Endodontic Treatment of Curved Root Canal Systems

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By: John Bogle, DMD, MS, FRCD(C)
2013-05-01

The goal of quality endodontic therapy has remained the same since its inception. Appropriate
removal of pulpal tissues with proper cleaning and shaping, followed by an obturation system
and coronal seal, will satisfy both mechanical and biological objectives.1 As clinicians we need
to appreciate each of these aspects and know that our therapys success is dictated by the
weakest element of our treatment. One area that has the potential for improvement is our
ability to accurately instrument root canal systems in a manner that maintains the original
path of curvature in both significant and multiple curvature systems. Failing to realize canal
curvature before treatment can lead to preparation errors apical zips, perforations, canal
blockages, or instrument separation which can leave the canal unprepared and lead to
continued pathology compromising the outcome of treatment.2

The question now becomes, How do we treat these excessively curved cases appropriately?
The purpose of this paper is to provide dentists with the available tools and knowledge to
treatment plan success for tooth retention through endodontic therapy on curved root canal
systems. Cases are provided to demonstrate a sample treatment sequence.

STEP 1 - STRATEGIZE YOUR APPROACH TO SUCCESS
The most logical approach to begin treating these intricate root systems is to start with a clear
vision of what you are trying to accomplish. Understanding the anatomy prior to the onset of
treatment allows the clinician to anticipate potential challenges and work to prevent
procedural errors. Several tools can be beneficial in this regard, one of these being the
American Association of Endodontists (AAE) case assessment form.3 In a checklist format, a
dentist can use this form to select whether the patient falls into a minimal, moderate or high
difficulty ranging from radiographic analysis, canal calcification, medical history to tooth
access. This document is readily available online to assist with treatment planning. A key point
within this form is Canal and Root Morphology. Justifiably, the degree of curvature or
multiple curvatures increase the difficulty of the case from minimal to high levels of difficulty.

The degree of curvature and number of curves within the tooth can produce challenges for
appropriate shaping of the canal system.4 Prior to initiation of treatment, the clinician should
consider both the angle and radius of curvature, as this has been suggested as a more accurate
resemblance of true canal anatomy.5 The greater the angle of curvature and the smaller the
radius of curvature, the greater the complexity of the case (Fig. 1). However, the disadvantage
of conventional periapical radiographs is that they only provide information in two dimensions.

Another critical tool is the radiographic evaluation of the tooth. Conventional periapical
radiographs are important with endodontic treatment. These images can provide information
regarding the curvature of a canal or root. While conventional and panoramic radiographs
allow the operator to visualize the root structures in two-dimensions, the advent of three-
dimensional radiography allows for accurate assessment of the root canal space in multiple
planes.6 Three-dimensional imaging can allow the clinician to view proximal views with a high
degree of accuracy. This is beneficial because many teeth have curvatures that are only
present in a proximal view.7 One example of a cone beam CT machine is the Kodak 9000 3D. It
has been shown to accurately depict the relationship of the internal canal anatomy compared
radiographically and histologically.8

STEP 2 - HAVE THE TOOLS NECESSARY TO MAE THIS SUCCESS A REALITY
In the treatment of curved canals, several key products are instrumental in achieving true
success. These include small stainless steel handfiles, nickel-titanium hand files, and rotary
nickel titanium files. First off, the stainless steel hand files are used to assist with creating a
glide path. Passive movement with a light touch is necessary to debride pulpal tissues and
negotiate apical anatomy1. However, larger stainless steel instruments can alter the internal
structure of the canal (i.e. increased canal transportation) when compared to nickel titanium
instruments.9 Nickel-titanium hand files can be used to increase the diameter of the glide path
while maintaining the canal anatomy. Nickel-titanium rotary files are flexible, but multiple
curves or significant curves can still put incredible strain on these instruments. Recently, a new
product, Typhoon Infinite Flex NiTi files with Controlled Memory (Clinical Research Dental),
has been developed that uses thermal treated NiTi alloy that enhances the mechanical
properties of Nickel-titanium.10 These files have been shown to be more resistant to cyclic
fatigue than standard nickel-titanium files.11 These three tools: small stainless steel hand files,
moderate sized nickel-titanium hand files and rotary Controlled Memory or CM files, are
essential for treating the moderately to severely curved canal systems predictably.

