wide Feule Wi or os 155s bam Symposium on Endodontics The Enigma of the Lateral Canal Franklin S. Weine, D.D.S., M.S.D.* The true significance of the lateral eanal in clinical endodontic therapy and here I emphasize the word clinical, has long evaded me. I cannot agree with those who seem to worship at the altar of the lateral canal, by displaying cases that demonstrate such conditions to give the impression that this is the dominant or even constant finding. However, further 1 cannot take the position of Shovelton’ and Korzen et al.? ‘who have minimized the significance of these features. The former stated, “There ‘was less bacterial invasion of dentin around a lateral canal than round the ain canal of the same tooth.” The latter wrote, “The periodontal ligaments adjacent to the (lateral) canals occluded by dentin fragments remained uninflamed regardless ofthe histopathologic condition of the pulp” and that dentin fragments as a result of instrumentation frequently blocked the orifices of the lateral canals.* Subtractive reasoning clearly indicates that the cleaning and packing of the lateral canals play a very small role in the total picture that leads to «successful endodontic case. Altman et al,' have reported on the number of lateral canals in central incisors. Rubach and Mitchell? investigated their frequency in posterior teeth as well. Both reported lateral canals in far greater numbers than even the strongest advocate could ever even attempt to fill As these canals are present so constantly, yet demonstrated much more rarely, many cases would fail if their consequences of cleaning and filling were the key ingredient in gaining suecess or lack of same, indicative of failure. It is my objective in this article to answer some of the most common questions relating to the significance of the lateral canal in endodonties. T will start with some interesting, but still peripheral, questions and use the answers to build up to the final and ultimate question. Although these questions and answers are generally theoretical, I will always attempt to uuse them in clinically relevant terms. Also, in these days of the need for s, I wish to emphasize that the’ views stated herein are mine 1 should not be construed to be that prevailing in endodontic circles in general, In fact, I recognize that there are many other theories fessor and Director, Postgraduate Endodontics, Loyols University School of Dentistry Mayen, Hino Dental Clinics of North America Vol. 98, No. 4, October 1984 833,834 PRaNKLIN §, WEIN in vogue concerning this subject, any of which may be more correct than teral Canal? What Is the Difference Between an Accessory and a L Although these terms are often used interchangeably, they do mean different things. A lateral canal extends from the main, central canal to the periodontal ligament. Although the path may be somewhat tortuous, anatomically it is a direct route. Most frequently, it is perpendicular to the main canal, The lateral canal is generally found in the main body of the tooth and migh be quite near to the gingival margin (see subsequent cases). The accessory eanal, on the other hand, is found in the apical regions of the tooth and goes from apical secondary branching of the canal to the periodontal ligament, Do Certain Filling Techniques Lead to Larger Numbers of Demonstrated Lateral Canals Than do Others? Although advocates of warm, vertical condensation would have you believe differently, the answer is no. I have demonstrated lateral canals with silver cones (Fig. 1), routine lateral condensation with gutta-percha (Fig. 2), and chloropercha (Fig, 3). In certain cases, the demonstration of a A, Preoperative radiograph of mandibular fist molar demonstrating petiapicl lesion associated withthe resi Foot, A necrotic pulp wae present. B, In mediate postfiling view, angled fro distal wit distal and mesiolingul canals fled swith Iaterally condensed utt-perein and Ken's antiseptic sealer and mesiobuccal ‘anal (eft) fled with a slver cone and the Saine sealer. The lateral canal (arrow) is sociated with the ser cone-fled cal G"Siteen pears ater orginal treatuent of the molar patient was referred in forte rent of the second bicspid. Endodontic healing othe perapiea lesion as been retained for this period of time and there has hea no lateral breakdown, (Unfortunately. needed sling has not heen performed, and there Periodontal problem on the dst ‘Tae Exess oF tHe Lat5. Weine eet than Jo mean alto the ‘ortuous, arto the ly of the at cases). legions of al to the have you ral canals tupercha ation of a radiograph the mesa ft By Ta Tom distal stale led seve and thesibsceal me ad the flat cana. nf ret Endodontic there ie 8 ‘Tue ENIGMA OF THE LATERAL CANAL 835 Figure 