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Krasner and Rankow laws, CBCT and Microscope

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Adherent calcifications do represent a significant challenge when one is trying to locate the root canal entries during the procedure. This patient was referred for a pre prosthetic root canal treatment on a calcified first maxillary premolar. In this case, the pulp chamber was completely obliterated by adherent calcifications as well as the root canal entries. Furthermore the root canals are also narrow.

The first step consisted in finding the pulp chamber floor position. A challenging task when the pulp chamber is completely obliterated. In order to estimate its depth as well as its location, the CEJ has been used as the ultimate guide (Using Krasner’s and Rankow’s both law of centrality and law of concentricity). Unfortunately, despite the fact that the approximate depth corresponding to the CEJ level has been reached, the narrow root canal entries were still obscured by reparative dentine. (Figure ).

Therefore, in order to limit the risks of tooth excessive destruction or perforation, a small volume 3D Scan was performed to display their exact location. While the coronal CBCT slice showed that the correct depth had been reached, the axial CBCT plane showed that, in palatal root, an extra 2mm of dentine had to be removed toward the palatal and also one mm troughing in the vestibular direction in the buccal root was necessary before entries could be reached.

A microscope and a Variolux NSK handpiece with a diamond coated tip has been used for that purpose. Once the root canal entries were located, the first instruments (Mani K files number 06) were reaching the apical constriction in both canals. Shaping with Mani K files and ProTaper Universal. Obturation with Pulp canal sealer from Kerr and gutta.

In this case, the microscope alone could not be used in order to locate the root canal entries. Krasner and Rankow laws helped in reaching the pulp chamber floor level, then, both CBCT and the microscope had to take over in order to finally be able to locate the entries.

Adherent calcifications do represent a significant challenge in endodontic procedures. According to this study: “as the extent of canal calcification increased one level of intensity, the difficultly in reaching the root canal constriction increased 7 times.”

Article on Krasner and Rankow Laws

Preserving a natural tooth or an implant therapy?

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24 Pre Root Canal Therapy  24 Pre Root Canal Therapy

On the pre operative X Ray, this asymptomatic tooth looks badly worn and its root canal is calcified, still, this tooth periodontal status is good and its crown to root ratio would still be acceptable even after having performed a potential crown lengthening procedure. Casted post bevelled margin preparation will include 2mm of preparation length on solid tooth to ensure an adequate length of parallel wall to achieve an effective ferrule.

In this case overall outcome success mostly relied on an intricate root canal procedure outcome. Dental operating microscope has been most helpful when attempting to locate this narrow root canal entry and thus, played a key role in helping preserving this natural tooth. Being able to perform a root canal in this case allowed the patient to preserve its tooth instead of extracting it and replacing it with a dental implant.

Root canal 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.

Saving a Tooth Through an Intricate Root Canal Procedure

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Root canal therapy on maxillary molar Pre operative 2015-08-27 1 Root canal therapy on maxillary molar Per operative picture 2015-08-27 1  Root canal therapy on maxillary molar Per operative 2015-08-27 1  Root canal therapy on maxillary molar post operative 2015-08-27 1  Root canal therapy on maxillary molar post and amalgam core build up 2015-08-27 1  Tooth # 16 post operative post and core build up picture

The patient urged my referring dentist to save his own natural tooth even though it was badly decayed and it presented with an uncomplicated crown fracture on its lingual side. Despite its apparent questionable restorability on pre operative Xray, the tooth is very long and its periodontal status is good so we accepted to perform both the root canal procedure and the post and core build up.

RCT procedure on this maxillary molar has been a time consuming one mostly due to its calcified root canal system and its 26mm length. MB2 root canal entry has been located with the help a dental operating microscope high magnification along with a coaxial Xenon illumination.
Armamentarium: Zeiss’s OPMI PROergo Dental Operative Microscope , 556 straight cross cut carbide tungsten bur, Ultrasonic tips (BUC 3), RC Prep, many Mani K files (envelop of motion), ProTaper Universal, 6% NaOCl, PUI, Pulp Canal Sealer + W.V.C.

Tooth has been restored with a FlexiPost (cemented with RelyX luting cement) and an amalgam core build up. (Slight excess of amalgam seen on post operative X ray on palatal aspect of the tooth has been removed prior to sending patient back to his own dentist for crowning)

A Difficult Root Canal Treatment on Calcified Root Canals

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Root Canal Treatment on Calcified Molar Pre Therapy 46969-14    Root Canal Treatment on Calcified Molar Post Therapy 46969-14

An intricate endodontic therapy to perform in order to preserve a very painful tooth, patient was taking 3 X 200mg Ibuprofen Pills  every 3 hours in order to get through the preceding night. Serous exudate accumulation resulted in mucosa swelling.

