Case 41 Lateral canal with apical curve

Pre operative x-ray #4

Patient was symptomatic.

Post operative x-ray #4

Note: Two lateral canals and curvature negotiated and obturated.

Comments: When contemplating root canal therapy on any tooth, curvatures can be problematic.  It is an ideal place for instruments to separate when the canal system is really small, this is a case that should be referred.  It was fortunate in this case the lateral canals were filled and a radial lucency can clearly be seen on a mesial aspect of this root. 

Case 40 Curvature at the Apex

Pre-operative x-ray #31 with
Positive/Negative reversed

Pre-operative x-ray #31

Patient was symptomatic and options were discussed; apicoectomy vs retreatment. Retreatment was the preferred option due to the location of the tooth.

Post - operative x-ray #31

Post-operative x-ray #31 with
Positive/Negative reversed

 Please note curvature of the apex.







Comment: The patient was symptomatic probably due to incomplete cleaning and obturation of the last 4-5mm of the mesial root which was extremely curved. With judicious cleaning of the mesial root and negotiation to the apex, a good fill is now noted. Prognosis is excellent.

Case 39 Lateral canals found in the funniest places

Pre-operative x-ray #6

Large apical lesion on the mesial aspect of #6. Buccal tissue is swollen and patient is asymptomatic.

Immediate post-operative x-ray #6

Obturation completed. Note lateral canal on the mesial aspect of the tooth. 

6 mo. post-operative x-ray #6

Patient is asymptomatic and lesion is practically gone. Please note bifurcation at apex also. 

10 mo. post-operative x-ray #6

Lateral lesion has practically healed completely.

Comments:  Lateral canals are often the reason that periapical lesions are present or teeth have continual problems after root canal therapy.  In many cases, they are not seen until after the work is completed. If a lesion remains after a root canal has been done and does not heal, many times unfilled lateral canals are the cause.

Case 38 2 canals often in distal root

Pre-operative x-ray #30

Patient was symptomatic and swollen.

File film #30

Second distal canal was located. 

Immediate post-operative x-ray #30

Retreatment was completed. Mesial canals were also retreated.

10 month check-up x-ray #30

Complete healing after ten months. 

Comments:  Always a choice between a surgical approach and retreatment on any root canal that is failing, if one is assured that a fracture is not the problem. Generally retreatment will confirm that either the canals have been poorly cleaned or other canals that have never been negotiated are present, as in this case of the distal root.

Case 37 Five canals more common than we think

Pre-operative x-ray #19

Patient presented with swelling and painful to bite.

Photo showing pulp chamber floor #19

Once the pulp chamber was clear, five canals clearly visible. Note: The fifth canal is usually in the isthmus area between distal buccal and distal lingual systems, if in the distal root. 

Post-operative x-ray #19

All canals were filled to the apex.

Comments: Usually if there are five canals you will find three in the mesial root more often than the distal root. Three canals in the either root are usually not three separate canals.  In my experience, a third canal either joins the  buccal or lingual canal system.  I can tell you from surgically treating first molars, that the isthmus area many times is the cause of periapical problems because the isthmus has not been or cannot be cleaned adequately.

Case 36 Lateral canals can be important.

Preoperative x-ray #4

Tooth is symptomatic.

Immediate post operative x-ray #4

Obturation with 2 lateral canals.

2 month post operative check #4

Tooth is asymptomatic.

6 year post operative x-ray #4

Note: resorption of lateral canal filling material.  Probably just sealer only, gutta percha does not dissolve. Lateral lesions have healed.

Please note: Apical lesion on #5.

7 year post operative xray

All lesions have healed around #4 and no evidence of lateral canals being filled.  Root canal was completed on #5.

Comments:

If lateral canals are not filled i.e. cleaned, there is a good chance that a tooth's apical area will never heal. 

In most cases, it is impossible to mechanically cleanse an lateral canal system. However, sodium hyperchloride may chemically clean a lateral canal. In most of my cases, if a lateral canal is filled it is with softened gutta percha and sealer.  This is speculation on my part, however. 

Case 35 Apicoectomy vs. Orthograde Retreatment

Pre-operative x-ray #19

Root canal completed by another provider with separated file in ML canal.  Tooth is extremely symptomatic.

Post-operative x-ray #19

Surgical approach was decided upon and no fractures noted. Three retro fills were placed, and a separated file was removed from ML canal with ultrasonics.  Despite large size of lesion and the amount of bone loss, the prognosis was good. 

3 month check-up #19

Patient is asymptomatic and healing was noted.

