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.
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
Patient has been referred for root canal treatment on both first and second maxillary molars. Tooth number 16 had necrotic pulp and tooth 17 presented with irreversible pulpitis. Patient was taking both antibiotics and analgesics.
To alleviate patient’s pain, both teeth had to be simultaneously cleaned and shaped during the first setting. A pulpectomy on 17 and a cleaning and shaping of 3 canals of tooth 16 have been performed. An interim calcium hydroxide dressing has been inserted and patient had to come back in order to locate clean and shape the second mesio vestibular. During the second appointment the dental operative microscope allowed us to uncover and treat both an apical split in tooth number 17 and a fourth canal in tooth 16.
Despite the fact that on the pre operative X Ray image tooth number 17 seemed to have a single large canal, it ended up being a Vertucci type 5 root canal configuration (a single canal splitting in two branches short of the apex). As for tooth 16 a second mesio vestibular was expected to be present in its mesio vestibular root, still, dental operative microscope has there too been very useful when trying to locate it.
Access opening has been performed with a combination of a 556 cross cut and a round tungsten carbide bur (Friction Grip). Operative field observation has been 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 in order to expose the second mesiovestibular root canal entry location.
Instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. Ultrasonic tip: BUC One from Spartan. P5 (Dentsply) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100.
First appointment procedure: Access opening, copious NaOCl 2,5% irrigation, two canal entries located by pre bending and scouting through deep main canal constriction, followed by 06,08,10,15 K files from Many. Irrigation protocol: NaOCl 2,5%, absorbent paper points + EDTA 17%, absorbent paper points, CHX 2% for 1-2mn, absorbent paper points, intracanal medication: Ca(OH)2 loaded with Barium Sulfate + Iodine (Metapaste), Teflon, Cavit. Barium sulfate displays a third canal in post operative dental X Ray film.
Patient is seen 3 weeks later, no more symptoms, scouting with pre bent 08 K file could not be of any use in locating this third canal entry neither as high magnification with coaxial Xenon light. Two previously located canals are shaped up to a 20 K file, followed by ProTaper “original” NiTi file sequence up to F3 in order to allow for ultrasonication. Adding ultrasonication to same irrigation+drying protocol, Pulp Canal Sealer and cold lateral followed by warm vertical in order to maximize the odds of “sealing” what will remain, despite all my efforts, an accessory canal.
Dental operative microscope root canal procedure (Microendodontics). Case Study Number 392346.
Referred patient has had two root canal procedure previously done on this very same tooth and pain was still present for weeks. Extraction and an implant supported crown has been suggested but patient still preferred to once more try to save his own tooth. The dental operative microscope allowed the uncovering of an extra canal ramification during the endodontic procedure. Pain subsided immediately after treating that previously under seen part of the root canal system.
This a class 3 level of difficulty root canal procedure which means that a root canal treatment such as this one is difficult and time consuming to perform. Nevertheless, treating that extra canal was all that was needed to save that tooth. No need for a dental implant here.
Microendodontics. Case Study Number 503746
A 40 years old male patient presented for an emergency dental examination.
Chief complaint: pain and swelling, unable to chew on right side
Clinical examination: gum swelling, broken filling, tooth tender to palpation and (gentle) pressure, tooth did not respond to thermal or electric sensitivity test, periodontal probing depth are wnl.
Radiographic examination: huge calcifications in distal root canal and pulp chamber, periapical radiolucencies around both roots, mesial pulp horn are in direct contact with saliva
The diagnosis was acute periapical periodontitis associated with an infected necrotic pulp.
The patient was keen to retain his tooth, therefore, went ahead with root canal treatment
First appointment: gaining access to root canal system (calcifications removal), shaping and cleaning, 5% NaCl, paper points and Ca(OH)2, coton pellet and provisional filling (Cavit)
Second appointment: Ca(OH)2 removal, rinse, dry, final obturation Pulp Canal Sealer and gutta percha, Nayyar core build up
A very rare anatomical variation: A Vertucci’s type V configuration in distal root and mesio vestibular portal of exit oriented toward mesial. Engine driven files beware!
An intricate root canal procedure. Case study number 524236
Two successive root canal procedure attemps failed on this mandibular molar. In the past three years patient had to take many courses of antibiotics to control pain and swelling. Patient is unable to chew on that tooth. An extraction and an implant supported crown has been suggested but patient wants to keep his own tooth despite all this.
Clinical examination shows vestibular swelling, probing does not show any narrow deep pocket. On radiographic examination filling material is overextended in distal root and a large bone rarefaction area is present on distal root tip.
Retreatment of the root canal on distal root is suggested because an untreated fourth canal is suspected. Once filling material has been removed no extra canal could be found, instead, with the help of high magnification an apical delta or Vertucci’s type V pulp space configuration could be noticed. 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 distinct foramina (1-2). According to Vertucci’s study in 1984 on a 100 mandibular molars sample, the type V configuration in distal root, occurred only in 8% of the teeth examined.
Consequently the untreated branch is filled with necrotic pulp and bacteria releasing toxins into the surrounding bone area. An ISO files number 08 is inserted into the untreated branch, then, a NiTi file is also inserted into the retreated branch through the same canal entry and a second Xray is taken. The second Xray clearly displays the apical split in last apical third of distal single canal. Each part of the split in distal root has been individually cleaned and shaped. NiTi files allowed us to follow both curved branches. Root canals have been filled with calcium Hydroxide and patient came back 8 days later to have those filled with Pulp Canal Sealer and gutta percha. (Lateral and vertical condensation). Last (Angulated) X ray to the right shows the two branches after final obturation.
Tooth symptoms have subsided shortly after calcium hydroxide have been inserted into the root canal system. Two months have passed and tooth is still symptoms free. Being able to get magnification and bring illumination to the root canal tip allowed for that tooth to be preserved. Patient was told to protect his tooth with cusp coverage.
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).