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Rhod-FM.qxd 10/11/05 10:47 PM Page i Advanced Endodontics Rhod-FM.qxd 10/11/05 10:47 PM Page ii John S Rhodes qualified from King’s College London in 1990, where he was awarded the Claudius Ash prize in conservation and the Jose Souyave endodontic prize. He continued his postgraduate education at Guy’s Hospital London, where he achieved a distinction in the Endodontic MSc. He is registered on the GDC specialist list in endodontics and now runs a busy endodontic referral practice in Poole, Dorset. John S Rhodes lectures widely in the UK and provides numerous postgraduate endodontic courses. He has published research papers in several refereed journals and is co-author of the endodontic textbook Endodontics: Problem-Solving in Clinical Practice. Rhod-FM.qxd 10/11/05 10:47 PM Page iii Advanced Endodontics Clinical Retreatment and Surgery John S Rhodes BDS(LOND) MSCMFGDP(UK) MRDRCS(ED) Specialist in endodontics The Endodontic Practice Poole, UK Rhod-FM.qxd 10/11/05 10:47 PM Page iv © 2006 Taylor & Francis, an imprint of the Taylor & Francis Group Taylor & Francis Group is the Academic Division of Informa plc First published in the United Kingdom in 2006 by Taylor & Francis, an imprint of the Taylor & Francis Group, 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Tel: (cid:1)44 (0)20 7017 6000 Fax: (cid:1)44 (0)20 7017 6699 E-mail: [email protected] Website: www.tandf.co.uk/medicine All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans- mitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, with- out the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs andPatents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P0LP. Although every effort has been made to ensure that all owners of copyright material have been acknowl- edged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omis- sions brought to our attention. Although every effort has been made to ensure that drug doses and other information are presented accu- rately in this publication, the ultimate responsibility rests with the prescribing physician. Neither the pub- lishers nor the authors can be held responsible for errors or for any consequences arising from the use of information contained herein. For detailed prescribing information or instructions on the use of any prod- uct or procedure discussed herein, please consult the prescribing information or instructional material issued by the manufacturer. ACIPrecord for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Data available on application ISBN 1-84184-436-5 ISBN 978-1-84184-436-7 Distributed in the United States and Canada by Thieme New York 333 Seventh Avenue New York, NY10001 Distributed in the rest of the world by Thomson Publishing Services Cheriton House North Way Andover Hampshire SP10 5BE, UK Tel: (cid:1)44 (0)1264 332424 E-mail: [email protected] Composition by Newgen Imaging Systems (P) Ltd, Chennai, India Printed and bound in Great Britain by CPI, Bath Rhod-FM.qxd 10/11/05 10:47 PM Page v CONTENTS Acknowledgements vi Preface vii Dedication viii 1 Rationale for endodontic retreatment 1 2 Decision making and treatment planning 23 3 Dismantling coronal restorations 45 4 Removal of pastes, gutta percha and hard cements 67 5 Removal of silver points and separated instruments 89 6 Perforation repair and renegotiating the root canal system following dismantling 113 7 Irrigation and medication 129 8 Introduction to surgical endodontics 147 9 Pain control, haemostasis and flap design 163 10 Surgical procedures 177 Index 201 Rhod-FM.qxd 10/11/05 10:47 PM Page vi ACKNOWLEDGEMENTS I wish to thank the following for kind permission to reproduce figures: Dr CPSproat: Figure 8:15 Dr J Aquilina: Figures 6:18 and 6:19 Mr DAOultram (Optident UK): Figures 7:09, 7:10 Mr S Bonsor, Mr G Pearson and Mr J Williams: Figures 7:11, 7:12, 7:13 I would like to acknowledge the contributions of the following people and companies who provided equipment for photography: Neil Conduit of QED, Douglas Pitman of DP Medical, David Mason of J&S Davis, Dentsply UK, Henry Schien UK, Optident and Denfotex; the staff at The Endodontic Practicewho agreed to be photographed for illustrative material; my parents, who helped edit the many drafts; and my wife Sarah and family, who supported me patiently while Icompiled this book. Rhod-FM.qxd 10/11/05 10:47 PM Page vii PREFACE This book is intended for the general practitioner with a special interest in endodontics, students undergoing specialist training and specialists alike. Endodontic retreatment poses many practical challenges. Advances in scientific knowledge and the integration of operating microscopes into endodontic practice have seen the possibilities for predictable endodontic treatment and retreatment expand dramatically. Advanced Endodontics: Clinical Retreatment and Surgery describes many of the techniques and methods available for practitioners who wish to undertake the planning and treatment of complex endodontic retreatment. The pages are copiously illustrated with high-quality photographs and case reports which are used to demonstrate practical non-surgical and surgical techniques. The text is referenced to provide a comprehensive but discreet source of scientific evidence, principles and further reading. Knowledge and theory are important in managing complex endodontic retreatment cases, but cannot be a substitute for essential practical and clinical experience. These skills need to be learned and practiced. Novices should always start with the simplest cases and never proceed beyond their confidence or skill level. Numerous practical courses are available for instruction on retreatment techniques and attendance on them can only be encouraged. John S Rhodes Rhod-FM.qxd 10/11/05 10:47 PM Page viii DEDICATION This book is dedicated to my endodontic mentors: Professor Tom Pitt Ford and Dr Chris Stock Rhod-01.qxd 10/11/05 9:37 PM Page 1 1 RATIONALE FOR ENDODONTIC RETREATMENT CONTENTS ● Introduction ● Biological Failings ● Cysts ● Cracked Teeth and Fractures ● Incorrect Diagnosis and Treatment ● Foreign Body Reactions ● Healing with Scar ● Neuropathic Problems ● Economic Constraints ● Conclusion ● References INTRODUCTION Endodontic failure comprises: ● biological failings (infection) Patients increasingly expect to retain their nat- ● cysts ural dentition and are often reluctant to have ● root fracture teeth extracted. Endodontic retreatment or ● incorrect diagnosis and primary treatment surgery may offer the patient a second chance ● foreign body reactions to save a root-treated tooth that would other- ● healing with scar wise be destined for extraction. ● neuropathic problems The success rate for root canal treatment ● economic constraints. carried out with currently accepted principles should be high. Indeed, published figures of between 70 and 95% have been quoted in BIOLOGICAL FAILINGS studies using samples derived from teaching hospitals.1However, there is marked variation The most common reason for failure of in the ability of operators to achieve successful root treatment is microbial infection. Micro- results. Some studies using data collected organisms and their byproducts have been from general practice have shown relatively isolated from the root canal system and the low success rates for root canal treatment. An external surface of the root in failed cases. They assessment into the standard of root canal may have persisted following a previous treatment in England and Wales for example, attempt at root canal treatment or gained access showed that 97% of molar root canal treat- through coronal microleakage. ment and 84% of canine and incisor root canal treatment had technical difficulties,2 whereas Intraradicular Infection in Scotland over 58% of root filled teeth showed signs of periapical radiolucency.3 Similar radiographic results have been found It is well documented in clinical studies that in studies from the USA4 and Holland.5 The teeth with technically deficient root fillings are prevalence of endodontically treated teeth more likely to be associated with periapical radi- showing periradicular radiolucency in olucencies. If a root filling is of poor quality, the Scandinavia has consistently been reported to root canal system may not have been effectively be between 25 and 35%.6Obviously, there is a disinfected or could have become reinfected contradiction between what is achievable and through coronal microleakage (Figures1.1, 1.2). what is actually achieved. So why does pri- The apical portion of the root canal sys- mary endodontic treatment fail? tem can contain bacteria and necrotic tissue