endomontreal

Endodontist (microendodontics) case study number: 449947 Pulp chamber and root canals are not visible on pre operating X Ray of second mandibular molar. Diffuse calcifications preclude easy canal entries location. This tooth needs a dental operating microscope assisted root canal procedure. 

 Progressive abrasion of attached pulp chamber calcifications with ultrasonic tips led to the canal entries. Required state of mind: No pushing but resolution. 

  First mandibular molar has an apical external root resorption in distal root making it difficult to obturate because of the absence of apical constrictions

   Post operative X ray dental film displaying final root canal obturation with gutta percha and Pulp Canal Sealer

 Amalgam post and core build up.

This last X ray dental film is a three years post operative control and is showing a complete regeneration of periradicular tissues, teeth are still functional and symptoms free. 

Should an implant have been put there in the first place to replace this second mandibular molar simply because this root canal procedure is extremely difficult to perform? Maybe, maybe not!

Both implant therapy and endodontics show excellent prognosis. To let the informed patient decide for himself  whether or not he want's to save his tooth instead of having a dental implant is simply common sense. 

Endodontist case study number: 197337

The recent addition of dental operative microscope (DOM) to endodontic therapy can allow better visualization and management of the intricate morphology of the root canal system during endodontic procedures through magnification and greatly improved high intensity lighting. Dental Microscope typically magnifies in the 4X to 25X range. The other commonly used magnification aide, through lens eyeglass mounted surgical telescopes, provides 2.5X to 4.5X magnification. 

We have been presented with this second mandibular molar that has only two canal entries on pulpal chamber floor. At first sight one could have easily concluded the presence of only two canals. In fact, the mesial root has a Vertucci's type 5 canal configuration. A Vertucci type V pulp space configuration can be described as follow: One canal leaves the pulp chamber and divides short of the apex into two separate distinct canals with two distinct foramina (1-2). Without magnification the root canal apical "split" could have been under seen, treating one branch out of two and leaving  pulp tissue inside the other branch. 

Surgical operating microscopes have a steep learning curve and require training, as well as patience and practice to master. Still this piece of equipment and the learning effort it implies is well worth it since cases that once seemed impossible can now be treated with a high degree of confidence and clinical success. 

"As the saying goes:"A picture is worth a thousand words", Click here to have a look at what can be seen at an operative field under magnified observation (10X to 25X range)." 

Case study in microendodontics number: 506846

Patient referred for endodontic treatment on this mandibular first molar. Coronal-radicular access was already done but canal entries are embedded in a mass of calcified dentine and could not be found.

Preoperative X ray dental film shows a complete mineralization of both mesial and distal canals coronal third. This is an intricate root canal procedure, because this pre operative condition involves dealing with complete canal stenosis caused by dystrophic calcifications. 

Dental operative microscope (Opmi Proergo from Carl Zeiss) and ultrasonic tips where most helpful in locating both mesial and distal canal entries.

Once located, our first instrument in four canals were K files number 06 (second X ray dental film). Then, mesial and distal canals have been shaped and cleaned with the Pro Taper system (Maillefer) and lots of RC PrepTM. They were subsequently filled with gutta percha (lateral and vertical condensation) and Pulp Canal Sealer EWT ^TM

Third X ray dental film (Clark's rule) shows all four treated canals. 

Amalgam corono apical core build up is shown in last post operative X ray dental film. A crown is planned by patient regular dentist.

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Clinical endodontic case study number: 505146 

A peculiar anatomical variation can be noticed on this mandibular first molar. What appeared to look like hypercementosis on apical aspect of distal root could in fact be a supernumerary root fused to the distal one (Radix Entomolaris). Careful removal of dentine with ultrasonic tips under high magnification of a dental operative microscope helped in locating this extra canal.  

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This week's new Dental Operative Microscope (D.O.M.) assisted root canal treatment displays an intricate root canal treatment procedure on a mandibular first molar presenting  a very long root canal configuration with calcified canals. This case report number 474446 can be found at:  A root canal treatment on a very long mandibular molar with apical third of root canals not visible on X ray image.

This case report is highlighted with an 8 second video of a rotating 3 D image of a first mandibular molar displaying the complex anatomical variations that can be found in such teeth.

These images and video may be obtained from "The root canal anatomy project" blog and where developed at the Laboratory of endodontics of Ribeiaro Preto dental school- University of Sau paulo by doctor Marco Aurelio Versiani and by doctor Jesus Djalma Pecora. The video displays the complex anatomy of such a root canal in red and gives us a better understanding on how difficult the cleaning and filling tasks of a root canal may be.  

