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 three 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 a lower molar with severe apical curvature.
Patient background
A 67-year-old female patient was referred to the practice. The referring dentist had identified the LL8 as requiring endodontic treatment, and had deemed the tooth to be restorable. When the patient presented, she was asymptomatic. The patient’s overall oral health was quite good, but she had existing restorations, including dental implants.
Assessment and diagnosis
Tests were carried out to assess the LL8. The tooth did not respond to the ice test, or to percussion, and the periodontal probing depths were less than 3mm. Apical radiographs were taken to assess the tooth structure. My assessment was that the restorability of the tooth was questionable, due to the substantial about of coronal tissue loss. However, the referring dentist had assessed the situation and wanted to proceed with endodontic and restorative treatment.
Treatment planning
The treatment options discussed included either root canal treatment or extraction, in addition to the option of doing nothing, which was not recommended in this case. The patient wanted to proceed with root canal treatment, and we discussed the risks associated with the coronal loss on the LL8, to ensure the patient was fully informed.
Treatment provision
Treatment began with an ID-block, followed by the placement of a HySolate Latex Dental Dam (COLTENE) to isolate the tooth. The tooth was opened, and three canals were located. The canals were found to have severe apical curvature, and the pulp was confirmed to be necrotic. Following this, the HyFlex OGSF file sequence from COLTENE was used to perform root canal treatment, beginning with the Orifice Opener file, followed by the Glidepath and Shaping files. I felt confident about using this canal sequence to clean the root canals, without the files separating, as the files are flexible and able to adapt to the curvature of the canals. The root canal treatment was completed with the Finishing file (30.04, 21mm).
Following this, the canals were sealed with gutta percha and bioceramic sealer, and the patient was provided with a temporary glass ionomer cement filling. The patient was then referred back to the referring dentist to receive her final restoration.
Treatment outcome
The patient was very happy with the treatment outcome, and I was pleased that the endodontic treatment was successful in such a challenging situation.
Learning points
In this case, I was tasked with performing endodontic treatment on a molar which had root canals with severe apical curvature. Management of curved canals is clinically challenging, with common errors including ledge formation, canal blockage, root perforations, zipping, and file separation. These complications can arise during the preparation of curved canals.[i] In some cases, it may be beneficial to pre-curve hand instruments and use smaller file sizes to navigate curved canals and reduce the risk of complications.[ii]
I would always recommend using a flexible file system in cases like this – such as the HyFlex OGSF file sequence from COLTENE – to enable you to negotiate the canals’ curvature. It is essential to use the latest high-quality files from a reputable manufacturer for the best results, ease of use, and reduced risk of file separation.
For more information, info.uk@coltene.com and 0800 254 5115
COLTENE website https://www.coltene.com/
Author: Dr Nicolai Orsteen
[i] Ambili, C., and BS KESHAVA PRASAD. “Trouble Curve: Endodontic Management of Severely Curved Root Canal System-A Case Report.” RGUHS Journal of Dental Sciences 13.1 (2021).
[ii] Ambili, C., and BS KESHAVA PRASAD. “Trouble Curve: Endodontic Management of Severely Curved Root Canal System-A Case Report.” RGUHS Journal of Dental Sciences 13.1 (2021).
