case originally presented

This 37 year old male was referred to me for endodontic consideration of #46. The patient had been complaining of diffuse dull ache in the area and difficulties with occlusion. The tooth presented with a well fitting 4 year old crown. The case had been endodontically treated by the referring general dentist prior to crown placement. A post of substantial depth and diameter was noted to be present in the failing distal canal. Radiography showed a lesion of endodontic origin as well as evidence of external apical resorption of the distal root. The endodontic filling had originally been close to the end of the root. (Fig.1)

After reviewing the film, my initial treatment recommendation was surgical treatment of the distal root. However, upon closer examination I found two complicating factors that made surgery less than desirable:

  1. The length of the resorbed distal root would be further shortened by surgical procedures.
  2. Because of the resorption, resection of the distal root would likely result in a situation where the retropreparation would be up against the stainless steel post. This would prevent the use of ultrasonic tips for retropreparation . The retroprep would have to be performed with a bur. This, in turn, would mean that axial preparation would be almost impossible and that further bevelling of the root would be necessary to allow access for the high speed surgical handpiece. Even more shortening of the root would result.
After consulting with the patient and the referring dentist, we agreed that the best solution would be to attempt post removal through the crown and conventional endodontic retreatment. This would allow for complete seal of the entire distal canal space. (It also would allow for use of ultrasonic retropreparation without sacrificing root length in the event that surgical treatment was required in the future.) We realized that removal of the post could result in complete dislodgment of the core and loosening of the crown. However, the dentist assured me that adequate circumferential ferrule was present at the time of crown preparation and that the chances for retention of the crown were high.

Access was made through the full gold crown and the post was located in the amalgam core material.. Thin tapered diamonds were used to remove the core material from around the post. Further removal of cement and amalgam was done with Ultrasonic tips. Once the post was isolated, the Ruddle Post Removal System was used to pull the post out of the canal. The post had been cemented with resin cement, so it was not an easy procedure. However, after about 45 minutes of access, isolation and removal, the post was in hand.

Removal of the previous gutta percha material showed the apex to be heavily resorbed to approximately a size #80 file at the terminus.( This was very significant because it indicates that the diameter of the foramen may have been much larger than the first clinician had anticipated.) Purulent exudate was also noted in the canal. Minimal cleaning and shaping of the canal space (17 mm working length) was performed with an emphasis on irrigation and trying to retain any apical constriction that was present.

The canal was dried with large numbers of extra coarse paper points used together. A large gutta percha cone was fitted using the Chloroform dip technique, in order to take an impression of the canal space, fit slightly short of the terminus. The cone was air dried with a syringe for 60 seconds and the apical section was checked to make sure the integrity of the gutta percha was intact. Minimal sealer was used ( Kerr sealer) and the case was packed using vertical condensation and heat. The access was then closed with amalgam. The treatment results were very satisfactory. I am not concerned about the excess old gutta percha in the periapical area. Note the good apical control of the material even though the canal diameter and foramen size is very large. The distal foramen seal will determine the success and I believe the prognosis is good. (Fig.2) 6 months later, the case is healing nicely (Fig.3)

Fig. 2 - After Retreatment of the Distal root

Fig. 3 - 6 Month Recall

By using a disassembly technique we managed to prevent the need for a surgical procedure, possible shortening of the distal root and ensured that the entire canal space ( from the access to the apex) was as well sealed as possible . Should further surgical procedures be necessary (because of lack of apical seal caused by the resorption and large foramen size) , they can be performed more conservatively with ultrasonic retropreparation. This further preserves root length and allows for easier surgical treatment.