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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 Lat5. 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 loge836 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 canaWeve
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 by838, 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 alone840 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 otheruk,
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 ofFigure 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 treatmeWane
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 theTuk: 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
846rapid 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, Chi848, 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 Put850 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 hal852, 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