International Journal of Applied Dental Sciences 2020; 6(4): 34-38

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2020; 6(4): 34-38
Alternative treatments to endodontic failure at
© 2020 IJADS
www.oraljournal.com
different stages
Received: 15-06-2020
Accepted: 18-09-2020
Jennifer Alondra Bocanegra Cedillo, Maria Argelia Akemi Nakagoshi
Jennifer Alondra Bocanegra Cedillo Cepeda, Sara Saenz Rangel, Jose Elizondo Elizondo, Maria Teresa Perez
Posgrado de Endodoncia. Master in
Science Student (endodontics), Quintero, Enrique Nieto Ramirez, Fanny Lopez Martinez and Juan
Universidad Autonoma de Nuevo
Leon, Facultad de Odontologia
Manuel Solis Soto
Monterrey, Nuevo Leon, Mexico

Maria Argelia Akemi Nakagoshi

DOI: https://doi.org/10.22271/oral.2020.v6.i4a.1045
Cepeda
Departamento de Histologia. Doctor Abstract
en investigacion, Universidad Introduction: The main objectives of root canal treatment are to provide comfort, function, aesthetics
Autonoma de Nuevo Leon, Facultad
de Odontologia Monterrey, Nuevo and long-term prevention of re-infection. Endodontic treatment has success rates of between 86% and
Leon, Mexico 98%. Treatment options after initial unsuccessful treatment include non-surgical retreatment, endodontic
surgery, dental autotransplantation, intentional reimplantation and extraction.
Sara Saenz Rangel
Objective: To review the literature on possible treatments to be performed following conventional
Departamento of Diagnostico. Doctor
en Educacion, Universidad Autonoma endodontic treatment.
de Nuevo Leon, Facultad de Methodology: Information was searched in PubMed, SCOPUS and Google Scholar. Key words were
Odontologia Monterrey, Nuevo Leon, used to search for information such as: "non-surgical retreatment", "apical surgery", "apicectomy",
Mexico "autotransplantation", "intentional reimplantation". Results: Endodontic retreatment is a non-surgical
Jose Elizondo Elizondo procedure that involves the removal of previous filling materials, followed by cleaning, shaping and
Posgrado de Odontologia Avanzada. filling the canals. Apicoectomy involves surgical treatment of a tooth with a periapical lesion that cannot
Doctor en investigación, Universidad be resolved by routine endodontic treatment. Autotransplantation is the repositioning of an autogenous
Autonoma de Nuevo Leon, Facultad
tooth at another site to replace teeth. Intentional replantation involves purposefully removing a
de Odontologia Monterrey, Nuevo
Leon, Mexico compromised tooth and replanting the tooth in its socket.
Conclusion: The first choice when dental treatment fails is non-surgical retreatment, which will allow
Maria Teresa Perez Quintero
the previously treated canal to be cleaned and better results to be obtained. Intentional reimplantation,
Departamento of Diagnostico. Doctor
en Educacion, Universidad Autonoma although not the most appropriate treatment, has been shown to be successful and is considered one of
de Nuevo Leon, Facultad de the last treatment options.
Odontologia Monterrey, Nuevo Leon,
Mexico Keywords: Non-surgical retreatment, apical surgery, apicoectomy, self-transplantation, intentional re-
Enrique Nieto Ramirez implantation.
Posgrado de Odontopediatria.
Especialidad en odontopediatria,
Universidad Autonoma de Nuevo 1. Introduction
Leon, Facultad de Odontologia For patients who have had pulp and periapical diseases caused by caries or trauma, the main
Monterrey, Nuevo Leon, Mexico goals of root canal treatment are to provide comfort, function, aesthetics, and long-term
Fanny Lopez Martinez prevention of re-infection. These goals are achieved through thorough cleaning and shaping,
Posgrado de Endodoncia. Doctor en filling the canals and restoring the affected teeth [1].
investigacion, Universidad Autonoma
de Nuevo Leon, Facultad de Endodontic treatment is a reasonably predictable procedure with success rates between 86%
Odontologia Monterrey, Nuevo Leon, and 98%. The success or failure of this treatment is evaluated by the clinical signs and
Mexico
symptoms, as well as by the radiological findings of the treated tooth [2].
