clinical _ canal patency

Regaining canal patency in endodontic retreatment: finding the path

Author_ Richard Mounce, U.S.A. _If there is a common denominator in the challenge presented by endodontic retreatment, it is the achievement of canal patency. More than any other single variable, this vexing and problematic issue can, along with the primary need for a coronal seal, determine long-term prognosis. The loss of canal patency can arise from separated files, canal blockage, canal transportation of all types, silver cones, carriers used in carrier based obturation, paste fillings that might be challenging to dissolve, amongst other possible sources. If patency can be achieved again during retreatment procedures along with the safe, efficient and effective removal of the previous endodontic obturation material, the potential for healing is enhanced. This article was written to discuss methods to allow the astute clinician to achieve and maintain patency at all levels in the canal in non-surgical retreatment due to blockages by canal debris. A brief description of the crossover applications for using these methods to aid the removal of metallic obstructions will also be provided (Figs. 1a, b). Creating a challenge in planning for retreatment is the fact that most often a clinician may not know preoperatively that the canal is blocked. Many blocked and ledged canals are not observable on radiographs. Some very small metallic obstructions such as the separated tip of a #6 or #8 hand file may also not be radiographically visible. Lack of patency does not occur in a vacuum and may only be one of many issues that require resolution during retreatment procedures. Achieving and maintaining patency of the canal should not occur at the risk of exacerbating and/or creating other and greater problems. For example, bypassing a blockage of any sort, especially separated files should not require that excessive amounts of tooth structure be removed to make access to the blockage and predispose the tooth to fracture. Sound clinical judgment is called for. Whether it is in first time treatment or endodontic retreatment, there are common strategies that provide patency and its attendant benefits (cleaner canals and fewer iatrogenic events). Blocked canals are the harbinger of separated files, canal transportations of all types, perforations, etc, all of which are deviations from ideal canal preparation. Strategies and materials to prevent blockage become even more vital during retreatment.

Fig. 1a

Fig. 1b

Figs. 1ab_ Badly ledged and blocked canal, after retreatment.

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_These strategies are:
_Using an enhanced source of lighting and magnification, optimally a surgical operating microscope (SOM) such as the Global SOM (Global Surgical, St. Louis, MO, U.S.A.) (Fig. 2). _Copious irrigation at all stages in the procedure, ideally after every file insertion, be they hand or rotary nickel titanium (RNT) files. _Use of a viscous EDTA gel like File-Eze (Ultradent, South Jordan, UT, U.S.A.) to hold the pulp in suspension especially in a vital tooth so that pulp tissue can be irrigated in a coronal direction instead of being pushed apically and become the nidus of a future blocked canal (Fig. 3).
Fig. 2_ The Global Surgical Operating Microscope (Global Surgical, St. Louis, MO, U.S.A.).

_A lack of apical patency is caused in several ways:

_ Canal debris is pushed apically. Blockage can occur anywhere, but it commonly happens either mid root in the presence of an abrupt mid root curvature or apically in fine canal anatomy that has been occluded with such debris. _ This debris is most often either pulp and dentin chips but metal obstructions of all types can occlude a canal and create a blockage. Most often these metal obstructions are separated files, silver cones, Gates Glidden drill heads and post fragments. Plastic carriers used in warm carrier based obturation can also become wedged with frictional retention and present a significant challenge in removal. _ Some pastes and cements used as obturation materials can be very difficult to dissolve or remove. In the worst-case scenario, there are materials that cannot be dissolved with any known solvents and which must be removed with ultrasonics if straight-line access to the material can be attained. While management of these pastes is beyond the scope of this article, it may be needed to force a file beyond the paste if possible without creating a ledge, a process which in some cases is possible and in others not. In any case, a paste, which cannot be dissolved, is a very clinically challenging event and almost always indication for referral. _ Transportation of the canal path where a ledge or perforation has been created such that the canal path cannot be traversed easily, if at all.

_ Endodontic therapy should always be carried out under a rubber dam. It is the ethical and legal standard of care in the United States. _ Anesthesia must be profound. Informed consent must be comprehensive. Both of these can only help relax the patient so as to create the most compliant and comfortable patient possible. A full and comprehensive pre operative assessment of the risk factors present in the clinical case should always be undertaken with an eye toward determining if referral is indicated. Strategies for avoidance of iatrogenic events should be determined before starting.

_Considerations before beginning retreatment and attempts to regain _ Access should be straight line in that the straight- apical patency:
away coronal portion of the canal can be reached with hand and RNT files without deflection against either a canal wall or the cervical dentinal triangle. _ Digital radiography (such as DEXIS, DEXIS digital radiography, Alpharetta, GA, U.S.A.) for pre-operative evaluation is ideal. Multiple angles of radiograph can and should be taken preoperatively to fully map the canal system that will later be negotiated. With these materials and strategies in place guiding the course of treatment, the chances for lost patency are minimized and future negotiation made more likely. _ The risk of perforation should always be considered. If the canals are likely to be perforated during removal of the coronal filling material because the existing canal preparation may already be oversized (and leave a canal wall thin), at high risk of vertical fracture, extraction may be the better option. _ Risk versus benefit of extraction relative to the options, most notably bridges and implants. The best implant is the natural tooth. When conditions conspire to make the restorability and long-term prognosis guarded to poor relative to the options available, extraction should be considered. The clinicians should always ask themselves, is the tooth restorable? Is the tooth strategically valuable? Do

Fig. 3_ File-Eze (Ultradent, South Jordan, UT, U.S.A.).

