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April 2005Why Shapes Matter

Fig. 1 - Preop Image #22

A 54 year old female patient presented with history of endodontic treatment and previous buccal apical swelling. She had been given Pen Vk antibiotics by a physician. She had traveled over 700 kms by airplane to see me, as she lived in a remote northern location. I immediately noticed not only an apical lesion, but a lateral apical lesion as well. ( Arrows) This strongly hinted at an unfilled lateral canal. (Dr. Donald Yu has previously described the tangential relationship between Lesions of Endodontic Origin and the positions of lateral canals .)

Fig. 2 - Previous Treatment Attempt

Also included with the patient was a mid-treatment film from the previous endodontic treatment. From the appearance of the film, it is obvious that the canal was inadequately cleaned and shaped. The access was minuscule. There was also evidence of a near access perforation on the buccal aspect, no doubt caused by the inadequate access.

Not only was there insufficient debridement, the shape could not possibly allow for proper sealing of of the canal system anatomy. A half hearted attempt had been made to stuff a few cold cones in the coronal aspect, but did the treating clinician really expect this to work? And what about the lateral lesion?

Fig. 3 - My Working Length

The original gutta percha was removed and a working length obtained. The canal was actually much larger than the original treatment would indicate. The foramen size actually was gauged as close to a #35 file. Copious irrigation with ultrasonically activated NaOCL 5.25% was used as well as EDTA 17%. A final rinse of 2% Chlorhexidine was used to try to eliminate as much of the bacterial content as possible. I made sure the canal could be dried adequately.

 Fig. 5 - Final Fill - Lateral Anatomy Filled

Generally, nonvital and retreatment cases should be handled in a multiple appointment scenario, if at all possible. This allows for placement of intracanal medicaments ( such as CaOH) to reduce the bacteria levels before obturation. However, there are situations in which it is simply is not practical ( because of travel distances) to have the patient return for multiple visits. This is one such case. The costs of travel for this patient were as much as two or even three times the treatment cost. Therefore, we are sometimes forced to treat them in a single appointment.

The original treatment was inadequate. Proper shaping and debridement allowed for obturation of the anticipated anatomy and a clinically satisfactory result. It is also fortunate that the original deviated access did not result in outright access perforation in the coronal aspect. The access was restored with a bonded composite and the prognosis is excellent. Although it is unlikely that I will see her for a recall exam, I hope to have recall films of this patient sent to me by her dentist at 6 months post op.