Case study number: 417847

Case number: 186336

A few days ago we were confronted to this three rooted mandibular first molar (Radix Molar or Radix Entomolaris), a very rare anatomic variation where a a third supernumerary root is located distolingually in mandibular molars. Tremendous amount of calcifications and a limited opening of the patients mouth made this endodontic procedure an extremely complex one. Dental Operative Microscope was most helpful in locating all canal entries.

To lurn more about Radix Entomolaris, please go to: R. Bansal & P. Ajwani: Prevalence and Morphological study Of Three Rooted Mandibular First Molar (Radix Molar) in Indian population. The Internet Journal of Human Anatomy. Volume 1 Number 1

Case number: 6937

Case study number: 473515 

OPMI PROergo from Carl Zeiss allowed us to clearly see the apical split. Each branch has been shaped, cleaned and filled with Pulp Canal Sealer and gutta percha using vertical condensation technique. 

Case number 474446

Deep deciduous restorations have been replaced 4 days ago. Patient has been experiencing severe spontaneous throbbing pain for the last two days. Tooth is presenting an irreversible pulpitis following a restoration replacement. 

Radiographic examination shows calcifications in apical third of all root canals, a thickened PDL in furcation and a very long tooth with a severe curvature in mesial root. The two mesial canals are merging in apical third and their length is 27mm.

Calcifications have been removed from pulp chamber with ultrasonic diamond coated tips from Spartan^TM, Endodontic treatment done in one appointment with lots of RC Prep^TM for chelating agent, Pro Taper^TM NITI files, gutta percha and Pulp Canal Sealer^TM . 

Case study number: 487445

Clinical examination: Sinus tract, mobility: 0, deciduous amalgam restoration. 

Radiographic examination: Alveolar bone with circumscribed lucency, apical root canal split, hypertaurodontism (bull's tooth), apical root canal split branches not visible on X ray dental film, hypercementosis 

Diagnosis: pulpal necrosis with chronic periapical infection,

Etiology: marginal leakage, caries

Root canal procedure:

First appointment: gaining access to the split, locating entries, shaping and cleaning apical root canal branches inserting intracanal medication for 8 days.

Second appointment: intracanal medication retrieval, copious CHX 2% irrigation, drying canals and permanent root canal obturation with Pulp Canal Sealer and gutta percha (lateral and vertical condensation).

In that specific case, microscope was most helpful during all the following steps necessary to insure a better prognosis for this patient:

1) Locating and gaining access to buccal and lingual root canal entries (apical split was clearly visible under magnified observation) 

2) Striving to find a third branch in apical split minimizing the chances of omitting an untreated canal 

3) Aiming at the right root canal orifice when:

• Inserting the two first endodontic files to confirm canal lengths 
• inserting a file sequence to shape and clean each canal 
• Positioning irrigating syringe needle tip and calcium hydroxide syringe tip toward the right canal entry 
• Inserting absorbent paper points in both canals when drying canals 
• Inserting master, accessory gutta percha cones and finger plugger when doing final obturation with lateral and vertical condensation  

4) Checking for pulpal tissue remnants prior to final obturation to minimise the chances of pushing them back into the apical area

Case study number 485946

Symptomatic mandibular molar, patient can't chew on that side. Referred to us for endodontic revision.

First appointment intervention steps:

Coronal-radicular access (access through PFM crown, access through coronal build up) taking great care not to perforate the previously weakened pulpal floor, gutta percha removal, locating DB, regaining patency in calcified distal canals to the apex without perforation or deviation, correcting step in apical third of mesiolingual canal, negotiation of mesial canals, CHX 2% irrigation, CHX 2% left in canal system for one minute, drying canals, insertion of calcium hydroxide dressing, provisional obturation (Cavit)

Second appointment intervention steps:

Removal of Ca(OH)2, CHX 2% for one minute, dry canals, cone fit checking and final obturation with Pulp Canal Sealer and Gutta Percha.

Small sealer overflow is a good warrant of apical seal.

Referring dentist is planning a fixed bridge 37, 36, 35 X. (Patient did not want an implant to replace missing #34)

Case study number: 486726

Patient was referred to us with a partial pulpectomy in 3 out of four canals. The case came with a note from referring dentist that MB1 was blocked with a calcification. Patient was in pain and was taking an opioïd analgesic prn (Oxycodone) and prn was high. First appointment we needed to take care of the pain issue by completely removing pulp tissue remnants from palatal and distovestibular root canals. Roots are very long and lots of denticles had to be removed from the canal system. Intervention has been done under observation with a dental operative microscope. A mixture of calcium hydroxide and Iodine was then inserted into those canals. This was the only thing that could be done on an emergency basis. Patient had to come back to address the blockage concern in mesio vestibular root canal.

