Patient undergoing restorative rehabilitation. Referred for endodontic treatment on tooth #14 with a note that there is a blockage of the Palatal canal, and a severe curve in the MB canal which is not able to be negotiated to the apex. After a thorough medical and dental history was obtained, the treatment and options were discussed with the patient. The PA Radiograph shows a PAL on the MB root, as well as a curved MB and DB roots. The tooth has a three unit attached temporary crowns, as well as a temporary over the previous access.
Rarely do teeth in general have simple canal anatomy, it is the exception rather than the norm. This is specially true in maxillary first molars. It is essential that magnification and proper lighting is used when searching for excess anatomy. This is the number one reason why the Surgical Operating Microscope (SOM) is used in 100% of the cases at Glendale MicroEndodontics. After all, how can we rule out extra anatomy if we don't look for them or can't see if they are there? This particular tooth not only had the usual MB2 Canal, but also had a P2 Canal. MB2 Canals exist in ~95% of the Maxillay First Molar MB Roots. A second Palatal Calan however, occurs ~1-2% of the cases.
The clinical photograph taken under the SOM during the gutta percha obturation shows one of the P Canals obturated, while the second P Canals separate and un-obturated. This photo is taken under a very high magnification to illustrate the point.
The Post Operative Radiograph illustrates the complex root canal anatomy of the Maxillary First Molar with the 2 Palatal Canals that start at a common orifice, divide midroot and stay divided to the apex. It also shows the the 2 MB Canals, and the single DB Canal (Note the curvature on the MB and DB Roots).
A 6-MO Recall radiograph show tooth #14 restored with a build up, ready for the final restoration. It shows the PAL healed. It is our policy at Glendale MicroEndodontics to recall all the teeth we treat in order to follow the healing of lesions, to make sure the patient does not develop any symptoms, and to keep a metric of our treatment rendered. We strive to maintain a close relationship with our referring doctors to provide high quality endodontic treatment in conjunction with the quality of care our referring doctors provide for their patients.
General dentist had pain in his First Maxillary Molar. He had his brother-in-law dentist initiate root canal therapy. When the treating dentist was unable to located the MB canal, he self referred to our office.
Pre Operative Clinical photograph under the SOM. Patient (dentist) drove directly after the MB canal was unable to be located. Note the size of the access. An endodontic access should allow unimpeded access to all the existing canals. The access should be a straight line access, and at the same time should conserve as much Peri-Cervical Dentin (PCD). However, it becomes meaningless to conserve tooth structure if the canals cannot be accessed.
Note the extension of the endodontic access in the MB direction. This extension was performed in composite. Therefore, there was no sacrificing of sound tooth structure, and at the same time, this access now allowed an un-impeded access to the existing canals.
A high magnification view with the SOM reveals the MB Canal Complex. Whereby the endodontic literature shows an up to 95% existence of the MB2 Canal clinically utilizing the SOM, there is a small percentage of teeth that exhibit and MB3 or even an MB4 canal. It is only through proper search that these accessory canals can be located. Note the decay that is also now revealed under the existing composite inlay.
It is only with proper magnification and illumination, a proper access and the knowledge that excess anatomy can and does exist, we are able to located 3 MB Canals in this Maxillary 1st Molar.
Clinical photograph under the SOM which shows the 5 canals obturated with Gutta Percha, as well as all the caries removed from the mesial and distal aspect of the Composite Inlay. The mesial and distal aspects of the old inlay were kept to be used as a matrix for the new Core Build Up.
Clinical photo shows an Encore Build Up placed in the access. Tooth is now ready to be crowned.
It is important to assess the needs of the tooth as far as the access is concerned to allow for the proper cleaning and shaping of the entire root canal system, as well as to minimize or eliminate the probability of an instrument fracture by creating a straight line access to the root canal.
Post Operative Radiograph showing the obturation of all canals. MB1, and MB2 met mid-root.
Patient presented for second opinion on tooth #4. He was given the options by his prosthodontist to have the tooth extracted and replaced by an implant/crown; or to have tooth treated by the endodontist. First endodontist recommended apical surgery to treat the PAL, and to salvage the crown. Patient was advised by Dr. Odabashian that the long term prognosis of a surgical procedure is poor to guarded. Especially since the previous root canal obturation (and likely cleaning and shaping) was inadequate. Retreatment was proposed, and the patient opted to have the tooth retreated with long term calcium hydroxide therapy.
PA Radiograph of tooth #4 with calcium hydroxide intracanal medication at one month appointment. Note the reduction of the PAL. Old crown used as a temporary. Tooth was re-dressed with calcium hydroxide, and patient was asked to return three (3) months later to confirm osseous healing.
PA Radiograph (6 months post) treatment initiation. Note the extensive osseous repair of the original PAL. Apical segment of the roots was obturated with MTA due to the apical size, and two fiber posts were cemented and an Encore build up was placed. The tooth was prepared under the microscope and temporized. Patient was referred back to the Prosthodontist for new crown fabrication.
Patient was advised that tooth #3 also needed retreatment. Patient was to return for retreatment of tooth #3.
Patient saw her GP, who initiated RCT, however; he was unable to find any of the calcified canals. Instead of jeopordizing the tooth any further with removing critical dentin mass, he referred the patient to our office.
Clinical photo of tooth, shwing the pulp chamber calcification and lack of any located orifices for the four existing canals.
Clinical photo of MB1/MB2/DB and canals, and Palatal canal (partially seen) obturated with gutta percha and a bonding agent applied for the Access Build Up to be placed.