1/27/2018 CBCT Imaging’s Insight Into Endodontic Retreatment Success | Dentistry Today

CBCT Imaging’s Insight Into Endodontic Retreatment Success

Category: Endodontics Created: Thursday, 01 September 2016 13:06 Written by Brian McCormack, DDS Print

INTRODUCTION
Success Versus Survival
Endodontic therapy under modern treatment protocols has been shown to have long-term clinical success rates in
the range of 81% to 97%.1,2 The “success” rates can go to either extreme of that range depending on whether we
are evaluating healed versus nonhealed under the strict guidelines that the endodontic literature holds for
success. Or, is the tooth being held to the looser evaluation criteria set forth when discussing “survival”? Even
with the high clinical success rate of initial endodontic treatment, it’s obvious to see this leaves clinicians with a
19% incidence (on the very high side) of encountering post-treatment disease in our patient population.

Post-Treatment Disease
No matter what criteria we use, it becomes obvious when we evaluate the prognostic indicators in the literature
that some of these “failures” could have been avoided with proper restorative treatment. One large study in
particular found a 97% survival rate for initial endodontic therapy.2 When some of the prognostic indicators are
evaluated, such as a good coronal restoration, we can see that a large number of these failures can be attributed
to an inadequate coronal seal. Of the 3% of failures in this particular study, 85% of the teeth presenting with
post-treatment disease had no full coronal coverage. Other common causes of post-treatment disease can also be
iatrogenic in origin, while others are related to more complicated microbiological and host response factors
including persistent or reintroduced intraradicular micro-organisms, extraradicular infection, foreign body
reaction, and true cysts.3 There are a multitude of reasons for any of the above clinical situations to arise.

Advanced Imaging Aids Treatment Planning

As clinicians, the questions that are left for us to answer through radiographic imaging and clinical testing are
(1) what is the etiology, and (2) what is the prognosis of any suggested treatment? There have been countless
articles in the literature that have shown no correlation between clinical and radiographic testing and histological
findings.4 Some authors, though, have suggested the potential to correlate 3-D imaging with histological
findings.5 For many years, 2-D radiographs have aided in diagnosis of dental disease, with the first dental
radiograph claiming to have been taken in 1896. However, as with all technology, there are limitations. When
reviewing cases for nonsurgical retreatment, surgical retreatment (apicoectomy), or extraction, I prefer to piece
the puzzle together using all the potential diagnostic information available. I routinely take a narrow-field CBCT
image of any teeth exhibiting post-treatment disease with an uncertain etiology.

This article will present 2 cases that were retreated with the aid of CBCT imaging (CS 9000 [Carestream
Dental]), along with appropriate CBCT followup scans. In my office, all cases are treated using enhanced
magnification and illumination with a surgical operating microscope (Global Surgical).

CASE REPORTS
Case 1
A 31-year-old male presented to the office on referral from his general dentist for evaluation of a periapical
radiolucency related to the maxillary left first molar, tooth No. 14. Upon initial evaluation, appropriate
radiographs were taken (Figure 1). Clinical testing was preformed and the recommendation was made to take a
narrow-field CBCT image of tooth No. 14 to gain better insight into the etiology of the presenting post-treatment
disease (Figures 2 and 3). The axial view (Figure 2) reveals an untreated mesial buccal-2 (MB2) canal on No. 14
with the sagittal view (Figure 3) revealing apical periodontitis related to the MB, distal buccal (DB), and palatal
(P) roots of No. 14 as well. The sagittal view also shows a short fill related to the MB, DB, and P roots, meaning
the entire canal space may not have been properly shaped and cleaned. With the CBCT imaging, we now have a
better understanding of why No. 14 is presenting with post-treatment disease. This information is extremely
important whenever we plan to discuss etiology and prognosis with our patients. Based upon current nonsurgical
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retreatment literature, we can expect a success rate for our proposed treatment plan of approximately 86.5%,6
assuming that the patient follows up and has a final restoration placed in a timely manner.

