Non-surgical Root Canal Treatment Case II:
Mandibular Anterior
Jessica Russo Revand and John M. Russo
Chief Complaint
“My tooth hurts and my gums are swollen.”
Medical History
The patient (Pt) was a 12-year-old male. Review of systems indicated cardiovascular, within normal limits (WNL); respiratory, WNL; gastrointestinal, WNL; genitourinary, WNL; musculoskeletal, WNL; neurologic, WNL; endocrine, WNL. There were no current medications and no known drug allergies (NKDA). Vital signs were as follows: Blood pressure (BP) = 94/60 mmHg left arm seated (LAS); pulse = 92 beats per minute (BPM).
The Pt was considered American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
Complete maxillary and mandibular orthodontic treatment was initiated six months prior to his initial endodontic visit. Pt’s parents reported a history of trauma to the lower anteriors approximately two years prior to placement of orthodontic brackets. He began to experience pain and swelling in the area of tooth #25 approximately one week ago with some relief when drainage occurred through a sinus tract the day before.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
No lymphadenopathy was present and the Pt was afebrile.
Intra-oral examination (IOE)
Swelling of the buccal (B) mucosa appeared in the area of the right mandibular incisors with a sinus tract on the B gingiva between teeth #25 and #26 (Figure 8.1). Probing of tooth #25 from mesial (M) to distal (D) of Facial (3 mm, 2 mm and 3 mm) and M to D of Lingual (3 mm, 2 mm and 3 mm).
Figure 8.1 Preoperative buccal swelling with sinus tract between teeth #25 and 26.
(Photograph courtesy of Dr. Domenico Ricucci).
Diagnostic Tests
| Tooth | #24 | #25 | #26 |
| Percussion | – | ++ | – |
| Palpation | – | + | – |
| Cold | + | – | + |
| Mobility | 0 | 2 | 0 |
| EPT | + | – | + |
| Sinus Tract | No | Yes | No |
EPT: Electric pulp test, ++: Exaggerated response, +: Response to percussion or palpation, and normal response to cold and EPT; -: No response to percussion, palpation, cold, or EPT
Radiographic Findings
The periapical (PA) radiograph showed the lower mandibular teeth #23–#27 (Figure 8.2). The teeth were non-carious and had orthodontic brackets and wire present. Normal bone height was present. There was a periapical radiolucency (PARL) at the apex of tooth #25 approximately 4 mm x 6 mm that extended along the distal (D) surface of tooth #25 to just below the crestal bone. The apex of tooth #25 appeared to be slightly mesially displaced.
Figure 8.2 Preoperative radiograph of teeth #23–27. Note the slight mesial displacement of the apex of tooth #25 and bone loss along the distal root surface. (Radiograph courtesy of Dr. Domenico Ricucci).
Pre-Treatment Diagnosis
Pulpal
Pulp Necrosis, tooth #25
Apical
Chronic Apical Abscess, tooth #25
Treatment Plan
Recommended
Emergency:Pulp debridement with calcium hydroxide (Ca(OH)2)
Definitive:Non-surgical root canal treatment (NSRCT)
Alternative
No treatment, extraction
Restorative
Composite core build-up
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): BP was 94/60 mmHg LAS, pulse was 92 BPM. After clinical and radiographic examination, diagnosis, and treatment (Tx) planning, the risks and benefits of Tx were discussed with the Pt and his parents. Informed consent for endodontic Tx was obtained from Pt’s parents. Anesthesia was achieved by topical 20% benzocaine followed by administration of mental nerve block, B and lingual (L) infiltration with 36 mg lidocaine (lido) with 0.018 mg epinephrine (epi). Rubber dam isolation (RDI) was achieved with Ivory® 9 clamp (Heraeus Kulzer, Wehrheim, Germany) placed apically to the orthodontic bracket and wire on tooth #25. The coronal surface was wiped with a cotton pellet soaked in 3% sodium hypochlorite (NaOCl). The access cavity was prepared with #2 surgical length round bur and fissure bur on a high speed handpiece. The outline of the endodontic access was shaped as an oval with the incisal edge slightly flared to aid in visualization of the canal orifice (Figure 8.4). The area of the cingulum was extended towards the L to aid in the detection of a possible L canal. After the B canal was identified, the L canal was detected by angling the tip of the size #10 K-file by 30° and running the tip of the file along the L surface of the B canal. Working lengths (WL) were determined with radiographs and the use of an electronic apex locator Root ZX® II (J. Morita, Kyoto, Japan)using a size #10 K-file (Figure 8.3). The two canals were found to be confluent in the apical third (Vertucci type II configuration). The canals were instrumented manually with K-type and Hedstrom files in the apical third to a size #20 Hedstrom file and with Gates Glidden burs #2, #3, and #4 in the coronal two-thirds of each canal. Irrigating solution was 1% NaOCl. The canals were dried with sterile paper points. Ca(OH)2 paste was placed in the canal with a Lentulo® Spiral Filler (Dentsply Sirona, Ballaigues, Switzerland) and condensed with paper points and cotton pellet. The access cavity was sealed with Cavit™ (3M, Two Harbors, MN, USA). Post-operative instructions (POI) given including the use of warm salt water rinses to encourage drainage of the swelling through the sinus tract.
