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32 I I case report _ failed root-canal treatment (basedontheradiographicappearance)tobesensitive to percussion and tooth #14 would be within normal limits. In essence, before a determination of a failed root canal on tooth #15 could be made, symptoms arising from tooth #14 would have to be ruled out. Testing tooth #14 with regard to percussion, palpa- tion,mobilityandprobing,aswellasperformingacold test could alert the clinician to any symptoms arising from tooth #14. In essence, the clinician must reproduce the pa- tient’schiefcomplainttoassurehimthattheclinician has the correct tooth before making a diagnosis. Knowing whether the patient has pain in reaction to hot or cold would be a vital piece of information. Unfortunately,thisinformationhasnotbeengivento us. If the patient’s chief complaint is a sharp, linger- ingpaintohotorcold,itismostlikelythatavitaltooth is the offender and not pain from a failed root canal. Knowingalsowhetherthepainwaslocalisedtotooth #15 would be valuable. Localised pain to tooth #15 thatisreproducedbyapositivepercussiontestwould go a long way towards confirming the diagnosis. _Clinical management While limited to one radiographic view, given what appears to be coronal leakage as the primary source of failure, re-treatment would be the most practical, efficient and economical solution. The toothappearstohaveadequatebonesupport.Witha lack of coronal seal, assuming that a proper pre- operative radiographic and clinical examination did notsuggestanotherdiagnosisortreatmentmodality, re-treatment is favoured. Clinically, re-treatment would require that unnecessary dentine removal be avoided in order to minimise the risk of strip per- foration. Aggressively removing the existing gutta- percha could easily cause strip perforation and/or removeexcessivedentine,andasaresultleadtolong- term vertical root fracture. Using a heat source such as the Elements Obturation Unit (SybronEndo) as a first line of gutta-percha removal would minimise the risk of unnecessary dentine removal and provide a passive means to eliminate the obturation before solvents and/or mechanical means are used. While not directly related to re-treatment, this case is a strong argument for the use of bonded obturation. Relative to gutta-percha, in vitro and in vivo bonded obturation has been shown to either decrease the movement of bacteria in a coronal to apical direction and/orreduceapicalinflammationandinfectionthat resultsfromalossofcoronalseal.Inthisclinicalcase, it could be argued that if the obturation had been bonded that it could have provided some additional defence against the evident loss of coronal seal. RealSeal(SybronEndo)masterconesand/orRealSeal1 Bonded Obturator (SybronEndo) would both have beenexcellentchoicestoprovidethisbondedobtura- tion clinically. Finally, apical surgery is contra-indicated in this case for several reasons: 1. Thecrown-to-rootratioisunfavourable.Removing several millimetres of the apex of each root would make a short tooth (#15) even shorter and risk long-term vertical fracture. 2. The endodontic literature states that endodontic surgery is more successful in the short term than the long term. One of the reasons for this is due to coronal leakage, as evident here. Removing the apicesandplacinganapicalfillingmighthealinthe short term, but the long-term assault by coronal leakage would remain unabated, reducing the probabilities of clinical success. 3. The tooth should be re-treated first (if it is to be retained) and if necessary, apical surgery would be one option for the long term, amongst others. A clinically relevant look at a failed root canal with regard to treatment planning and several clini- cal considerations has been presented. Emphasis has been placed on a comprehensive examination that combines both the subjective and objective findings in order to determine the correct clinical diagnosis and the most predictable treatment alternatives. I welcome your feedback._ Figs. 4a & b_Re-treatment of a failed root-canal treatment using the concepts and strategies discussed in the article. roots1_2010 DrRichardE.Mounce 12503S.E.MillPlainBlvd., Suite215 Vancouver,WA98684 USA Tel.:+13608919111 E-mail:RichardMounce@ MounceEndo.com www.mounceendo.com www.deadstuck.com roots_contact Fig. 4a Fig. 4b