Académique Documents
Professionnel Documents
Culture Documents
Technique
Atousa Rashedi
Institute of Odontology
Karolinska Institutet
Huddinge, Sweden
Summary
The aim of this study was to review the definition, indication, and treatment possibilities
and case presentations of a retrograde therapy. Definition of retrograde endodontic
treatment is removal of periapical pathology due to failure of root canal treatment, root
fracture, obliteration of the root canal or unidentified canals. The radiographic feature
is radiolucency surrounding the bone at the apex of the root. A sinus tract will and
therefore the pus will decrease the intensity of the pain. Retrograde endodontic
treatment involves laying a mucoperiostal flap and remove of inflammatory tissue, to
achieve optimum access to the root end. The reason is to make a root resection and
sealing the cavity with apical sealant materials.
Introduction
The definition of retrograde endodontic treatment, apexectomi, is removal of periapical
pathology due to failure of root canal treatment. Non-healing periapical pathology associated
with endodontically treated teeth is customarily managed by retreatment of the previous
therapy. Root-end resection or retrograde endodontic treatment is less often the first optional
treatment. The treatment might be the option after an unsuccessful retreatment or if
retreatment is impossible.
Before, the term ¨conservative treatment¨ was used as a synonym for nonsurgical
treatment. According to Chivan the term indicates that periapical surgery is radical but it
should be considered that this procedure might save the tooth and therefore it cannot be
counted as radical [1].
The cause of periapical pathology is infectious products from an infected pulp space or
from the peiapical area. Microorganisms that colonize these areas release their product into
the periapical tissue and causes a lesion in the bone. The severity of the destruction is
depended on the amount of products as well as the resistance of the host. The inflammatory
development might be acute, and leading to a periapical abscess or chronic with sign of a
periapical granuloma or a cyst.
In the past century, endodontic surgery has been done frequently and was included in
almost all cases of periapical pathology. The clinical experience and usage of different
advanced techniques and materials, indicates that conventional re-orthograde endodontic
treatment succeeds in a higher rate without a retrograde procedure and therefore the frequency
of periapical surgeries are less than before.
61
Atousa Rashedi
acute or chronic periapical abcess, could be from an improper made root filling, a root
fracture, an unidentified root canal or false obliteration.
Chronic periapical abscess can be developed from an acute periapical abscess or might have a
quiet development. The chronic periapical abscess might develop even though the tooth has
been endodontically treated. The accumulation of dead cells and consequent release of
lysosomal enzymes produces pus, which is drained through a sinus. A sinus tract may open
exrtraorally in the oral mucosa (Fig. 1.1), in the skin (Fig.1.2), or internally in maxillar-sinus,
nasal-cavity or in the floor of the mouth and releases the symptoms as the pus is drained.
Patients usually complain over bad taste in the mouth.
Fig. 1,1: mucosal sinus drainage Fig. 1,2: Extraoral sinus tract
The radiographic feature is a radiolucency indicating inflammation and bone loss around the
apical part of the root. This area is sometimes surrounded by a band of radiopaque sclerotic
trabeculae, which is a chronic sign [2]. Removal of infected pulp tissue is a prerequisite fir
successful healing. A conventional root canal treatment, instrumenting the root canal with
endodontic files and irrigating with hypo-chlorite a solution and using antibacterial calcium-
hydroxide in the canals as an inlay, before the final root-filling. If the above-mentioned
treatment has failed a retrograde treatment might be the best option if an orthograde
retreatment is impossible.
Retrograde endodontic procedure involves laying of flaps and removal of tissues from
outside the root canal space, including bone, periodontal membrane, and periosteum [3]. After
root end is exposed and detected with microscope, there are possibilities to examine and
recognize the pathology behind the periapical pathosis, and thereafter a proper treatment.
Retrograde endodontic surgery may induce postoperative pain, oedema and discoloration,
which is all reversible.
Periapical microbiology
There are many different ways for microorganisms to invade the dental pulp. Either through
an open cavity, caused by dental caries, or by trauma that has removed the barrier of enamel
and the dentine. Microorganisms are also able to penetrate into the pulp through the dental
tubules, especially when the pulp has been injured. Their entry might be through the salivary
contamination or during dental preparation. Another way is through the gingival sulcus or
periodontal ligament. If the periodontal destruction develops to a sufficient degree, the canal
might be exposed to microorganisms without any caries or trauma. Failure of root canal
treatment or retreatment could be caused either by presence of bacteria in the root canal
system, or occurrence on the apical part surface of and occasionally in the periradicular tissue
near to the apical foramina [4].
The correlation between bacterial invasion and endodontics has been a basic science.
Gram-negative anaerobic microorganisms are not clinically found in the synergistic nature.