STEP 3 - USE THE TOOLS APPROPRIATELY
Each instrument has a specific function and should be used in the correct manner. Endodontic
files are designed to create additional space within the root canal to decrease contact with
subsequent files. Endodontic files should have minimal contact along the root canal. Slow,
consistent enlargement of the canal can decrease the forces applied to each file used during
instrumentation, minimizing chances for instrument failure. Hand files should be used in a
watch-winding, or preferably, the balanced force technique.12 Rotary instruments should
never be forced apically to avoid unnecessary strains and possible failure/fracture of
instruments.13

Two types of failure occur with root canal instruments, torsional loading and cyclic fatigue.
Torsional loading occurs if a file binds within the canal and continues to rotate to the point of
separation (torsional failure). Cyclic fatigue is the result of continued forces being placed on an
instrument as it operates around curves. This results in repeated strain on the file resulting in
eventual work hardening and fracture.14 In root canals with significant curves, cyclic fatigue is
always a concern during treatment. The literature has demonstrated two key points. One,
using CM files increase the resistance to fracture vs. non treated NiTi rotary files. Two,
operating CM instruments in the presence of fluid increased resistance to fracture versus use
in a dry environment by over 200%.15 Clinicians should always operate endodontic rotary
instruments with canals flooded. This increases contact time between the internal root surface
and the disinfectant as well as decreases potential for instrument separation.

Now that the steps to treat curved canal systems have been discussed, I would like to present
a few cases that show the utilization of these steps and techniques.

CASE 1
A 17-year-old male with non-contributory medical history presented for evaluation of
Quadrant 1. Vitality tests confirmed a diagnosis of irreversible pulpitis with acute apical
periodontitis for tooth 1.62. Cone Beam CT images (Kodak) confirm pronounced curve in MB
canals and S curvature in DB canal. Dental caries were removed and aseptic treatment was
maintained with a resin modified glass ionomer cement (Fugi II, GC Corporation). Vital tissue in
five (MB1/2/3, DB and P) canals was confirmed upon pulp chamber access. Initial coronal
debridement with a rotary Sx file (Dentsply Tulsa) in conjunction with stainless steel hand files
removed pulpal tissues. A glide path was created using a combination of stainless steel hand
files and NiTi hand files (Flex files, Dentsply Tulsa). After achieving repeatable patency
measurements with the Elements Apex Locator (Sybron Endo) and 15 NTK, a 20/04 Typhoon
(Clinical Research Dental) rotary file was introduced into each canal. Passive movement into
each canal allowed for appropriate cleaning and shaping of the canal system. If the file
appeared to stop moving apically while in the canal the instrument was withdrawn and
irrigation and recapitulation with a 15 NTK hand file was used. In an apical enlargement
approach, initial instrumentation with a 20 and 25 NTK was used. Subsequent 25/04 through
35/04[3] instruments were used in all buccal canals and a 45/04 for the palatal canal. After
disinfection was completed, obturation with master gutta-percha cones, Kerr EWT sealer
(Sybron Endo) and Calamus gutta-percha (Dentsply Tulsa) was completed. The floor of the
chamber was sealed with a resin modified glass ionomer cement (Fugi IX, GC Corporation) and
temporized with Cavit (3M).

CASE 2
A 39-year-old female with non-contributory medical history presented for evaluation of
Quadrant 4. Vitality tests confirmed a diagnosis of necrotic pulp with symptomatic
periradicular periodontitis for tooth 4.6. Cone Beam CT images indicate significant mesial and
distal canal curvatures. Access through the porcelain fused to metal crown was completed
with a combination of coarse #2 diamond and #557 carbide burs (NeoBurr, Microcopy).
Necrotic tissue in two distal canals and vital tissue in three mesial canals were confirmed upon
pulp chamber access. Similar instrumentation completed as in Case 1 with the MB/ML canals
shaped to a 35/04, the middle mesial to a 25/04 and the distal canals to a 40/04.4

