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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

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)

Microendodontics with Zeiss OPMI PRO Ergo Operative Microscope: Striving to Find a Pathway to the Apices and to Clean a “C” Shape RC system.

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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.

Atypical Canal Configurations, 'C' Shaped Canal System, Root Canal Treatment Pre-Therapy 319947-1  Atypical Canal Configurations, 'C' Shaped Canal System, Root Canal Treatment Per-Therapy 319947-1  Atypical Canal Configurations, 'C' Shaped Canal System, Root Canal Treatment Post-Therapy 319947-1

Endodontist. Case Study 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.