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 Table of Contents  
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 98-101

Surgical management of an endodontic retreatment failure of a mandibular first molar

Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication25-Oct-2016

Correspondence Address:
Srinidhi Surya Raghavendra
Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-4696.192975

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One of the common endodontic iatrogenic mishaps is the extrusion of obturation material which has a negative effect on the long-term prognosis of the tooth. Surgical endodontics has enabled us to save teeth with persistent infections and extrusions when orthograde treatment has been unsuccessful. Apicoectomy of the molars is not frequently performed even though its success rate can reach that of anteriors and premolars. This case report describes the orthograde and surgical management of a mandibular first molar with external root resorption, instrument separation in the canal, and extruded obturation material, which had been unresponsive to endodontic retreatment.

Keywords: Apicoectomy, extruded gutta-percha, mineral trioxide aggregate, surgical endodontics

How to cite this article:
Gathani KM, Raghavendra SS, Dadpe A, Shah JR. Surgical management of an endodontic retreatment failure of a mandibular first molar. J Dent Allied Sci 2016;5:98-101

How to cite this URL:
Gathani KM, Raghavendra SS, Dadpe A, Shah JR. Surgical management of an endodontic retreatment failure of a mandibular first molar. J Dent Allied Sci [serial online] 2016 [cited 2023 Jun 5];5:98-101. Available from: https://www.jdas.in/text.asp?2016/5/2/98/192975

  Introduction Top

The principal modalities available to manage endodontic treatment failures are orthograde retreatment and apical surgery.[1] The success of root canal treatment depends on complete debridement and obturation of the root canal system.[2] Causes of failure include incomplete obturation, root perforation, external root resorption, coexistent periodontal-periradicular lesions, grossly overfilled or overextended canals, canals left unfilled, developing apical cysts, adjacent pulpless teeth, inadvertently removed silver points, broken instruments, unfilled accessory canals, constant trauma, and nasal floor perforation.[3] Ideally, the filling material and the endodontic instruments should be limited to the root canal without extending to the periapical tissues or other neighboring structures. Filling material, broken file, and gutta-percha extruded in the periapical area cause a foreign reaction to the connective tissue. Depending on the organism's immune response, the connective tissue tends to absorb the foreign body or more frequently, surrounds it with a fibrous capsule.[4] The prognosis for an endodontically treated tooth with overfilling depends on the response of the periradicular tissue to the canal obturation material, which is a consequence of the complex and an unpredictable interaction between the materials and the host defenses.[5]

Root canal failure following gutta-percha overfilling can be managed by nonsurgical method or periradicular surgery or both. The aim of the endodontic surgery is to remove the periradicular pathosis and restore the health and function of tooth periodontium.[6] This case report describes the surgical management of a case of endodontic retreatment failure with extruded obturation material and external root resorption.

  Case Report Top

A 21-year-old male reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of pus discharge from the lower left posterior region. On oral examination, a sinus was seen on the buccal-attached gingival with mandibular left first molar (36). The tooth was tender on percussion and palpation. The patient had a history of spontaneous throbbing pain due to caries with the tooth, for which he underwent initial endodontic treatment 1 year back in a private clinic. Symptoms of the pus discharge started 1 month after the initial endodontic treatment. The tooth was subjected to endodontic retreatment after which the clinical symptoms remained unresolved. A diagnostic periapical radiograph of the tooth revealed extruded obturation material in both mesial and distal roots, external root resorption in the distal root, and two separated instruments in the mesial root [Figure 1].
Figure 1: Preoperative radiograph, (a) extruded obturation material, (b) files separated in mesial canal, (c) external root resorption

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The initial treatment plan proposed was orthograde retreatment. Need for surgical intervention, if necessary, was explained to the patient and consent was obtained. After the removal of gutta-percha, the broken files in mesial canals were bypassed with a #10 K file (Mani, Japan) using watch winding motion followed by thorough cleaning and shaping. The canals were then obturated with mineral trioxide aggregate (MTA) (Angelus, Soluçöes em Odontologia, Londrina, PR, Brazil). Moist cotton was placed in the pulp chamber and the patient was recalled after 7 days.

On recall, the patient was asymptomatic, there was no pus discharge, and the sinus had resolved. However, a surgical intervention was necessary to remove the extruded obturation material in the periapical region to ensure complete disinfection. A full-thickness mucoperiosteal flap was raised from 34 to 37. On flap reflection, bone loss was seen on the buccal aspect of the tooth between the mesial and distal roots near the furcation area of 36 [Figure 2].
Figure 2: Bone defect seen on the reflection of flap

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The osseous cavity was enlarged with a surgical round bur to obtain access to the root apices and extruded obturation material [Figure 3].
Figure 3: Bony cavity drilled to gain access to the mesial and distal roots

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Once access was gained, approximately, 3 mm of the mesial and distal root ends was resected and the bony cavity curetted to remove the extrusions and granulation tissue. Complete removal of the extrusions was confirmed radiographically before the placement of interrupted sutures.

