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.

Case 43 Root amputation still an option

Pre-operative x-ray #18

Apical lesion mesial root with 12mm pocket. Diagnosis: fractured root.

Post operative x-ray #18

Post amputation due to mesial root fracture.  Viable option to salvage bridge.

7 month post operative x-ray #18

With healing, bridge is firm.






Comments:
With the loss of a posterior abutment for a bridge, then the entire bridge is lost. Patient has two options either to try a root amputation or extraction with implants. Cost is always a factor, and in this case, it was a major factor.  Patient wanted to salvage the bridge as long as possible.  I think we have given this bridge more time.

Case 42 What happened?

Pre-operative x-ray #8

Patient is asymptomatic - digital x-ray shows a metal instrument or some kind of metal filling material bent at the apex of tooth #8. General dentist describes root canal treatment completed prior to 1991.

Photo showing object

Metal instrument in periapical lesion was not connected to the instrument or file in the canal. It is not a silver cone. The instrument or file had obviously corroded off at the apex of the canal system.

Photo of object (hemostat for scale)

Surgically treated, instrument in the canal could not be removed via apex.  If periapical healing does not occur, then retreatment may be an option.

Comments:

Retreatment is usually the most obvious option when root canal therapy fails.  However, a surgical approach is a valid option when retreatment may not be adequate.

Best advice is to have a periapical x-ray on a tooth prior to placement of a crown.