Juan Manuel Solis Soto Factors that may be attributed to endodontic failure include persistent bacteria, inadequate
Departamento de Fisiologia. Doctor
en Ciencias, Universidad Autonoma
filling of the canal, over-extension of the filling material, incorrect coronal seal, untreated
de Nuevo Leon, Facultad de canals, iatrogenic procedural errors such as poor access cavity design, and complications of
Odontologia Monterrey, Nuevo Leon, instrumentation such as perforations or separate instruments [2].
Mexico
The main reason for endodontic failure is the presence of some species of bacteria within the
Corresponding Author: root canal system, such as Enterococcus faecalis. These bacteria are more resistant to
Juan Manuel Solis Soto
Departamento de Fisiologia. Doctor
disinfection agents, causing persistent intraradicular or extraradicular infection [3, 4]. Treatment
en Ciencias, Universidad Autonoma options after initial unsuccessful treatment include non-surgical retreatment, apicoectomy,
de Nuevo Leon, Facultad de dental autotransplantation, intentional re-implantation and extraction. From the perspective of
Odontologia Monterrey, Nuevo Leon,
Mexico health care economics, the alternative to retaining the natural tooth should result in lower total
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lifetime costs or provide greater lifetime function, absence of and reciprocal nickel-titanium (NiTi) and stainless steel
disease, comfort or acceptability to a patient [5]. systems to optimally achieve this goal [11].
It is important that initial root canal treatment be performed to Removal of the filling material can be achieved by different
high standards to reduce the risk of future failures. The first techniques, such as the use of manual endodontic files, nickel-
treatment option after root canal treatment failure is not tooth titanium reciprocating and rotary files, and Gates Glidden and
extraction and replacement with a fixed prosthesis or a single Peeso burs. Heated instruments, ultrasound and solvents can
tooth implant [6]. also be associated with this procedure [12].
Patients choose non-surgical root canal treatment to retain It has been investigated that manual instrumentation is
teeth and preserve the natural aesthetics of their smile and to associated with longer retreatment times than those treated
relieve pain [7]. with rotary/reciprocating systems. However, no procedural
The high survival rates of dental implants have created a errors were reported with the former. NiTi retreatment files
paradigm shift in treatment planning that has sometimes have no advantages over conventional techniques.
resulted in the unnecessary extraction of these teeth [1]. Reciprocating and rotary systems exhibit similar capabilities
There is no comprehensive review in the literature on the in removing root filling material [13].
different treatment alternatives to the failure of the initial When used in the initial penetration stage, solvents can
endodontic treatment, which are presented in an orderly improve the root canal penetration of the files, but can make
fashion according to the sequence in which they are cleaning difficult and, if used after instrumentation, can
performed and mention their success or failure rates. reduce residual filling material [14].
The aim of this review is to analyze the literature about the Recent studies reported a 95% success rate after conventional
treatments to be performed after a conventional endodontic root canal treatment in cases of irreversible pulpitis. Eighty-
treatment that was not successful, which are non-surgical re- five percent of necrotic teeth were successfully treated using
treatment, apicoectomy, autotransplant and intentional non-surgical endodontic treatment [15].
replantation. Endodontic treatments may not be able to solve the problem
because of the complex anatomy of the root canal system,
2. Materials and methods such as the reticular structures of the lateral and accessory
Articles on the subject published through the PubMed, canals, as well as the oval root canals, which make complete
SCOPUS and Google Scholar databases were analyzed, with cleaning and shaping difficult [16].
emphasis on the last 5 years. The quality of the articles was Untreated areas of the root canal allow bacterial growth, and
evaluated using PRISMA guidelines, i.e., identification, the remaining pulp tissue, necrotic tissue and microorganisms
review, choice and inclusion. The quality of the reviews was are considered the main cause of non-surgical retreatment
assessed using the measurement tool for evaluating systematic failure [17].
reviews (AMSTAR-2). It is concluded that after a conventional root canal treatment,
The search was performed using Boolean logical operators the total amount of bacteria may not have been eliminated, so
AND, OR and NOT. that in the future that treatment may fail, in which case the
It was performed with the words "non-surgical re-treatment", primary option for solving that problem is non-surgical
"apical surgery", "apicectomy", "autotransplantation", retreatment, which will allow the previously treated canal to
"intentional replantation". be cleaned more thoroughly and to obtain better results.
