Endo Addict

When Extraction Isn't the Safest Option

Sometimes, the most challenging tooth isn't the one we plan to save—it's the one we plan to remove.

A patient presented with severe pain involving the maxillary right second molar (17) and third molar (18). The initial treatment plan appeared straightforward: perform root canal treatment for tooth 17 and extract the symptomatic 18.

However, radiographic examination completely changed the treatment strategy.

The preoperative radiograph revealed extensive maxillary sinus pneumatization, with the sinus floor intimately surrounding the fused roots of the maxillary third molar. The anatomy indicated that extraction carried a high risk of creating a large oroantral communication, which could potentially develop into a persistent oroantral fistula.

The situation became even more challenging after discussing the patient's medical and social history. He was a heavy smoker and admitted that smoking cessation would be extremely difficult, if not impossible. This significantly increased the risk of delayed healing and postoperative complications should an oroantral communication occur.

After discussing all available treatment options, risks, benefits, and prognosis with the patient, a conservative approach was selected. Instead of extraction, we decided to attempt nonsurgical root canal treatment of tooth 18, together with conventional root canal treatment of tooth 17.

The patient also had a very limited schedule and requested that treatment be completed in a single visit, if feasible.

Despite the significant technical challenges—including the posterior position of the maxillary third molar, restricted access, difficult angulation, and complex anatomy—the patient maintained adequate mouth opening and excellent cooperation throughout the procedure.

Both teeth were successfully treated in a single appointment. Root canal treatment was completed for teeth 17 and 18, followed by definitive coronal restoration. Both teeth were subsequently restored with full-coverage crowns.

K-File #10… My Favorite File… Until It's Time to Retrieve It. 😅

Hopeless... or Worth Fighting For? 🤔

Sometimes, what looks like a hopeless tooth deserves a second look.

Case Presentation

A 36-year-old male presented seeking restoration of tooth #16. The tooth exhibited extensive structural loss due to a large carious lesion. Clinically, a pink soft tissue mass was visible in the center of the cavity, strongly suggesting a perforation with exposed periodontal tissue.

Clinical Findings
Symptomatic tooth.
No tenderness to percussion or palpation.
Physiological mobility.
Short root trunk.
Roots in close proximity to the maxillary sinus.
No furcation involvement.
Moderate oral hygiene with moderate calculus deposition.
Adjacent teeth were intact, showing only small proximal carious lesions.

Although the patient was cooperative, he admitted that he hated dental visits and could not even remember his last dental appointment.

Treatment Dilemma

The prognosis was clearly compromised.

Extraction followed by implant placement would normally have been the preferred option. However, the patient strongly refused extraction and wanted every possible effort made to save his natural tooth.

Implant therapy was also rejected because it would require a sinus lift procedure.

A conventional fixed bridge was not considered appropriate because it would sacrifice healthy neighboring teeth, while a removable prosthesis was impractical for this patient. A resin-bonded bridge (RBB) was also excluded because the patient was unwilling to accept the possibility of repeated debonding.

Treatment Planning

Following detailed clinical assessment and CBCT evaluation, a conservative treatment plan was developed.

Interestingly, the pink tissue seen clinically was not a perforation. It was a pulp polyp (chronic hyperplastic pulpitis) originating from the palatal canal.

During careful excavation of the deep caries, a small furcation perforation unfortunately occurred. The defect was immediately repaired with MTA, minimizing contamination and preserving the prognosis.

The Restorative Challenge

The greatest challenge was not the endodontic treatment—it was restoring the tooth.

There was insufficient remaining tooth structure to obtain an adequate ferrule effect.

Neither crown lengthening nor orthodontic extrusion would have provided enough sound tooth structure because of the patient's naturally short root trunk, while both options would have further compromised the long-term prognosis.

