The Squid. A Study in Persistence and Access Design

I know it’s been a long time since I’ve posted so I thought I’d show a case that caused me some trouble recently. The owner of this tooth had suffered a significant facial swelling and ended up in hospital. Fortunately, the swelling had subsided by the time I saw him and he was keen to save the tooth.

Lower Premolar with unusual anatomy

A Wide Canal That Narrows Suddenly is an Indication of a Splitting Canal.

Lower premolar AP 2
Apical Periodontitis is Apparent. Note the Bulbous Shape of The Root.

The thing to note about this pre-op xray are that the canal appears to split at the mid root level. Even if you can’t see the split, the fact that the canal narrows suddenly is an indication of a split in the canal system. The second telling point that we are dealing with something complex is the bulbous shape of the root, when compared to the first premolar. This alone would tell us that we should be looking for anatomy other than a single canal.

I was able to locate two canals, and confirm that these canals joined apically, but I wasn’t happy with the position of the files in the radiograph. As you can see, the lingual canal was quite centred in the root, while the distobuccal canal is shifted to the distal. It doesn’t look right does it? There must be another canal.

Lower Premolar with unusual anatomy showing working length

Note the Off-Centre Location of the Second File

So…. I know to look for a third canal, but no matter how hard I looked, I just couldn’t find it. The canal were prepared and obturated, with the result below.

Initial Obturation Unusual Premolar

After Preparation and Obturation a Small Squirt of Sealer to the Mesial Confirms the Missed Anataomy

So you can see the squirt of sealer to the mesial at the mid-root point. There is no doubt that some anatomy has not been properly cleaned, and would likely be full of infected tissue. Back in we go. The GP was removed and the access expanded to allow location of the canal to be identified and confirmed with a file.

Unusual Anatomy in Premolar

There it is!

The third canal was then prepared. It too joined the other canals apically. The key to cleaning this sort of anatomy is passive ultrasonic irrigation, which I have discussed previously. The only way to then obturate is with a warm technique such as continuous wave or warm vertical. The tooth, of course needs a crown. In this case persistance paid off and the outcome can be much more certain now that the full anatomy has been cleaned and obturated. In hindsight, a cone beam CT scan may have assisted in locating the full anatomy.


Premolar with unusual anatomy

I Call This Tooth “The Squid”

Unusual Anatomy of Premolar After Obturation

The Arrow Shows the Spot Where the Missing Canal Was Located

19 Responses to “The Squid. A Study in Persistence and Access Design”

  1. dr aparna June 17, 2012 at 1:18 pm #

    comlpex anatomy n superb work!!!!!!!!!!!!!!!!!!

  2. Mateus Miranda June 17, 2012 at 1:31 pm #

    Great Job Patrick! Amazing case.

  3. Dr. Ibadatpreet June 17, 2012 at 2:04 pm #

    nice one i have also treated a case with the canals in same configuration however the patient wasn’t relieved from symptoms. maybe i have missed the third canal. ll try nxt time

  4. Suzana Sarout June 17, 2012 at 3:16 pm #

    Nice work,and usefull hints to uncover complex anatomy!

  5. Dr Sanjay Jamdade June 17, 2012 at 4:14 pm #

    Nice work!

  6. dr. Chaniotis Antonis June 17, 2012 at 4:55 pm #

    Nice work. thumbs up!!!

  7. Dr. Natalie Archer June 17, 2012 at 9:48 pm #

    Love the learning! Love how how you share this step-by-step. This is indeed a lesson and case that should be shared with all dentists practicing endodontics. Congratulations on pursuing and achieving clinical excellence!

  8. Unni June 17, 2012 at 10:48 pm #

    Brilliant stuff. Thanks for sharing. The mental F looks scary close.Nice apical control.

  9. Dr Sanjay Nayak June 18, 2012 at 1:42 pm #

    Fantastic work ..SQUID it is!!!!!

  10. Jamisson June 19, 2012 at 10:07 pm #

    Nice work,Thanks for the presented case.

  11. anand patil June 20, 2012 at 11:47 pm #

    superb … even the other pm has cmplex anatomy

  12. dr bhadra rao June 25, 2012 at 2:12 pm #

    its a good case i have done a similar case like this but the problem with my case was that the pt was an old female 70 yrs of age .u can think how difficult it will be to locate a canal in those cases becos mst of the canals have thinned out but the end result was fantastic i have iopas of that case

  13. Katie Simpson August 15, 2012 at 10:26 am #

    U rock Pat !!!!!!!!!!

  14. Pat Caldwell August 15, 2012 at 7:50 pm #

    Thanks Katie!

  15. nadezda August 20, 2012 at 1:19 am #

    Thanks for education.great job.

  16. Harry December 27, 2012 at 8:04 pm #

    obviously great efforts. You need patience ,practice , experience, updated knowlede and guidance to tackle this challenges

  17. Karina Cvejic March 4, 2013 at 5:41 pm #

    Wow! What an interesting case and some intriguing anatomy. I have just stumbled across your site Pat, enjoying it thoroughly! Thank you for sharing your expertise!

  18. Kaveh Iranparvar August 5, 2013 at 5:02 am #

    Great! Bravo.

  19. Dylbert February 1, 2014 at 5:18 am #

    Also just stumbled across your site Pat and also thoroughly enjoying it.

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