Case 28 Think outside the box: buccal approach

Pre-operative x-ray #24

Top view of access #24

Lingually displaced lower anterior

Straight line approach with file #24

Post-operative x-ray #24

Final filling in place #24

Comments:
Lower anteriors, especially when displaced to the lingual, are more readily accessed on the buccal instead of the lingual. This is by far the easiest way to approach root canal therapy when aesthetics is not an issue. The bonded composites on the market provide matching color to the surrounding enamel.

Case 27 Age 101 and counting

Pre-operative x-ray #12,13

I performed root canal on #12 when the
patient was a young man in his early 90's.

Patient presented with symptomatic tooth # 13
 with no radio-graphic visible canal spaces.

Post-operative x-ray #13

Comments:
It would seem to me that I am treating more and more older (65+) patients who present not only with health problems, but with very small sclerosed canal systems.  My best advice is if you are contemplating doing a root canal on a senior citizen or anyone where canal spaces are not clearly visible on an x-ray, I would suggest not attempting at all. Experience has taught me that at one time each tooth has a canal(s) and it takes less time each time I work on these kind of teeth because I have a little better idea of where the canal orifices should be.

Case 26 Separated instrument - surgical approach

Pre-operative x-ray #13

Separated lentulo-type paste filler in apical third of root.
Periapical lesion present and the tooth is symptomatic to occlusal pressure.

Photo of removed instrument with bur for scale

Post-operative x-ray #13

Comments:

Separated instruments pose two problems: should they try to be removed or should the tooth holding the separated file be surgically retreated? My philosophy is any separated file in the top one-third of the canal system has a good chance of being removed. I also believe any separated instrument in the last half of the canal system is usually non-retrievable. If a surgical approach is done, all attempts should be made to retrieve the separated instruments apically. Any kind of apical filling seals best when a metal instrument has been removed. It is difficult to make an adequate apical preparation against a metal instrument. Indecently, plastic thermal files are relatively easy to prep against.

Case 25 Lateral canals - many times the key to success

Pre-operative x-ray tooth #5 

Patient presented with symptomatic #5.  X-ray shows lateral lesions on both roots, one to the distal and one to the mesial.

Post-operative x-ray #5

Note: both lateral radiolucensies

Lateral canals in both roots

14 month post-operative x-ray #5

Tooth is asymptomatic and lateral radiolucensies are healed.

Comment: Lateral lesions on teeth with no evidence of fracture usually indicate a lateral canal system. If root canals are done and the lesions fail to heal, I would generally retreat before contemplating other options, i.e. surgery or extraction.