2. A, Preoperative view of mat ‘ary anterior area, with fling endodontic treatment of centeal and Iateral incisors. Pet: apleal and Iateral lesions are apparent on ‘entra incior.B, Immediate posting view ‘anal led by lateral condensation of gutta percha and Wach's paste, with sealer exiting {ough lateral eanal on mesial portion ofthe central C, Twelve years after original treat. tment, all lesions healed! nd remaining nor mal, Note tht no sealing materials apparent Fadlographiclly on lateral surfice of ental any loge836 Frank §. WEINE Hee Figure 2. A, Immediate posting lm of masilary second bicuspid indicating multiple lateral canals demonstrated. Canal were filled with the chloropercha method. B, Excellent sling of all Iatersl and periapical lesions retained dn this il taken 10 years alter orginal treatment. Note the bred in the continuity of the flaor of the nuilry sinus in A that is ‘estore iB. (Restorations hy Dr. Sherwin Strauss, Chica lateral canal is quite predictable (Fig. 4). Ifthe operator is so inclined, specific method for demonstrating a lateral canal might be employed. However, many cases of demonstrable lateral canals are achieved without previous intent or anticipation (Fig. 5) by whatever method is commonly Utilized, Therefore, my advice is to fill canals by the technique with which Figure 4. A, Proopertive film of max: lary second bicuspid area with very large distal lesion, indicative ofa sigplicant lateral canal. B, Immediate posting film, canals filled. with literally condensed gutta-pereha and Ker’ antiseptie sealer, with lateral canal tothe dial demonstrated, Two year ater anal filling indeatng execlent healing. (Res toratins by Dr Asher Jacobs, Chicago) THe ExGMs oF tHe Lan Figure 5, A, Immediate Intra canal to the mos ha resi. B, Eleven yeas later. the operator is most com pated. Ifa canal is not de one, a refilling might be Although T doubt th great effect on the numb aspects of preparation do are demonstrated. Canal ment of the orifice, lari, sodium hypochlorite as it anals and consequently The article by Baker et al water as intracanal irrigant that the necrotic solvency so that as much undesiral side canals as there are | directly contacted by the i with necrotie pulps will d with vital pulps. because cleaning and dissolving wh Do Certain Teeth Have a Others? In my experience, percentage of lateral canaWeve rosie stipe scellent rial A tht is ined, a sloyed. without smonly which ™ fa age eal canals gers Meu var THe ENIGMA OF THE Lavina. CANAL Figure 5. A, Immediate postfilling view of mandibular cuspid indicating demonstrated Iatral canal tothe mesial that was unespectedly found in the gingival third of the root to the mesh B, Eleven yeas later, periapical and lateral ares remain normal the operator is most comfortable, whether or not a lateral canal is antiei- pated, Ifa canal is not demonstrated on a case that would appear to have one, a refilling might be considered (Fig, 6) Although I doubt that the type of canal filling technique does have a great effect on the number of lateral canals filed, I do think that certain aspects of preparation do have an effect on the frequency with which they are demonstrated. Canal preparation techniques that emphasize enlarge ment of the orifice, flaring of the main body of the canal, and heavy use of sodium hypochlorite as intracanal irrigant will yield better cleaned main canals and consequently some chance for better cleaning of side canals. The article by Baker et al.,? which encouraged the use of sterile, distilled Water as intracanal irrigant was a step in the wrong direction, It is important that the necrotic solvency action of the sodium hypochlorite be employed so that as much undesirable material is removed from both the main and side canals as there are multiple areas inside the tooth that cannot be directly contacted by the intracanal instruments. Greater numbers of tecth with necrotic pulps will demonstrate lateral canals as compared with those with vital pulps because the sodium hypochlorite is more effective in cleaning and dissolving where no vitality is present Do Certain Teeth Have a Higher Percentage of Lateral Canals than do Others? In my experience, mandibular bicuspids have a seemingly higher age of lateral canals than do other teeth (Fig. 7). As stated by838, Fraxkuy 8. WEINE, Figure 6A, Mn end ple eth rg ated eon suse oe prs rl an he pe straw oe oo pe pp cee ice tc anal wes demonsted although one won expe C, Ca eel ae versal condensation sno tere enone Diyas Siena ae shee esr by Dv. Rober Wheser Cha THE EMIeMa oF tite Larenat Rubach and Mitchell,® a sign con the distal surface of the m 8). When a lateral rather than teeth with nonvital pulps, } demonstrated Lateral lesions are not i