Figure 8.3 Access opening tooth #25 after obturation completed. The preparation has been extended half-way through the incisal edge to improve access to the large canal space in a young patient. The mesio-distal preparation is conservative to reflect the external and internal anatomy. (Photograph courtesy of Dr. Domenico Ricucci).
Figure 8.4 Working-length determination. (Radiograph courtesy of Dr. Domenico Ricucci).
Second visit (Day 8): The Pt was asymptomatic and the sinus tract had closed. There was no evidence of soft tissue swelling in the facial vestibule of teeth #24–#26. Oral consent obtained from Pt’s parents for Tx. Anesthesia was achieved by topical 20% benzocaine followed by administration of mental nerve block, B and L infiltration with 36 mg lido with 0.018 mg epi. RDI was achieved with Ivory 9 clamp placed apically to the orthodontic bracket and wire on tooth #25. The instrumentation was completed to apical size #40 Hedstrom file with step-back hand instrumentation to size #60 using K-type and Hedstrom files. Irrigating solution was 1% NaOCl. The canals were dried with sterile paper points. A size #40 gutta-percha (GP) point was placed in the B canal (to the WL) and size #30 GP point in the L canal (to the level of confluence) with Pulp Canal Sealer™ Extended Working Time (EWT) sealer (Kerr Corporation, Romulus, MI). The canals were obturated with cold lateral compaction using the blue finger spreader and fine–fine accessory points. Excess GP was removed to the level of the cementoenamel junction (CEJ) using a heated spoon excavator. A permanent core build-up was placed using etch, bonding agent, and composite. The composite surface was polished and the occlusion checked. POI were given to the Pt and his parents. A postoperative (PO) radiograph showed sealer extrusion through a large L canal on the D root surface (Figures 8.5 and 8.6).
Figure 8.5 Postoperative radiograph of tooth #25. Oburation of the canal space includes fill of large lateral canal on the distal surface. (Radiograph courtesy of Dr. Domenico Ricucci).
Figure 8.6 Postoperative angled radiograph to visualize complete obturation of the buccal and lingual canals. (Radiograph courtesy of Dr. Domenico Ricucci).
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size | Obturation Materials and Techniques |
| B | 22.0 mm | 40 | Pulp Canal Sealer™ EWT, Cold lateral compaction |
| L | 22.0 mm | 40 | Pulp Canal Sealer™ EWT, Cold lateral compaction |
Post-Treatment Evaluation
Third visit (13-year follow-up): A 13-year follow-up showed complete healing of the preoperative radiolucency with formation of a lamina dura along the entire root perimeter (Figure 8.7). Resorption of the extruded sealer on the D root surface was noted. Tooth #25 was asymptomatic to percussion and palpation. There was 0 mobility on tooth #25. Probing depth was 3 mm, 2 mm and 3 mm (from M to D of Facial) and 3 mm, 2 mm and 3 mm (from M to D of Lingual).
Figure 8.7 Thirteen-year follow-up. There is complete healing of the preoperative radiolucency and resorption of the extruded sealer on the distal surface of the root. (Radiograph courtesy of Dr. Domenico Ricucci).
Fourth visit (14-year follow-up): A 14-year follow up shows normal periapical tissues radiographically (Figure 8.8). Tooth #25 was asymptomatic to percussion and palpation. There was 0 mobility on tooth #25. Probing depth was 3 mm, 2 mm and 3 mm (from M to D of Facial) and 3 mm, 2 mm and 3 mm (from M to D of Lingual).
Figure 8.8 Fourteen-year follow-up. (Radiograph courtesy of Dr. Domenico Ricucci).
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