These organisms need specific nutrients for growth. Many species that are present in the
62
Atousa Rashedi
normal, non-pathological oral flora may become invasive and produce toxins in another
environment together with other microorganisms. Bacterial infection of the dental pulp may
be the cause of a periapical pathosis.
The presence of E.faecalis from the root canals of teeth in which the previous treatment has
failed is notable. According to a study made by Sundquist et al [5] the microbial flora was
evaluated before and after orthograde endodontic retreatment and the presence of E.faecalis
was shown in 9 cases of a total of 54 canals. The bacterial test was taken during three times,
first when the gutta-percha was removed without any antibacterial irrigation and the canals
were left empty to allow any surviving bacteria in the root canal to multiply to a level that
would be detectable at the next appointment. A week later bacteriologic samples were taken
without any use of antibacterial solution. After the final instrumenting the canals were filled
with calcium hydroxide paste. The third appointment began with the bacterial test from the
canals with sterile saline solution. The root canals were then filled with gutta-percha. A
follow up examination was made yearly. In samples taken at the time of root filling,
microorganism were found from six canals and four of these lesions did not heal. E.faecalis
infected three of these 4 canals and the fourth tooth contained Actinomyces israelii. The
success rate in this study between the teeth that had a positive bacteriological sample at the
time of root filling was very low 33% in comparison to 80% from those that was not infected.
Next layer is the zone of contamination (B), affected by diffuse antigens and irritants from the
root canal and is dominated by plasma cells and lymphocytes. Adjacent to this layer is the
zone of irritation (C), were osteclasts and macrophages are the dominant cells. Macrophages
are able to remove and destroy cellular debris in this zone due to lack of root canal antigens.
Beyond this layer is the zone of stimulation (D). This zone consists of young fibroblasts and
osteoblasts, which produce a fibrous capsule around the lesion [6].
63
Atousa Rashedi
Contraindication
Beside local contraindication there are general contraindications were the medical condition is
complex and must be discussed with the patient's doctor.
The local contraindications are; I) poor periodontal support, II) non-restorable tooth and III)
poor access.
I. Apicectomy is also contradicted where the root is too short, or there is an extensive
gingival recession, or extensive marginal periodontitis.
II. If there are not any optional treatment because the tooth is carious or fractured.
III. Another reason is if the access to the apical part of the tooth is severely restricted and
it is difficult to carry out endodontic surgery.
Surgical procedure
A successful treatment of a periapical surgery is depended on the hemostasis among other
factors. Hemostasis is essential for better visualization and good environment for replacing of
the retrograde filling material. A good hemostasis-agent makes the hemostasis easy to achieve
and manipulate, is biocompatible, does not impair healing, is reliable and is relatively
inexpensive. There are different ways to achieve hemostasis; one is through pre-surgical local
anesthetic with 2-3 carpules of epinephrine with multiple infiltration sites, the other is during
surgery. Putting a sterile cotton pellet dipped in epinephrine into the bony crept after removal
of granulation tissue. Calcium sulphate is an alternative hemostasis agent, which is
biocompatible and will be dissolved in 2 - 4 weeks. Another way to accomplish hemostasis is
by using ferric sulphate solution or post-surgical compression for decreasing the bleeding and
post-surgical swelling. [10,11].
When an optimum hemostasis is achieved the flap can be raised. There are three different
incision-methods; a) intrasulcular flap, b)submarginal flap, c) semilunar flap or vertical
incision.
64
Atousa Rashedi
Intrasulcular
Intrasulucular flap extends along the gingival sulcus of the tooth being treated. There is a
vertical incision at each end, which should give sufficient access to the root end these two
cuts are united with a sulcus incision. This flap provides a good visualisation for the surgeon
and the blood supply to the flap is being kept. The flap is elevated and access to the apex
foramina is achieved with an elevating instrument (Norbergs Raspatorium). Postoperative
pain and swelling are usually minimal. A possible disadvantage is gingival recession, this is
normally a concern in the anterior region [12,13]. Palatal flaps are only used for treatment of
palatal roots of molars or premolars. The incision involves several teeth along their gingival
sulcus. Here there is a need of carefulness to not damage the palatine neurovascular bundle.
Submarginal
The submarginal flap is made in the attached gingiva and follows its contours. This flap
cannot be used in the mandible because of restricted width of the attached gingiva. The reason
of choosing this flap is when the gingival tissue should be undisturbed, particulary adjacent to
a crown. The flap should be minimized as possible to prevent ischemia of the remaining
attached gingiva. The semilunar incision is entirely in the alveolar mucosa and is curved at its
ends. This method is not widely used because of the small surgical access and the cause of
ischemia [14].