examined carefully to note th of early exiting apical foramin Tengths. Most lesions are in r the sides of the roots. This ma Whether or not this occurs, e tion of these lateral as well « probably should be referred to lesions, They are really one an lesions. Postiilling Radiograph, Doe Filled? No one has done radivisot ability of materials extruded i the question is unknown, In fa more than sealer is packed int stated that in his warm gutta forced into the lateral canals. as compared with sealer alone,Weise ive ofthe resent. B, tad Keres , Canal Tue Extewa oF THE LatenaL, Canal 7 Figure 7. , Preoperative view of man dibular second’ bicuspid. area indicating endodontic failure with imesal and apical lesions. Previous treatment obviously incor porated insulfcent canal preparation ad oor filling B, Immediate pertiling fm following literal condensation with gate, percha and Wach’s paste Excess scaler has been expressed past apex and through the resi lateral canal, Post rtm has been prepared. C, Six vents alter filing, indteat Ing excellen’ healing. Restorations by Dr. Robert Salk, Chicago.) Rubach and Mitchell,® a significant percentage of lateral canals are found on the distal surface of the mesial root of the mandibular first molar (Fig, 8). When a lateral rather than a periapical lesion is found in these areas on teeth with nonvital pulps, lateral cinals are usually, but not always, demonstrated. Lateral lesions are not infrequent, and preoperative films must be examined carefully to note their presence. Such lesions may be indicative of early exiting apical foramina and are important in determining working lengths. Most lesions are in relation to lateral canals when they occur on the sides of the roots. This may or may not be demonstrated during filing. Whether or not this occurs, evaluation of healing must include the evalua, tion of these Tateral as well as immediate periapical areas. Such lesions probably should be referred to as periradicular rather than merely periapical lesions. They are really one and the same, rather than periapical or lateral lesions, When a Radiopaque Area Corresponding to a Lateral Canal Is Noted on 4 Postfilling Radiograph, Does It Mean that the Lateral Canal Has Been Filled? No one has done radioisotope or dye studies to investigate the sealing ability of materials extruded into lateral canals. Therefore, the answer to the question is unknown. In fact, no one is certain whether or not anything tore than sealer is packed into these side canals. However, Schilder has stated that in his warm gutta-percha technique, softened gutta-percha is forced into the lateral canals. This would improve the likelihood of sealing as compared with sealer alone840 Faavkin 8. WeINe Figure 8. A. Preoperative radiograph of mandibular molar area, with a furcation radiluceney and a soll periapical lesion asucated with the mesial rol, A 5 tm pocket ‘ould be probed into the fareation, although the patent’ periodontal condition was otherwise txcellent. The pulp was necrotic and mesial aris lesion we noted. B, Canals led by luteral condensation of gutta-percha with Kerr's antiseptic sealer. A lateral canal Is demow strated on the distal surface of the west 0 Investigations into the sealing of main canals indicates that imperme: ability to isotopes or dyes does not always occur using standard filling techniques. Therefore, I find it difficult to believe that these side canals, exiting in unknown and unpredictable directions, have a high percentage of sealing, be it attempted by any conventional method including warm guttapercha. However, a very high percentage of lateral canals indicated by sealing material corresponding to lateral lesions do seem to heal. A small percentage of these eases heal initially, but break down again later, possibly due to a sealing failure. My own analysis of why these lesions heal despite imperfect sealing will be presented later in this article. On the basis of these observations, rather than referring to lateral canals as being filled, I prefer the term demonstrated, If Canal Has Been Well ateral Canals Are Demonstrated, Does that Indi Filled? Probably not. I have taken many radiographs during the course of canal-filling and noted material in lateral canals after only a few auxiliary cones had been placed, much before the main eanal has been completely sealed (Fig. 9). I have also seen cases several months to several years after treatment in which lateral canals are demonstrated, but the treated tooth is failing at the apex. The operator should never be deluded into thinking, that the canal is well filled merely be I canal is demonstrated Only when the entire canal is packed out by the technique of choice should the filling procedure be