Sutures were removed after 7 days [Figure 4], and a postendodontic restoration with a full coverage crown was given [Figure 5].
Figure 4: After suture removal on day 7

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Figure 5: Full coverage crown placed

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The patient was recalled periodically and 1 year follow-up demonstrated complete healing both clinically and radiographically [Figure 6].
Figure 6: One year follow-up radiograph

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  Discussion Top

One of the iatrogenic complications is overfilling of the root canal, which has a negative effect on the prognosis of endodontically treated teeth.[5] Failure of conventional orthograde treatment may be due to failure to remove the infection completely or due to re-infection. Orthograde retreatment should be the treatment of choice in failed cases. In spite of this, there may be persisting clinical symptoms or nonhealing lesions that dictate the need for more definitive and advance treatment, i.e., periradicular surgery.[3]

Periapical extrusion in a lower molar needs surgical intervention as orthograde re-treatment may not be able to completely eliminate any foreign bodies. Intentional replantation and root resection, though present as other treatment alternatives, are not commonly used due to their nonconservative nature and short-term prognosis. Although difficult, retrograde approach is a more suitable method for the management of such complications due to its proven long-term clinical success. However, it requires a greater level of clinical competence.[7]

Gutta-percha is the most commonly used material for obturation of the root canal space. Gutta-percha is biologically inert and resilient. Pure gutta-percha can be considered absolutely biocompatible because no effect has been reported on the frequency of chromosomal aberrations in in vitro studies. Gutta-percha consists of 20% gutta-percha, and the main component is ZnO (60–70%), which is necessary to make it radiopaque. Commercially available gutta-percha points can be cytotoxic due to the substances added to the base material, particularly Zn, as this might leak into the surrounding soft tissues.[8] Cytotoxicity has been reported with both commonly used cements and gutta-percha when subjected to scanning electron microscope analysis. This cytotoxicity can induce periradicular inflammation or necrosis of the periodontal ligament, and for this reason, overfilling should be avoided as much as possible because it can lead to failure of short-term treatment or a long-negative prognosis.[5]

Endodontic surgery, once thought to be the treatment of the last resort, has advanced in the recent years and increases the clinicians' ability to achieve more predictable clinical outcome with a success rate exceeding 90%. Age, gender, tooth type, root-end filling material, and the magnification system had no significant effect on the proportion of success.[9],[10]

Littner et al. studied the relationship between the apices of mandibular molars and the mandibular canal and found that most frequently, the upper border of the mandibular canal was located 3.5–5.4 mm below the root apices of both the first and second molars.[11] In this case, distance from the inferior alveolar canal was approximately 8 mm, which is a safe margin for successful apicoectomy procedure.

External inflammatory root resorption involves a pH drop of 3–4.5, following pulpal necrosis, with an increase in the osteoclastic/odontoclastic activity. MTA is a tricalcium silicate-based material that attains an immediate pH of 12 by the release of calcium ions which lasts for months. Because of its high pH and the ability to stimulate cementoblasts/odontoblasts, it can be used in the cases of root resorption.[12]

MTA has also been successfully used by eminent clinicians and researchers to obturate the entire canal due to its favorable physicochemical and biological properties such as superior sealing, good marginal adaptation, minimal microleakage, high biocompatibility, and bioinductive and antimicrobial properties.[13] In this case, the clinical symptoms had disappeared after orthograde MTA obturation. However, a surgical intervention was necessary due to the extruded obturation material.

  Conclusion Top

The most ideal management of iatrogenic errors would be its prevention. Mandibular molars present a challenge for endodontic surgery due to its proximity to inferior alveolar nerve and difficulty in accessibility. However, in cases of previous endodontic retreatment failure and when extruded obturation material is present in periapical tissues, endodontic surgery is likely to enhance the prognosis of the tooth.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hepworth MJ, Friedman S. Treatment outcome of surgical and non-surgical management of endodontic failures. J Can Dent Assoc 1997;63:364-71.  Back to cited text no. 1
Ektefaie MR, David HT, Poh CF. Surgical resolution of chronic tissue irritation caused by extruded endodontic filling material. J Can Dent Assoc 2005;71:487-90.  Back to cited text no. 2
Pasha S, Madhu KS, Nagaraja S. Treatment outcome of surgical management in endodontic retreatment failure. Pak Oral Dent J 2013;33:554-7.  Back to cited text no. 3
Stavrianos C, Eliades A, Kokkas A. An interesting unusual case report of madly endodontic treatments. Res J Med S 2010;4:98-101.  Back to cited text no. 4
Yadav RK, Chand S, Verma P, Chandra A, Tikku AP, Wadhwani KK. Clinical negligence or endodontic mishaps: A surgeons dilemma. Natl J Maxillofac Surg 2012;3:87-90.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
Pai AV, Shrikrishna SB, Shah N. Surgical management of overfilled gutta-percha and root capping with mineral trioxide aggregate in a young patient. Indian J Multidiscip Dent 2014;4:148-51.  Back to cited text no. 6
Gurtu A, Singhal A, Singhal P, Mohan S. Retrieval of separated instrument in mandibular molar by surgical approach-a case report. J Dent Sci Oral Rehabil 2011;2:32-3.  Back to cited text no. 7
Mallineni SK, Nuvvula S, Matinlinna JP, Yiu CK, King NM. Biocompatibility of various dental materials in contemporary dentistry: A narrative insight. J Investig Clin Dent 2013;4:9-19.  Back to cited text no. 8
Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y, Ceresoli V, Del Fabbro M. Outcomes of surgical endodontic treatment performed by a modern technique: An updated meta-analysis of the literature. J Endod 2013;39:332-9.  Back to cited text no. 9
von Arx T. Apical surgery: A review of current techniques and outcome. Saudi Dent J 2011;23:9-15.  Back to cited text no. 10
Littner MM, Kaffe I, Tamse A, Dicapua P. Relationship between the apices of the lower molars and mandibular canal – A radiographic study. Oral Surg Oral Med Oral Pathol 1986;62:595-602.  Back to cited text no. 11
Aggarwal V, Singla M. Management of inflammatory root resorption using MTA obturation – A four year follow up. Br Dent J 2010;208:287-9.  Back to cited text no. 12
Wahengbam B, Wahengbam P, Tikku AP. A simplified technique of orthograde MTA obturation on the elected canals of posterior teeth: Two case reports. J Conserv Dent 2014;17:80-4.  Back to cited text no. 13
[PUBMED]  Medknow Journal  


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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