RETROGRADE INSTRUMENTATION OF

SURGICALLY RESECTED ROOTS USING

CONTROLLED MEMORY FILES: A HUMAN
CADAVER STUDY

PRESENTED BY:
DR.KARUNAKAR PRESENTED BY :
DR.UMRANA FAIZUDDIN M.RASAGNA
DR.ASHISH JAIN PG 3RD YEAR
 INTRODUTION

Apical surgery belongs to the field of endodontic surgery that also

includes incision and drainage, closure of perforations, and root or tooth
resections.
• Von Arx in his article has stated that  the objective of apical surgery is to
surgically maintain a tooth that has an endodontic lesion which cannot be
resolved by conventional endodontic (re-)treatment.

• The goal is achieved

Root-end resection

Root-end cavity
preparation

Bacteria-tight closure of
the root-canal system at
the cut root end with a
retrograde filling
•  In addition, the periapical pathological tissue should be completely
debrided by curettage in order to remove any extraradicular infection,
foreign body material, or cystic tissue. 

• Apical surgery has greatly benefited from continuing development and

introduction of new diagnostic tools, surgical instruments and materials,
making this method of tooth maintenance more predictable. 
 REQUIREMENTS FOR SUCCESSFUL RETROGRADE PREPARATION

• Prepare and clean a cavity up to a depth of 3 mm.

• Parallel preparation following the anatomical path of the canal.

• Prepare the complete cross section of the canal.

• Identify any isthmus.

• Avoid weakening of dentin bridges.

• The objective of retrograde preparation is to create a cavity for tight

obturation of a root end canal.
• A root-end amputation of less than 3mm does, most likely, not remove all
of the lateral canals and apical ramifications, therefore, posing a risk of
reinfection and eventual failure.
• In the past decades root-end cavities have traditionally been prepared by
means of small round or inverted cone burs in a micro-handpiece.

• Problems associated with it are :

 Access to the root-end is difficult, especially with limited working space.

 There is a high risk of a perforation of the lingual root-end or cavity

preparation, when it does not follow the original canal path.

 There is insufficient depth and retention of the root-end filling material.

 The root-end resection procedure exposes dentinal tubules.

 Necrotic isthmus tissue cannot be removed.

 In addition, the osteotomy may need to be enlarged greatly to allow

sufficient access for the handpiece and bur.
• Ultrasonic devices were developed to cut bone atraumatically using
ultrasonic vibrations.

• This provides an alternative to the mechanical and electrical instruments

used in conventional oral surgery.

Microsurgical root-end preparation with ultrasonic diamond coated tip.

• Key features of ultrasonic instruments include their ability to selectively
cut bone without damaging adjacent soft tissue,

• To provide a clear operative field, and to cut without generating heat.

• Saunders et al. , while experimentally using the ENAC system (smooth

stainless steel tips) on extracted teeth reported crack formation in the walls
of the cavity,

• This may increase the chance of apical leakage.

• However, Layton et al. suggested that the cracks might be a result of
the experiment design,

• As the previous study used demineralized and dehydrated the teeth,

which may have predisposed towards crack formation.

• Recently, Diamond coated ultrasonic surgical instruments have been

introduced in recent years in hopes of minimizing dentinal fractures
through their ability to abrade dentine more quickly,
• Thereby, minimizing the time that the instrument is in contact with
the root-end.

Traditional root-end preparation instruments

with burs and modern ultrasonic instrument.
• Khabbaz et al. found that cracks did not correlate directly with the
surface area of the root-end surfaces but rather with the type of retrotip
used.

• Preparation with smooth stainless steel ultrasonic tips produced fewer

intradentin cracks than diamond-coated stainless steel ultrasonic tips and
sonic diamond-coated tips.

• Also, a majority of the ultrasonic tips can penetrate to only a depth of 3

mm into the canal.

• Indications for longer retropreparations include grossly and

inadequately cleaned and obturated canals and missed canals.
• A recent randomized controlled trial evaluating the outcome of
endodontic microsurgery revealed 9 times greater chance of failure if the
quality of the root filling was inadequate .
 AIM OF THE STUDY

• The purpose of this study is to evaluate the amount of residual obturation

material of retro-instrumented surgically resected roots using controlled
memory files.

• To evaluate the incidence of adverse treatment outcomes including file

separation, root fracture/cracks, and root perforation.

• All cadaveric specimens were obtained through the Texas A&M College of
Dentistry Anatomical Gift Program.
 MATERIALS AND METHODS
• Thirty maxillary anterior teeth within the maxillae of embalmed cadaver
heads were used to maximize the replication of the clinical scenario.
 INCLUSION CRITERIA

• Intact teeth with minimal dental caries and/or restorations.