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the risks outweigh the benefit to argue for retreatment versus the options? These questions are the cornerstone for a decision to begin retreatment procedures. _ Are there 4 walls to the access preparation so as to hold the irrigants and gutta-percha solvents in the chamber? The benefits of creating these 4 walls are obvious if they are not already present. Using composite to rebuild the walls of the tooth is a precursor to having a full command over the tooth during all stages of the retreatment in addition to using a rubber dam and SOM visualization.

means, 23 drops of a gutta-percha and RealSeal solvent such as chloroform can be placed over the orifice. With a small hand K file, usually a #10 or #15, the file can be introduced into the canal to help disperse the solvent and dissolve the obturation material passively. All of the gutta-percha or RealSeal is removed from the canal before an attempt is made to bypass the obstruction to regain patency. Making sure that all obturation material is removed allows the clinician to only have one obstacle (the blockage or ledge) to the apical terminus and allow a more focused control over the attempted bypass. Obturation material left in the canal while the trying to regain patency is likely to cause debris to be further propelled apically. It may be necessary to apply chloroform and then wick the slurry up with paper points until the entire canal is visibly cleared of gutta-percha. Then and only then should negotiation be attempted. Once the clinician has removed all of the obturation material that is possible with the above means and an obstructed canal is discovered or confirmed, the clinician is ready to regain patency. Canal anatomy is three dimensional in nature with multiplanar curvature, i.e. buccal to lingual curvature and mesial to distal. The clinical application to this fact is that simply pushing on a hand file in the same orientation repeatedly or with force can oftentimes accentuate an existing ledge and/or make the given blockage worse. RNT files are never used as pathfinders or as ice breakers in the sense that the RNT is used to power through the blockage. Use of the file in this manner is the precursor of a rapid separation especially if the tip should become locked and the major diameter of the file still has the torque to rotate in the canal. In tangible practice, these hand K files are always pre curved with an instrument like an EndoBender pliers (SybronEndo, Orange, CA, U.S.A.). For tactile control, a 21 mm #10 hand file can be snipped with a pair of scissors approximately 2-3 mm above the tip and create a smaller and more rigid instrument that is helpful in pushing through a blockage of debris. Similarly a #6 or 8 can also be snipped as well to give the

Fig. 4_ The EndoBender pliers (SybronEndo, Orange, CA, U.S.A.). Fig. 5_ Pre curving of a hand file with the EndoBender pliers.

_Steps to regain apical patency:

1) After straight-line access is achieved, removal of the coronal obturation material must be carried out slowly and methodically. Ideally gutta-percha (other than on carrier based products) should be removed with heat or a mechanical means and not chemicals, especially if the coronal orifice is opened to approximately a .08 taper or greater. Visualization and control are enhanced if the chamber is left dry during coronal removal relative to the alternatives. A heat source such as the SystemB or the Elements Obturation unit (SybronEndo, Orange, CA, U.S.A.) is ideal for this purpose. The EOU has the added advantage of being able to extrude filling material such as gutta percha or RealSeal bonded obturation material (SybronEndo, Orange, CA, U.S.A.) as well provide the heat source for GP removal. Alternatively, an orifice opener can be used with the caveat that removal is passive, gentle and done with control of the insertion forces and speed. Rotations at higher RPMs such as 1.000-1.500 RPM are most efficient. Great care must be taken to avoid perforation through the thinnest wall present, which is usually the furcal side of a molar root. 2) After there is no additional benefit to removing obturation material mechanically, passively and progressively, a cycle of solvent placement and exploration with the hand files is undertaken so as to move the hand file apically to the estimated working length. After the bulk of the gutta-percha is removed from the coronal third, with the above

