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May 2007 – Case Selection - How Best to Handle That Calcified Anterior Tooth?

A 73 year old female patient was sent to me for completion of an endodontic case that had already been accessed.

Fig.1 Referral’s Preop

In Fig.1 the referral’s preoperative radiograph shows no discernable canal space. There was no history of trauma .Pulp tests were negative to cold and electricity. Perio findings within normal limits but tooth has elevated mobility and a draining buccal sinus. There was evidence of the mesial proximal restoration on at least two occasions. Buccal palpation sensitivity was minimal and aside from the draining sinus and greater than normal mobility, the patient was asymptomatic. She didn't seem too concerned about anything other than the sinus and the perceived area of "infection".

Diagnosis – Chronic Periradicular Periodontitis secondary to pulpal necrosis – Severe canal calcification

Endodontic treatment required but how best to treat this case?

Figure 2 - My Preop #1
Figure 3 -My Preop #2

The referring dentist attempted endodontic access. After being unsuccessful, the case was referred to me. Figs 2 & 3 show the case as it arrived in my office.

The coronal aspect of the tooth was beginning to become compromised and this was recognized by the dentist. The film does not show any radiographic evidence of a canal until almost the level of the foramen ( Fig.3) and even then, it could just be superimposition of the lesion/apical resorption over the root apex.

Figure 4 – Limit of Access

After approximately 30 minutes of slowly proceeding down the root I was almost at the limit of the Munce Burs I was using for access. I also noticed that I was beginning to drift distally. If I continued much further the risk of distal perforation was high. We also must recognize that the apical portion of lateral incisor roots also tends to bend distally and palatally, increasing the chances of perforation at that level.

Figure 5 – Final Image

At that point I decided to stop my access attempts and explain to the patient that the most apical canal space was not negotiable from this aspect. I offered her three alternatives:
  1. SRCT (not advised)
  2. Implant
  3. Extraction and addition to existing partial upper denture
Because we had enlarged the access so much in our initial attempts to find the canal, I was not happy with the long term prognosis for the tooth should we continue with a surgical root resection and retrofil. The physical structure of the tooth would be compromised and the crown root ratio would be poor. An implant was out of the question for financial reasons.

After explaining all options to the patient, she elected for extraction and addition to her current cast partial upper denture. She did not seem to be concerned about loss of the tooth and I felt that because of this ( and her limited dental IQ) this offered the best solution for her.


In hindsight, I believe that this patient would have benefitted from better preoperative case assessment and evaluation of overall level of difficulty. The canal was clearly not visible radiographically and would have been extremely difficult to locate, even with a scope. The initial access was larger than desirable. Had I received the case prior to the access, I likely would have not elected to treat the tooth conventionally and proceeded directly to surgery. In that way the root dentin would have been conserved and the strength of the tooth would not have been compromised. We probably could have saved this tooth with a very easy, conservative surgical procedure that had a high rate of success. However, after explaining the steps involved, the patient was NOT interested in a SRCT. Implant replacement not possible because of financial considerations. Ultimately the patent chose extraction addition to the existing partial denture. She seemed relatively unperturbed by the potential loss of the tooth and was satisfied that we had done our best under the constraints of the options she gave us.

What can we learn from this case?
  1. Before considering endodontic access in the aesthetic zone, we need to seriously consider the possible destructive effects of the access when attempting to locate calcified canals. If you attempt this without using an SOM (even WITH loupes! ) the problem is usually not the level of magnification . ( Though that IS important!) Most often you simply do not have enough light that far in the canal to see the changes in dentin coloration that lead you to the canal. The deeper you go the less light you have and more poorly you see.

  2. If we cannot improve the situation by conservative treatment we need to weigh all factors and decide whether a surgical alternative may be the right treatment for the case. This needs to be done BEFORE we initiate treatment.

  3. Some patients ( especially those with a history of multiple extraction and removable partial denture prostheses) have a limited dental IQ and appreciation for keeping their teeth. As such they are generally not good candidates for surgery and frequently elect for extraction rather than surgical intervention.
We can't care more about patient's teeth than they do !