Study case number: 482026

Because of an extreme canal stenosis by calcification and because of its obliterated pulp chamber by adherent pulpstones, this first maxillary molar root canal system is not visible on preoperative X ray dental film.

Patient is given full knowledge of the possible risks and benefits of such a complex procedure.  This tooth vestibular cusps are broken, the patient is in pain. She definitly wants to keep her own tooth and give an informed consent. 

Operative field observation is enhanced with high magnification and coaxial xenon lamp illumination (Carl Zeiss OPMI PROergo dental operative microscope). Dystrophic calcifications have been removed from pulp chamber with ultrasonic diamond coated tips. We have been striving to locate all four canal entries (we have been striving a lot more to find MB2 canal entry) and we also had been striving to progressively regain patency by widening each root canal. Lots of chelating agent was needed.  

Our first instruments in the root canals were ISO K Files 06. Canals have then been shaped to K file size 15 and calcium hydroxide inserted. Following appointment allowed us to finish shaping, cleaning and obturation of the root canal system. Root canals have been sealed with Pulp Canal Sealer EWT. 

MB1 and MB2 were not merging at the apex, but both exits were closely juxtaposed. For that reason only a single mesiovestibular root canal shows on post operative X ray dental film. It also appear to be overenlarged but this is not the case.

Knowing that for each uninstrumented millimeter from the apex, a 14% increase in treatment failure might be expected, help of a dental operative microscope in such a case is a no brainer to us. 

Case number: 403616

Case number: 6937

Case study number: 465016

Patient has been referred to to us in order to complete a previously started root canal treatment on completely calcified root canal system. Pulp chamber is obliterated with embedded pulpstones, root canals are not visible on preoperative X ray dental film.

Patient is given full knowledge of the possible risks and benefits of such a complex procedure.  Patient is in pain and she wants to keep her own tooth and give an informed consent. 

Dystrophic calcifications have been removed from pulp chamber with ultrasonic diamond coated tips. Operative field observation is enhanced with high magnification and coaxial xenon lamp illumination. Once located root canal entries had to be widened in order to progressively regain patency in each root canal. Second X ray shows our first instruments in the root canals, these are K Files 06. Canals have then been shaped to K file size 15 and calcium hydroxide inserted. Following appointment allowed us to finish shaping, cleaning and obturation of the root canal system. Final outcome can be seen on fourth X ray dental film. 

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: 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)

Case study number: 434426

Patient was refered to us to locate MB2 and DB canal entries with the help of a dental operative microscope. Calcifications had to be removed with ultrasonic diamond coated tips from the pulpal chamber floor in order to expose those canal entries. 

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.

Case study 107926

Symptomatic first maxillary molar, canals not visible on pre operative X ray dental film. Dental operative microscope assisted root canal.