Adherent calcifications do represent a significant challenge in endodontic procedures. In cases of complete root canal system obliteration by calcifications, it is extremely difficult to locate, negotiate, and fully instrument very narrow root canals. The odds of never being able to find the canals, to break an instrument, to perforate the tooth are extremely high.
This 23 year old patient wanted a second opinion because an endodontist told her that the probability of a successful outcome in such a calcified tooth would be as low as 20%. Patient was keen on saving her own tooth and decided to come and see us because she had seen on this blog that we have been treating calcified root canal systems for quite a long time now .
It was true that the pulp chamber was completely obliterated by adherent calcifications as well as the root canal entries. Furthermore the mesial root canals were also narrow. However, we cannot just replace a good tooth with an implant just because it has calcified canals. The patient understood that no promises were made but we were in agreement to attempt salvaging the tooth via a root canal treatment.
The first step consisted in finding the pulp chamber floor position. A challenging task considering that the pulp chamber was completely obliterated. In order to estimate its depth as well as its location, the CEJ was used as the ultimate guide (Using Krasner’s and Rankow’s both law of centrality and law of concentricity). Unfortunately, despite the approximate depth corresponding to the CEJ level having been reached, the narrow mesial root canal entries were still obscured by reparative dentine. Only the distal root canal could be located, shaped and filled with interim calcium hydroxide. Due to the apical resorption and bone rarefaction an extrusion of calcium Hydroxyde material occurred. An overfill which has no impact on the outcome.
A microscope and a Variolux NSK handpiece with a diamond coated tip was used in order to carefully remove the reparative dentine in order to uncover the mesial entries. Once the root canal entries were located, the first instruments (Mani K files number 06) could reach the apical constriction only after coronal enlargement.
Root canal shaping with Mani K files and ProTaper Universal. Obturation with Pulp canal sealer from Kerr and gutta.
If an endodontist or a general practitioner is not comfortable or does not have the proper tools to treat calcified root canals, he should consider referring to an endodontist or a general practitioner who has extensive experience in dealing with such challenging teeth.
As stated by John I. Ingles: “The practicing dentist should not be cited for faulty judgment when even the so-called experts tends to disagree on prognosis… All in all, one must ultimately develop confidence in one’s own abilities. Being able to practice using a great variety of techniques and not being “married” to a single approach in every case will greatly enhance one’s capabilities. And on this is based good prognosis, the result of skill, knowledge, and self confidence.”
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