The keywords were used individually, as well as each of them
related to each other. 3.2 Apicoectomy
Initially, the titles of all the articles were selected, the abstract Surgical and non-surgical endodontic treatments have a high
of each one was evaluated and the articles were chosen for a success rate in the treatment and prevention of periodontitis
complete reading review. apicalis. However, periapical endodontic lesions remain in
some cases and additional treatment should be considered
3. Results & Discussion when periodontitis apical persists [18].
3.1 Non-surgical re-treatment Apical surgery or apicoectomy has been considered one of the
In root canal therapy, the infected pulp is removed from a last attempts to save teeth that cannot be treated with a
tooth, the root cavity is disinfected and the root canal is filled conventional endodontic approach [19].
with a sealing material. However, if the microorganisms that Apicoectomy involves surgical treatment of a tooth with a
caused the infection are not completely eliminated, after a periapical lesion that cannot be resolved by routine
while they can cause a disease at the apex of the root, called endodontic treatment [20].
periapical lesion [8]. The goal of apical surgery is to obtain tissue regeneration,
The treatment for this requires a second operation, which can creating a barrier between the root canal system and the
be performed in the same way as the first treatment, from the periradicular tissues. This goal should be achieved by
crown to the root canal, to remove the existing filling and resection of the root end, preparation of the root end cavity,
clean and disinfect it as best as possible before resealing [3]. and a bacterial tight closure of the root canal system at the end
Retreatment of the root canal is a non-surgical procedure that of the cut root with a retrograde filling, complete debridement
involves the removal of previous filling materials from the of the periapical pathology by curettage to eliminate any
tooth's root canal, followed by cleaning, shaping and filling source of infection [19, 21].
the canals [9]. Factors associated with a better chance of success with
The removal of filling materials from the root canal system is apicoectomy include patients under 45 years of age, upper
a primary objective in root canal retreatment procedures as anterior or premolar teeth, cases without preoperative pain,
this would allow instruments and irrigation solutions to reach lesions without periodontal compromise, absence of
a larger portion of the root canal system, which would perforating lesions, and teeth with only one periapical
consequently promote better cleaning and disinfection [10]. surgery. In the case of apicoectomy failure, the tooth may
Several studies have examined the ability of manual, rotary need to be extracted [22].
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A 2016 study compared the clinical effectiveness of the survival rates of up to 98% for self-transplanted teeth [33, 34, 35].
surgical (apicoectomy) or nonsurgical (root canal retreatment) Reported complications of autotransplantation include pulp
approach for healing apical lesions and found no evidence of necrosis, root resorption, and hypermobility [31].
superiority of either approach at one year, four years, and 10 The clinical application of a computer-aided rapid prototype
years of follow-up [9, 23]. model (CARP) for autotransplantation was first introduced in
The success rate of apical surgery has been reported to range 2001 using 3D computerized tomographic (CT) image
from 37% to 91%. The wide range and inconsistency of acquisition, followed by the manufacture of a 3D impression
results can be attributed to variation in treatment planning, copy model [36].
surgical technique, methodology, and follow-up period [24]. This technique allowed surgeons to simulate the contour of
The generally recommended surgical level of root-end the recipient bone using full-size CARP models of the donor
resection is 3 mm; however, there are articles that have teeth and recipient alveolar bones prior to the operation. The
recommended a 3.6 mm resection, and in other studies, a use of CARP models for autotransplantation has the
higher percentage of lateral canals have been removed with a advantage of minimizing extraalveolar time and trauma to the
resection level of 3.5 mm compared to 3.0 mm (92.59% vs donor tooth, which increases the success rate of the surgery
[37]
74.07%). These findings suggest a modified resection level of .
