Patient: 61year-old female with unremarkable medical history

Dental History:  Caries exposure noted on the mandibular right second molar (#31) and the patient was referred for root canal treatment before restoration.  

Significant Findings:
Clinical examination revealed gross occlusal caries and a slight response to cold thermal stimulation (#31).  Radiographs and CBCT imaging revealed complex root anatomy and root apices approximating the mandibular canal. The Innerview finding showed a favorable energy return graph (ERG) for #31 but a very poor ERG for the implant in the #30 site which remained unrestored.

Pulp and Periradicular Diagnosis: Vital pulp (caries exposure) with a normal periapical periodontium  (#31)

Treatment Prognosis: Good (#31)

Special Considerations of Performed Treatment:
This molar presented wtih extremely long roots with multiple curves noted for the mesial root.  A high risk for strip perforation was noted. The video of the CBCT coronoapical slicing from the tip of the mesial root as it starts on the mesial tended to curlto the lingual indicating a multiplanar course.  Finishing to a standard Protaper Gold F1 file would have likely perforated out the furcation side on this mesial root. ProTaper Ultimate files were used  for a little more “curve safety”.  

Considering the philosophy of Dr. Herbert Schilder,  there are three challenge levels you can choose on a case like this (I personally feel I have failed to achieve my best effort if I settle for Level 2, Level 3 is an absolute treatment failure).

Easier Level 1: it is popular to use an advanced irrigant activation system like GentleWave or a laser and presume a file that never reaches the apex will still clean the apical root canal system.  This relies on a “squirt” of root filling to the apex.

Harder Level 2:  Relies on cleaning and shaping to the tip but a cone is not fit to the root canal terminus the cone is utilized as a piston to compress sealer to the apex. 

Hardest Level 3:  The root canal system is cleaned and shaped to the radiographic terminus and a cone is fit to the root end.   Ideal waves of condensation and deformation of the cone at the tip is not necessarily accomplished, but the time and effort passing files and flushing with irrigant to the apex likely means better apical debridement.  Fitting a cone requires more time in the case with irrigant flushing and development of apical space for irrigant disinfecting action.

Key Learning Points:

Curved, long, narrow root require extreme caution and patience during treatment. Routinely favored files may have to be abandoned in favor of instruments more suited to unusual anatomy.  If unusual anatomy is suspected preoperatively then a CBCT scan should be taken to understand the potential complexities before starting treatment.

1. Prepare the patient for the possibility of more appointments than anticipated. If you start root canal treatment and the preoperative radiograph fails to show a complicated anomaly, then more time will be required to perform treatment.
2. Three dimensional imaging with CBCT is essential and a standard for modern endodontic treatment. 
3. Definitive quality root canal treatment requires time and patience without rushing. Appointment scheduling should allow for flexible time needed to treat challenging cases. Unusually challenging cases should be scheduled to be open-ended without the presence of a subsequent patient creating anxiety and the impulse to rush.
4. Look for creative alternate options if treatment objectives cannot be satisfactorily met. Extraction is always an option if the objectives of treatment cannot be satisfactorly met or harm to the patient can occur (eg. paresthesia).