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 (RCT) on a severely calcified canal.
Patient background
The patient, a male in his 60s, experienced trauma against the UL1 when he was young. He had fractured part of the tooth, and had needed a crown.
He was asymptomatic for many years following his injury. Although he had received a lot of restorative treatment, the patient’s overall oral health was fair. The main concern was the UL1, which had become discoloured over time, turning yellow and brown.
Assessment and diagnosis
The patient was originally referred concerning this tooth in 2022. A CBCT scan was recommended because the clinical assessment revealed no pathological findings – however, a small lateral lesion was suspected. A periapical x-ray revealed severe calcification of the tooth.
The patient returned in May 2024 reporting a history of slight discomfort from the tooth. In the intervening two years, the patient’s dentist had applied a composite build-up, secured using two pins, making the UL1 heavily restored. A new CBCT scan showed severe calcification of the root canal, and a lateral radiolucency mid-root on the distal aspect (marked with red arrow).
Treatment planning
Treatment planningThe patient was presented with 3 options. The first, to do nothing for now and monitor the tooth. The second was to extract the tooth and replace it with an implant. The third, was to attempt RCT.
Although patient was warned that the RCT might not be possible because of the severe calcification, he opted for RCT because he wanted a fully functional and aesthetic crown, and wasn’t happy with the current appearance of the tooth. He also wanted to avoid a dental implant for as long as possible.
Treatment provision
The HyFlex OGSF sequence from COLTENE was the system of choice for this procedure, due to the system’s excellent cutting efficiency. All of the files in the sequence, consisting of an Orifice Opener, Glidepath File, Shaping File and Finishing File were employed, with irrigation between each file.
Locating the canal was challenging due to the extent of the calcification. Establishing the location took time, and required a dental microscope. Once the tooth was opened with the Orifice Opener, it was over to a MicroMega K-File ISO 08 to reach as deep down as possible into the canal. Then it was the turn of the Glidepath File, 1mm short of the length achieved with the K-File, and this process was repeated all the way to the root apex.
Once the root was open, the Shaping File was utilised, ending with the 30/.04 Finishing File to clean out the canal, completing the OGSF sequence. The canal was irrigated using COLTENE CanalProTM NaOCI 3% during the instrumentation and COLTENE CanalProTM EDTA as a finial irrigation.
The tooth was restored using a glass ionomer cement, and the patient went back to the dentist for the final restoration.
Treatment outcome
Both the patient and I were happy with the results. The tooth was successfully restored all the way down the root. The prognosis for the tooth going forward is positive.
Learning points
Learning pointsThe main challenge in this case was the calcified canal. Pulp calcification is the gradual formation of hard tissue along the root canal walls. It can take place slowly as part of the ageing process or due to tooth decay, but dental trauma can accelerate the deposition of hard tissue. The process of rapid narrowing or complete closure of the root canal space is called calcific metamorphosis, root canal calcification or pulp canal obliteration.[i]
Performing endodontic treatments where there has been root canal calcification is complex and presents significant challenges. If the root canal space is partially or completely obliterated, it is very difficult to locate, establish, and maintain the glide path. This is due to the restricted space, loss of visibility and lack of clear reference points to indicate the anatomy of the canal.[ii]
In my experience, when treating a severely calcified canal it is vital to use good files and magnification – ideally using a microscope.
For more information, info.uk@coltene.com and 0800 254 5115
COLTENE website https://www.coltene.com/
[i] Chaniotis A, Sousa Dias H, Chanioti A. Negotiation of Calcified Canals. J Clin Med. 2024 May 4;13(9):2703. doi: 10.3390/jcm13092703. PMID: 38731233; PMCID: PMC11084956.
[ii] Nasiri K, Wrbas KT. Management of calcified root canal during root canal therapy. J Dent Sci. 2023 Oct;18(4):1931-1932. doi: 10.1016/j.jds.2023.06.018. Epub 2023 Jun 27. PMID: 37799891; PMCID: PMC10547979.
