CONTINUING EDUCATION

Endodontic treatment of curved root canal systems

Dr. John Bogle offers some cases to treatment plan success for tooth retention

T he 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 therapy’s 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 (i.e., 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 will be 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
Dr. John Bogle, DMD, MS, FRCD(C), is an endodontic
specialist and maintains a private practice this
to endodontics in Calgary, Alberta. He is a mentor in
several local study clubs and presents to multiple
groups on various endodontic topics. Dr. Boglegreater
conflict of interest related to this article. smaller the radius of curvature, the greater
Educational aims and objectives
This article aims to discuss the treatment of excessively curved root canal
systems.
Expected outcomes
Correctly answering the questions on page xx, worth 2 hours of CE, will
demonstrate the reader can:
• Recognize the intricate anatomy of these root systems to anticipate
potential challenges.
• Realize the necessity for various tools for treatment.
• Recognize how to use these tools appropriately.
Figure 1: Pruett’s method to calculate the radius of curvature5
Association of Endodontists (AAE) case However, the disadvantage of conventional
difficulty assessment form.3 In a checklist periapical radiographs is that they only
format, a dentist can use this form to select provide information in two dimensions.
whether the patient falls into a minimal, Another critical tool is the radiographic
moderate, or high difficulty ranging from evaluation of the tooth. Conventional
radiographic analysis, canal calcification, periapical radiographs are important with
and medical history to tooth access. This endodontic treatment. These images
document is readily available online and can provide information regarding the
there to assist with treatment planning. A curvature of a canal or root. While
key point within this form is “Canal and Root conventional and panoramic radiographs
Morphology.” Justifiably, the degree of allow the operator to visualize the root
curvature or multiple curvatures increases structures in two dimensions, the advent
the difficulty of the case from minimal to of three-dimensional radiography allows
high levels of difficulty. for accurate assessment of the root
The degree of curvature and number canal space in multiple planes.6 Three-
of curves within the tooth can produce dimensional imaging can allow the clinician
challenges for appropriate shaping of to view proximal views with a high degree
the canal system.4 Prior to initiation of of accuracy. This is beneficial because
treatment, the clinician should consider many teeth have curvatures that are only
both the angle and radius of curvature, as
present in a proximal view.7 One example
has been suggested as a more accurate
limited of a cone beam CT machine is the Kodak
resemblance of true canal anatomy.5 The 9000 3D. It has been shown to accurately
has no the angle of curvature and the depict the relationship of the internal canal
anatomy compared radiographically and
the complexity of the case (Figure 1). histologically.8

xx Endodontic practice Volume 6 Number 5


Figure 2: Typhoon CM rotary files
Step 2 – Have the tools necessary
to make this success a reality
In the treatment of curved canals, several
key products are instrumental in achieving
true success. These include small stainless
steel hand files, nickel-titanium hand
files, and rotary nickel-titanium files. First,
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 anatomy. 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 Controlled Memory
(Clinician’s Choice), 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
Volume 6 Number 5 Endodontic practice xx
Figure 3: Tulsa Dentsply Flex NTK® hand files
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 increases the resistance
to fracture versus 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 1.6.
CONTINUING EDUCATION
Figure 4: Preoperative CBCT image (S curve on DB root and
significant curve on MB root)
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 5 (MB1/2/3, DB, and P)
canals was confirmed upon pulp chamber
access. Initial coronal debridement with
a rotary Sx file (Dentsply Tulsa Dental
Specialties) in conjunction with stainless
steel hand files to remove pulpal tissues. A
glide path was created using a combination
of stainless steel hand files and NiTi hand
files (Flex Files, Dentsply Tulsa Dental
Specialties). After achieving repeatable
patency measurements with the Elements
Apex Locator (Sybron Endo) and 15 NTK®,
a 20/04 Typhoon (Clinician’s Choice)
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, irrigation and
recapitulation with a 15 NTK® hand file.
In an apical enlargement approach, initial
instrumentation with a 20 and 25 NTK® was
used. Subsequent 25/04 through 35/04
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 Dental Specialties)
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
CONTINUING EDUCATION
Figure 5: Postoperative radiograph with Figure 6: Postoperative radiograph
obturation complete with distal angulation
symptomatic periradicular periodontitis
for tooth No. 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.
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
take 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
straightforward. 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
specialist’s knowledge and discuss cases
xx Endodontic practice Volume 6 Number 5
Figure 7: Preoperative CBCT
image (radius of curvature on
M root)
Figure 9: Postoperative radiograph
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. EP
References
1. Schilder H. Cleaning and shaping the root canal. Dent
Clin North Am. 1974;18:269-296.
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, MO: Mosby, Inc.; 2006: 290-
357.
3. American Association of Endodontists. AAE
Endodontic Case Difficulty Assessment Form and
Guidelines. http://www.aae.org/uploadedFiles/Dental_
Professionals/Endodontic_Case_Assessment/2006Case
DifficultyAssessmentFormB_Edited2010.pdf. Accessed
February 16, 2013.
4. Schäfer E, Diez C, Hoppe W, Tepel J.
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FINAL.pdf. Accessed February 16, 2013.
Figure 8: Preoperative CBCT image (coronal view
demonstrating three canals in mesial root)
Figure 10: Postoperative radiograph
with distal angulation (obturation of three
mesial canals)
Acknowledgements: I would like to thank
Dr. Joe Petrino for his professional review
and advice regarding this manuscript.
This article was reprinted with permission
from Oral Health.
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