• Absence of periapical radiolucency.

• Root length of at least 13 mm.

• Entire root within the maxillae.

 NONSURGICAL ROOT CANAL TREATMENT

• Preoperative radiographs were taken on each sample, with working

length established at 1 mm from the radiographic apex.

• Teeth were instrumented with serial preparation to size 25/ 04.

• Canals were irrigated with 3% NaOCl and dried with paper points.

• After drying the canals, the teeth were obturated with gutta-percha
and a resin sealer.
• Post-op radiographs were taken to check for homogenous obturation.

• No restoration was placed in the access cavity.

• The samples were then stored in 100% humidity for 7 days to allow for
complete setting of the sealer.
 SURGICAL ROOT CANAL TREATMENT
• Later, a soft tissue flap was raised with a periosteal elevator to mimic
the clinical scenario.

• A standardized 4-mm osteotomy was made with #4 round bur.

• Next, a 3-mm root resection with as close to 0 degree bevel as possible

was made with a Lindemann bur.

Periapical radiograph after nonsurgical root canal

treatment, osteotomy, and 3-mm root resection.
• A microsurgical ultrasonic diamond tip was used to make 1- to 2-mm
starting point for the retropreparation.

• A new 25/06 and 30/06 VTaper 2H were bent at about 90 degree angle to
mimic the clinical and anatomic restrictions .

• The 2 files were used in an alternating fashion to advance down the canal
incrementally.
• The file was run at a speed of 600 rpm and 440 g-cm on a ProMark Endo
Motor.

• The file was first advanced to a depth of 10 mm, and if no adverse event
occurred, the file was advanced to a depth of 14 mm.

• Postoperative radiographs were taken to have a 2- dimensional evaluation

of the retropreparation.
 MICROCOMPUTED TOMOGRAPHIC ASSESSMENT OF
RESIDUAL OBTURATION VOLUME AND CRAK FORMATION.

• After retropreparation, each of the samples was scanned separately by

using the micro– computed tomography (micro-CT) system.

• The scan settings were as follows: voxel size of 20 mm, 70 kV, 114 mA.

• The experimental teeth were removed atraumatically from the

maxillae of the embalmed cadavers by sectioning through the
surrounding bone.
• Analysis of the percentage of remaining obturation material was
calculated by using Mimics Innovation Suite.

• Using threshold and region growing tools, 2 masks (residual obturation

and empty canal) were created at 5 mm and 10 mm from the apex, and
their corresponding volumes were calculated.

• The percentage of residual obturation was calculated at each level (5 mm

and 10 mm) by using this formula:

 Volume of residual obturation/Volume of residual obturation+ volume of

empty canal.
 RESULTS
ROOT LEVEL FROM
RESECTION
PERCENTAGE OF RESIDUAL 5MM 10MM
OBTURATION Median: 6.65% Median: 28.41%
IQR: 11.54% IQR: 28.47%
Range: 0.00%–30.57% Range: 0.00%–68.66%
VOLUME OF RESIDUAL 5MM 10MM
OBTURATION Median: 0.18 mm3 Median: 1.97 mm3
IQR: 0.36 mm3 IQR: 1.99 mm3
Range: 0.00–0.91 mm3 Range: 0.00–4.13 mm3

Median, Interquartile Range, and Overall Range of Percentage and Volume

(in mm3 ) of Residual Obturation at 5 and 10 Millimeters from the Apex .
 ADVERSE EVENTS TOTAL NUMBER OF
CASES EVALUATED

DURING INCIDENCE OF FILE 30

EXPERIMENTAL SEPARATION= 4*
PROTOCOL (13.3%)

DURIG MICRO-CT INCIDENE OF 24†

ANALYSIS CRACK /LEDGE
FORMATION=0(0%)

Number and Percentage of Adverse Events That Occurred during

Retropreparation Are Reported on Basis of When They Were Discovered.
 DISCUSSION
• The rationale for the introduction of a novel retrograde
instrumentation technique is biological.

• Some studies have shown that prognosis for successful root-canal

therapy was poorer when there were voids apically between the root
filling and the wall of the canal.

• It seems very likely that necrotic debris and microorganisms cannot be

completely eliminated from the prepared root canal.
• If the canal space is not sealed adequately then micro-organisms
themselves, or their toxins, can cause inflammation in the periapical tissues.

• Numerous studies have evaluated the efficacy of various techniques for

gutta-percha and obturation material removal during nonsurgical
retreatment procedures.

• But various studies stated that no instrumentation system or technique can

effectively remove all obturation material.
• The inability to completely remove all obturation material provides a
potential etiology of future failure as bacteria and biofilm may persist in
these untouched areas.

• In a 10 year follow –up study, of endodontic surgery revealed a healing

rate of 91.6% at 1 year and 91.4% healed rate at 5 years, respectively.

