A four years follow up on a RCT on a maxillary first molar presenting with an apical delta in palatal canal (Vertucci’s type 5 . Each branch of the delta has been cleaned and shaped with stainless steel Mani K files up to size 35. Each branch has been filled with a single gutta cone and Pulp Canal Sealer from Kerr.
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. “C” shape canals are a real challenge to preparation of root canal treatment and may cause technical complications such as transportation, steps, stripping with perforation in the thin wall area or blockage of the canal.
The following link to a short video of the tooth in 3D gives a better understanding on how difficult the cleaning and filling tasks of a “C” shape root canal may be.
This procedure requires a full understanding of this anatomy to prepare an optimal access cavity to pulp chamber, 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 and lower the risk of procedural mistakes.
Patient came in presenting with pain and a swelling on the palatal side of tooth 24. Crown and post removal, root iatrogenic defect repair and crossed canals endodontic revision. Crossed root canals (A rare Vertucci’s Type VI Root canal Configuration) is the reason why previous practitioner could not reach the apices.
Patient experienced recurrent pain episodes and swelling coming from an infected previously treated root canals on tooth 15. Extraction and Implant surgery was the sole option offered to her until she landed in our office to get a second opinion. Upon radiographic examination, noticing the fact that the bone rarefaction was mostly located on the distal aspect of the root, we suspected an infected lateral canal. Treatment plan was a root canal revision procedure, a new core build up and a crown.
Root canal system has once more been completely cleaned, shaped, irrigated with NaOCl and then filled with an interim Ca(OH)2 paste. Patient came back a few weeks later and symptoms had completely subsided. Not all lateral canals will create such an infection issue but this one did. For that specific reason, I felt I had to find a way to fill this oddly located one for a better outcome. Neither cold lateral or WVC did allow for an adequate filling, thus a new technique was needed.
The technique: Both canals were filled in their apical third with NeoMTA root canal sealer and gutta (cold lateral condensation). The remaining coronal part has been loaded with NeoMTA root canal sealer and I have used a sterile strip of Teflon for its thermoplastic properties, condensing it to make the sealer squirt through the lateral canal. The ”Teflon Hydraulic Condensation Pressure Technique”was born. An amalgam post and core build up has then been placed into the coronal part of the root canal.
Tooth is now asymptomatic and functional, a crown will be the next and final step to prevent that tooth from being extracted.
RCT and amalgam core build up on a very long, remote and heavily calcified 26 (Irreversible Pulpitis)
Endodontic procedure instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. pulp stones removal with Ultrasonic tip: BUC One from Spartan. P5 (Dentsply) under high magnification and coaxial illumination (Opmi PROergo dental operative microscope from Zeiss) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100.
In some rare instances, a molar may have two distal root instead of one. Leaving this extra root untreated may lead to a complete root canal therapy failure. This patient came into our office on an emergency basis, thanks to the magnification, the supernumerary root canal entry could rapidly be located allowing for this procedure to be completed in a single setting.
Patient seen on an emergency basis for irreversible pulpitis on second maxillary molar. Pulp stones removal and pulpectomy performed + interim Ca(OH)2 on palatal canal only.
I had to make the patient come back for another setting to complete RCT.
The most difficult part of this procedure has been to obtain patency in a remote mesio vestibular canal as it was located at the bottom of a pulp chamber presenting with taurodontia and also because this canal had a very sharp curve in the first mm of its coronal part. Microscope Opmi ProErgo, Mani K stainless endodontic files, ProTaper from Dentsply.
First maxillary molars typically have 4 canal entries and four distinct canals. This molar has only two canal entries and a deep split in its vestibular root (A Vertucci type V root canal configuration). Both canal entries were also embedded in a mass of adherent calcifications. Furthermore, to my dismay, palatal canal last apical instrument size was a F5. In a case such as this one a dental operating microscope has been most helpful when attempting to locate root canal entries as well as when time came to visualize the deep apical split.
Endodontic procedure instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. pulp stones removal with Ultrasonic tip: BUC One from Spartan. P5 (Dentsply) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100. Opmi Proergo microscope