Patient came back 8 days later, symptoms had completely subsided in a mater off hours post op and patient was able to sleep. On second appointment we have been striving to regain patency in MB1 but failed. Then, since a lot of MB1 and MB2 are merging at the apex, we strived to find MB2 canal entry and we did find it. We were hoping to be able to bypass MB1 blockage and seal both canals at once. But blockage was there too, exactly at the same level as in MB1. Root canals have been sealed with Pulp Canal Sealer EWT. Patient has been advised that the mesiovestibular root canals could not be shaped and cleaned to the apex and that for each missed millimeter from the apex a 14% increase in treatment failure might be expected. Both uncleaned canals parts represented a total length of 20 mm. 

This patient is working (as a explosive expert) in a Nickel mine in a very remote area of Northern Canada. Closest dentist is 1000 miles from the exploiting site. He did not want to experiment another blow up of this kind up there, so he decided to come back for a corono apical amalgam, an apicoectomy and a MTA retrofilling on MB1 and 2 before going back to work. Crowning was done by his own dentist. (The very same dentist asked me to do the core build up in amalgam)

This is a symptomatic mandibular first premolar (bridge abutment) with a "C" shape root canal system. Most C-shaped canals occurs in mandibular second molars but they have been also reported in the mandibular first molar, the maxillary  first and second molars and the mandibular first premolar. This "C" shape first mandibular premolar root canal system is extremely rare. The only orthograde way to endodontically treat this anomalous root is to bring our first K file #06 to the apical third by bypassing what looks like a "mega concretion". Use of the dental operative microscope, sonic and ultrasonic instrumentation is mandatory. Being familiar with access cavity preparation for "C" shape RC through prosthetics, being familiar with cleaning, shaping and an obturation of a mineralized "S" shape root canal is also important. A cone beam tomography would have been most helpful in determining which root canal configuration we were dealing with prior to initiating this RCT and this very same tomo would have helped us in orienting our search for the pathway to the apex, but patient was reluctant to this innovative technology and decided to go for it only if symptoms persisted. Only one single pathway to the apex was found, tooth is now completely asymptomatic. Since we could not confirm this with a tomo, lets hope we were dealing with only one apex. (a type III Vertucci root canal configuration). A close follow up is planed.  

Esforzandose para hallar los caminos hacia el apice contorneando un "mega pulpolito" en  un sistema de canales radiculares anormales.

Este es un primer molar mandibular sintomatico (diente pilar) con un sistema radicular (nervio)  en forma de "C". Muchos canales radiculares en forma de "C" ocurren en los segundos molares pero ellos han sido reportados en el primer molar mandibular(inferior), el primer y segundo molar maxilar(superior), y el primer premolar mandibular(inferior). Esta forma de "C" en el canal radicular del primer premolar mandibular(inferior) es extremadamente raro. La unica forma(orthograde) para tratar endodonticamente de esta anomalia radicular es trayendo nuestro K file #06 hacia el tercio apical contorneando lo que parece un mega pulpolito (piedra). El uso del microscopio dental, instrumentacion sonica y ultrasonica es obligatoria. Estar familiarizado con el acceso a la preparacion cavitaria en forma de "C" a traves una corona, estar familiarizado con la limpieza, dar una forma al canal y hacer la obturacion de un canal radicular mineralizado en forma de "S" es tambien importante. Una tomografia (CBCT) podria haber sido de mucha ayuda determinando cual canal radicular nosotros debemos tratar antes de comenzar, y esta misma tomografia podria habernos ayudado en la orientacion de nuestra busqueda de los caminos hacia el apice, pero el paciente rehusa esta tecnologia innovadora y decide ir solo si los sintomas persisten despues del tratamiento. Solo fue hayado un camino simple hacia el apice, el diente es ahora completamente asintomatico. Desde que nosotros no podamos confirmar esto con una tomo, esperando que nosotros tratamos solo un apice. (un canal radicular de tipo III de Vertucci), un seguimiento cercano del caso es planeado.

Radiografia preoperatoria de un segundo molar inferior(mandibular), caso un poco complejo debido a la morfologia radicular propia de este caso en el podemos observar un canal radicular en "S", pero despues de haber realizado la instrumentacion nos damos cuenta que la raiz mesial presenta dos conductos que se intercomunican entre si, despegandose al final del primer tercio radicular y volviendose a unir al conducto principal a nivel del tercio apical.