CASE 1

Figure 1. Conventional periapical (PA) Figure 2. CBCT (axial view), tooth No. 14,
radiograph. showing missed mesial buccal-2 (MB2) canal.

Figure 3. CBCT (sagittal view), teeth Nos. 4

and 5, showing extent of PA lesion.

Figures 4 and 5. Thermafil plastic carriers (Denstply Sirona) removed.

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Figure 6. Immediate post-op, tooth No. 14. Figure 7. CBCT (sagittal view), tooth No. 14
at 9 months postoperatively, showing almost
complete resolution of the apical lesion with
intact lamina dura.

Figure 8. CBCT (axial view), tooth No. 14 at Figure 9. Conventional follow-up PA

9 months postoperatively. radiograph.

At the patient’s next appointment, the nonsurgical retreatment of tooth No. 14 was begun. After proper
anesthesia and rubber dam isolation, access was gained using a surgical operating microscope (Global Surgical).
Conservative access was gained through the occlusal of tooth No. 14. Upon access, it was noted that the MB,
DB, and P canals were obturated with Thermafil plastic carriers (Dentsply Sirona). The untreated MB2 canal
was located with the aid of the operating microscope along with an ultrasonic unit (Satelec) and treated. The
Thermafil carriers were removed from the other canals with the aid of irrigants, Hedstrom files, and ultrasonic
instruments (Figures 4 and 5). All 4 canals were treated with a calcium hydroxide paste for 10 days. At the
patient’s next visit, No. 14 remained asymptomatic. After proper irrigation and additional cleaning and shaping,
the tooth was obturated and a temporary Cavit (3M) seal was placed (Figure 6). It is important to remind our
patients that endodontic therapy is not complete until they have had a permanent restoration (ensuring coronal
seal) placed by their referring dentist. Generally speaking, I do not routinely take a CBCT followup until after
the patient’s one-year recall. For this particular case, I was eager to see the patient for a 6-month recall to
observe the extent of healing that can be achieved after a shorter recall period. With the use of a narrowfield
CBCT (CS 9000) unit, the effective dose for the patient when imaging a maxillary posterior tooth is not
significantly different than taking a conventional periapical (PA) radiograph for their follow-up exam. In my
opinion, this, coupled with that fact that the CBCT imaging can give us better insight into the patient’s healing,
warrants CBCT imaging for follow-up when the patient initially presented with a large PA radiolucency. The
patient was unable to make a 6-month recall but reported after 9 months for the follow-up CBCT image (Figures
7 and 8). The sagittal view shows almost complete bony healing of the previous PA lesion related to tooth No.
14 in only 9 months; and the axial view now shows an obturated MB2 canal as well. We can only assume to
expect complete bony healing in the following months based on the current progress of the case. A well-
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fabricated final restoration by the patient’s general dentist (Figure 9) aids in the pronounced healing that we see.
The patient will be followed for regular recall examination at my office.

Case 2
A 50-year-old male presented to the office complaining of pain and swelling in the upper left posterior quadrant.
His general dentist had referred him for evaluation of his maxillary left first and second molars, teeth Nos. 14
and 15 (Figure 10). After clinical evaluation and testing, it was noted that there was an intraoral P swelling
between Nos. 14 and 15. Testing revealed a necrotic pulp diagnosis for No. 14, and No. 15 had been previously
treated endodontically. The periradicular diagnosis of acute apical abscess needed to be further investigated with
3D imaging (CS 9000) (Figures 11 and 12). After evaluation of the CBCT scan, it was clear to see that the acute
apical abscess was related to the P root of tooth No. 14 and that there was a less than ideal initial endodontic
treatment of No. 15.