Final Decision

To maximize structural integrity while preserving as much remaining tooth as possible, the tooth was reinforced using:

✅ Ribbond fiber reinforcement
✅ Fiber-reinforced composite build-up
✅ Indirect Hyper-Ceramic onlay restoration

This case reminds us that every compromised tooth deserves a comprehensive assessment before making the decision to extract.

Sometimes, with proper diagnosis, meticulous treatment planning, modern endodontic techniques, adhesive dentistry, and a motivated patient, we can preserve teeth that initially appear beyond saving.

Because in Endodontics... "hopeless" is not always the final diagnosis.

stay tuned full case soon

Don't rush, and take a deep look 😉

An 11-year-old female patient presented to my clinic complaining of:

🔸 Severe pain in the lower right posterior region
🔸 Grade II mobility of the mandibular first molar
🔸 Mild facial swelling

On taking the history, the patient's parent reported that the tooth had received a composite restoration approximately 9 months earlier, but no endodontic treatment had been performed.

After thorough clinical and radiographic examination, the diagnosis was established as:

✅ Pulpal Diagnosis: Necrotic Pulp
✅ Periapical Diagnosis: Symptomatic Apical Periodontitis with symptomatic apical involvement

🩺 Treatment Plan
First Visit (Emergency Appointment)

✔️ Access cavity preparation
✔️ Complete chemo-mechanical preparation with thorough cleaning and shaping of the canals
✔️ Irrigation protocol performed meticulously
✔️ The canals were sealed at the end of the visit without placing an intracanal medicament, aiming to control the infection through effective debridement and a well-sealed environment.

Second Visit (1 Week Later)

The patient returned completely comfortable with resolution of pain and facial swelling.

Treatment included:

✔️ Final irrigation protocol
✔️ Three-dimensional obturation of the root canal system
✔️ Coronal sealing of the access cavity

The tooth was then referred to the prosthodontic team for definitive coronal restoration, ensuring long-term protection against coronal leakage and fracture.

# # Saving a Strategic Premolar: When Every Millimeter Matters

A 23-year-old female patient was referred by her prosthodontist for nonsurgical root canal retreatment of a her first premolar. The tooth was asymptomatic, but radiographic examination revealed a short previous root canal filling associated with localized asymptomatic apical periodontitis, indicating persistent infection despite the absence of clinical symptoms.

The case presented a unique challenge. Although the remaining coronal tooth structure was in a compromised but manageable condition, the tooth held significant esthetic and functional value for the patient. With a wide smile line and a strong desire to preserve her natural dentition, maintaining this premolar was especially important because the adjacent first molar had already been extracted. Losing the premolar would have further complicated her restorative options and negatively impacted long-term function.

A thorough discussion was held with the referring prosthodontist regarding the restorability and strategic value of the tooth. Following clinical and radiographic assessment, the tooth was deemed restorable with a favorable restorative prognosis. The prosthodontist's request was clear: provide the highest possible quality of endodontic treatment to maximize the long-term survival and success of the tooth within the overall treatment plan.

Despite the challenging root canal anatomy, a decision was made to complete the retreatment in a single visit. This approach was chosen to minimize the risk of coronal leakage and bacterial recontamination associated with temporary restorations between appointments, particularly in a tooth where preservation of the remaining structure was critical.

The previous root canal filling was carefully removed, the complex canal system was thoroughly cleaned and disinfected, and the canals were obturated to their full working length. The treatment was completed successfully in one session, providing an optimal biological foundation for definitive restoration.

This case highlights the importance of interdisciplinary treatment planning, strategic tooth preservation, and meticulous endodontic retreatment. Even in the presence of apical pathology and challenging anatomy, a well-executed nonsurgical retreatment can offer a predictable opportunity to retain a valuable natural tooth and support long-term restorative success.

First she said ‘No treatment.’ After the pain of extraction, she returned… and now I’m facing a long, severely curved canal in a patient with a gag reflex that tests every bit of my patience.

