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Tooth #3 with 5 +1 canals
I saw this patient for RCT #3 following a large carious pulp exposure when his dentist was attempting a restoration. Upon access, I noticed that he had 6 canals : 2 in each root (MB1, MB2, DB1, DB2, P1 & P2). I was unable to negotiate MB2 all the way to the apex despite all the time, effort, ultrasonics, 17% EDTA & multiple use of c-files.
Posted in Root canal anatomy
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Tooth #2 with an extra palatal root
I saw this patient for RCT #2 sometime back. The patient had a separate second palatal root. As discussed in my previous posts on Radix, an extra lingual root in madibular molars are called Radix entomolaris. However, I am not sure whether an extra palatal root on the upper molar can also be catagorised as Radix entomolaris. I loved performing the treatment for her & decided to share this unique anatomy with you all.
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Pre-Op x-ray showing extra palatal root
Master cone x-ray
Post-Op x-ray
Posted in Root canal anatomy
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MB3 Canal
I saw this patient sometime back for ReTX #3. RCT was done in several years back in India. Patient was asymptomatic. Initial RCT was inadequate with periapical radiolucencies on all the roots. The tooth was percussion & palpation negative. Probings & mobility were WNL.
Diagnosis: Previously treated with asymptomatic apical periodontitis #3.
Treatment plan: ReTx #3
Upon access, I found missed MB2 & MB3. During the first visit, all the canals were cleaned & shaped & a Calcium Hydroxide dressing was placed as an intracanal medicament. Patient relocated to India & the treatment was never completed by me.
Since it’s not usual to find MB3, I decided to share it on my blog. 
Pre-Op x-ray
Access picture showing MB3
Posted in Root canal anatomy
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C-shaped Molar #18 Melton’s Type I
Here is another case of C shaped Molar with Melton ‘s Type I Classification at the orifice. Patient was from Indian subcontinent. Upon access, a continuous C was noticed. Again, I do not have any access pictures to prove it but to trust my words for the fact. Persistent hemorrhage despite thorough cleaning was observed. Ultrasonic vibration & copious irrigation with Sodium Hypochlorite, intracanal dressing with Calcium Hydroxide, 17% EDTA for smear layer removal were employed to maximize the removal of pulpal remnants from the unreachable areas.
Here are the pre-op & post-op x-rays.
Notice the mesial open margin in the temporary restoration. The temporary restoration was replaced immediately.
Posted in C-Shaped Molars, Root canal anatomy
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C- shaped molar #18 Melton’s Type III
I saw this patient approximately 8 months back. She was in her early 30′s & immigrated to US from China. Patient had her #19 extracted at a very young age resulting in mesial tilt on #18. Her dentist had diagnosed a crown on #18 & unfortunately she developed severe pain in the tooth following crown prep. When she came to me, she still had her temporary crown on. She had an abnormal, lingering response to cold & percussion tenderness. Palpation, perio probing & mobility were within normal limits (WNL). Based on the tests, the pulpal diagnosis was symptomatic irreversible pulpitis & periapical diagnosis was symptomatic periapical periodontitis.
On the pre-op x-ray, notice the conical fused roots. C-shaped molar was suspected considering the root canal anatomy & the ethnicity of the patient.
In a different angled pre-op, you can notice the vague separation of roots & canals seems to be merging at the apex. Also, notice the proximity of canals to the furcation.
I completed the treatment in one visit considering that the tooth was vital. Here is the post-op x-ray. Looking back, I wish I was more cautious about the extent of sealer extrusion.
Posted in C-Shaped Molars, Root canal anatomy
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C-Shaped Molars
The C-shaped canal was first recognized by Cooke and Cox in 1979. C –shaped molars is so named for their C-shaped cross sectional morphology of the root and the root canal. These teeth generally have conical fused roots & a longitudinal groove on lingual or buccal surface of the root (Usually deep groove, mostly lingual). C-shaped canals have a fin or web connecting the individual root canals—the orifice may appear as a single ribbon-shaped opening with a 180° arc linking the two main canals.
It is speculated that this anatomy is caused by the failure of the Hertwig’s epithelial root sheath to fuse on the lingual or buccal root surface. However may also be formed by coalescence because of cementum deposition.
