Two Easy Radiograph Solutions
October 26, 2018
A Sinus Tract is a Dentist’s Best Friend
December 14, 2018
I really believe dentists and dental specialists like endodontists really need to start sharing more of our success cases with the world. That way, everyone will see just how beneficial root canal therapy can be, and just how many teeth can actually be saved. (And if you want to experience more successes, I definitely suggest you enroll in E-School: Everyday Endo Made Easy!) Today I want to share a root canal recall case that went well.
So many clinicians get scared when they see a large lesion, and they automatically assume the tooth is not restorable or that the tooth is cracked. Well, here is a case that proves that theory wrong. Wanna see? Let’s go!
A Root Canal Recall Tooth Story
For context, my patient is a 28-year-old female. She did not have any pain, but her general dentist spotted something suspicious on the radiograph.
A periapical radiolucency was identified on the distal root of tooth #30. The patient had no response to cold and no pain to percussion on tooth #30.
So, her diagnosis was Previously Treated and Asymptomatic Apical Periodontitis #30. (Need help with pulpal and periapical diagnosis? I’ve got you covered.)
Since it’s a retreatment, I always take a CBCT. Here it is:
Now you can really appreciate the size of that radiolucency, and it does NOT make me want to abort treatment on this tooth. Instead, I want to know what is causing this radiolucent area. Even though the root canal appears to be well done on the radiograph, the axial slice tells the full tooth story.
The disto-lingual canal was missed and never treated. In these situations I like to tell my patients that their infection is as old as the root canal, since the original bacteria was never removed. Check out the coronal view. It clearly shows the missed canal as well.
So, I retreated this tooth in two visits, medicating it with calcium hydroxide for several weeks. This is what the tooth looked like in the end.
I also ended up treating tooth #29 as well since there was a carious pulp exposure on that tooth.
The patient came back for her one year recall and this is how she looked.
The bone looks great, but since the lesion in the initial periapical radiograph didn’t look as large as in the CBCT, the patient wanted to see the 3D version. So, we decided to compare apples to apples and take another CBCT at her recall visit and this is what we saw…
That bone is back, baby!! Remember, it always goes back to those TWO cardinal rules of endodontics: 1. Find all your canals, and 2. Get to the end of every canal. Otherwise, your stuff just isn’t going to work.
Let’s look at those images side by side!
This patient was so happy with the outcome, and she was stoked to be able to see it with her own eyes!
Do you ever do this with your patients? Show them exactly what has happened in their body? In my experience, people WANT to know and they LOVE seeing the evidence.
-Sonia
20 Comments
Great case, and another good example of CBCT aiding in diagnosis.
Thanks for sharing cases like this. I agree with you that general dentists like myself need to see these success cases to remind ourselves why retreatment can be the best option. The CBCT in cases like these can give you the confidence to know what most likely caused the failure and that success can be had.
I enjoy your blogs, keep them coming!
Great job Docteur; You medicated this tooth with Calcium Hydroxide for several weeks, did you think you could have the same result if you had use MTA?
Thank you..
Thank for sharing
We can learn to better serve our patients
Agreed! Thanks for reading!
-Sonia
No worries – more cases on the way!
Thanks again for following.
-Sonia
This is awesome! I always tell my patients that you want endo done well–the first time! I am so excited for e-school!
very Interesting !! Thank you
But I have a question ?
In these case is it necessary the retreatment for all canals or only complete the missing canal ?
I’m excited for you to take this course and see how it impacts your practice!
-Sonia
Hi Mayra – The canals are a continuous web so I would think they would all be contaminated, so I would retreat the whole tooth.
Thanks for following!
-Sonia
On the coronal view it looks like the distal root had one wide canal. On the PA after your retreat it looks like a Weine Type 2 configuration. So were there two distinct canals that joined or was it just one wide canal?
Was that one wide canal or two canals with one common POE?
Hi and thanks for reading! It was two canals coronally with one portal of exit. I always like to instrument as it was 2 separate canals.
-Sonia
Hi Salem,
I don’t use MTA as an intracranal medicament like I do calcium hydroxide. Can you give me more background on your question?
-Sonia
I wanted to say that if you did use the MTA, not as intracanalar medication, but as an apical filling’s biomaterial in association with gutta percha. (Obviously without using Calcium Hydroxide).
Salem, in this particular case or any case like this, I prefer to use gutta percha and sealer for my obturation. Using MTA in a case like this can be difficult, especially getting it down to the apex. So, gutta percha is my first choice here. I save my MTA for a tooth with a more open apex. Hope this helps!
My best,
Sonia
Thank for your precious advices..
My best,
Salem
Sonia can you post the name and pic of the calc hyd. I want to use something with ease of delivery. Also how long did you keep it in the tooth? 2 weeks
Great case. Mesial shift or distal one, which should b taken ? Second on PA the obturation is upto the apex but in CBCT it look short why? Thanks
Not sure which angle it is in this case, but it doesn’t really matter after all is said and done. Sometimes the mesial works and sometimes the distal works, and sometimes you have to try both. Be careful, not to read your CBCT like a 2D image. The snapshot is a “slice” of the object, so it depends on how you slice it with the software. This comes with practice of reading CBCT.
-Sonia
I use Ultradent’s UltraCal and I place it for 2-4 weeks. It is Ah-mazing. Check out my top 10 tools blog, there is more info in there as well. And hang tight though, I am getting my Eschooler’s some awesome discounts to some of my favorite products too!!
-Sonia