Vertical incision
This is made vertically over the root and is reflected vertically over the apex. This does not
cut the vessels off and could be used if the roots are long, but the surgical access is limited
and the incision may directly lie over the blood clot in the bony cavity.
65
Atousa Rashedi
The ultrasonic tip is smaller than the burs, that were usually used (Fig.3). This tips converse
tooth structure and give more parallel preparation that makes the root end filling more precise
and decrease the risk for microbacterial leakage. Parallelism, which is accomplished with
ultrasonic machine, is an important issue during a retrograde preparation, and is achieved with
an axial and lateral force. This allows an improved sealing [17]. The relevant clinical features
about using ultrasonic devices, because of their various angled design and the small size of
the retro-tips, are the greater access to the apical part of the root and it requires smaller
osteotomy for surgical access [18]. The ultrasonic tips allows the operator to make very
precise preparations, because of the ease which it removes old gutta-percha and the way it
cleans and widen canals narrowed by reparative dentine to make an excellent shape for the
apical sealant.
Two different types of preparation have routinely been used by endodontists. One is the
"class I" and the other is, "slot" or "matsura type". Before the preparation of the apex, the root
must be bevelled. Bevelling is obtained by use of fissure bur on a handpiece and the cut
should have an approximately 45-degree angle to the long access of the tooth (Fig.4). This
with the help of a specially designed mirror (Fig.5) allows a better visualization of the entire
root face.
With good bevelling technique of the root tip no significantly reducing root length is
accomplished. After bevelling, the configuration of the root is either round, oval or 8 shaped
as shown in Fig. 6. It is essential not to leave unclean space in the root end preparation,
therefore the preparation should be extended to a well-condensed gutta-percha filling. Class I
preparation is very similar to the occlusal class I preparation, only in a miniature form. If the
root end canal has an oval or 8 shape, the proper preparation will be using a tip on the
ultrasonic device and make it round, but touching preparations. The slot or Matsura
preparation is used when it is inconvenient to utilize the other mentioned technique. This
preparation requires much less periapical bone removal. Therefore the slot technique is used
in cases where removal of tooth structure will lead to an insufficient root ratio crown, such
examples are maxillary bicuspid and molars near the maxillary sinus and mandibular molars
near the mandibular canal. The preparation is started at the apex of the root, and the bur is
brought towards the cervical margin and then with help of an ultrasonic device or smaller burs
the corners of the preparations are sharpened to provide undercut for retention of the root end
sealant [19,20].
66
Atousa Rashedi
Table. 1: Comparison of 12- month success rate for the treatment methods [21].
Groups treatment of retrograde cavity success rate
A 4-year study that included 320 cases compared different root-end material and techniques
are presented in table I [21]. Group 2 and 4 received CO2 laser treatment on the exposed
radicular dentine with 1 W intensity (CO2 is a laser-melted hydroxy apatite). On the other two
groups IRM sealant was used and polished. This study reported that there were no significant
differences between uses of CO2 laser and IRM sealant. The only difference was between the
use of micro-burs or ultrasonic devices.
Magnifying glasses
Use of loupes and magnifying glasses have been common among dentist for a long time.
Recently operating microscopes have been introduced as an endodontic support during
operating theatres. In addition this makes the surgery better and has given the ability to take
photos of high quality and magnification for use in presentation and articles.
Some questions that can be discovered if the dentist is using the surgical operating
microscope are:
1. Should a reverse filling be placed or is the existing filling sealed?
2. Is there a septum between the two major canals that should be addressed? For example in
the mesial roots of mandibular molars and mesiobuccal roots of maxillary molars.
3. Is there an additional canal or is there a fracture line?
67
Atousa Rashedi
Amalgam
Amalgam has been documented with good clinical results. When amalgam is used as a
restorative material, its seal improves with time as a result of the accumulation of corrosion
particles [23]. Its potential disadvantages are; initial leakage, secondary corrosion, release of
mercury and tin, moisture sensitivity, microleakage as a result of needing an undercut
preparation, staining of hard and soft tissue and management control of particle scatter.
Amalgam is known to undergo corrosion intraorally, and will also appear intraradiculary. But
there has been some reported cases, were some patients have developed discoloration of the
oral mucosa adjacent to the apical part of the tooth [24,25].
Table. 2: Differences in periapical healing when amalgam or glass ionomer cement are used
as apical sealant after apical surgery [27].
Number of teeth_________________________
Classification 1-year follow up 5-year follow up____
of healing amalgam glass ionomer amalgam glass ionomer
Complete healing 18 19 20 28
Improvement 19 18 15 7
No improvement 1 1 0 1
Failure 3 3 6 5
Gutta-percha
For being able to use gutta-percha, the surgical access has to be excellent and therefore cases
must be carefully selected. The gutta-percha could either be softened by heat, cold condensed,
softened by chloroform (Fig.5). The use of gutta-percha has been limited in the clinical use,
because of the tissue reaction is not favourable as in use of eugenol containing sealant [27].
