At Irvine Endodontics, located in Irvine, CA, Dr. Omid Dianat and his team understand the importance of combining clinical expertise with real-world learning. In the ever-evolving field of endodontics, case studies offer a unique window into the complexity of diagnosis, decision-making, and outcomes. This blog presents a selection of case studies to highlight practical lessons and illustrate how diverse presentations of dental pathology require nuanced approaches. Whether you’re a dental student, a general practitioner, or simply curious about what goes on behind the scenes in endodontic treatment, these real-world examples offer valuable insights into the decision-making processes that shape successful outcomes.
Case Study 1: Missed Canal in Retreated Maxillary Molar
Missed canals remain one of the leading causes of endodontic failure, particularly in maxillary molars. In this case, a 47-year-old patient presented with persistent pain in tooth #14, despite a root canal treatment completed two years prior. Clinical examination revealed tenderness to percussion, and radiographic imaging displayed periapical radiolucency adjacent to the mesiobuccal root. Upon re-evaluation using cone-beam computed tomography (CBCT), a previously untreated MB2 canal was identified.
During retreatment, careful access modification allowed location of the MB2 canal, which was necrotic and harbored infected tissue. After thorough cleaning, shaping, and obturation, the patient’s symptoms subsided, and follow-up imaging at six months showed periapical healing.
This case reinforces the importance of understanding complex canal anatomy, particularly in upper molars where multiple canal systems are common. The use of advanced imaging like CBCT can dramatically increase diagnostic accuracy. Clinicians must also consider retreatment when symptoms persist and imaging supports a suspicion of missed anatomy, even if previous treatment appears adequate at first glance.
Case Study 2: Internal Resorption in a Mandibular Premolar
A 35-year-old female patient was referred for evaluation of an unusual radiolucency in tooth #29. She was asymptomatic, and the lesion was an incidental finding on a routine bitewing. Radiographs showed a well-defined, oval-shaped radiolucency in the mid-root area. Based on clinical and radiographic signs, a diagnosis of internal resorption was made. The etiology was uncertain, as the patient had no history of trauma or extensive restorative work in the region.
Root canal therapy was initiated promptly to arrest the resorptive process. During instrumentation, care was taken not to perforate the weakened dentinal walls. Warm vertical compaction and thermoplastic techniques were employed to fill the irregular internal resorption defect completely. The post-operative radiograph confirmed excellent adaptation of the filling material, and at the one-year follow-up, the tooth remained asymptomatic with no signs of progression.
This case demonstrates the importance of early diagnosis in managing internal resorption. Though asymptomatic, internal resorption can rapidly compromise structural integrity if untreated. Utilizing flexible obturation techniques and cautious instrumentation is essential to preserve tooth longevity while fully treating the affected areas.
Case Study 3: Complicated Crown Fracture with Pulp Exposure in a Young Patient
In this case, a 13-year-old male presented with a traumatic injury sustained during a basketball game. Tooth #8 had sustained a complicated crown fracture with evident pulp exposure. The tooth was immature, with incomplete root formation. Given the patient’s age and root status, the treatment goal shifted from traditional root canal therapy to apexogenesis — preserving pulpal vitality to allow continued root development.
Calcium hydroxide was initially placed to control bleeding, followed by placement of mineral trioxide aggregate (MTA) over the pulp. A bonded restoration was then completed to seal the tooth. Over the following months, the patient was monitored closely, and radiographs showed continued root formation and apical closure. Two years later, the tooth demonstrated a fully developed root and remained vital with no periapical pathology.
This case highlights the importance of age-specific considerations in endodontics. Pediatric and adolescent patients require tailored approaches that prioritize long-term tooth development. In cases of trauma with immature roots, preserving vitality can offer more favorable outcomes than conventional endodontic treatment.
Case Study 4: Cracked Tooth Syndrome in a Mandibular Molar
A 54-year-old male reported vague, intermittent pain in the lower right quadrant, exacerbated by chewing. Tooth #30 was restored with a large amalgam and responded positively to thermal tests but negatively to percussion. Using transillumination and bite tests, a crack was identified extending from the central groove toward the distal marginal ridge.
The decision was made to perform root canal therapy due to pulpal symptoms and high suspicion of a propagating crack into the pulp chamber. Intraoperatively, a complete fracture line was confirmed during access preparation. Despite the presence of a crack, the tooth was deemed restorable. The canals were treated and obturated, and a full-coverage crown was later placed. At the six-month check-up, the patient remained symptom-free with no radiographic signs of failure.
Cracked tooth syndrome presents diagnostic challenges due to its subtle and inconsistent symptoms. Clinicians must rely on patient history, detailed examination, and sometimes exploratory treatment to confirm a diagnosis. Early intervention and proper restoration are key to saving these teeth, as untreated cracks can lead to vertical root fractures and eventual extraction.
Lessons in Diagnosis and Treatment Planning
Each of these case studies underlines the necessity of accurate diagnosis, advanced imaging, and a tailored treatment plan. Endodontics is far more than performing root canals—it involves recognizing when intervention is necessary, selecting the appropriate technique, and monitoring for complications or healing over time. Diagnostic tools such as CBCT and transillumination aid significantly in complex cases, particularly when anatomy or pathology is atypical.
Clinicians must also stay up to date with modern materials and technologies. MTA, bioceramics, and thermoplastic obturation techniques have all improved the success rate of treating previously challenging conditions. Furthermore, a solid understanding of healing patterns and the biological responses of periapical tissues supports better long-term outcomes.
The Role of Interdisciplinary Collaboration
Often, successful endodontic treatment is not accomplished in isolation. Many cases require collaboration with restorative dentists, pediatric specialists, oral surgeons, or even orthodontists. In the case of immature teeth, for example, orthodontic planning may be paused to allow root development. Similarly, cracked or structurally compromised teeth require input from prosthodontic colleagues to ensure that post-treatment restorations can withstand occlusal forces.
Effective communication and shared responsibility among dental professionals enhance patient care and reduce the risk of failure. Timely referrals, detailed treatment notes, and cross-discipline consultation improve the overall experience and clinical results for patients facing complex endodontic scenarios.
Why Case Studies Matter
Case studies serve as educational tools for both novice and experienced clinicians. They showcase the unpredictable nature of dental disease and the nuanced approaches required to manage different scenarios. From missed canals to internal resorption and trauma in adolescents, each case reinforces core principles while offering a real-world example of their application.
Moreover, these studies build a bridge between academic theory and clinical practice. They allow practitioners to reflect on the subtleties of technique, patient presentation, and healing, while also contributing to a collective understanding of best practices in the field.
At Irvine Endodontics in Irvine, CA, Dr. Omid Dianat believes that continuous learning through real-world examples is essential to clinical growth. By studying these cases, dental professionals can better navigate complex challenges and improve outcomes for the patients they serve.
Resources:
- Torabinejad, M., & Walton, R. E. (2009). Endodontics: Principles and Practice. Saunders Elsevier.
- Patel, S., Durack, C., Abella, F., Shemesh, H., Roig, M., & Lemberg, K. (2015). Cone beam computed tomography in Endodontics – a review. International Endodontic Journal.
- Ricucci, D., Loghin, S., & Siqueira, J. F. (2014). Correlation between clinical and histologic pulp diagnoses. Journal of Endodontics.