After the proper periradicular diagnosis was made for both teeth in question, the decision was made to
nonsurgically retreat tooth No. 15—as the etiology was clear, thanks to the advanced imaging that was provided
by the CBCT unit—and to provide initial treatment for No. 14. At the same appointment, No. 15 was accessed;
the MB root presented with gutta-percha and was retreated. The untreated DB and P roots were located and
treated, and then all canals were medicated with calcium hydroxide paste (Figure 13). At this point, No. 14 was
accessed (Figure 14), and after careful review of the CBCT image, all 4 canals were located. After both teeth
were medicated with calcium hydroxide for 10 days, the patient returned for his obturation visit. Upon clinical
exam, the P swelling had resolved and the patient was symptom-free. Obturation was completed and
conventional post-op radiographs were taken (Figure 15); the MB2 being seen on the completion film for Nos.
14 and 15. The patient presented for a 22-month recall, and at this appointment, a follow-up CBCT image
centered on Nos. 14 and 15 was obtained (Figures 16 and 17). Again, the full bony healing of the lesion can be
seen. From the recall radiograph (Figure 18), one can also see that the patient received an excellent coronal seal
from his general dentist, vital to the long-term success of this case.

CASE 2

Figure 10. Pre-op PA radiograph, teeth Nos. Figure 11. CBCT (sagittal view), showing a
14 and 15. palatal lesion.

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Figure 12. CBCT (axial view), showing MB2, Figure 13. Working film, No. 15.
No. 14; untreated distalbuccal and palatal
roots, No. 15.

Figure 14. Working film, No. 14. Figure 15. Immediate post-op, teeth Nos. 14
and 15.

Figure 16. A 22-month CBCT (sagittal view) Figure 17. A 22-month CBCT (axial view)
with complete bony healing. showing obturation of the all 4 canals of No.
14.

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Figure 18. Conventional post-op PA taken at

22 months.

DISCUSSION
After proper diagnosis and testing, aided with CBCT imaging, treatment plans for these patients were decided
upon with input from each patient’s general dentist. In the author’s opinion, the treatment plans chosen were
minimally invasive and cost effective in both cases presented. The patients will be evaluated with annual recall
visits in the endodontic office to evaluate their long-term success. Both patients received informed consent prior
to treatment, explaining that, due to the size of the lesions, an additional procedure of apical surgery may be
needed. All patients should receive a proper informed consent prior to finalizing the suggested treatment plan.
Judging by the complete healing attained at 9 months for case 1, and at 22 months for case 2, any additional
procedures will likely not be needed to maintain the teeth in question.

CLOSING COMMENTS
Endodontic therapy for a diseased tooth, whether it be initial treatment or nonsurgical retreatment, is the best
option that we have to save the natural dentition. Some important components to success include consistently
taking a team approach when devising the patient’s treatment plan. Another important step is to always assure
that the patient is well informed and understands all aspects of the treatment plan. The patient should know in
advance of the treatment what steps will come next after the endodontic therapy is complete, such as the need
for a final coronal restoration. When this approach is taken it greatly increases our chance for longterm
endodontic success.

References

1. Friedman S, Abitbol S, Lawrence HP. Treatment outcome in endodontics: the Toronto Study. Phase 1:
initial treatment. J Endod. 2003;29:787793.
2. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an
epidemiological study. J Endod. 2004;30:846850.
3. Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39:249281.
4. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data
and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol. 1963;16:969977.
5. Aggarwal V, Logani A, Shah N. The evaluation of computed tomography scans and ultrasounds in the
differential diagnosis of periapical lesions. J Endod. 2008;34:13121315.
6. Gorni FG, Gagliani MM. The outcome of endodontic retreatment: a 2-yr follow-up. J Endod. 2004;30:14.

Dr. McCormack received his DDS from Stony Brook (NY) School of Dental Medicine. After completion of a
general practice residency at Northport Veterans Affairs Medical Center, he went on to complete his endodontic
training at Stony Brook School of Dental Medicine. He currently works full time in his private practice in Stony
Brook. He is involved in research related to dental trauma, nonsurgical endodontic retreatment, and 3-D

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imaging. He teaches as an attending endodontist at St. Charles Hospital, general practice residency, as well as in
the postdoctoral endodontic program at Stony Brook University. He lectures on current endodontic treatment
protocols. He can be reached at (631) 7511400 or via email at advancedendoli@gmail.com.

Disclosure: Dr. McCormack reports no disclosures.

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