|Case of the Month
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July 2003 – 3 Rooted Molar Presents Challenges
By definition, Endodontic specialty practice deals with a lot of molar teeth. Approximately 75-80% of the cases I treat involve molars. While much attention is focused on Maxillary Molars because of the "notorious" MB2 ( and MB3 !), mandibular molars too can present difficulties due to anatomical variations. C shaped mandibular 2nd molars are relatively common and are frequently associated with patients of asian or aboriginal background. One other variation of this tooth has a "Lingual" or third root.
This month's case of the month deals with the wife of a referring dentist who presented with a mandibular right first molar that required treatment after an all ceramic restoration had been placed by her husband. The tooth had never been totally comfortable and she wished me to perform endodontic treatment due to continuing persistent symptoms.
The preoperative film showed a deep restoration with pin core composite.
Fig. 1 - Preoperative film - Vital Tooth with no Pathology visible.
Look closely at the Distal root outline, especially on the mesial side.
Fig. 2 - Working length image showing 4 canals and three separate roots.
After considerable efforts over 2 appointments, all canals were negotiate, cleaned and shaped using small hand files ( .06 and .08 initially) followed by ProTaper Rotary Ni-Ti files. The DL canal had the typical buccal curvature toward the apical third and was extremely narrow.
Fig. 3 - Final fill - Restoration to be completed by the referring Dentist
Anatomical variations must be constantly kept in mind when considering endodontic treatment. Expect the "unexpected" and always make sure that preoperative images are closely examined for root anomalies, extra canals and unusual coronal anatomy that may tip you off to an unexpected situation.
Failure to take these factors into consideration can result in problems. In the best case scenario, lack of treatment of part of the canal system in a vital case can result in a chronically sore tooth that doesn't resolve even though the post treatment image may appear to "look good". ( That is also an excellent reason to take multiple angles the tooth.) In the worst necrotic cases, it can result in outright endodontic failure with periapical pathology and serious patient discomfort or blow up.