A Perfect Re-RCT

The use of CBCT at the diagnostic and treatment planning stage allows to detect presence of refractory endodontic pathology root by root in multicoated teeth. Teeth affected by pathology in one root only due to the presence of missed anatomy cannot be re-treated surgically and a selective orthograde re-rct approach can be opted for.

The use of the Bull-Y Re-Treaty file from Perfect Endo allows “dry” desobturation without using solvents, this approach is very efficient and ideal in cases where the obturation present in the healthy roots should not be disrupted. Dentine structure economy is also recommended, this approach significantly differs from the nonsensical restricted and ninja approaches: access cavity needs to be convenient but as wide as practical to achieve apical disinfection.

Refractory endodontic infection are mostly caused by residual endodontic infection. Among the several reasons for endodontic failure missed anatomy is a major culprit (Nair 2006). An eighty-two year old male with clear medical history, was referred by his general practitioner for persisting fistulous tract in the lower right quadrant. Fistulography long cone periapical revealed unclear origin and a large periapical lesion encompassing both the 45 and 46. The primary RCT on the 46 was carried out in 2011 by an Endodontic specialist, a year later due to non resolving lesion the 45 was treated as well. Prior to committing to any form of further treatment a small FOV CBCT was prescribed. In particular detection of erratic anatomy as the presence of a middle medial canal is very important. The middle medial canal is present in 13.3% of mandibular molars (Honap et al 2020). Alternative  approaches may include the use of print and try technique that may aid even further in localising the missing anatomy (Tonini et al 2021). A non treated mesio-buccal canal in the mesial root of the 46 was visualised on the CBCT scan, whereas a merging middle mesial canal was filled as main canal together with the mesio-lingual. Presence of a completely empty canal system discouraged the surgical re-treatement approach (that could efficiently address also the lesion encompassing the 45). A staged approach with non-surgical re-RCT of the 46, potentially followed by re-rct of the 45 was opted for. The use of the Perfect Re-Treaty sequence as demonstrated in a previous article (https://endodontics.styleitaliano.org/conservative-retreatment-using-re-treaty/) allows a conservative re-treatment approach that, thanks to the Bull-Y file efficiently removes the pre-existing obturation material without the need to use solvents and minimising the radicular dentine removal. Subsequently The Skinn-Y can be utilised to regain apical patency, followed by the shaper 1 and 2 (and optionally the Shaper3) to complete the shaping and removal of the apical infected dentine, at limited expense of the coronal dentine thanks to the 5% taper. A fast and efficient shaping phase allows to indulge longer in the chemodebridement phase. A final obturation with bio ceramic single cone technique was carried-out.