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.