Incidence:
This shape can vary along the length of the root & therefore the appearance of the canal orifice may not be good predictors of the actual canal anatomy. Melton’s classification is not elaborate enough in describing these variations. Here is another classification of C-shaped canal system.
Clinical significance:
Type II: conical or square, vague separation of roots, the two canals are separate all along the root
Type III: conical or square, vague separation of roots, one canal superimposed on the separation
- Most common in lower second molars but can also be seen in maxillary molars & other mandibular molars & premolars
- Incidence: 31.5% in Chinese population & 13% of mixed Asian population (Yang ZP,et al.,1988), 2.7-7.6% in a Caucasian population(Weine FS, et al., 1998)
- When present on one side, a C-shaped canal may be found in the contralateral tooth in over 70% of individuals (Sabala et al. 1994)
This shape can vary along the length of the root & therefore the appearance of the canal orifice may not be good predictors of the actual canal anatomy. Melton’s classification is not elaborate enough in describing these variations. Here is another classification of C-shaped canal system.
Clinical significance:
- Radiographic clues: These teeth generally have conical fused roots. Fan B et al. proposed three radiographic types.
Type II: conical or square, vague separation of roots, the two canals are separate all along the root
Type III: conical or square, vague separation of roots, one canal superimposed on the separation
- The pulp chamber is usually situated deeply. In a recent µ-ct study by Fan B et al., in 98.1% of these teeth, orifices were located 3mm below the CEJ. Hence this should be taken into account during access opening.
- Canals are generally closer to furcation making them highly susceptible for strip perforation either during cleaning & shaping or post placement. Big sized & greater taper canal preparations should be avoided. Anti curvature filing technique is also helpful.
- Melton showed large amount of uninstrumented canal space & debri in histological sections. Cooke and Cox were first to describe the clinical significance of C-shaped canals, which present a challenge with respect to their debridement and obturation. This is especially true when it is uncertain whether a C-shaped orifice found on the floor of the pulp chamber may continue to the apical third of the root. Irregular areas in a C-shaped root canal system that may house soft tissue remnants or infected debris & escape thorough cleaning or filling. Copious irrigation with NaOCl, 17% for smear layer removal, Calcium Hydroxide as intracanal medicament, ultrasonic vibrations to disintegrate the attached debri are some of means of getting these canals clean.
- Obturation is also challenging due to their intricate anatomy. Thermoplasticized technique is advocated to obtain a three dimensional fill.
Posted in C-Shaped Molars
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Radiographic Illusion
Patient referred for a consult for Re-Treatment on #8 with a previous history of RCT five years back. Patient reported a previous history of trauma. As a result she fractured #8 & her then dentist recommended & performed RCT. Pt. is presently asymptomatic.
As part of my consultation, I tested rest of the upper anterior teeth. All of them responded normally to cold & percussion, palpation, perio, mobility were all WNL. #8 was percussion negative, palpation negative, perio & mobility was WNL & had no response to cold. PA shows Peri apical radiolucency (PARL) in relation to # 8. No palatal swelling, pain or discharge noticed.
I was a little suspicious with the look of PARL. I could clearly see the intact PDL of #8 within the shadow of the radiolucency. Advised my assistant to get me different angled PAs. Look at the shift in the radiolucency!!! Applying the SLOB rule, the radiolucency is located palatally.
Clinical impression:
Incisive foramen causing an illusion of peri apical radiolucency.
Differential diagnosis: Nasopalatine duct cyst (Incisive canal cyst).
Tx plan: Monitor. Pt. put on a 6 month recall to monitor for any symptoms & change in size of radiolucency.
Bottom Line: X-RAYS CAN LIE. WE NEED RADIOGRAPHS WITH MULTIPLE ANGLES TO BRING THE TRUTH OUT. Taking multiple pre-op x-rays for this patient prevented her from getting an unnecessary re-treatment of #8
I was a little suspicious with the look of PARL. I could clearly see the intact PDL of #8 within the shadow of the radiolucency. Advised my assistant to get me different angled PAs. Look at the shift in the radiolucency!!! Applying the SLOB rule, the radiolucency is located palatally.
Clinical impression:
Incisive foramen causing an illusion of peri apical radiolucency.
