A confusing case. Lower second molar root canal treatment with Vertucci class V classification
Irreversible pulpitis with tooth 37 (not the best pre-operative radiograph)
I am sharing a challenging root canal treatment case performed on a lower LHS second molar (#37). Following the diagnosis of a cracked tooth with irreversible pulpitis, RCT was initiated.
A distal crack was identified that upon intraoperative examination did not extend into the pulp chamber. A stainless steel orthodontic band was cemented for provisionalisation and the patient was advised of a guarded prognosis.
At the initial visit, only a singular mesial could be found. This really stunned me as although it is possible in rare cases for the mesial root to have one canal, research has shown two canals are present in the mesial root canal majority of time.
I investigated further with CBCT.
#37 mesial root coronal slice.
The coronal slice of the mesial root clearly showed the singular mesial canal dividing into two in the coronal 1/3.
Red dot - Gouge created in the floor of pulp chamber in attempt to search for the ML orifice.
Yellow Line - Single canal dividing to two in the coronal 1/3 of root (Vertucci class V classification)
With guidance from the CBCT, I enlarged the mesial orifice with gates glidden and #15 round pulp burs until the orifice was wide enough to allow me to visualise both the MB and ML canals under magnification. Following this, the case could be completed routinely. The CBCT helped me to avoid the danger area and create further iatrogenic gouging at the floor of the pulp chamber (red line below). This would have been where I would normal expect to find a ML orifice.
Area of mesial orifice that was enlarged in a buccal-lingual direction to allow straight line access to coronal 1/3 of MB and ML canals.
For myself, this was a challenging non-routine case. During the initial visit, the inability to correctly find and negotiate the ML canal was both stressful and extremely time consuming. Those days are the really tough ones in my job where you try so hard but seem to get nowhere. Fortunately, access to CBCT helped enormously.
