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Endodontic Treatment Challenges of Complex Anatomy

Terry Pannkuk, DDS, MScDClinical Endodontic Technique Instruction, Clinical Endodontic Technique Instruction, Cleaning and Shaping, Cleaning and Shaping, Sample Cases, Sample Cases, All by Date, All by Date


Preoperative radiograph (4/12/21)


Cone fit radiograph (4/26/21)


Check radiograph (4/26/21)


Immediate post-treatment radiograph (4/26/21)


Immediate post-treatment radiograph (off-angle, 4/26/21)


A recent subsequent case shows the the importance of debris clearing (preoperative radiograph, 4/29/21)


Case 2: CBCT showing the anomalous radix entomolaris root form (4/29/21)


Radiograph showing file lengths and highlighting curvatures (5/12/21)


Calcium hydroxide placement after the first visit (5/12/21)


Note the extreme curvature of the anomalous root and the challenge of cone fitting. Debris clearance was essential (6/10/21)


Immediate post-treatment radiograph (6/10/21)


Immediate post-treatment radiograph (off-angle, 6/10/21)

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Patient: 43 year-old female in good health

Chief Complaint: Patient complained of a constant throbbing toothache in the lower right posterior jaw. She reported 7/10 pain level and presented for emergency treatment

Dental History: A Zirconium crown had been placed on the lower right first molar (tooth #30) 6 months prior. The dentist had said the “decay was deep and near the nerve”. The pain increased the prior two weeks.

Significant Findings (#30):
Clinical examination normal periodontal probing depths. Percussion elicited slight sensitivity with normal biting and chewing tests. Radiographic examination revealed anomalous anatomy determined to be a radix entomolaris form. Thermal stimulation with heat resulted in a lingering throb which was relieved by cold.

Pulp and Periradicular Diagnosis (#30): acute irreversible pulpitis with an acute periradicular periodontitis

Treatment Prognosis: Excellent (#30)

Treatment Plan: Nonsurgical endodontic treatment (#30)

Special Considerations of Performed Treatment:
Management of a radix entomolaris can be challenging due to the anomalous lingual (third root) tending to be small in diameter, curved, with an abrupt apical buccal curvature. This unusual root tends to have an orifice located more lingual to the distobuccal canal orifice requiring access extension to, or even over the distobuccal cusp allowing entry. The initial canal path is usually canted to the extreme lingual.

First treatment visit (4/12/2021):
The focus of this treatment was emergency management. An attempt to rush and complete treatment on a case like this in one visit is foolhardy, likely to cause a treatment mishap, and cause the patient unnecessary pain. Endodontic access and pulp extirpation was performed. A new patented pulp dehydrating solution was used to facilitate quick scouting of the canal and achieve patency without tissue or debris blockage. Initial shaping was performed to create space for filling with calcium hydroxide. Length measurements were taken in all canals. A Cavit temporary filling was placed without a spacer and the patient was scheduled for treatment completion no sooner than one week later.

Second treatment visit (4/26/2021):
The temporary filling was removed and the calcium hydroxide removed with additional patented pulp dehydrating solution and the EndoActivator. Final cleaning and shaping was performed and the entire root canal system was filled with gutta percha and Kerr Sealer via the vertical compaction of warmed gutta percha technique.

A final core was placed as follows: Excess gutta percha and sealer removal with chloroform, drying with alcohol and microetching with 50 micron particles, Photobond and Luxacore incrementally placed, cut back from the occlusal surface, porcelain etch, silane, Optibond FL and layered Filtek Ultra Supreme to reproduce esthetic surface.

A second similar case is shown highlighting the importance of debris-clearing.

Key Learning Points:

  1. Anomalous root anatomical forms should be understood and recognized along with clinical management implications.

  2. Continuous flushing with appropriate irrigating and clearing agents along with small file recapitulations prevent tissue and debris blockage facilitating apical patency

  3. When presented with an endodontic emergency focus on pain management and plan an additional visit to meticulously and successfully complete treatment.

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