terminated, THe ENIGMA oF tite LarEnat C Figure 9, Vow of a maxillary fs pid during canal condensation with Dercha and Kerr's aniseptc sealer i 2 demonstrated Iateral canal (arr igh only two auliary cones haw oth Conditions Simulat ‘The answer to this is most is the existence of a laterally-c frequently mistaken for a later several millimeters from the n to ream, force, andior chelate aman-made canal beyond the tr Certain types of apical pe may appear as similar to a condensation (Fig. 11). Also, a canal divides in the body of th apical foramina. Such a cond mandibular first bicuspids and 12 and 13). When only one irrigation and condensation is. the second apical canal and res The questions posed to this they are not of great importan interested in direct clinical im the best clinical results? With approach the deepest and most ion or Infection Most definite Mitchell,® «, yes. Pape Staflileno," and otheruk, we red val bly ite sal of ly fer oth ing ed. Tie ENIGMA OF THE LATERAL CANAL Figure 8. View of« mally fst bicws id during canal condensation with gute Dercha and Ker’ antiseptic sealer indicating a demonstrated Iateral canal (arrow) a though only two ausilary cones have been peed. ‘The main canals are not yet well The answer to this is most definitely yes! The most common condition is the existence of a laterally-exiting apical foramen (Fig. 10). This entity is frequently mistaken for a lateral canal, particularly if the site of exiting is several millimeters from the radiographic apex and the operator attempts to ream, force, and/or chelate an area apical to that site, thus creating a man-made canal beyond the true exit stain types of apical perforations, Iateral transportations or “zips”! ppear as similar to lateral canals when well filled with heavy sation (Fig. 11), Also, a canal configuration exists where one main canal divides in the body of the tooth into two canals, each with separate apical foramina, Such a condition is found in at least 15 per cent of mandibular first bicuspids and in some maxillary second bicuspids (Figs. 12 and 13). When only one canal is located and prepared, but good irrigation and condensation is employed, material may be expressed into the second apical canal and resemble a filled lateral canal. The questions posed to this point are of interest theoretically. However, they are not of great importance to the pure clinician, who is primarily interested in direct clinical implications. What is of significance in getting the best clinical results? With the background developed, we must now approach the deepest and most important questions Can Inflammation or Infection from Lateral C; Disease? Most definitel Mitchell," Staffilen als Simulate Periodontal yes. Papers by Johnston and Orban,‘ Rubach and ”” and others,** have indicated that fureation areas ofFigure 11. Angled view fon the mest of iled matillary sec fond bicespid seemingly indicating Sdeinonatrated lteral canal to the thesia ts probably an apical lat cal perforation filled with sealer, 842 Figure 10, A, Preoperative radio raph of maullary fist bleuspi, with Intra periapieal lesion on the ines suriee. B, Immediate posting flim, nals led ‘with Tater condensed szutheperchs andl Waeh's paste as sealer Seemingly indiating a lateral canal Ac tually, St wis hort exiting enn canal C, Eucellent healing year later. (Res: toration by Dr. Jacob Lipper, Chi ‘igo, (Prom Weine, F, S.; Endadontic ‘Therapy. Fad 3 St. Louis, C. V. Mosby Company, 1982, with permission THe ENIGMA oP ove Laren G igure 12, Mandibular fst i cuspid area during cal filling by Tavera condensation of gutta-per cha" and Wachs paste There Seemed tobe a large demonstrated Intra ental to the most, bt, fact, is the division n the male ofthe root into two matin cay the distal of which seemed. well filled. At the time that T i this case, Twas not aware of theft quency with which the manila fest bicuspid hus one main eanal diving in mdr int to canal,ih ine fl, sealer, a Ac ites. hi “ont Merb Tue ENIGMA OF THE LATERAL CANAt Figure 12, Mandibular fst cuspid area during eanal lig by Lateral condensation of gutta por lat and” Wachs paste. There Seemed tobe a lange demonstrated Tateral canal tothe mesial, but an Fact the divs in the mide of the root into two main canals the distal of which seemed wel filled. at the tine that T did this cxse, Ive not aware of the fe ‘quency with which the mandibular fist biewspid has one tain canal Aisng in miro into two canals 3. St. Louis, C re 13. A, Preoperative view lary second bicuspid with periapical lesion Endodontie treatment was equlred on ascent teeth aswell B, Hadigriph tken immediately folowing canal’ lig by’ laterally co sutteperchs and Kerry antiseptic sealer A Tatra eanal tothe distal is ade. C, Two Years later, areas healed nicely. I now realize that this too. was probably a cae of single rain canal dlviding fn mideoot into two canal [Restorations by Dr Asher Jacobs, Chicago, (rem Weine. FS maxi: vdensed edontie Therapy. Ea V. Mosby Compan. 