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.

Vertucci's Type III canal configuration: "One canal leaves the pulp chamber and divide into two in the root; the two then merge to exit as one canal (1-2-1)" According to Vertucci's study in 1984, the percentage of human permanent teeth with this canal configuration are 5 % for the maxillary second premolar and 0% for maxillary first and second molars. This post operative X Ray shows that the Vertucci's Type III canal configuration is actually existing in a maxilllary first molar.

 

Vertucci’s Type III canal configuration: “One canal leaves the pulp chamber and divide into two in the root; the two then merge to exit as one canal (1-2-1)“

According to Vertucci’s study in 1984, the percentage of human permanent teeth with this canal configuration are 5 % for the maxillary second premolar and 0% for mandibular first and second molars. This post operative X Ray shows (once the huge denticle has been removed in coronal third) that the Vertucci’s Type III canal configuration is actually existing in a mandibular first molar.  As stated by Vertucci’s and al. :“the pulp canal system is complex, and canals may branch, divide, and rejoin“.  

28 mm long sclerotic and curved canals and a type III canal configuration in distal root.

Imagen radiografica en la que observamos una raiz distal con una configuracion  de canal tIpo III, con canales curvados y escleroticos largos de 28 mm.