🚨

A 24-year-old patient arrived at my clinic in extreme distress, literally hitting his face with his hand because of unbearable pain. This happened about 16 hours after completing root canal treatment on tooth #35 with another colleague.

The pain was so severe that the patient could barely communicate. With the "supervision of an ER physician" , we administered intravenous analgesics to stabilize him so we could take a proper history and perform an examination.

**History of the case**

For nearly a month, the patient had been visiting a dentist for treatment of tooth #35. What started as a simple filling turned into root canal treatment after the dentist discovered "deep caries".

According to the patient, the dentist explained that due to (deep decay and chronic inflammation) , the canal was blocked and required several visits to negotiate and clean.

After each appointment, the patient experienced pain for about "two days", but it was manageable with analgesics.

About **16 hours before coming to my clinic**, the dentist informed him that the canal had finally been obturated successfully and that he should return the following week for the final restoration.

However, 3 HOURS later, the patient began experiencing severe pain again. This time the pain did not respond to analgesics.

That night he could not sleep at all because of the pain. He tried contacting the clinic but received no response until the following day. The assistant informed him that the dentist believed it was a “flare-up” due to the difficulty of the root canal treatment and advised him to take Ibuprofen 800 mg every 6 hours.

Before reaching my clinic, the patient had taken (9 tablets), but each time the relief lasted less than one hour, and the pain returned even stronger.

**Clinical findings**

• Tooth #35 had a large temporary restoration with bleeding gingiva, as the patient had attempted to remove the filling himself to relieve the pain.
• **Severely inflamed gingiva** between #35 and #36.
• Sensibility tests were positive in #34, #35, and #36, but these results were **unreliable due to the patient's severe pain and psychological distress**.
• **Percussion:**
#35 +++ severe pain
#34 and #36 + mild pain
• **Palpation:** the patient could not tolerate touching the tooth or surrounding tissues.
• **Mobility:** grade I mobility in #35.

**Radiographic findings**

The radiograph showed:

• A "deep distal cavity" on #35 extending beyond the crestal bone.
• A (long radiopaque material running beside the root).
• The canal appeared **radiolucent with no visible obturation material**.

This strongly suggested the presence of a foreign body associated with the root canal treatment**.

**Treatment decision**

The patient insisted on **immediate extraction** because of the unbearable pain.
His father, however, strongly wanted to save the tooth if possible.

After evaluating the situation, I explained that extraction would be necessary to remove the foreign body, but we could attempt **intentional replantation** to preserve the tooth.

Initially, the patient refused. After reassuring him that he would have (direct contact with me at any time), and that if the pain became unbearable I would extract the tooth even in the middle of the night, he agreed to proceed.

**Treatment procedure**

1️⃣ Local anesthesia
2️⃣ Atraumatic extraction of tooth #35
3️⃣ The tooth was immediately placed in HBSS to preserve the periodontal ligament cells
4️⃣ Under magnification and strong suction, the gutta-percha piece was carefully located and removed while protecting the PDL
5️⃣ Apicoectomy followed by retrograde filling with MTA
6️⃣ The deep coronal margin was sealed using flowable composite
7️⃣ The tooth was replanted into the socketand stabilized using a flexible splint with wire and composite
8️⃣ Additional coronal reconstruction was performed to secure the temporary restoration
9️⃣ The root canal was extirpated and irrigated with saline
🔟 The canal was medicated with (corticosteroid-antibiotic paste) to control inflammation and reduce the risk of **inflammatory root resorption**, especially in the traumatized root surface where cementum was lost.

NOTE : Extra-Oral time : 17 m

The patient was also prescribed systemic antibiotics, NSAIDs, and paracetamolfor pain control.

**Follow-up**

The next clinical follow-up is planned "after 6 weeks", with regular phone calls to monitor the patient’s condition.

📞 **Next-day phone call:**
The patient reported (significant comfort and relief, and he appreciated our effort to try to rescue his tooth)

✨ **Stay with us for the continuation of this case and the final outcome.**