1982,sat Braykin §. WEIN molar teeth may harbor many accessory or lateral canals. This means that there may be a direct path to the periodontal ligament via an infected or inflamed pulp canal or to the canal via an infected or inflamed periodontal ligament. If the pulp becomes necrotic in a molar tooth with a significant lateral canal exiting toward the furcation area, it is possible that the initial linical and radiographic signs will be noted not apically but near the fureation area (Fig. 8). Such lesions might be assumed to be periodontal rather than endodontic, and could lead te incorrect treatment Such condition need not be on molar teeth only, but could occur on any tooth where a significant lateral canal exits near the gingival margin and an appearance of periodontal breakdown is manifested. These conditions clear up only when correct endodontic therapy is employed (Fig. 14). The condition is, as previously stated, two-way, of course. A tooth with a relatively normal pulp may become involved if a lateral canal is exposed because of apically-progressing periodontal disease (Fig. 15) or periodontal treatment. The site of exposure is different from that of a large carious Tesion, but the net effect may be exactly the same. If endodontic therapy is correctly performed, that portion of the problem will be solved, but the apical progression of the periodontal portion of the condition will not be alleviated. Figure M4 A, Mauillary frst i cuspid referred for endodontic teat. tment because of periapical lesion. A Bm pocket tothe ‘mosil.B, Immediately after cana ing with lteraly condensed guti-per- tha and Wachs paste. The packet had healed. following. canal preparation Note the sealor eating through the lateral canal (arroe)C, Excellent Ipealing 3 years later. (Restorations by Dr. Jay Herschman.) From Weine,F S2 Endodontic Therapy. Ed. 3.'St. Lous, CV. Mosby Company, 1982,) Ta: ENIGMs OF THE Lat Figure 15. 4, Mandbul The patent had a nub of [ sigeested an extraction be further consultation with be treatment. Femedtey fl The eal was led with ite lateral canal farrne sted ‘ha this tots had palp ep tly and no postoperative the Failure to Clea Other Symptoms Durin The answer here is that this is by no mea fortunate, Despite virtu closed during treatmen some teeth are ineorre treatment, when the s Although the leaving of the total number of app term analysis of success However, I have treated and directly related to t In these cases, teet to me for completion. A pain that forced me to 1 a filling first technique fo film demonstrated latera of these conditions seem retain enough irritants, because of the superint cavity, to perpetuate the Thave had several persisted during treatmeWane rs that ted or vdontal uficant initial ar the dontal, sitions 4). The with a posed edontal therapy Int the not be fist bi tesion. A cdiothe Sana Bl tet bad Excellent tations by Weine, F a3. st Take ENIGMA OF THE LATERAL CANAL. Figure 15. A, Mandibular second bicospid with periapical lesion and a deep distal pocket The patient had a numberof ether advanced periodontal problems. Ta tot was mole and T suggested an extraction because of the poor outlook ofthe periodontal situation, B Aer further consultation with both the periodontist and the patient, twas decided to aitempt treatment. Immediately following the eanal preparation, the tooth tightened considerably The canal was filled with ltealy condensed gitsperch and Wach’s paste, The demonstrated lateral canal arrow) is noted just to the depth of the pockel on the distal Lt very posable that this tooth had «pulp exposure via the significant later aa. The ease was Wea very recently and no postoperative fini yet avaible Can the Failure to Clean Lateral Canals Cause Pain, Discomfort, and Other Symptoms During Treatment? The answer here is definitely yes. However, it must be emphasized that this is by no means a constant or even frequent finding, which is fortunate. Despite virtual unanimity over the importance of keeping teeth closed during treatment, particularly when vital pulp tissue is present, some teeth are incorrectly left open after the initiation of endodontic treatment, when the symptom of tendemess to. percussion is. present Although the leaving of @ tooth open during treatment usually increases the total number of appointments needed to complete therapy, the lon term analysis of success does not seem to be affected by that procedure However, I have treated several eases in which symptoms