Case 57 Mesial Buccal Root Amputation

Pre Op # 14

Fractured mesial buccal root. Patient had option to extract with implant or mesial buccal root amputation.

Final Film #14

Mesial buccal root removed. Solid bone around distal buccal and palatal roots.

Post Op 7 Months #14

Healing has occurred with bone fill in in the area of the mesial buccal root. Probing is within normal limits.

Post Op 13 Months #14

13 Months with crown. Pt extremely happy. No periodontal problems.








Comment: Some patients just do not want teeth removed. If within reason there are alternative treatments for fractured teeth, for instance, if a fractured root can be removed with no undue periodontal problems and the patient understands the home care situation, then amputation is a viable option. The patient must understand that a new crown has to be placed.

Case 60 MVA

Pre Op #22,23,24

22,23,24 are symptomatic to pressure, no response to cold.

Final Film #22,23,24

Asymptomatic

Post Op 8 Months #22,23,24

Asymptomatic, almost complete healing.












Comment: Oral trauma can devitalize teeth and one must test all teeth in a quadrant or a specific area to make sure a tooth that is necrotic is not overlooked.

Case 59 What Would You Do?

Xray #8,9

Horizontal fracture apical third.












Comment: Patient traumatized tooth #8 as a child years ago. Has been referred for possible root canal although there are no symptoms. Tooth responds slightly to an ice pencil but not near as does #9. The tooth is yellower in color than 9. My recommendation is no treatment, what is yours?

Case 58 The Perfect Root Canal?

Pre Op #30

Symptomatic #30.

Final Film #30

Ideal.









Comment:I wish they would all turn out like that.

Case 56 Locate ALL Canals

Pre Op #30

Symptomatic tooth, #30 that had been referred where all the canals had not been found. In particular, the mesial buccal canal had never been negotiated.

Pre Op #30

Additional Pre Op film

Final Film #30

Mesial buccal found and there were two canals in the distal.

Final Film #30

Additional final film.










Comment: When dealing with lower molars remember there are usually at least three canals. Two canals maybe found occasionally in second and third molars.

Case 55 Bone Loss in Furcation Usually Indicates Fracture, USUALLY

Pre Op #30

Root canal with furcation bone loss but not probeable.

Final Film #30

Retreatment completed, no fractures noted in access opening.

Post Op 6 Years #30

Bone completely fills furcation.










Comment: A dirty canal system in a tooth with a root canal is not recognizable on an x-ray. Cleaning the canal system is the only way to ensure that the canals are clean and sterlie. An access opening also can reveal the presence of a fracture many times.

Case 54 Retreatment Very Common, Mesial Root Not Cleaned

Pre Op #19

Symptomatic with swelling over mesial buccal root.

Final Film #19

At First appointment mesial canals cleaned thoroughly, at second appointment all canals were obturated down to radio graphic apex.

Post Op  21 Months #19

Symptoms gone and apex area of mesial root completely filled in with bone.








Comment: Mesial canals of lower molars are very commonly not cleaned well enough to the radio graphic apex. When retreatment done the canals in the mesial root are cleaned thoroughly down to the radio graphic apex.

Case 53 Third Molars Are Tough

Pre Op #32

Symptomatic #32 with Periapical lesion.

Final Film #32

Final Film

Post Op 13 Months #32

Periapical lesion gone.










Comment: Third molars can be tricky besides being hard to get to with a rubber dam. Don't be surprised if you tackle a RCT on a third molar that there may be a variety of canal systems from 1-5.

Case 52 Sclerotic Canals in Mesial Root

Pre Op #31

Symptomatic to pressure, necrotic.

Final Film #31

Final Film

Post Op 14 Months #31

Complete healing at 14 months.










Comment: Examine x-ray before starting. If canals can not be seen you probably don't want to start.

Case 51 Good Healing 4 Canals

Pre Op Xray #3

Symptomatic with apical lesions on all roots.

Final Film #3

Final Film

Post Op 4 Months #3

Complete Healing.









Comment: Routine Follow up can demonstrate healing in a rapid amount of time.

Case 50 Implant Vs. Root Canal

Pre-Operative x-ray #3

Tooth number 3 is symptomatic with buccal swelling and an apical lesion is noted. Patient was advised to either have an implant or a root canal. Canals appeared to be sclerosed in the distal buccal and palatal. Options were discussed and patient wanted to save tooth if at all possible. 

Immediate Post-operative x-ray #3

All canals were found and obturated with gutta purcha and sealant. There was no separate MB2. 

6 Month POT x-ray #3

Patient is asymptomatic and healing is complete. 

