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December 2003Restoration Compromise - A Recipe for Failure?

Fig. 1

The premolar in Fig.1 was referred to me after having an access attempt by the referring Dentist. He indicated that there was a buccal perforation under the crown margin and that he was frustrated that he was unable to locate the canal system in what appeared to be a "relatively large, easy canal". ( Endodontists know better than to characterize mandibular premolars as "easy".) The referral also indicated that finances were a problem and that hygiene was also questionable. I was asked to try to keep the crown on the tooth (if possible). I noted that the canal appeared to narrow sharply at the apical third, indicating a possible split in the canal anatomy. The root curvature was also significant.


Fig. 2
Reluctantly, I opened the access through the crown.. My initial working length files penetrated only half way into the canal and I noted a sharp bend in the WL file.. (Fig. 2)
   

Fig. 3
Figure 3. Further progress was eventually made and I was able to access the more apical sections with a larger file (#15).
   

Fig. 4
Fig.4 and Fig.5 shows the results of canal filling. An undiagnosed and tortuous 2nd canal is visible in the canal fill.
   

Fig. 5
Fig. 5 The area of perforation is visible below the crown margin.
   

Fig. 6

   

Fig. 7
Fig. 6 and 7
The patient's hygiene level ( or lack of it) - recurrent decay (black arrow) and the position of the previous perforation ( white arrow) suggest that this treatment is bound to fail under the present conditions. Attempts to "patch" such restorations may save the patient the cost of the new crown but they ultimately risk loss of the tooth and failure of the endodontics.

Conclusion
There is a saying in Endodontics: "Once you put a white line in it... You own it." Any future problems that may make the tooth symptomatic will usually have it end up in your office. Expecting Endodontists to perform treatment on teeth/patients like this WITHOUT having a say in the restoration or treatment planning of the case places them in a very uncomfortable position. The success of the case could be dependent on treatment (or lack of it) that is NOT under their control. This is both unfair and unreasonable.

In this case, hindsight suggests that removal of the crown would have led to a higher likelihood that the canal system would have been better cleaned and shaped. This should have been done from the start but in this case a compromise was made.

Patients should be properly treatment planned BEFORE being referred and told that a new crown is an integral part of the overall treatment success. Should the patient not be willing to make the financial and hygiene commitments, then serious consideration should be given to extraction. There is no point in working hard on a difficult premolar only to risk coronal leakage or caries that results in Endodontic failure. Endodontics is hard enough to do without such compromises and patients should not ask their dentists and specialists to perform treatment under such conditions.