Differential diagnosis: Nasopalatine duct cyst (Incisive canal cyst).
Tx plan: Monitor. Pt. put on a 6 month recall to monitor for any symptoms & change in size of radiolucency.
Bottom Line: X-RAYS CAN LIE. WE NEED RADIOGRAPHS WITH MULTIPLE ANGLES TO BRING THE TRUTH OUT. Taking multiple pre-op x-rays for this patient prevented her from getting an unnecessary re-treatment of #8 #19 with 5 canals & Radix entomolaris
This was my last patient on a Friday. Patient was late & we were about to go home. Since the patient was in pain & we decided to perform the treatment staying back late. It was totally worth it. It was so much fun performing the treatment & patient was highly appreciative of it.
#30 yr old Korean Male referred for consult & treatment of tooth #19
C/C: “ Hurts when I drink something cold. It really hurts bad”
Patient had deep Restoration (Ag) close to pulp
Tests: Cold AB Percussion +ve, Palpation –ve, Perio/Mobil WNL
Diagnosis : Symptomatic irreversible pulpitis with symptomatic apical periodontitis
When I opened it, I noticed the DL orifice located too far distally. Upon troughing between MB & ML, found a Middle mesial (MM) closer to MB orifice. MM joined with MB at coronal & middle third. This office did not have microscope & the treatment was done with my 4.5x loupes. I wish I had a microscope with a camera adaptor. The access with 5 canals looked really pretty.
Fig 1: Pre-Op x-ray
Fig 2: WL x-ray 1
Fig 3 : WL x-ray 2
Fig 4: MC x-ray 1
Fig 5: MC x-ray 2
Fig 6: Post Op x-ray
Here is some information on Middle mesial canals:
Fig 1: Pre-Op x-ray
Fig 2: WL x-ray 1
Fig 3 : WL x-ray 2
Fig 4: MC x-ray 1
Fig 5: MC x-ray 2
Fig 6: Post Op x-ray
Here is some information on Middle mesial canals:
- Incidence rate : 1 to 15%.
- MM canal may have a separate foramen or join apically with either the mesiobuccal or mesiolingual canal.
- Clinical clues: Trough between MB & Ml & carefully look for a catch from the orifice of MM (If present).
Posted in Radix Ento/Paramolaris
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Periapical Cemental Dyplasia
I recently saw this young East Indian women for an endo consult for teeth # 23,24, 25. Patient was asymptomatic. She reported previous history of trauma 5 years back. She fell off chin down resulting in laceration to the lower chin area. I could see the scar on her lower chin from previous trauma & suturing. My first instinct was pulpal necrosis resulting in Peri apical radiolucency in her lower front teeth due to delayed effects of trauma. Peri apical cemental dysplasia was not in my list of differencial diagnosis at all at that time due her obvious history & ethnicity. Perhaps I would be more suspicious of this condition if I had a middle aged afro american women on my chair.
When I did my usual vitality tests as part of my consultation, I was amazed to find out that all her lower teeth gave a normal response to cold test. Percussion/palpation/ probing depths & mobility were all within normal limits (WNL).
I was able to get her year old FMX & saw the same PA lesions on #23,24,25 even then. I ordered a pano to see if there were any other lesions in rest of her jaw & did not find any.
LOOKS ARE DECEIVING!!!!!
Here is some information about this condition.
Here is some information about this condition.
- Reactive or dysplastic process rather than neoplasm.
- Abnormal response of periapical bone & cementum to some unknown local factor.
- Occurs at apices of vital teeth: usually multiple teeth, common in lower anteriors
- Common in middle aged women of afro american descent
- Three types: periapical cemental dysplasia (common in blacks), focal cemento-osseous dysplasia (caucasians), and florid cemento-osseous dysplasia (blacks). periapical occurs most commonly in the mandibular anterior teeth while focal appears predominantly in the mandibular posterior teeth and florid in both maxilla and mandible in multiple quadrants.
- Diagnosis is by positive(normal) tooth vitality test
- Cemento ossifying fibroma is differential for single lesion where tooth has been removed
- No treatment is needed. Infact, I have heard from an oral pathologist that unnecessary endodontic treatment/surgery or extraction makes the lesion worse.
Posted in Non-Odontogenic causes
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