were recalcitrant and directly related to the presence of lateral canals In these cases, teeth left open by the initiating dentist were referred to me for completion. Attempting to keep them closed resulted in severe pain that forced me to resort to surgical resolution of the problem, Using 4 filling first technique for the presurgical step, observation ofthe postfilling film demonstrated lateral canals (Figs. 16 and 17), The coincidental finding of these conditions seems to indicate that these lateral eanals were able to retain enough irritants, in a protected sanctuary, of a high enough level because of the superinfection offered by the communication to the oral cavity, to perpetuate the pain Thave had several eases, still a very small minority, im which pain persisted during treatment of teeth kept closed. This was identified by theTuk: ESieMa oF tie Laven patient by digital stimulatic these teeth were filled, ust canals could be idenifed Sensitive fora fee days folk is predictable. Certainly. chronic dra lesions (Fig. 19, sometim ceoney. These tracts clear canal preparation. os the coinminication ‘wth the some instances, the sinus Preparation procedures, pe Prevents its being adequat the lateral eanal is dems this situation ts thot the p sufficient cleaning, but by the sealer blows thro an These tissues are wel equ igure 1A, Mandibular nor ae: The ot al Ben vee ig an aut pera previously noxious eleme Sea al el ee a esa aes meen, eee ee ee Patient in the few days a Sie at ateptd, the oth bare very plans topene wos neces Ae Eick dissappear Sth cea Seed peo serene: Th cal ose wh shy onde ate pech and Tae pro the suretge, an rile bic ceric aan B Oe heer ina te al ing are, ete healing Spare Sango by Dr Samuel. Paterson, Tndunapal Figure 17. Similar history to Figure 16. A, Maxillary central incisor let open prior to being telerred to me for completion of treatment. Tooth defied closure, B. Surgery was schedule athe canal Billed with laterally condensed gotteperchs and Tublised, with pot room prepared The lateral canal apparent to the mes in tira 846rapid fl Mer ke with ‘aera slings prior to wey wae i Sah post THE ENIGMA OF THE LaTeRat. CaNst 847 patient by digital stimulation of tissue short of the apex of the tooth. When these teeth were filed, usually despite some remaining discomfort, lateral canals could be identified (Fig. 18). Generally, these teeth become quite sensitive for a few days following the filing procedure. Fortunately, healing is predictable. Certainly chronic draining sinus tracts have been traced to lateral lesions (Fig. 19), sometimes without the presence of a periapical radio ceney. These tracts clear up almost immediately in most cases following canal preparation, as they do when the sinus tract is found to be in communication with the more immediately periapical area, However, in some instances, the sinus tract may persist following the routine canal preparation procedures, probably because the position of the lateral eanal prevents its being adequately debrided. Fortunately, in most eases, when the lateral canal is demonstrated by sealer, the lesion heals, My analysis of this situation is that the priviledged sanctuary of the lateral canal resists sufficient cleaning, but by building up of pressures during condensation the sealer blows through and forces the debris into the periradicular tissues. These tissues are well equipped to neutralize and lead to healing of these previously noxious elements. Generally, such cases are painful to the patient in the few days after the canals are filled, but these symptoms quiekly dissapear Figure 18. A, Preoperative view of rmaullary first bicuspid. The patient com plained of pain consistently during treat. tment, not athe apex, but rather in mi root,” B. “Canal filling with ater condensed gutta-percha and Wach's paste The lateral cana is apparent to the distal and exited to the spot Indicted by the patient, Ths site was acutely tender in the few days following cana filing, but then bhecame asymptomatic, Tres years later. (Restorations by De. Morton Rosen, Chi848, Fraxkuiy §, Wen Figure 19. Chronle draining sinus tract traced by a gutaspercha cone in a straight (A) and angled view fom. the ‘mesial (B). C, Film taken following canal Alig with laterally condensed gutta per cha and Kerr's antiseptic sealers with bt ral canal demonstrsted exaty to the site the sinus tet previous exiting point ract had healed following preparation of cana teral Canal Lesion by Itself Cause a Failure of an Endodontic Case When the Immediately Periapical Area Either Heals Following ‘Treatment or When the Area Prior to Treatment Is Normal and Remains Normal Postoperatively? This is the ultimate question. For many years I felt that