• However, this rate dropped by about 10% to 81.5% after 10 years.

• Von Arx et al stated that three tooth groups (i.e., maxillary incisors and
premolars and mandibular molars) accounted for nearly all long-term
failures.
• Studies stated that failure to thoroughly clean and debride the root canal
system are the most significant potential reasons for failure after endodontic
surgery.

• Therefore, the proposed technique has a biological rationale.

Nonsurgical
orthograde
Success rate retreatment
is completed
for surgery
before the
apical
surgery
It has reported to have a healing rate over 90% , which is considerably higher than
in most other studies in which retreatment may not have been performed.

• This novel technique provides an avenue to effectively re-treat the

canal system in a retrograde fashion, removing more of the etiologic
factors of failure than a 3- mm retropreparation.

• The results showed a median volume of residual obturation material of

0.18 mm3 and 1.97 mm3 at 5 mm and 10 mm, respectively.

• In addition, the median percentage of residual obturation was 6.65%

and 28.41% at 5 and 10 mm, respectively.
0% incidene
Micro-CT
of crack
analysis
or ledge
reported
formation
• In case of traditional nonsurgical retreatment, every attempt is made to
remove as much of the previous obturation material as possible.

• This is achieved by using a rotary endodontic file that is larger than the
existing preparation size.

• However, this concept may not be applicable when rotary files are used
for retropreparation.

• When the file is used in this technique, it will inevitably remove less
material as the file progresses coronally because of the reverse taper of
the file relative to the previously prepared canal.
• This explains study’s finding that more material remained at 10 mm from
the apex compared with 5 mm from the apex.

• The incidence of instrument separation was 13.33% (4/30), with all being
retrievable with hemostat.

incidence range of 1.3%–10.0%.

In orthogradefracture
endodontics
frequency
treatment,
of NiTi
a review
rotary of
instruments is
the literature quite
reveals
higher
that the
• In a five year retrospective clinical study, of the 28 separated rotary NiTi
instruments, 18 separated in retreatment cases, whereas 10 separated
during initial treatment .

• In this study, 2 separations occurred in lateral incisors and 2 in canines.

• In this study, all the separated instruments were easily retrievable and
therefore unlikely to affect the treatment outcome.

• Micro-CT analysis revealed 0% incidence of crack or ledge formation in

this study .
 Potentially
advantageous
outcome

Controlled memory
rotary files

Ultrasonic
instrumentation in
retroinstrumentation
• Various studies have reported Ultrasonic instruments have been shown to
have an increased incidence of crack propagation after retropreparation in
endodontic surgery.

• Transportation is more likely with ultrasonic tips because they are very
efficient in cutting dentin.

• Longer Ultrsonic tips could very quickly get off axis and may result in
procedural errors.
 CONCLUSION

• Retroinstrumentation of surgically resected roots using controlled

memory files is able to clean the canal effectively, with relatively low
adverse treatment outcomes.

• Although this novel technique is limited in application, it is a safe and

effective way to achieve a deep, clean retropreparation.
 Apical resection and ultrasonic preparation could form dentinal cracks. OCT and
DM showed different detection frequencies of cracks with very weak correlation.
DM showed superior sensitivity compared with OCT.
• Roots with the butterfly effect featured significantly more buccolingual cracks
following root resection and ultrasonic rootend preparation.

• This may explain the high prevalence of VRFs that run buccolingually and that
may be promoted by cutting a root-end cavity.

• Obturation of the root canal with ProRoot MTA potentially protects against
crack formation during apical surgery.
 Preexisting dentinal microcracks result in more number of microcrack
formation/propagation after root-end cavity preparation. Root-end cavity
preparation with both diamond-coated and zirconium nitride-coated ultrasonic
tips caused insignificant increase in dentinal microcracks.
 TAKE HOME MESSAGE

• A novel technique using controlled memory files for retrograde

instrumentation in endodontic microsurgery may be a viable
technique

• That can safely and effectively debride the canal system and can
achieve deep, clean retropreparations.

• However,further studies are needed to evaluate the effect of these

controlled memory files on sealing ability of various techniques.
 CRITIC ANALYSIS
MERITS
• First study to evaluate the feasibility
of using rotary files in endodontic
surgery.
• Provides an avenue to effectively re-
treat the canal system in a retrograde
fashion, removing more of the
etiologic factors of failure.
• 0% incidence of crack or ledge
formation seen with this technique.
DEMERITS
• No Control group.
• Technique is only feasible on anterior
teeth because of anatomic
restrictions.
• Additional studies are needed to
evaluate the obturation and sealing
ability of this novel retropreparation
design.
• Pre-Operative scan was not taken.