This type of root canal treatment has a high level of difficulty because calcified canal shaping is prone to endodontic file torsional fracture inside the tooth. Calcified root canals entries where located with the help of a Carl Zeiss Microscope. These where embedded in a mass of pulpstones and calcifications which had to be removed with ultrasonic tips. Shaping performed with stainless steel K hand files  06, 08, 10, 15, 20,25, 30 from Maillefer (Envelope of motion technique and lots of chelating agent). Calcium Hydroxide Antibacterial gel insertion was mandatory to control infection within the root canal system. This gel has been removed in a subsequent appointment and replaced by a permanent root canal filling. (Cold lateral condensation gutta + Pup Canal Sealer)

Root Canal Treatment on a Tooth Presenting With a Rare Anatomical Variation

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Anatomical variation 35 and root canal treatment Pre op Mandibular first premolar, necrotic pulp, AAA, patient has a gag reflex making it difficult to take a pre op. X ray dental film revealing a peculiar anatomy variation.

Anatomical Variation and root canal Treatment on 35 Ca(OH)2 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.

Anatomical Variation and Root Canal Treatment  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.

 

A Root Canal Treatment on a Badly Worn Wisdom Tooth, Was it Wise?

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3.7 Root Canal Treatment Pre operative

3.7 Root Canal Treatment Post operative

A 70 year old patient complained about mastication difficulty due to the
loss of mandibular first and second molars for many years. He wanted a fixed
prosthesis to replace his removable one but did not want implant surgery
because his thin alveolar ridge would also imply a block bone grafting.
Patient knew that he could not overcome his dental surgery fear.

Throughout his life, he never wanted to pull out his badly worn wisdom tooth
and always insisted to have it filled over and over again. It turned out in
the end, that he was right because a root canal treatment allowed for this
tooth to be preserved and used as a fixed dental bridge abutment sparing him
the need for a wisdom tooth extraction and also two more implant related
surgeries.

His tooth position in the arch, tooth axis inclination, calcified canals
made this root canal treatment a difficult one to perform
in 2008.

Relieving Pain With An Intricate Root Canal Treatment on a C Shape Root Canal

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endomontreal dental clinic case study by Dr Pierre Pizem. Pre-Treatment Root Canal      Root canal filling and Nayyar Core build up

An intricate endodontic therapy to perform in order to preserve a very painful tooth, patient was taking 3 X 200mg Ibuprofen Pills  every 3 hours in order to get through the preceding night. Serous exudate accumulation resulted in mucosa swelling

This type of root canal treatment has a high level of difficulty because debridement of those ribbonlike C shape root canals is extremely painstaking to perform.

High level of difficulty root canal treatment to perform in a C shape canal, a root canal anatomy variation. Image from: "The Root Canal anatomy project"

These pictures of a “C” shaped second mandibular molar from the rootcanalanatomyprojectblogspot.com have been taken by Dr Marco Versiani. They display the complex anatomy of such a root canal system. Those pictures give a better understanding on how difficult the cleaning and filling tasks of a “C” shape root canal may be.

High level of difficulty root canal treatment to perform in a C shape canal, a root canal anatomy variation. Image from: "The Root Canal anatomy project"

Calcified root canals entries where located with the help of a Carl Zeiss Microscope. These where embedded in a mass of pulpstones and calcifications which had to be removed with an ultrasonic tip. Calcium Hydroxide Antibacterial gel insertion was mandatory to control infection within the root canal system. This gel has been removed in a subsequent appointment and replaced by a permanent root canal filling. Tooth corono apical build up is an amalgam  Nayyar core. A permanent crown is planned.

Root Canal Procedure on Calcified Wisdom Tooth Presenting With a Severe Root Canal Curvature

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Advanced Root Canal Procedure on a Tooth Presenting with a severe Root Canal Curvature

Advanced Root Canal Procedure on a Tooth Presenting with a severe Root Canal Curvature

calcification, canal obliteration
Root canal procedure on Calcified and Curved Root Canal

 

Root Canal Therapy on a Calcified Root Canal With an S Form Curvature (Case 525214)

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Root canal on calcified maxillary first premolar pre-therapy. Advanced Endodontics case number 525214-1

Root canal on calcified maxillary first premolar per-therapy. Advanced Endodontics case number 525214-1

Root canal on calcified maxillary first premolar post-therapy. Adavanced endodontics case number 525214-3

Endodontic. Case Study Number 525214

Locating both root canal entries without lateraly perforating the root and without destroying to much sound tooth structure in order to keep tooth restorable, then, cleaning and shaping those root canals without loosing patency, without breaking an endodontic file and without perforating the root represent the two major endodontic procedure problems to overcome when treating calcified canals with an S form.