Unlike many of my peers here in North America, I use lots of calcium hydroxide paste in my cases for reasons like these. The medication gives less-than ideal work a more-than fighting chance to be successful.

Here’s how I first saw these teeth. There is a blurry history of trauma (kickboxing injuries) and when I first saw the patient there was discharge associated with 22.

This first xray is from August 2nd, 2006.

At this point, 22 looked like it had suffered from incomplete root formation, some external resorption, possibly dens-in-dente, and of course infection. I thought I’d have a rough time locating the canal.

Not so. During treatment, I found a massively large canal that was much, much shorter than where I expected it to end. I cleaned things up as best I could and then loaded the canal up with calcium hydroxide for a couple of weeks (or a month…I can’t remember off hand).

The next xray is from October 11th, 2006. Obturation is obviously short of where the root ends, but electronic apex readings were consistent to this point. This angle also shows that what I thought was a root with a canal was actually just one side of the actual root. I started to worry about some sort of vertical root fracture having split the root up the middle. There was no internal visual evidence of this however, and the medicated phase had cleared up the sinus tract.

Later films will show that that left part of root might actually be a root tip that’s floating around from a horizontal root fracture. I reasoned that the short apex readings were either from a resorptive perforative defect through the root at that level, or because of the blunderbuss apex.

When there’s doubt, I use the apex locator as my diviner of length. Once I can get consistent readings with it, I tend to trust it beyond what my eyes see.

One more thing: I informed that patient that a lesion was now becoming apparent apical to 21.

The next film is from November 8th, 2006. Tooth 22 was doing fine, but another sinus tract had appeared. A sinugram traced it to the apex of 21.

A retreatment with a medicated phase was initiated for the tooth.

The canal was cleared, medicated with calcium hydroxide for a month, and then obturated. The apical canal area was irregularly calcified because of the incomplete root formation and the previous work. That’s still no excuse for the voids in the obturation…But proof of success is always in the pudding.

This xray is from February 26th, 2007. It’s post-obturation of 21.

And this next one is from July 30th, 2007. The lesions are shrinking and trabeculation is becoming apparent within them. I’m still not sure what happened with 22 and I’m not sure at this point what is happening. There’s either some external resorption going on as the bone heals and remodels, or that one thing that looks like a root is a root and it’s moving around…

I’ve been temped to go back into 21 and try to improve the appearance of the apical obturation so that the case is more presentable. That, however, won’t necessarily be serving the patient’s best interest. Healing is occurring, so we know there are no bacteria up there. The remaining obturation is good. Any corrective work would be for my benefit rather than the patient’s.

I was moving wood last weekend to try to clear the backyard up a bit more before the landscaping started. I had just climbed on top of the pile of wood that I was creating when one of the pieces rolled down and landed on my left hand. It then bounced off and landed on my right index finger tip squishing it so much that it broke skin just under the front of the nail. Blood copiously dripped out.

I was so deeply under the influence of Advil Cold and Sinus pills for my allergies that I hardly felt anything. I did notice that my knuckles were scraped quite nicely on my left hand and did think that my right index finger should be hurting more than it was.

Anyway, being right-handed, and having a sore finger there, it’s a given that this week all of my cases would involve picking my way down calcified canals or around curves. The finger is definitely hurting now.

Here’s a retreatment that I finished today. It was completed by an endodontist late last year and remained bite sensitive. He recommended apical surgery to address the symptoms. The patient came to me for a second opinion.

Because I thought that I could improve on the endo, I recommended a retreatment with consideration for an adjunctive surgery if necessary. Long story short, the post op film shows some decent improvement on the technical quality, but what’s more interesting is the up-bend at the tip of the mesial root. WTF? No wonder my finger is sore today.

At least the patient is comfortable with the tooth now.

I’m almost finished posting all of my interesting archived cases. Just one more to go after this one:

This one is from about 6 years ago, which explains the multiple backfill voids in the obturation. Anyway, I don’t know how many of my peers would attempt a retreat on this tooth. That post which looks like it would tack down drywall appears menacing to remove. It actually came out extremely easily. That was a pleasant surprise. The other surprise was the fifth canal.

That’s one mutant tooth.

The first xray is a duplicate which accounts for the poor quality. The case was referred to me by the patient’s new dentist. When I saw the patient, a parulis existed in the buccal furcation area. Apparently the endo was done in the 80′s and retreated by the previous dentist 1-2 years ago. That was when obturation material was pushed out the apex and the carbon fibre posts were placed and the bridge with the open distal margin was glued on.

I’m posting this case to show that extruded gutta-percha generally doesn’t cause problems.

The canals were cleared and medicated with calcium hydroxide paste for 6 weeks. The parulis disappeared. I obturated the canals.

Carbon fibre posts are a real pain to get out because I have to pretty much drill or ultrasonically destroy them to get them out; unlike metal posts which I can usually get out in one piece.

The extruded material had no impact on healing. The open margin on the distal will have an affect on healing if it isn’t addressed.

I just saw this case for a recall. The first xray is preop from May 2005, the second is a recall film from Jan 2007.

I wasn’t able to get the silver point out in toto from the MB1 canal because it ended up fragmenting on me around the curve. I was able to bypass it though. The tooth was medicated with calcium hydroxide paste for a couple of weeks then obturated.

Looks like healing is progressing well. However I wouldn’t be surprised if, once healing is complete, we see a residual lucent area around the extruded part of the silver point. Chances are a persistent foreign body reaction will go on there.