the answer was absolutely no. In the past ten years, however, I have observed cases that indicated that even though the percentage is extremely low, there are some teeth that heal or remain normal apically but fail laterally because of untreated lateral canals. Although other possibilities may exist, the most common condition is improper utilization of the post room prepared to accommodate the subsequent restoration. If this area is left vacant for too long a period of time (Fig. 20), or the attempt to seal itis insufficient (Fig. 21), and a lateral canal of significant size is located in this area, a failure due to lateral canal breakdown may occur. T again emphasize that this Tae ENIGMA oF THe Late Figure 20. 4, Preoperitve present. B, Endodontic treaties Interally condensed gutta-percha | py. C, Si fd that portion of the canal vel Sealer. The demonstrated lteral prepared, E. Eighteen mon restoration by Dr Steve Put850 FRAvkLN S. Wein Figure 21, A, Mandibular second bicuspid bad received endodontic therapy and a silver ‘one atl een ase to Bl the canal several years earlier. Now a crown was necessary and i Stas decided to remove the iver cone and Bll the canal with putts percha to allow for post Toor preparation, The lateral lesion to the distal really vas wot noted at this time. B, The Siver cone was removed the cial prepared and fled with laterally condensed gutta-percha tnd Wach's paste. Post room ss prepared and the demonstrated laeral cata clay sen, [Endodontic treatment by Dr, Harold Gerstein, Milwaukee, Wisconsin) C, Seven yeas ater Ionic dralning sinus tracts present, traced wih agutt-pereha cone (arrest the distal Surface Note thatthe peepared post room is poorly used and that no lesion Is present atthe x of the tooth. D. The crown was removed, the post came out easy, and the ca prepared to size #110. 2. The coronal portion of the canal was filed with stray condensed fate percha and Keer’ antiseptic sealer, Note the demnnsteated lteal canal F. Four years Tater the area has healed very wel. (Final restoration by Dr. Sherman Jobnston, Highland Park, Min, THe ENioMa oF tHe Lav requires an extremely following: 1 The presence ofa amount of tissue ina state is generally packed off, an been removed to provide 3. The room provide and the cement used allo oral cavity 4. Although not abso tooth is vital a the incept breaks down and become The tissue in the lateral ca prevented the sealer from however, andl acts as ani ‘The solution to this post room when the t Secondly, every attemt ensure that the post tak Large, vacant or partial canals, if they are prese1 It is difficult to sum is certain that his case } views that are contrary ceases. Bearing this fact j 1. Lateral eanals are der than they exist. This varian demonstrated lateral canals should include examination 2. Lateral eanals may b ‘anal preparation may enh neerotie pulps probably ye pps 3. Lateral canals hitb during endodontic teatien problems with treatment Periodontal disease may ca 4. Improper use of pos ina lateral canal 5. The enigma of the discussion in. many articles, endodontic therapy forthe |Warne ing cal “nth ee thes dontie ing ed eases here are suse of he most pared to It for too ent (Fig a failure that this THe ENIGMA OF Tite LATERAL CaNAl 849 Figure 20. A, Preoperative view of masllry csp, considerable subgingival decay present. B, Endodontic treatment completed through teraporary evown, canal ile with Laterally condensed gutta-percha and Wach’s paste and post room prepared The pulp had lncen vital prior to Merapy. C, Sit months later, a temporary posterown has eet fabricated, bt a distal lesion is present atthe site where the post preparation ended. D. The apical portion ofthe post room was widened to size #100, heal terignted with sodun hypochlorite and tit portion of the cana veflled with Interallycondessed gutta percha and Kerr ante pti sealer. The demonstrated lateral canal is readily apparent. New, shorter post room was also Prepared, E, Eighteen months liter. al restoration in place and lateral lesion healed Final Festoration by Dr, Steve Potashnick, Chicago.