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 Without 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.

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. 




Case 41 Lateral canal with apical curve

Pre operative x-ray #4

Patient was symptomatic.









Post operative x-ray #4


Note: Two lateral canals and curvature negotiated and obturated.








Comments: When contemplating root canal therapy on any tooth, curvatures can be problematic.  It is an ideal place for instruments to separate when the canal system is really small, this is a case that should be referred.  It was fortunate in this case the lateral canals were filled and a radial lucency can clearly be seen on a mesial aspect of this root. 

Case 40 Curvature at the Apex

Pre-operative x-ray #31 with
Positive/Negative reversed
Pre-operative x-ray #31
Patient was symptomatic and options were discussed; apicoectomy vs retreatment. Retreatment was the preferred option due to the location of the tooth.




Post - operative x-ray #31
Post-operative x-ray #31 with
Positive/Negative reversed


 Please note curvature of the apex.







Comment: The patient was symptomatic probably due to incomplete cleaning and obturation of the last 4-5mm of the mesial root which was extremely curved. With judicious cleaning of the mesial root and negotiation to the apex, a good fill is now noted. Prognosis is excellent.

Case 39 Lateral canals found in the funniest places

Pre-operative x-ray #6


Large apical lesion on the mesial aspect of #6. Buccal tissue is swollen and patient is asymptomatic.









Immediate post-operative x-ray #6


Obturation completed. Note lateral canal on the mesial aspect of the tooth. 









6 mo. post-operative x-ray #6



Patient is asymptomatic and lesion is practically gone. Please note bifurcation at apex also. 








10 mo. post-operative x-ray #6



Lateral lesion has practically healed completely.










Comments:  Lateral canals are often the reason that periapical lesions are present or teeth have continual problems after root canal therapy.  In many cases, they are not seen until after the work is completed. If a lesion remains after a root canal has been done and does not heal, many times unfilled lateral canals are the cause.

Case 38 2 canals often in distal root

Pre-operative x-ray #30


Patient was symptomatic and swollen.








File film #30


Second distal canal was located. 








Immediate post-operative x-ray #30



Retreatment was completed. Mesial canals were also retreated.








10 month check-up x-ray #30


Complete healing after ten months. 








Comments:  Always a choice between a surgical approach and retreatment on any root canal that is failing, if one is assured that a fracture is not the problem. Generally retreatment will confirm that either the canals have been poorly cleaned or other canals that have never been negotiated are present, as in this case of the distal root.

Case 37 Five canals more common than we think

Pre-operative x-ray #19

Patient presented with swelling and painful to bite.









Photo showing pulp chamber floor #19


Once the pulp chamber was clear, five canals clearly visible. Note: The fifth canal is usually in the isthmus area between distal buccal and distal lingual systems, if in the distal root. 






Post-operative x-ray #19



All canals were filled to the apex.








Comments: Usually if there are five canals you will find three in the mesial root more often than the distal root. Three canals in the either root are usually not three separate canals.  In my experience, a third canal either joins the  buccal or lingual canal system.  I can tell you from surgically treating first molars, that the isthmus area many times is the cause of periapical problems because the isthmus has not been or cannot be cleaned adequately.

Case 36 Lateral canals can be important.

Preoperative x-ray #4


Tooth is symptomatic.





Immediate post operative x-ray #4


Obturation with 2 lateral canals.





2 month post operative check #4


Tooth is asymptomatic.





6 year post operative x-ray #4



Note: resorption of lateral canal filling material.  Probably just sealer only, gutta percha does not dissolve. Lateral lesions have healed.
Please note: Apical lesion on #5.



7 year post operative xray


All lesions have healed around #4 and no evidence of lateral canals being filled.  Root canal was completed on #5.










Comments:
If lateral canals are not filled i.e. cleaned, there is a good chance that a tooth's apical area will never heal. 

In most cases, it is impossible to mechanically cleanse an lateral canal system. However, sodium hyperchloride may chemically clean a lateral canal. In most of my cases, if a lateral canal is filled it is with softened gutta percha and sealer.  This is speculation on my part, however. 

Case 35 Apicoectomy vs. Orthograde Retreatment


Pre-operative x-ray #19

Root canal completed by another provider with separated file in ML canal.  Tooth is extremely symptomatic.








Post-operative x-ray #19


Surgical approach was decided upon and no fractures noted. Three retro fills were placed, and a separated file was removed from ML canal with ultrasonics.  Despite large size of lesion and the amount of bone loss, the prognosis was good. 





3 month check-up #19

Patient is asymptomatic and healing was noted.







9 month check-up #19

Patient continues to be asymptomatic and the bone almost completely filled in








Comments:  Separated instruments are just a way of life for those who do root canal therapy.  The instrument itself is not a problem.  What it represents is: a blockage of a possible dirty canal.  In this case, I just speculated that the separated instrument was the cause of this patient's problem.  Do I know this for sure? No.  Therefore all canals were retrofilled.

Case 34 Another look required prior to crown?

Pre-operative x-ray #19


Distal canal not negotiated and a mesial lingual canal not negotiated.  Tooth is symptomatic and very tender to percussion.








Immediate post-operative x-ray #19

I was able to negotiate the distal canal and mesial lingual canal to the radiographic apex.  I was not able to fully negotiate the mesial buccal canal.





6 month post-operative check appointment



The tooth is asymptomatic. Almost complete resolution of the apical lesion of the mesial root is noted.







Comments:
Before final cementation of a crown on a tooth that has a "partial" root canal, my best recommendation is that a second opinion is necessary on a questionable root canal.  Too many patients are upset when I have to penetrate a new crown to "complete" a root canal that is only partially done and they were not aware.  I must admit, I don't know what a patient has been told, only what they tell me.  If questions occur and the patient is irritated, I will always call whomever placed the final crown to see if they have told the patient about the possibility of any future problems, i.e. is there something written in the patient's chart notes? As always, communication between providers is key.

Case 33 MTA obturation

Pre-operative x-ray #8
Immediate Post-operative x-ray #8



Symptomatic # 8 which has been apically resorped.


Obturation with MTA entirely.







4 month check x-ray #8

3 year check x-ray #8
After 4 months, asymptomatic with marked apical healing.


After 3 years, asymptomatic with apical radiolucency entirely resolved.








Comments:
In my clinical experience with the use of MTA, which I admit is extremely hard to handle, obturation of canals where the root structure has had resorption, results seem to be very positive. I fill the entire canal system with MTA, never using gutta percha. 

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.