68
Atousa Rashedi
Composite resin
Composite in combination with saucer preparation and excellent moisture control has
achieved good results over both short and longer period of time [28].
MTA material is indicated for use as; a) root-end filling material (Fig.7) ; b) for the repair of
root canals as an apical plug during apexification; c) for repair of root perforations during root
canal therapy; d) as a pulp capping material
69
Atousa Rashedi
Complications
After surgical treatment, patient can have symptoms such as postoperative pain, swelling and
discoloration. Most of these patients are absent from work after the surgery and they consume
self-prescribed analgesics. While patients treated with an orthograde retreatment usually are
asymptomatic after the procedure. A study made in Gothenburg indicated that retrograde
therapy brought greater indirect costs than nonsurgical retreatment [30].
Case reviews
70
Atousa Rashedi
Fig. 8,3: Sulcus and vertical incision Fig. 8,4: Flap reflection
Case II
1. Re-examine the access to the pulp chamber.
2. Re-evaluate canal preparation. Are there any canals that have been missed? Fig 9.1
3. Redress the canal with calcium hydroxide after irrigating with Sodium hypochlorite
solution.
4. Obturate the canal with gutta-percha and re-evaluate the treatment.
5. In the absence of periapical healing after retreatment, consider periapical surgery. The
cause might be intraradicular or extraraducular infection that cannot be accessed by
conventional orthograde endodontic treatment. As shown in fig. 9.2 the apical delta
prevented an adequate treatment.
6. Root-end resection, involving curettage and cleaning of the root apex with ultrasonic
device obturation made with amalgam (Fig.9.3).
7. Almost complete healing after 6 months (Fig. 9.4).
71
Atousa Rashedi
Acknowledgement
The author would like to thank the Divsion Head, PhD, Mickael Ahlquist at the department of
Endodontics, Faculty of Odontology at Karolinska Institute for his guidance through the study
and for making this study possible.
References
[1]. Chivan N. Surgical treatment- a conservative approach, JNJ Dent Soc
1969;40:234,
[2]. Paul W, Goaz S, Stuart C. White, Oral Radiology Principles and Interpretation.
3rd ed. Dallas (Texas), Mosby; 1994.
72
Atousa Rashedi
[3]. Gutmann JL, Pitt Ford TR. Management of the resected root end: a clinical
review. Int Endod J 1993;26:273-83.
[7]. Franklin S, Weine B, Endodontic therapy, 5th ed, St Louis, (Missouri), Mosby;
1996: 523-605.
[13]. Harrison, J, Jurosky K. Wound healing in the tissue of the periodontium following
periradicular surgery. The incisional wound. J Endod 1991; 17:425-35.
[14]. Kramper B, Kaminski E, Ostetk EM, Heuer M.A. A comparative study of the
wound healing of three types of flap design used in periapical surgery. J Endod
1984;10:17-25.
[16]. Carr GB, Ultrasonic root end preparation. Dent Clin North Am 1997;41: 541-51.
[18]. Von Arx T, Walker W. Microsurgical instruments for root-end cavity preparation
following apicoectomy: a literature review. Endod Dent Traumatol 2000;16: 47-
62.
73
Atousa Rashedi
[20]. Matsura, S. A simplified root end filling technique. J Michigan State Dent Assoc
1962;44:40-5.
[26]. Rud J, Andreasen J, Möller J. A follow-up study of 1000 different cases treated by
endodontic surgery. Int J Oral Surg 1972;1:215-28.
[27]. Jesslèn P, Zetterqvist L, Heimdahl A. Long term result of amalgam versus glass
ionomer cement as apical sealant after apicectomy. Oral Pathol Oral Radiol Endod
1995;79:101-3.
[28]. Rud, J, Rud V, Munksgaard E. Retrograde root filling with dentine bonded-
modified resin composite. J Endod 1996;22:90-3.
[29]. Pro Root MTA (Mineral Trioxide Aggregate) Root Canal Repair Material,
manufacture instruction from DENTSPLY Tulsa Dental.
[30]. KvistT, Reit C. Postoperative discomfort associated with surgical and nonsurgical
endodontic retreatment. Endod Dent Traumatol 2000;16:71-8
74
Atousa Rashedi
[35]. O'Mara, Mounce R, Root resection and retrofill: defining objectives to achieve
surgical success, Part III. Dent Today.1995;14:44-9.
[37]. Chou H, Lin C, Kuo J, Lan W. Scanning electron microscopic evaluation of the
cleanliness of a new ultrasonic root end preparation. J Formos Med Assoc
1997;96:727-33.
75
Atousa Rashedi
76