$. Were and sve say and iow or post me. B, The fala perc “ihe dal toeot tthe td the canal veondensed oy Highland Tae E JoMA OF THE LATERAL CANat 851 requires an extremely rare combina following: ion of conditions, which are the L. The presence of a lateral canal of sufficient size to accommodate a significant amount of tissue in a state of ehronie inflammation 2. The location of this canal away from the apical fourth of the tooth where it is generally packed off, and more im the midroot area where Jbeen removed to provide the room for the post 3. The room provided for the post is either completely unused, of the post and the cement used allow for communication between the lateral caval and the oral eavity 4. Although not absolutely always true, in virtually all tooth is vital at the inception of treatment, b breaks down and becomes necrotic after the completion of the endodontic case ‘The tissue in the lateral canal had retained its vitality at the time of treatment andl prevented the sealer from entering that arca. This tissue eventually breake down, hhowever, and acts as a nidus of inflasnmation und a later the filling material has ses, the pulp of the but the tissue within the lateral canal radiohicency develops ‘The solution to this problem is prevention, initially, by only preparing. post room when the treated tooth is close to the time of restoration Secondly, every attempt should be made by the restorative det ensure that the post takes up as much of the space provided as is possible. Large, vacant or partially filled post spaces are very conducive to latera canals, if they are present, breaking down. ist to SUMMARY It is difficult to summarize an article of this type, is certain that his case has been presented fa views that are contrary could be stated cases. Bearing this fact in a in which the author ly, but is aware that other and endorsed by pertinent clinical ind, I wish to reiterate the following 1. Lateral ean is are demonstrated in endodontic eases with much less frequency than ti demonstrated lateral canals may realy be ater conditions Preoperative evluon should inelude examination of radigraphs fy lateral aswell perapeal, leo 2, Lateral canals may he demonstrated bya variety of fling techniques. Cart canal preparation may enhance the frequency of such demonstration, Cases with neerotie pulps probably yield more frequent demonstration than do eaves with ial pul 3. Lateral canals harboring inflamed and/or infected material may cause pain during endodooti treatment They may simulate periodontal disease nnd ay cease problems with treatment A present when a tooth i let open for dainag Periotntal disease may cause pulp exposnre via tera canal fate coronal 4. Improper use of post room may lead to lateral flue fom bread of tissue fn lateral ana 5. The enigma of the lateral canal his been the abject of description and discussion in-many articles, but noone is truly certain ofr eat signee ta endodontic therapy forthe Ton hal852, Fraxkuin 8, Weine REFERENCES 1. Alton, M., Gutta, J, Seidberg, BL HL, et al: Apical root canal anatomy ‘Oral Surg. 694-650, 1970 2, Baker, NS. Elewer, PD Averbach, BR. E., et al: Scanning eh stu of the efficacy of various irgating solutions. J Endodaat, 122 3. DeDeus,Q. D Frequency, location, and direction ofthe lateral, secondary, nd accessory fas, J. Endodont, 1361-966, 1973, 4. Jolinston, H. B,, and Orbin, B. Interrdicular pathology as related to accessory’ root canals J. Envdodont,, 321-25, 198, 5. Korzen, B. Ht, Krakow, A.A. and Green, D. #8: Pulpal and periapical responses in ‘conventional and monoinected gootobiotic rats, Oral Surg. 374789. 902, 1974 6, Ruibach, W. Cand Mitchell, D. Ps Perindontal ds thos f. Pernt, 3:38, 195, 7. Shivelton, D. S. The presence and dstebution of microorgnisins within nonvtal teeth, Br. Dent J., 7101-107, 1964 8, Simting, Mo, and Goldberg Me The ps 1. Per 3522-18, 1968 9, Stafleno, Hl. J Surgical management of the Fuca invasion, Dent, Chin. North Am TIO3-113, 16 10, Weine, F. 8. Healey, H. J. and Theiss, B. Pe: Endodontic emergency dilemma: Leave touth open or keep it dosed? Onl Sung, #0:581-536, 1075, LL Weine, FS. Kell, RF, and Li, PJ: The effect of prepuration procedures on rigid canal shape and on apa frames shape J, Endodont. 1-198-202, 1075, pocket approach: Retrograde periodontitis Layola University School of Dentistry 2160 S, Fist Avenve Maywood, Minos 60153 Symposium on Endodontic In general, attitudes an treatment procedures are ve professions. We are often 1 procedures because we fear a not result in the same outcon All of us, whether we are cl tend to operate within a eon treating patients, educating : very basic biologic questio together all of the observatio on a particular subject or prob belief become available and ai in order to accommodate thi endodonties change and expa available to us. Research st intracanal medicaments, and have led us to expand and, 4 concerning the clinical condu Our ability to grow and ¢ by our willingness to reexam alter, at times, some of the untenable under the light of The concept of doing co not new. However, itis only » concerning the inclusion of endodontics appear to be expanding favorable clinical e able clinical research studies, from being an empirical tec treatment procedure for cert surveys conducted by Lander *Diplomate, American ios ard of En Dental Clinics of North America Vol