ROEN0410

I 07 case report _ open-apex retreatment I roots4_2010 _Case report A 32-year-old male patient was referred to our practice for evaluation of the maxillary left central and lateral incisor. Medical history was non-contrib- utory. There was a history of trauma at the age of 10. Clinical evaluation revealed no signs of infection in the area of the maxillary left incisor. Probing was within normal limits, and cold and electric vitality tests of the lateral incisor were positive. The central incisor was protected by a full coverage crown. Radi- ographic examination (Fig. 1) revealed a previously treated open-apex central incisor associated with a large radiolucent area at the end of the root-canal systemofboththecentralandlateralincisors.Gutta- perchaconeswereextendedfarbeyondtheopenapex inside the lumen of the peri-radicular lesion. It was evident that the previous dentist attempted to obtu- rate the wide canal using the wrong technique and without previous apexification. The result was the extrusion of the obturation material far beyond the apex. The patient was informed of the possibility of performing surgery to resolve the problem following the orthograde attempt to retreat the wide-open canal. After crown removal, a prefabricated post was revealed. The post was easily removed by ultrasonic vibration, and access was achieved. Retrieval of the overextendedgutta-perchaconeswasachievedwith ISO size 45 Hedstrom Files (DENTSPLY Maillefer). No solvents or Gates-Glidden burs were used in order to avoidcuttingorsofteningoftheoverextendedmate- rial. With the help of a microscope (Global Surgical), an ISO size 45 file was inserted between the dentinal wall and the under-condensed material. Withdrawal of the Hedstrom File in one stroke retrieved the ma- jority of the gutta-percha cones from the wide canal, leaving only the overextended ones (Fig. 2a). For the retrievaloftheextrudedcones,thefilewasbentatthe tipusingtheEndo-Bender(SybronEndo;Fig.2b).Care wastakennottopushtheremainingconesoutofthe open apex, and the whole procedure was accom- plished under x16 magnification. Figures 2c and d show the radiographs of the successful procedure. Length was radiographically assessed using an ISO size 110 Hedstrom File (Fig. 3). After retrieval of the gutta-percha cones, the wide-open canal was cleaned using ultrasonic irrigation with 4.8% NaOCl (Irrisafe, Satelec). The canal was then dried and filled with Ca(OH)2 (UltraCal, Ultradent). One week later, access was regained and Ca(OH)2 was removed by ultrasonic irrigation with 4.8% NaOCl. A 17% solu- tionofEDTA(SmearClear,SybronEndo)wasleftinthe canalforoneminute,andthefinalrinsewasachieved using syringe irrigation with 4.8% NaOCl. The canal was dried and an absorbable gelatine haemostaticsponge(SPONGOSTAN,Ethicon)wascut to fit the width of the canal (Fig. 4a). The sponge was Figs. 2a–d_Radiographic assessment of gutta-percha cones retrieval (a, c & d), Hedstrom tip modification using Endo-Bender (b). Figs. 3a & b_Length determination radiograph. Fig. 3a Fig. 3b Fig. 2dFig. 2a Fig. 2b Fig. 2c