Case study in endodontics number: 498946

Endodontist case study of root canal procedure number: 362515

Pecora al. in 1993 reported second maxillary premolars (among 435 studied) to have one root in 90,7%. The typical maxillary second premolar may be considered having only one root with a single canal among the Caucasians (Pitt Ford, 1997). According to Vertucci's study in 1984 on 200 maxillary second premolars, in 75% of the cases, a second maxillary premolar will present with only a single canal at the apex. The type V configuration occured only in 6% of the teeth examined by Vertucci and 9% of the teeth examined by Sert (2004) 

A Vertucci type V pulp space configuration can be described as follow: One canal leaves the pulp chamber and divides short of the apex into two separate distinct canals with two distinct foramina (1-2).

Preoperative radiological findings that might help us in suspecting such a pulp space configuration: root canal abruptly becomes invisible short of the apex. 

Only one file at a time could pass through the narrower root canal part in apical third, each root canal branch has been shaped cleaned and filled individually with lateral and vertical condensation. Root canal system is having canal curvature with an s form. 

Armamentarium: OPMI PROergo dental operative microscope from Carl Zeiss, Rubber dam and rubber dam clamp and frame, Stainless steel K endodontic files, gutta percha and Pulp Canal Sealer, finger plugger.

The name comes from the letter "C" shape appearance of a very large isthmus in the pulp chamber floor when viewed from above. This isthmus or groove is the result of the merging of some or all of the root canals at the cervical area near the pulp chamber floor. Incidence is 2,7% in Caucasian and up to 13% in asian population. Pre operative X Ray dental film shows a blurred image of the canal system, canals are not visible and pulp chamber is almost not visible. Looking at these features it may not be possible to diagnose a C shape canal but we must suspect either this canal configuration or severe fibrosis/calcification.

"C" shape canals are a real challenge to preparation and may cause technical complications such as transportation, steps, stripping with perforation in the thin wall area or blockage of the canal.

This procedure requires a full understanding of this anatomy to prepare an optimal access cavity to pulp chamber through a PFM abutment,  to know where to look for the root canal entries and to be cautious about the thin wall area. This endodontic procedure also requires much more operating chair time for debridment. No rapid techniques does exist to shape clean and fill those peculiar root canal shapes. This specific endodontic procedure also justifies the use of a dental operative microscope to better see what we are doing. 

Case number 319947

This 3D video of a "C" shaped second mandibular molar from the rootcanalanatomyprojectblogspot.com displays the complex anatomy of such a root canal system. In just a few second the video gives a better understanding on how difficult the cleaning and filling tasks of a "C" shape root canal may be.  

Last september, a new generation of endodontic file has been presented at the CAE meeting in Quebec city-Canada by Dr Zvi Metzger, Professor and Chair Department of Endodontology school of Dental Medicine at Tel Aviv University. Although at the moment, the Self Adjusting File System (SAF System) is not yet readily available everywhere in Canada, this innovative endodontic file adapts to root canal shape thus, may represent in a near future, a valuable approach to more efficient debridement in C shape canals and a safer way to address thin wall section that is always present in this anatomical variation. Here is a promotional video showing how it works. 

Case study number: 397137

Tooth history: First attempt of RCT on this mandibular second molar in 2005 did not eliminate symptoms, a second attempt in 2006 did not turned out to be any better, tooth was still having episodes of severe pain (preoperative X ray dental film taken in January 2007). Patient was told by the second practitioner to remove that tooth but she would rather try to save it for the third time. 

Patient was already aware of the tooth poor prognosis and that implant therapy would be the safest way to eliminate symptoms. Still she agreed to retreat the tooth endodontically.

During the procedure, a zip with perforation and apex blunderbuss could be noted on mesial root canals as well as in distal root canal. An apical split (with no existing apical constrictions) was also noted by probing in the distal canal. Serous exsudate was coming out of those root canals in such an amount that it could not be dried even with lots of paper points. Calcium hydroxide was inserted into the canals and patient came back 8 days later. By then symptoms had subsided. After removal of calcium hydroxide into the canals, serous exsudate was still present but in lesser amount. Another attempt with calcium hydroxide replacement was made. Patient came back, symptoms free, 2 weeks later. At this point, almost no exsudate was remaining. All canals, including apical split in distal root, were "plugged" with MTA (Mineral trioxide aggregate) under high magnification. Coronal part of the tooth was sealed with a posterior composite and no promises where made to the patient who decided not to invest in a crown considering the prognosis. This procedure has been achieved in August 2007, the X ray dental film on the right shows a 4 years post operative outcome. Even though circumscribe apical radiolucency is still present the tooth remained symptom free and functional.

In this specific case, MTA used as a root-end filling material proved so far to be effective in promoting regeneration of the original tissues when it is placed in contact with the periradicular tissues. High magnification with excellent coaxial illumination insured a better placement of this material. 

To read more about MTA applications please go to: 

Clinical applications of mineral trioxide aggregate

Mahmoud Torabinejad DMD, MSD, PhD^1,  and Noah Chivian DDS, FICD, FAC²