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January 2002The Effects of Canal Transportation In Mandibular Molars

Fig. 1

This 31 year old female patient presented with a history of recent endodontic treatment in both mandibular first molars. They both had been restored with full gold crown restorations. (Fig.1) The patient subsequently attended a second dentist that took radiographs of these teeth and was concerned with their radiographic appearance. (Figs. 3 & 4) She was then referred to me for endodontic evaluation of both teeth. The patient arrived without discomfort and was somewhat perturbed at the thought that these teeth required further treatment.

Fig. 2

The mandibular right first molar showed evidence of furca radiolucency and the presence of a fistula. This was traced to the furca area. (Fig. 2)

Fig. 3
The tooth apparently had a furca strip perforation. Although the tooth was asymtomatic, the overall prognosis was poor under the circumstances. In order to attempt to salvage the tooth, disassembly retreatment and nonsurgical perforation repair with MTA could be attempted. If that wasn't enough of a challenge, the mesial canals had been internally transported, a problem that would be extremely difficult to correct without periapical surgery.

Fig. 4

The mandibular left first molar was also endodontically treated and similarly restored with a full gold crown. The mesial canals also showed obvious straightening and internal canal transportation. Both mesial and distal apices were showing signs of periapical pathology. The distal fill was long and of questionable density. Although this tooth was also asymptomatic, it was likely that this tooth would also require endodontic retreatment.

At this point, the biggest problem that I faced was trying to tell this asymptomatic patient that retreatment of BOTH teeth was required. The prognosis for the perforated right molar was less than optimal because of the furca involvement. It was likely that both molars would require complicated endodontic surgical procedures in the mandible. It would also be necessary to inform the original treating dentist of the current situation, the need for retreatment or possible tooth loss. The potential financial and legal consequences of this situation were both severe and expensive.

Review of the bite wings shows that this patient's dentition is almost virgin. These are the only two teeth in the mouth that are restored with more than a single surface. Both second premolars are virgin and the second molars have only single surface amalgams. Cutting these teeth down to place bilateral 3 unit bridges would be less than desirable. If extractions (rather than periapical surgery) were preferred by the patient, two implants and all their attendant costs would be necessary.

The most disappointing aspect of the case centers on the total lack of regard to root and canal anatomy and lack if informed consent. Furthermore, once the canals were obviously treated in a less than optimal manner, the restoring clinician appears to have had no hesitation in restoring these teeth as if the pathology did not exist. Had this case occurred in the United States, there is no doubt in my mind that the treating dentist would be facing a substantial fee for settlement and possible disciplinary action.

Endodontic treatment can often be difficult. Mistakes, perforations and canal transportation do occasionally happen even when clinicians are careful. However, when less than optimal results do occur, it is incumbent on the clinician to explain the problem to the patient. This is part of informed consent.

Restoration of the tooth should be delayed until such time as the problem is treated and the treatment results evaluated for confirmation of radiographic and clinical healing. Failure to inform the patient of such problems combined with disregard for pathology prior to restoration can lead to charges of negligence. When problems do occur, they must be discussed with the patient and the appropriate referral to a specialist should immediately be made.