This tooth story is more like a tooth SAGA!! Spanning three treatments and seven years, this totally illuminating case blew my mind, and I think it’s going to blow yours, too.
Let me begin by asking: Have you ever seen a tooth that just doesn’t want to heal?
Root canal anatomy is tricky. When a tooth doesn’t heal from a root canal, most people just assume that the tooth is cracked and that it can’t be saved—basically a one-way ticket to extraction. This is probably my biggest pet peeve that is all too common in dentistry. The term “cracked tooth” gets thrown around way too loosely. And I think this story will illustrate why it’s usually not as simple as that.
In fact, there aren’t as many cracked teeth as you may think in dentistry, and often it’s just a flat out misdiagnosis.
Hopefully this case will illuminate how you might think differently about failing root canal cases.
Let’s take a look at the case’s early days.
I first met this patient way back in 2013. Below is her preoperative radiograph. She had a nice ol’ lesion on the MB root. You could even say it looks exactly like that “J shaped radiolucency” that defines a cracked root. What’s more, the tooth had no response to cold and no pain to percussion or palpation. To boot, all of her probing depths were within normal limits.
Here is an off-angle radiograph to give you another view:
And the bitewing, for good measure:
Applying a clinical eye to the root canal’s anatomy, you can see all the microleakage and the way that bacteria managed to sneak into this tooth. It’s pretty clear these are childhood amalgams that have never been replaced and now allow bacteria to make their way to the pulp. Leaving these restorations to sit for decades is not the move! When you start to see these spider webs emanating from the restoration, you know they are leaking and the teeth are developing cracks. BUT, these cracks are coronal and they don’t probe, so keep that in mind.
There is a HUMONGUS difference between a crack in the tooth and a vertical root fracture!! Nomenclature is really important here and when it comes to a case like this, you can’t be too careful with your words.
Adding an additional tricky layer to the root canal anatomy, this patient had no pain because there was a sinus tract. But since there was a sinus tract, we traced it and… sure enough, it led to a lesion. Thought it was sneaky, didn’t it!
The final diagnosis for this tooth was Necrotic Pulp and Chronic Apical Periodontitis #3. Keep in mind, I performed this case when I was a baby endodontist. It was one of my earlier root canals. At that time, I only found 3 canals in this maxillary first molar.
Here’s something I learned from this case: Look for MB2s!
This is the case that made me realize that MB2s are always there and that if you don’t find one, you should probably use a CBCT to get a closer look at the root canal anatomy. Better yet, just start always taking a preoperative CBCT so that you get a more complete picture before you even start. Doing so can help you do risk assessment and lead to greater success down the line.
Listen, MB2s don’t always have to stare you in the face. They are often a bit deeper and more apical than the orifice of the MB1, and you have to selectively trough the area in order to find them.
But, hindsight being 20/20, one thing I wish I would’ve noticed is just how offset that single MB canal is within the MB root. That is a dead giveaway that there is a second canal hanging out waiting to be found in the root. In the radiograph below you can very clearly see the offset that I’m talking about.
The saga continued the following year.
The patient ended up returning to my office in 2014 and the sinus tract was still there. She never healed. Great. 😥
At the time, I didn’t take a CBCT on every patient, but I ended up taking one when she returned. The axial slice showed me this bad boy:
I can see from this radiograph that there is a very broad MB root and that means there’s room for an MB2. Now, I can’t see the actual canal on the CBCT, but that doesn’t mean that the MB2 is not there—it’s probably just super skinny. So now I have to pull on my detective gloves and FIND IT.
And I did. There was honestly so much more to this tooth’s root canal anatomy than I realized. In the radiograph below you can catch a glimpse of that teeny tiny MB2.
And here is the final result:
And the off angle radiograph …
But GET THIS— the story doesn’t end here.
The story keeps going!
Fast forward to 2021 (SEVEN YEARS LATER) and the lesion is still there. ARE. YOU. KIDDING?! 😵 😱
Okay, okay. Let’s slow down.
What could this mean? Is this tooth cracked? I mean we saw all of those cracks coming from that amalgam that perhaps one of them propagated over time. There is clearly a vertical root fracture, right? Well, I am not so sure.
Take a closer look at the radiograph below. Can you see the tiny sealer track coming from the MB2? Could that be an MB3? And if it is…how am I supposed to get to that?
I had a long, honest talk with the patient about her treatment options. I told her that since her last retreatment was done, there have been some advances in technology like the GentleWave Procedure. We could choose to retreat the tooth one more time with it, or we could take the surgical approach and do an apico. The patient opted for the surgical approach.
My associate, Dr. Tanya Reiter, did the surgery and—dang! Did she knock it out of the park! Check it out.
She did the root resection and used an ultrasonic to really clean out the isthmus that existed between the MB1 and the MB2.
She followed that up with the retrofill:
This is what the root end looked like: there was way more to the root canal anatomy than was expected, there was an apical MB3, one heck of an isthmus, and not one crack to be found!
And when you take the postoperative off angle radiograph it looks like this…holy smokes, right?!
Soon this client will return for her follow-up and I’m crossing my fingers that it’s a healed tooth.
Lessons learned from this epic tooth story
I know she must be frustrated, that it has taken her three treatments (and seven years!) to get this far. The reality is that part of this stems from my inexperience when she first came to me as a patient. But it also has to do with the lack of technology back then and the root canal anatomy of the tooth.
I point this out because I think it’s important not to beat yourself up when a treatment doesn’t go exactly how you want. You don’t deserve that. Instead, learn from it!
This case was a HUGE learning opportunity for me. It made me start taking CBCTs when I don’t find an MB2 because I know that they should be there almost every single time. It also taught me that troughing can help you find the MB2 and help you get a handle on the oh-so-variable root canal anatomy. So don’t forget it!
Let MY mistake be YOUR lesson.
Many people would have extracted this tooth, but my goal is that this tooth story makes you think about the other possibilities and can help you inform your patients and make the best decisions together.
What comes up for you when you check out this tooth story? Let me know in the comments!
How do you think this case would have turned up had gentle wave been used right from the beginning?
Thanks for sharing,
I think with the GW right from the beginning, it would probably would have healed easier. That’s the beauty of technology and our field expanding. I do wish the GW was invented when this case was first started. I do think this would have been a different tooth story.
Did you charge her for each retx?…the pt went thru alot of procedures over a period of time..what’s your thought of ext , implant or fixed bridge in this scenerio… thoughts from a general dentist.
I charged her for the initial root canal and the apico, but the not the retreatment in between. The possibility of an apico is always a possibility with any root canal and this is never covered in the cost of the root canal. This is covered in the informed consent prior to treatment since it usually is not the fault of the operator. There can be natural anatomy or obstructions in the tooth that are not observed until you enter the tooth. I hope that makes sense :).
Love your tooth stories!
Before I took Cliff Riddle’s course I didn’t realize how many maxillary first molars have 4 canals. One of my patients had 5 canals! Assymetry of the canal in the root is a great thing to make you realize there is probably another canal. Your posts are great!
I learned a lot from this story . Thank you sooo very much. You really are a true tooth saver. You inspire me to save more teeth.
Thank you for reading!