Fig. 4

Fig. 5

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needed diameter and stiffness of the hand file. Such modified hand files are invaluable in creating an ideal explorer and pathfinder to allow one the greatest balance between safety and efficiency in passing an obstruction. Safety, in that the ledge will not be accentuated, efficiency in that the blockage can be removed as easily as possible (Figs. 46). 3) When encountered, the tactile feel of the obstruction can tell the clinician how best to proceed and can also allow from the very start for the clinician to know what the expected chances are for achieving patency. If the hand file reaches a very definite stop and no advance is possible, the chance for a breakthrough is diminished. Many times, this type of blockade means that either a ledge has been created previously or the canal, if it has not been transported, is completely occluded. Alternatively if the obstruction encountered is somewhat soft there is a far better chance of achieving patency. In either event, sodium hypochlorite should be reapplied copiously after every file insertion. Refreshing the surface area of the obstruction with a tissue dissolving substance along with the mechanical forces applied can improve the chances for progression. 4) Once the blockage is encountered, the curved hand file is inserted multiple ways within the canal so as to attempt to find or create path through the blockage. Time, patience and ingenuity are required. For example if a #15 hand file will not traverse the blockage, a #10 should be attempted and then a #8 followed by a #6. If the 21 mm variety of each of these files will not traverse the blockage, the snipping described above can be used. It is also possible to use carbon steel hand files such as the Pathfinder CS series, (SybronEndo, Orange, CA, U.S.A.). Carbon steel is harder than stainless steel and this inflexibility is helpful to provide more focused pressure against the blockage. 5) In addition to the above, it may also be possible to use the M4 reciprocating handpiece (SybronEndo, Orange, CA, U.S.A.) with a small hand file (ideally not modified by snipping). The M4 attachment fits onto an E-type handpiece attachment. This is not a method that should be employed with a separated file or metal fragment or if the blockage is complete, irrespective of its source. If there is a small amount of give in the blockage, the hand file can be placed against the blockage (at a reduced setting between 200300 RPM). If the blockage can be pierced and the file attached to the M4 will advance, it can be taken apically very slowly. Caution is advised with this concept as even though reciprocation is very safe, this method carries with it an increased risk of fracture of the file tip, especially if the clinician keeps pushing when the file tip will not advance passively. If advancement is possible, the tactile control of the file should be short 12 mm amplitude apical and

Fig. 6

Fig. 6_ Modified hand K files. The file is snipped at its end in order to give greater tactile control and stiffness. Fig. 7_ File sponge, note the number of hand files at the left of the sponge ready to be used in gaining patency.

Fig. 7

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Fig. 8a

Fig. 8b

Fig. 8c

coronal movement. Ideally, each apical movement will allow the file to progress further apically. If advancement is not possible, the other methods are employed and this approached is stopped immediately. In a badly ledged canal, numerous packs of hand K files may be needed. It is not uncommon in a difficult blockage to require 610 packs of files. It must be remembered that new files are sharper and the most efficient. Saving money by using dull files is a false economy as the costs associated with not achieving patency far greater than the alternatives. (Fig. 7) In clinical practice, not all obstructions and ledges can obviously be removed or bypassed. It is a valid question when one can and should stop attempting to gain patency. If all the aforementioned strategies have been employed repeatedly and full and unobstructed access has been created down to the level of the blockage, the clinician must weigh the chances for a larger iatrogenic event relative to the benefits of achieving patency. Suffice it to say that when the risks of further attempts will risk the integrity of the tooth for whatever reason, consideration should be given to completing treatment to the level of the blockage. If healing does not occur, apical surgery is one option going forward. The above techniques and skills have cross application with removal and bypassing of several other obstructions, such as separated files and metallic fragments of all types. For example if a separated RNT fragment is present, it is possible for a tapered RNT fragment to still only occupy a limited volume of the canal lumen and as such create an opportunity for smaller hand K files to bypass the fragment. It is certainly possible that a #6 or 8 might be able to traverse the canal alongside the fragment. If the #6 or 8 will easily and passively bypass the fragment, it is not immediately removed from the canal but rather moved vertically with 12 mm amplitude until it moves freely in the canal. Then the next larger hand file is used to bypass the RNT fragment and so on until the canal is shaped ideally. A RNT file is never inserted into a canal that already has a RNT fragment as a sec-

ond separation is imminent. Once a RNT separation has occurred, the canal must be treated by hand for its duration. As much as possible care should be taken so as to assure that enlargement does not dislodge the RNT fragment into the canal lumen and create blockage. If the fragment is loose in the canal and removal is indicated, a Hedstrom file can be used to obtain a purchase on the fragment and attempt coronal movement and removal of the file. While not entirely predictable, this can be effective in some cases (Figs. 8ac). In summary, achieving and maintaining apical patency in endodontic retreatment is a higher order skill that is central to the clinicians access to regions of the canal that have not been accessed previously. Materials and methods have been described which can help the clinician achieve this goal. Amongst other strategies, pre curved hand K files modified by snipping their tips inserted passively can often allow clinicians to bypass obstructions that otherwise might not be addressed._ Dr Mounce has no commercial interest in any of the products mentioned in this article.

Fig. 8ac_ Removal of a separated instrument through bypassing the canal first with hand K files and its ultimate retrieval with a Hedstrom file.

_author info

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Dr Mounce lectures globally and is widely published. He is in private practice in Endodontics in Vancouver, WA, U.S.A. Amongst other appoint-ents, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau. Korror, Palau (Micronesia). Richard Mounce, DDS Vancouver, WA, U.S.A. Email: Lineker@aol.com and RichardMounce@MounceEndo.com www.MounceEndo.com

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