Comment: Implants are an option if routine root canal therapy fails and retreatment is not a viable solution. If a tooth is not fractured and all canals are found, root canal therapy is very predictably successful. 

Case 49 Apical Surgery with out the benefit of previous Root Canal.

Pre-operative x-ray #28

Patient referred for the treatment of tooth number 28. The buccal tissue was swollen and the patient very symptomatic. The pulp chamber could be seen in the digital picture, but the canal system appeared sclerosed.

X-ray #28

The canal system could not be negotiated too the apex so an alloy was placed and apical surgery scheduled.

Immediate post-operative x-ray #28

Apical surgery completed with a IRM retrofill.

13 months POT x-ray #28

13 months POT. Patient is asymptomatic. Apical healing appears complete.

Comment: Even though a canal system may appear sclerosed it is usually necessary to try and negotiate. Apical surgery is an option if orthograde is unsuccessful. 

Case 48 A Good Use For M.T.A

Pre-operative x-ray #6

Number 6 referred because of a perforation accidentally placed while making a post hole.

Immediate post-operative x-ray #6

The canal space that was accidentally placed was located, cleaned, and dried. Viscostat was placed in the perforation for approximately a minute for the apical bleeding to subside. The M.T.A was packed into the perforation using paper points and a large gutta purcha condenser.  Routine x-rays were taken throughout this procedure to make sure M.T.A was well condensed. 

Comment: M.T.A is available for perforations if there are no periodontal pockets going to the perforated area. If a perforation is treated quickly the chances of success are almost 100%. 

Case 47 Silver Cones Again

Pre-operative x-ray #19

Silver Cones tend to corrode over time. In this particular case tooth #19 was treated decades ago and was now symptomatic. There is bone loss around both roots. Retreatment is probably the only option besides extraction. Even the retreatment prognosis is guarded due to the bone loss already present.

#19

Canals clean. A fourth canal was found in the distal root. The distal buccal and distal lingual canals joined.

Immediate post-operative x-ray #19

 Case completed canals obturated with gutta percha. 

13 month recall x-ray 

Patient is asymptomatic. Healing is incomplete at the mesial apex. The corrosion products from the silver cones probably prevent complete healing, but follow up will continue. 

Comment: Silver cones tend to corrode over time. Retreatment or extraction are ordinarily the two options. At times apical surgery is appropriate but definitely not the first choice.

Case 44 Incomplete root canal under crown

Pre-operative x-ray #19

A root canal had been attempted some time in the past, evidenced of some type of material in pulp chamber. It seems the canals were not located or negotiated. The patient was unaware of any attempt of a root canal on that tooth. The crown did not have an access opening through it.  Therefore, the crown was placed after root canal was attempted.  Patient was not aware of dates of treatment for this tooth.

Immediate post – operative x-ray #19

As you can surmise from the x-ray, I had an extremely difficult time locating the canal system.

1 year post-operative x-ray #19

Patient is asymptomatic with apical lesions continuing to heal.

Comments:

I would not recommend putting full coverage on a tooth where root canal treatment was not completed, regardless if the tooth is asymptotic at the time. At the very least a consultation is necessary.

Please note: A pulpotomy was done on tooth #18, but patient did not want to pursue treatment at this time because it was asymptomatic. Patient was informed, if this tooth was to have full coverage, a root canal would have to be performed first.

Case 45 Retreatment & teeth treated “overseas”

Pre-operative x-ray #18

Three teeth treated overseas with a paste root canal filling material. The only tooth that was symptomatic was #18, with untreated mesial canals.

Post –operative x-ray #18

Retreat distal canal and treated both mesial canals.

 Please note: The obturated channel between the mesial-buccal and mesial-lingual canals.

Comment:
I see in my practice, many teeth done overseas that have paste root canal fillings which are asymptomatic. I would not treat a tooth with paste fill which is asymptomatic, even if is obvious short-fill, unless the crown is going to be placed /replaced or if an apical lesion is present.  In this particular case #19 & #20 should be left alone.

Case 46 Apical Healing?

Pre-operative x-ray #4

Sypmptomatic tooth #4 with periapical lesion.

Immediate post-operative x-ray #4

Obturation was complete with sealer through the apex.

6 month post-operative x-ray #4

Tooth is asymptomatic healing is almost complete.

Comments:
Apical healing may not occur completely as far as the radiograph is concerned. If the patient was symptomatic to start with, but is now asymptomatic, sometimes this is the best we can hope for. However, it also may take some time for complete healing. i. e. for the apex to completely restore.