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The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. - Photos courtesy:Marga Ree

 Tough distal canal
From: Marga Ree
Sent: Wednesday, December 06, 2006 8:52 PM
Subject: [roots] Tough distal canal

This patient was referred because of persistent complaints when 
biting on 36. Her dentist had performed rct some months ago, 
because of these complaints. According to the dentist,
it was a vital case, but after the treatment, she still wasn't 
able to use the tooth. As you can see on the pre-op rads, the 
distals were short, and the apical shape of the mesials looked 
weird. It has been shown in the lit that after vital pulpectomy, 
the best success rate has been reported when the procedures 
terminated 2 to 3 mm short of the radiographic apex. I have my 
doubts about this, and this case is an example that staying
short can result in persistent complaints.

I decided to retreat.
The distals were very difficult to negogiate, and I was pretty 
sure there was a sharp curve to the distal.

Anyhow, after 6 weeks of Ca(OH)2, she was nearly symptomfree, 
so I decided to fill today. Strange anatomy, I am not sure if 
these were the original canal configurations, and two
voids in the BU...:-(   But the patient is happy, and can use 
her tooth again - Marga

Marga, what a great service to the patient . Excellent. Have you been able to negotiate the beginning of the lateral canal? did you use solvents? - Jörg Thanks Jörg. Yes, I was able to negotiate at least a part of the apical curve, my file came out with a very sharp bend at the end. I was not able to obtain patency in the distals. I used choroform, as I usually do in retreatment cases - Marga Dear Marga Nothing to say but excellent!! thanks for sharing, your work is inspiring!!! could you tell somethig about obturation materials and tech in this particular case?. The apical contron on mesials looks great - Carlos Heilborn Carlos, In this kind of retreatment cases, it's all about trying to "don't make it worse". The previous dentist used too stiff instruments, Rob Kaufmann hit the nail on the head, see his post, he is a very keen observer, and really knows how to explain things. In these cases, time and patience are very important. Here is my approach: Precurve files # 08 and 10 with an endobender or a nail clipper I learned this from Gary Carr. With the latter, you will be able to put a tiny curve, only the last flute. You have to do this under the microscope. Then, pick a little with these, while endodancing 360 degrees, use EDTA and NaOCl alternately, and try to find a sweet spot. Switch between regular files and C files. I love the C+ files for this purpose. Use lots of new files. As soon as you feel a catch, try to work the file down a little bit, increments of 0.5-1 mm, and switch to a regular # 06 or 08 file. Sometimes I use a M4 handpiece to loosen it up, as soon as a have a path. If I am in doubt, I take an radiograph to check if I am on track. I filled with resilon, using System B for the downpack and the Obtura gun for the backfill - Marga I think this is a great example of classic "internal transportation" of the canal - but you managed to save the case nicely. . If you look closely at the final mesial fill, the mesial canals look trifid ( or more!). The original operator used instruments that were obviously too stiff. The result was that the canal straightened at the terminal portion and the final fill looks "fanned out". Fortunately, there was no perf. The distal was straighted in a similar manner except that you managed to get around the distal curve (which shows great technique.) Salvaging those mangled cases is probably the most difficult treatment that you can do. Nice job. You know, we all have a tendency to take a quick look at an endo radiograph and judge it in an instant. In this case someone may say "Oh my gosh , who did THAT!?" Unfortunately, what you can't appreciate with a fast glance is that many of these awful looking cases are actually "saves" that took a lot of talent and effort to treat. They sure don't look pretty in the classic sense, but the fact that the case is asymptomatic and shows no pathology is really what matters. We all need to be more careful when judging radiographic appearances. Many succesful retreat cases are just plain ugly - Rob Hi Marga ................Fantastic case. Just a few queries.... 1:What do you think about the final size of the mesial canals in relation to the root strength of the remaining structure in this case . 2: Such a apical curve is a common presentation in the distal canals of the lower molars. Until now I was under the impression that the file would be curving at the apex and many a times I have found that it does but here in this case I see that the files appear straight at the apex and so does the obturation and the apical curve in the distal root is evident in the form of a lateral canal or bifidity. So were you able to instrument this area ? My viewpoint regd. the 2-3 mm short in vital cases............. ....if we keep in practicing short in vital case we might have trouble in instrumenting this area in non vital / infected cases from the sheer lack of practice and be prone to failure . Now this might not hold true for experts like you and many others on Roots but for the many of us we still are learning and should practice in all cases what we would be doing in the tough cases........... just my humble viewpoint - Sachin Thanks Sachin, if we keep in practicing short in vital case we might have trouble in instrumenting this area in non vital / infected cases from the sheer lack of practice and be prone to failure I think you raised a very good point here, thanks for your input . Some lecturers and dental schools advocate to stay short in vital cases because it may be difficult to negotiate the last 2-3 mm. Of course it can be harder to negotiate an acute apical curve, but with the right technique and instrumentation sequence, it is doable. I don't undertsand this reasoning, because the very same arguement applies to retreatment cases, in which it is of paramount importance to negotiate the last 2-3 mm..............And we know from our clinical experience how difficult it is to regain length and negotiate the very apical part in retreatment cases that were instrumented short, because we not only have to deal with the original uninstrumented apical part, but in addition with set sealer and a ledge which we have to address and bypass. So staying short in vital cases can complicate retreatment, as I showed with this case. What do you think about the final size of the mesial canals in relation to the root strength of the remaining structure in this case . The root strength may indeed be compromised. The canals were already pretty much enlarged, as you can see on the pre-op rad. I took care not to enlarge the mesials further, but there was an isthmus between the mesials, and the canals were pretty oval shaped in bucco-lingual direction. So I throughed the isthmus, and while negotiating the apicals part of the mesials, it felt if there was a pretty large interconnecting fin between the mesials. This may partly explain the fat filling in the apical part of the mesials So were you able to instrument this area ? As for the distals, the previous clinician has probably instrumented with too large and too stiff files. So the original canal configuration was ledged. I thought I was able to negotiate at least a part of the distal apical curve, my files came out with a very sharp bend at the end. I was not able to obtain patency in the curved distal. I am pretty sure that the original POE must have been located on the distal aspect of the distal root, and not apical. I think the latter is a " man-made canal"...:-)) - Marga

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