Dr Nicolai Orsteen is a Specialist in Endodontics. Nicolai graduated from the dental school at the University of Oslo in February 2002, going on to study for a further 3 years, specialising in endodontics. Dr Orsteen has been working in private dental clinics in Oslo and London since 2002 and enjoys the challenge of difficult root canal cases. Since 2017 he has been the principal dentist at the Root Canal Dental Referral Centre in Richmond, London, which is a private practice solely limited to endodontics. See www.rootcanalcentre.co.uk for more information.
Here, Dr Orsteen describes a challenging case in which he performed root canal treatment on an upper pre-molar with three root canals.
Patient background
A young male patient was referred to the practice reporting pain in the upper left quadrant. Overall, his oral health was quite good, however he did have some decay and some existing fillings.
Assessment and diagnosis
A clinical examination was carried out, and it was found that the UL5 was sensitive to percussion, and had a positive reaction to cold testing. Periodontal health was good, with periodontal probing at 3mm. A deep composite filling was present on the distal-occlusal aspect. A periapical x-ray was taken at this time, which confirmed that there was a high probability that there were three root canals present. A diagnosis of symptomatic irreversible pulpitis in the UL5 was given.
Treatment planning
When planning treatment for the tooth, there were three potential options. These were root canal treatment, extraction, or no treatment with continued monitoring of the tooth. The patient was in pain, and so did not want to wait and monitor the tooth. Additionally, it was preferred to save the tooth on this occasion, rather than opt for extraction. As such, the patient agreed to undergo root canal treatment.
Treatment provision
To begin, local anaesthetic was delivered to the area. Following this a HySolate Latex Dental Dam (COLTENE) was applied to isolate the tooth. The tooth was accessed using a DIATECH Multilayer Diamond Bur (FG 848 016 10 ML) from COLTENE and all three of the canals were located. It was confirmed that the vital pulp was inflamed. Because the treatment involved a pre-molar tooth with three canals, it was more complex and required a reliable and predictable treatment approach.
As such, I opted to use the HyFlex OGSF file system from COLTENE because the files have a conservative taper, they are flexible, and they facilitate a modern approach to root canal cleaning and instrumentation. The HyFlex OGSF sequence allows the clinician to preserve more dentine, as well as being safer and more efficient. The sequence consists of an Orifice Opener, Glidepath File, Shaping File, and Finishing File which, when used in order, enables an effortless preparation, without the need for a lengthy decision-making process. In this case, I established a glide path, then used the Glidepath File, followed by the Shaping file, and finished the preparation with the Finishing file which is 30.04.
After cleaning the root canals, they were filled with gutta percha and bioceramic sealer. A temporary glass ionomer filling was provided. The patient was then referred back to a general dental practitioner for their final restoration.
Treatment outcome
The treatment was a success and both myself and my patient were happy with the results. The patient was relieved to no longer experience pain after the procedure.
Learning points
In general, a pre-molar tooth is expected to have one to two root canals. In this case, I performed root canal treatment on an upper pre-molar with three. In maxillary second pre-molars, laboratory studies have demonstrated an incidence of three root canals at between 0.3-2%.[i] As such, the rare third canal has the potential to be easily missed, making it essential to have a meticulous knowledge of root tooth morphology, carry out a thorough assessment and diagnosis, and carefully interpret radiographs prior to beginning treatment.[ii]
Due to the unique root canal anatomy in this case, it was absolutely vital to have a conservative approach to treatment, being careful not to remove too much dentine in the process. Utilising instruments which facilitated this was essential for a successful outcome.
For more information, info.uk@coltene.com and 0800 254 5115
COLTENE website https://www.coltene.com/
[i] Mohammadi Z, Shalavi S, Giardino L, Asgary S. Endodontic Considerations in Three-canalled Premolars: A Practical Update. Iran Endod J. 2016 Spring;11(2):134-7. doi: 10.7508/iej.2016.02.012. Epub 2016 Mar 20. PMID: 27141223; PMCID: PMC4841350.
[ii] Sulaiman AO, Dosumu OO, Amedari M. Maxillary first premolar with three root canals: a case report. Ann Ib Postgrad Med. 2013 Dec;11(2):105-8. PMID: 25161429; PMCID: PMC4111068.