9 month check-up #19

Patient continues to be asymptomatic and the bone almost completely filled in

Comments:  Separated instruments are just a way of life for those who do root canal therapy.  The instrument itself is not a problem.  What it represents is: a blockage of a possible dirty canal.  In this case, I just speculated that the separated instrument was the cause of this patient's problem.  Do I know this for sure? No.  Therefore all canals were retrofilled.

Case 34 Another look required prior to crown?

Pre-operative x-ray #19

Distal canal not negotiated and a mesial lingual canal not negotiated.  Tooth is symptomatic and very tender to percussion.

Immediate post-operative x-ray #19

I was able to negotiate the distal canal and mesial lingual canal to the radiographic apex.  I was not able to fully negotiate the mesial buccal canal.

6 month post-operative check appointment

The tooth is asymptomatic. Almost complete resolution of the apical lesion of the mesial root is noted.

Comments:

Before final cementation of a crown on a tooth that has a "partial" root canal, my best recommendation is that a second opinion is necessary on a questionable root canal.  Too many patients are upset when I have to penetrate a new crown to "complete" a root canal that is only partially done and they were not aware.  I must admit, I don't know what a patient has been told, only what they tell me.  If questions occur and the patient is irritated, I will always call whomever placed the final crown to see if they have told the patient about the possibility of any future problems, i.e. is there something written in the patient's chart notes? As always, communication between providers is key.

Case 33 MTA obturation

Pre-operative x-ray #8

Immediate Post-operative x-ray #8

Symptomatic # 8 which has been apically resorped.

Obturation with MTA entirely.

4 month check x-ray #8

3 year check x-ray #8

After 4 months, asymptomatic with marked apical healing.

After 3 years, asymptomatic with apical radiolucency entirely resolved.

Comments:

In my clinical experience with the use of MTA, which I admit is extremely hard to handle, obturation of canals where the root structure has had resorption, results seem to be very positive. I fill the entire canal system with MTA, never using gutta percha. 

Case 32 - More examples of long canal systems

Patient 1 Post-operative x-ray #19

Patient 1 pre-operative x-ray #19

Patient 2 post-operative x-ray #18

Patient 2 pre-operative x-ray #18

Patient 3 post-operative x-ray #31

Patient 3 pre-operative x-ray #31

Patient 4 post-operative x-ray #3

Patient 4 pre-operative x-ray 3

Comments:
Long canals measured over 25 mm pose not only obturation problems, but cleaning problems as well. Recapitulation is mandatory.  I use not only hand instrumentation, but use rotary instruments back and forth to ensure I clean to the apical stop.  Filling vertically can be very difficult and the master cone should fit within 1-2 mm of the apical stop. Vertical condensation will drive the cone to the end of the canal.

Case 31 Long Canal Systems (25+ mm)

Pre-operative x-ray # 11

Patient was very symptomatic and swollen, it was necessary to place a drain to get her out of pain.  In my practice, drain placement involves incising gum tissue and also exposing the root tip of the tooth to ensure drainage.

Post-operative x-ray #11

Tooth #11 with a working length of 31 mm and numerous lateral apical canals.

Comments:

In my practice I consider a long canal to be over 25 mm in length. Teeth with long canals are the palatal roots of upper molars and maxillary cuspids. Gutta percha comes usually 30 mm in length.  I see many canal systems in which the apical 3-4 mm is never filled in long canals, which probably means this area was not cleaned successfully either, therefore, having a greater risk of failure. If you are going to treat these types of canals, longer files, i.e. 30 mm files are necessary. 

Case 30 Crazy canal system

Pre-operative x-ray #18

Symptomatic # 18 Small occlusal composite filling. Apical breakdown noted.

Photo #18 after accessing

Photo #18 note: only 1 mesial

Initial access 3 canals but...

Only one mesial and two distal canals

Immediate post-operative x-ray #18

Comments:

Just remember when accessing for a root canal, the canals are not always going to be where they "should" be. The floor of the chamber is usually grey, and anything outside the grey is usually a perforation.

Case 29 Another look at re-implantation

Pre-operative x-ray #18

Previous root canal with silver cones and separated file in mesial root. Patient was symptomatic.  My initial diagnosis was a fractured root. No attempt was made to retreat and I extracted assuming I would find a fracture.

Post-operative x-ray #18

I saw no fracture, so I did retrofills on all canal systems and replaced.

8 year post-operative x-ray #18

Tooth is asymptomatic after 8 years with no mobility. My only concern is the distal root apically which may appear to have some bony breakdown. Will continue to monitor.

Comments:

Don't assume anything. Re-implantation is just another way of treating a failed root canal.