Endodontics: managing a three-rooted maxillary second premolar

Greg Creavin presents a case involving endodontic management of a three-rooted maxillary premolar using the reciprocating Endoperfection Varyflex single file.

Complex anatomy provides challenges in any dental procedure. This includes the unusual incidence of three roots in a maxillary second premolar, with an incidence rate of just 1% (Verruci, 1984).

Understanding and interpretation of the preoperative radiograph is the key to successful management and planning of such cases.

One example of this comes in the form of the following case report. It demonstrates how a complex case was managed with a single reciprocating Endoperfection Varyflex file to achieve excellent results.

Patient need

  • Figures 1a and 1b: Preoperative radiograph

This 41-year-old female was referred by her general dental practitioner for completion of root canal work, after the anatomy proved too challenging.

Upon presentation at the practice, she was found to be in fairly good dental health. She had a few restorations and her general health was fine.

Radiographic examination showed complex anatomy with three distinct roots (two buccal and one palatal) (Figure 1).

The root canal work had already been started by her dentist. Therefore, completion of the root canal was the only treatment choice available. The patient understood this and was happy to proceed on that basis.

The treatment journey

Figure 2: The Endoperfection reciprocating Varyflex file

Non-surgical conventional root canal treatment was planned for an hour-long appointment.

Using a microscope for enhanced vision of the treatment area, the pulpo-dentinal complex was accessed and three distinct roots were found, as expected from the preoperative radiograph.

Coronal disinfection was completed with 5.25% sodium hypochlorite.

A glide path was established with a size 10 K file. The Morita Mini Root ZX was used to measure length with a size 10 K file. A size 15 K file was found to go easily to working length in all three canals.

Cleaning and shaping were completed with a single reciprocating Varyflex 25 Endoperfection rotary file (suitable for small/medium canals) (Figure 2) in all three canals to working length, with patency maintained with a hand file.

Figure 3: Working length

Recapitulation and irrigation was completed with ETDA 17% and 5.25% sodium hypochlorite.

Matched R25 Endoperfection reciprocating gutta percha points were used and measured at length (Figure 3), precisely following the shape created by the file to achieve the ideal final fill.

The postoperative radiograph (Figure 4) shows three excellently obturated canals. The high expectations of both the endodontist and general dentist were met. The patient was equally happy to have completed the root canal phase of her treatment.

The patient was then sent back to her general dentist for immediate cuspal coverage restoration. Apart from returning in six months for a check-up, she will remain with her usual practice moving forwards for maintenance and care.

Figure 4: Postoperative radiograph

A streamlined workflow

A combination of high-quality postgraduate education and experience, as well as having a great team, means that the workflow for this kind of treatment can easily be streamlined even in challenging clinal circumstances.

The file of choice here, the Varyflex 25 Endoperfection reciprocating rotary file, has proved to be a brilliant tool that allows the achievement of predictable, reproducible results to the highest standard. They are gentle on the patient and save time, both of which this patient commented upon, and offer a similar benefit for the dental team, in addition to cost savings.

Ten simple steps

Using the reciprocating Varyflex file

  1. Isolate the tooth using rubber dam
  2. Gain access to the root canal system
  3. Coronal irrigation with 5.25% sodium hypochlorite
  4. Scout the canals initially using a small hand file
  5. Most canals can be fully shaped with a Varyflex reciprocating file size 25 if size 15 file goes to working length. However, if at this stage a size 20 K file easily passes to the estimated working length, a Varyflex reciprocating file size 40 should be selected
  6. Using a dedicated endomotor, introduce the file into the canal, gently progressing the file apically. Adjust the access as necessary to ensure straightline access into the coronal third of each canal. This is achieved by a gentle lateral brushing action of the Varyflex reciprocating file, always working away from any furcation
  7. The working length should now be determined using radiographs and an electronic apex locator
  8. Once patency has been achieved, take a size 15 K file or Endoperfection Guide file to the full working length to achieve a suitable guide path
  9. The final shape can now be achieved simply using one Varyflex reciprocating file. Gradually progressing the file until it reaches the full working length. Every three to four ‘pecks’ if the file hasn’t reached the full working length, it should be removed, inspected for damage, cleaned and re-introduced
  10. Once the Varyflex reciprocating file has reached the full working length, preparation is complete.

Products used

  • Mini Root ZX – Morita
  • Varyflex – Endoperfection.

Reference

Vertucci FJ (1984) Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 58: 589-99

This article was first commissioned for Clinical Dentistry magazine. To sign up and receive upcoming issues of the magazine, visit www.fmc.co.uk/shop/clinical-dentistry.

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