How To deal with Splits " Different Scenarios "
Failure to locate and disinfect all the root canals may be a major reason for endodontic failure. The first Step to reach the success of root canal therapy is to have a good knowledge of the root canal morphology in order to get a successful Root Canal Treatment Slowey has suggested that mandibular first premolars , often called as " Endodontist's Enigma " may present the greatest difficulty of all teeth to perform a successful endodontic treatment due to their unpredictable anatomy with a wide variety of morphological rarities - - A recently published systematic literature review by Kottoor et al. summarized that “ lower bicuspids commonly have a single root (97%), with the mandibular first premolars being twice more likely to present with two canals (23.55%) than second premolars (12.64%)The aim of this article is to report diagnosis and endodontic treatment of a mandibular premolars with two or three canals.
A young female patient came to my clinic complaining from a severe pain related to lower right area , she had pain for about 1 month , the previous dentist suggested that there was a calcification, and he was facing a blockage , then she was addressed to my clinic The Pre-Operative Xray Shows an enlargement of the periodontal ligament Space and disappearing of the main canal in the mid root that confirming a Split related to tooth No. 44
Access Cavity after Pre-Endo buildup & Refinement
Scouting of the main canal " Lingual " was easy but the difficulty was in how to catch and scout the buccal canal so I made some refinement of the access cavity in Bucco-lingual direction then i pre-curved the smallest St. St. manual file " 8k " and made the file sliding up & down alongside the lingual wall without rotation to avoid any changes in the tip direction and made its pre-curved tip toward the buccal wall until I could get a catch
This Pic shows the effervescence action of irrigation while heating
Irrigation Protocol was 5.25 % Naocl , 17 % EDTA Solution and Alcohol heated by FastPack & Activated by Ultrasonic " Ultra X device "
-I shaped the root canals up to 30.04 with Controlled memory files
I cut the gutta-percha 4-5 mm apical from the apex by down packing technique using FastPack device
Obturation of the buccal & Lingual canal at the Split level
Back-filing of the whole canal Space by thermoplastisized GP Using Fastfill Device
Then the case was refereed back to the previous dentist for completion of the final restoration
Tooth No. 35 with Coronal Split into 2 canals
A- Trials to Catch the buccal canal
B- Catching & Scouting the Canal
C- Check Master cone Fitting
D&E - obturation by WVC Tech.
This video shows us how to obturate the canals at the split level in tooth No. 35
Other Scenario of Diagnosis & Management of Mandibular 1st Premolar with three canals
During taking a working length Xray , I revealed that we hade a fast break phenomenon apically that suggests a Split in tooth No. 34
Then I tried to scout in more than one direction in order to catch other canals
Clinical Pic Shows 3 Canals Apically " L , MB & DB "
All canals were prepared up to 25.04 using CM Files
I put each Master cone Separately and cut it at the split level using fastback device
Obturation by WVC Technique Using Fast-fill device , then restored the tooth with resin composite
1st premolar “ tooth no. 34 “ also has a division in the coronal 1/3 into three canals and managed by the same protocol that we discussed before
The Outcome of endodontic treatment can be jeopardized by a lack of anatomical knowledge and a poor attention to the Preoperative Xray Never underestimate the case you deal with especially the mandibular premolars A careful examination of the pre-operative x-ray can help the clinician in identifying such anatomic peculiarities in order to select the strategy and the correct instruments before starting the root canal therapy.
1- Albuquerque D, Kottoor J, Hammo M. Endodontic and clinical considerations in the management of variable anatomy in mandibular premolars: a literature review. Biomed Res Int. 2014;2014:512574. doi: 10.1155/2014/512574. Epub 2014 May 8. PMID: 24895584; PMCID: PMC4034431.
2- Kararia N, Chaudhary A, Kararia V. Mandibular left first premolar with two roots: A morphological oddity. Contemp Clin Dent. 2012 Apr;3(2):234-6. doi: 10.4103/0976-237X.96840. PMID: 22919233; PMCID: PMC3425116.
3- Arnaldo Castellucci, Endodontics text book, Access Cavity and Endodontic Anatomy P.244.
4- Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent Assoc
5- England MC Jr, Hartwell GR, Lance JR. Detection and treatment of multiple canals in mandibular premolars. J Endod 1991;17:174 – 8.