CONCLUSION
Although manufacturers often tout a preassembled system for root canal debridement, it is
imperative for the clinician to assess each tooth or canals on a case by case situation and
realize which instruments or techniques give the best chance of success. It is often far too easy
to adhere to the cookie cutter pamphlet included in the packet of files, rather than taking
the time to strategize the correct sequence to treat a tooth. Each tooth, and furthermore each
canal of a tooth, is unique and requires diligent attention to detail for success to be possible.
For example, the palatal canal of Case 1 was relatively straight forward. A standard cleaning
and shaping protocol could be applied to produce a good result. However, when we approach
the buccal canals, our strategy needs to be much more detailed and calculated to ensure
appropriate treatment. Our role is to think biologically rather than operate as a technician. Do
not misinterpret what is being presented. We are all capable of providing excellent endodontic
therapy. I would like to challenge each of you to push for that higher level of treatment. As the
complexity of the system increases, so must your expertise in this field. Appropriate courses
can help you advance your craft. Utilize your local endodontic specialists knowledge and
discuss cases during local study club events. Follow the current literature on new products and
resources. Our profession prides itself on an evidence based approach to treat our patients in
the highest standards possible. Apply these resources and focus on the end result.

Acknowledgements: I would like to thank Dr. Joe Petrino for his professional review and advice
regarding this manuscript.OH

Dr. Bogle is an endodontic specialist and maintains a private practice limited to endodontics in
Calgary, AB. He is a mentor in several local study clubs and presents to multiple groups on
various endodontic topics. Dr. Bogle has no conflict of interest related to this article.

Oral Health welcomes this original article.

REFERENCES
1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am 1974;18:269-96.

2. Peters OA, Peters CI. Cleaning and shaping the root canal system. In: Cohen S, Hargreaves
KM, eds. Pathways of the pulp. 9th ed. St. Louis: Mosby, Inc., 2006:290-357.

3. American Association of Endodontists, AAE Endodontic Case Difficulty Assessment Form and
Guidelines. Accessed on Feb 16, 2013 on
http://www.aae.org/uploadedFiles/Dental_Professionals/Endodontic_Case_Assessment/2006
CaseDifficultyAssessmentFormB_Edited2010.pdf

4. Schafer E, Diez C, Hoppe W, Tepel J. Roentgenographic investigation of frequency and
degree of canal curvatures in human teeth. J Endod 2002;28:211-6.

5. Pruett JP, Clement DJ, Carnes DL. Cyclic fatigue of nickel-titanium endodontic instruments. J
Endodon 1997;23:77-85.

6. Patel S, Dawood A, Pitt Ford T, Whaites E. The potential applications of cone beam
computed tomography in the management of endodontic problems. Int Endod J 2007;40:818-
30.

7. American Association of Endodontists position statement, Cone Beam-Computed
Tomography in Endodontics. Accessed on Feb 16, 2013 on
http://www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_Colleagues_for_
Excellence_Newsletter/ecfe%20summer%2011%20FINAL.pdf

8. Michetti J, Maret D, Mallet JP, Diemer F. Validation of Cone Beam Computed Tomography as
a Tool to Explore Root Canal Anatomy. J Endod 2010;36:1187-90.

9. Esposito PT, Cunningham CJ. A comparison of canal preparation with nickel-titanium and
stainless steel instruments. J Endod 1995;21:173-6.

10. Gambarini G, Plotino G, Grande NM, Al-Sudani D, De Luca M, Testarelli L. Mechanical
properties of nickel-titanium rotary instruments produced with a new manufacturing
technique. Int Endod J 2011;44:337-41.

11. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Fatigue testing of controlled memory wire
nickel-titanium rotary instruments. J Endod 2011;37:997-1001.

12. Roane JB, Sabala CL, Duncanson MG. The balanced force concept for instrumentation of
curved canals. J Endod 1985;11:203-11.).

13. Peters OA, Barbakow F. Dynamic torque and apical forces of ProFile .04 rotary instruments
during preparation of curved canals. Int Endod J 2002;35:379-89.

14. Haikel Y, Serfaty R, Bateman G, Senger B, Allemann C. Dynamic and cyclic fatigue of engine
driven rotary nickel-titanium endodontic instruments. J Endod 1999;25:434-40.

15. Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Effect of Enviornment of Fatigue Failure of
Controlled Memory Wire Nickel-Titanium Rotary Instruments. J Endod 2012;38:376-380
Photos

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Caption: Figure 2. Typhoon CM rotary files.

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Caption: Figure 3. Tulsa Dentsply Flex NTK hand files.

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Caption: Figure 4. Preoperative CBCT image (S curve on DB root a...

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Caption: Figure 5. Post operative radiograph with obturation com...

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Caption: Figure 7. Preoperative CBCT image (radius of curvature ...

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