Case 10 Root canal with curved anatomy

Pre-op xray #18
Very curved mesial root.

Post-op xray #18
Completion of root canal.

Comment:
It is important before endodontic treatment is started that one looks carefully at the anatomy of the tooth. Curved roots present many problems including fracture of instruments and incomplete debridment of the canal system, which can lead to failure. At the very least, cases like this, should be referred for consultation.

Case #9 Fractured or Not?

#19 Pre-op x-ray

#19 File film

Possible diagnosis fractured tooth, however, not probe-able.

#19 Final Film

38 month post op x-ray

No evidence of fracture in access opening.

Comment:
Do not assume fractures.  Always probe carefully around the tooth, fractured roots usually have a significant periodontal pocket. Always check carefully in the access opening for a fracture. There is a dye on the market that can be used if one is unsure.  The consequences of unnecessary extraction can be very costly to a patient especially when the tooth is a bridge abutment.

Note: A root canal had just been completed on tooth #20 by his primary dentist.

Case 8 Consequences of an un-restored tooth - fracture

Pre-op film

Root canal required for tooth number 14.  Tooth was symptomatic to occlusal pressure and was necrotic.

Immediate post op film

Root canal was completed.  Patient was advised to have full coverage as soon as possible.

5 month post treatment x-ray

Patient was symptomatic to pressure and a periodontal defect was developing along the mesial buccal root. 

Photo showing fracture

Fracture noted, tooth non-restorable.

Comment: If at all possible most teeth will require full coverage after root canal therapy. Our office lets the patients know that they should get back to their dentist as soon as possible for a crown. However, if for whatever reason, this is not done in a timely manner, fractures can and do occur, making the tooth non-restorable.  Patients need to be informed when they are referred for root canal therapy that the tooth needs to be restored as soon as possible. The consequences need to be discussed i.e. fractures.

Case #7 Orthograde Vs. Apicoectomy

Pre op #10

Dentist attempted to locate the canal, could not.  Advised patient a possible  apicoectomy may be necessary.

File film #10 polarized view

Using ultrasonics I located the canal and  cleaned.  A polarized view will sometimes more clearly define the end of the file to the apex of  the tooth.

Immediate post op #10 polarized view

Again, this polarized view clearly  demonstrates the relationship of the root  canal filling to the apex of the tooth.  Please note: lateral incisors typically have a curve in  the apical end of the root.

Comments: Even though canals cannot be  initially negotiated, they are always there to  some degree. It is just a matter of finding  them.  Granted, some canals are not  negotiable, and surgery may be necessary. Generally surgery is not the first choice in root  canal therapy.

Case 6 Apicoectomy of 2 Teeth

Pre-op #12 &13 previous root canal therapy

Patient was very symptomatic and buccal tissue slightly swollen, both teeth were very tender to touch and pressure.

Options were discussed ranging from exodontia to retreatment to apical surgery.  I recommended that the most predictable outcome would be apical surgery on both teeth.

Immediate post-op #12 & 13 after apicoectomy w/retrofills

No fractures were noted and periodontally there were no issues.

3 month follow up xray

Apical healing on both teeth was observed and the patient was completely asymptomatic.

Comment:
Questions always arise as to why things are not healing. In this case, is it the over-extension of the filling material? I think probably not. Usually it comes down to the fact the tooth canal system has not been properly cleaned or due to the anatomy of the canal systems cannot be cleaned well enough. Once the apical foramen is sealed, the symptoms disappear and healing can occur.

Case #5 Two Separated Files w/Apical Lesion

Pre Op - 2 separated files in #13

Patient presented with 2 separated files and an apical lesion.  Patient was symptomatic. Options were discussed ranging from retreatment to a surgical approach to extraction. Patient did not want to loose the tooth and I recommended a surgical approach which would have a more predictable prognosis.

Immediate Post Op - Partial separated files with retrofill

Portion of the separated file in the facial canal system is present as well as the file in the lingual canal.  Retrofills were placed that covered both separated files and the isthmus between. 

8 month Check-Up

Patient is now asymptomatic and the apical lesion has completely healed.

Comment: Most separated instruments are impossible to remove especially if the breakage occurs in the apical third of the canal system. If the apical foramen can be successfully sealed the chances of success are greatly enhanced. It is necessary, however, to  have these patients on a routine 3-6 month recall for 2-3 years.