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.