3.5 mm [25]. The CARP models improve the survival rates of teeth with
Modern microsurgical techniques have increased the success mature roots to 88.1% and 68.2% at 3 and 12 years,
rate of apicoectomy relative to traditional approaches. In respectively. In addition, self-transplants improve the
previous studies, assisted apical resection has been performed maintenance of naturally attached gums, leading to good
using a computer-assisted design three-dimensional printed aesthetic results [37].
template. Guided apicoectomy allowed precise root resection, Recently, high success rates have been reported for cases with
suggesting that this technique can be advantageous in mature teeth, and self-transplantation is becoming a
complex anatomical situations [26]. predictable option in contemporary restorative dentistry [38].
Success rates have improved considerably thanks to the The main factor for successful autogenous tooth
minimally invasive technique of retrograde filling under a transplantation is the vitality of the PDL attached to the
dental microscope. Because orthograde retreatment has been transplanted tooth [31]. Although simple in concept,
shown to significantly improve the results of apical surgery, it autotransplantation remains a controversial treatment option;
has been recommended before the operation to promote high however, it has been suggested as the treatment of choice in
success rates [27]. selected cases. A successfully transplanted tooth erupts with
In conclusion, we know that apical surgery is the first option growth and can also be moved orthodontically. If a transplant
to be performed after non-surgical retreatment was not as fails at a later stage, a well-maintained ridge can be prepared
successful as expected. Innovations have been made in the for an implant when more appropriate. For a successful
area of apical surgery, such as the implementation of the outcome, preservation of the periodontal ligament of the
microscope or the use of surgical guides that allow accuracy transplanted tooth is the key to successful self-transplantation
in the procedure and therefore a less invasive and through prevention of ankylosis [39].
conservative treatment. As a conclusion we have that autotransplantation is a long-
established surgical technique that has a high success and
3.3 Autotransplant survival rate, making it a good alternative treatment for
Autogenous tooth transplantation refers to the repositioning of endodontic failure when other procedures have already been
an autogenous tooth at another tooth extraction site or at a tried and were not successful.
surgically formed recipient site. This procedure is used to
replace teeth that are, for example, congenitally missing or 3.4 Intentional replantation
involve ectopic eruption, severe decay, periodontal disease, Intentional replantation is a procedure that involves the
trauma, or endodontic failure when a suitable donor is extraction of a tooth and its almost immediate replacement,
available [28]. with the aim of apically filling the canals, while the tooth is
By using the patient's own tooth, self-transplantation presents out of the cavity [40].
a number of advantages compared to other treatment options Although intentional replantation is considered a treatment
(i.e., dental implants or fixed partial dentures), such as greater option of last resort, it was reported that the treatment had a
resistance to occlusal loading, maintenance of the periodontal 90% success rate in the first 6 months [41].
ligament (PDL) and surrounding bone, and the potential for Between 6 and 12 months, the survival rate decreased from
improved aesthetics [29]. 85% to 80%, and after 48 months, the survival rate of
This treatment is indicated in situations where congenital replanted teeth stabilized [42].
teeth are missing, movement of impacted or severely ectopic A meta-analysis of 6 studies also showed a high success rate
teeth, premature loss of permanent teeth (severe caries, of 89.1% of intentionally replanted teeth [43]. The success of
trauma, iatrogenic damage, developmental abnormalities), this procedure is influenced by several factors, including the
periodontal disease, endodontic failure, growing patients extent of periodontal disease and the presence of root fracture.
correcting arch discrepancies, and when a suitable donor is However, it is a fairly simple procedure that is less expensive
available [30, 31]. than dental implants and has minimal morbidity for the
This is a viable treatment option for replacing missing teeth, patient [44].
but as with any surgery, complications can arise including Although the survival rates of replanted teeth do not compete
pulp necrosis, inflammatory and replacement resorption, poor with those of classic periodontal treatment and endodontic
periodontal healing and ankylosis. These are complications treatment, survival is remarkably high and is a conservative
that can be prevented or lessened by proper planning and option that may be viable for some patients [45].
following the correct protocols [32]. Intentional replantation is the atraumatic extraction of a tooth,
Success rates for this procedure are as high as 96% and a resection and extraoral filling of the root, followed by
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International Journal of Applied Dental Sciences http://www.oraljournal.com

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