Case 24 Surgical Approach Multiple Teeth

Pre-operative x-ray

Periapical abscess approximately 2cm across with de-vital #22 & #25.  Root canals on 23 & 24 were completed some time in the past. Patient is symptomatic.

Immediate post-operative x-ray

Non negotiable canals in both #22 & #25.  No attempt was made to try to negotiate the canal space in #22 as there was no obvious canal visible. #22-25 were retrofilled.

4 month post-operative x-ray

Bone fill in is very apparent and all symptoms are gone.

Comments: 

Lower anteriors are very difficult to treat and their premature loss poses a very difficult restorative situation. In this instance, it was decided that retreatment of #23 & #24 would not be beneficial in the long term and a surgical approach would be more predictable as far as healing was concerned.

Case 23 When a fracture is not a fracture, tooth #18

Pre-operative x-ray

Necrotic tooth with periapical lesions

Photo of access opening with fracture circled in red

Please note: fracture line down distal

Immediate post-operative x-ray

6 month post-operative x-ray

Periapical radiolucencies are gone

Comment:
When fractures are noted, careful probing of the pockets in the area of the fracture line is needed.  Many times a good periapical x-rays will show bone loss which will indicate a non-restorable tooth. Patients need to be informed of fractures and the possibility of eventual tooth loss if one does exist. However, in my experience, teeth that are periodontally sound after initital root canal treatment and immediate full coverage tend to remain so.

Case 22 Why root canals fail/ 5 canals, tooth #19

Pre-operative x-ray

Previous root canal treatment.  It appears that there are spaces in the root canal system that have not been negotiated or cleaned, especially the distal root.

Post-operative x-ray

Note: 3 files in distal root

Photo: 5 canal orifices

Post-operative x-ray

All canals were cleaned and filled to the radiographic apex.

Comments:

Though teeth may have multiple canal systems and some of the canals may meet apically, a dirty canal will inevitably cause periapical symptoms as contamination may occur from the unclean canal.  A canal obturated with gutta percha will not stop contamination from a neighboring canal that joins it.

Case 21 Hemisection to preserve tooth

Pre-operative x-ray

Patient presented with a periodontal pocket along side mesial root, with a diagnosis of fracture mesial root.  Options discussed; extraction of whole tooth or hemisection of mesial root.  Patient wanted to save as much tooth as possible.  An implant was not an option. I told patient, if the tooth was hemisected, not to restore the tooth until it was stable with no periodontal pockets.

Immediate post operative x-ray

Distal root is stable.

8 mo check appointment

Mesial root socket has healed. Patient is asymptomatic and distal root is firm.  Patient can either have a single unit crown or three unit bridge.

Comment:

Hemisections are an option when the patient has choices on treatments including implantation.  If a patient desires tooth retention, then this option of hemisection is a good choice. I do not think full coverage is necessary until the remaining root is stable and periodontally sound.

Case 20 Curved roots always a challenge

Pre-operative x-ray #30

Post-operative x-ray #30

Comments:
Carefully observe canal morphology before attempting root canal treatment. Curvatures like these invite file breakage. Smaller files are required, carefully checking the flutes for distortion. In cases like this, if you attempt, do not be surprised that many of your files can only be used once because of bending or straightening of the flutes.

Options: retreatment versus a surgical approach

Post operative x-ray 9 months after root canals on #27,28 

Original root canal was completed in my office.  Patient was asymptomatic but radiolucent areas were still present.  Patient desired no additional treatment.

1 year post operative x-ray

Same as 9 months

Pre-operative x-ray / 6 year check up

There was a significant change in radial lucency and the tooth was becoming symptomatic.

Immediate post-operative x-ray

Surgical approach was decided for both #27 and #28 as being the most predictable as the original root canal therapy seemed to be adequate.  During the surgery no fractures were found nor any unusual periodontal problems.

15 month check up

Patient is asymptomatic and apical healing is observed around both roots.

Comments:
It is always difficult to decide whether to retreat a root canal or to approach it surgically. If all canals have been found and the obturation seems to be adequate, probably a surgical approach would be more appropriate and more predictable.

Case 18: Predictable endodontics

Case 18a: pre-operative x-ray

Case 18a: photo

Case 18b: pre-operative x-ray

Case 18b: photo

Please note in both cases alloy on pulp chamber wall.

Comments:
As noted above many restorations are placed close to if not into the pulp chamber. In both of these cases, patients were very surprised that this was the case. Granted, most of the time the dentist who place the restoration tell patients of the situation and the possible need of root canal therapy due to the depth of the filling.  However, in my experience, patients never hear this. If a restoration will probably lead to future root canal therapy, it needs to be well documented in the patient's record and explained in detail to the patient as to not infer it was the dentist's "fault" it was so deep.  Most of the time, these fillings are replacements for other fillings because of fracture or decay. Symptoms may occur only after the new filling is placed.  It also needs to be explained that the tooth may be asymptomatic prior to the new filling, but may become symptomatic after the filling.