4.9
Obturation of the Root Canal 2
Frédéric Bukiet, Maud Guivarc’h, and Thomas Giraud
Objectives
This case aims to discuss the use of calcium silicate–based sealers (CSBS) for root canal space obturation. The reader should be aware of their specific properties and understand why, when and how to use them.
Introduction
A 28‐year‐old male patient presented with spontaneous pain and biting sensitivity from the lower right first molar (LR6). He mentioned having received a root canal treatment on this tooth six months before the consultation.
Chief Complaint
Pain from a tooth on the lower right and cheek swelling.
Medical History
The day before the endodontic consultation, the patient was prescribed systemic antibiotics. The medical history was unremarkable except for elevated body temperature and asthenia during the infectious episode.
Dental History
The discomfort started one year ago. A primary root canal treatment of tooth LR6 was performed six months ago.
Clinical Examination
Extraoral examination revealed a right cheek swelling (Figure 4.9.1a). Intraoral examination highlighted a non‐fluctuant swelling in the buccal sulcus adjacent to tooth LR6. Tooth LR6 was restored with an occlusal composite restoration and was tender to percussion. Pulp sensibility tests were negative on tooth LR6. Periodontal probing depths were 3 mm or less around tooth LR6. A pre‐operative periapical radiograph was taken (Figure 4.9.1b).
The periapical radiograph revealed:
- Good bone levels.
- Extensive coronal restoration with a mesial void.
- An existing root canal filling sparsely condensed, with evidence of a possible unobturated second canal in the distal root.
- A large apical radiolucency associated with the mesial and distal roots.
Diagnosis and Treatment Planning
The diagnosis for tooth LR6 was an acute apical abscess associated with an existing root canal filling.
What were the treatment options for the patient?
- No treatment (not suitable considering the history and the diagnosis).
- Root canal retreatment.
- Apical microsurgery.
- Extraction.
After discussion with the patient and considering the clinical and radiograph information, it was decided to attempt a root canal retreatment on tooth LR6.
Treatment
The retreatment of the tooth LR6 was scheduled over two visits.
First visit
After local anaesthesia and dental dam placement, the occlusal restoration was removed and the access cavity was revised. After filling materials were removed, two additional canal entrances were identified in the distal root (Figure 4.9.2):
- One corresponding to the disto‐lingual canal that was missed during the primary root canal treatment.
- One additional canal starting lingually from the disto‐lingual canal. Scouting this canal revealed an abrupt initial curvature. A radix entomolaris was suspected.
Root canal shaping and disinfection were initiated. A cone beam computed tomography (CBCT) scan was carried out to assess the complex root canal anatomy before calcium hydroxide (Ca[OH]2) intracanal dressing for one week.
Cone beam computed tomography analysis
The CBCT analysis (Figures 4.9.3–4.9.5) revealed:
- Significant bone destruction surrounding the mesial and distal root from the middle third to the periapical area.
- A narrow pathway through the buccal cortical plate connecting the periapical lesion and the soft tissues, explaining the cellulitis.
- The presence of a disto‐lingual canal merging the disto‐buccal in the middle third.
- A fused radix entomolaris containing a separate canal.
Second visit
Root canal shaping was completed after electronic working length determination. A 17% ethylenediaminetetraacetic acid (EDTA) solution was used to remove calcium hydroxide remnants and smear layer. Then 3% NaOCl solution agitation/rinse was performed. After gutta percha master cone adjustment, a final rinse with sterile water was implemented and the canals were slightly dried with a micro suction tip and one sterile paper point per canal.
A calcium silicate–based sealer was injected within the root canals before gutta percha cone insertion to the full working length (hydraulic condensation). They were then sectioned and gently condensed with a vertical plugger at the level of the canal entrances. A temporary restorative material was placed. The immediate post‐operative periapical radiographs showed satisfactory obturation (Figure 4.9.6). The patient was scheduled the next week to place a direct composite restoration (Figure 4.9.7).
Follow‐up
At eight‐month review, the patient was asymptomatic and the tooth was functional. Periapical radiographs and review CBCT revealed clear signs of bone healing (Figure 4.9.8).
Discussion
CSBS have grown in popularity over time. This discussion aims to address their specificities and their clinical use.
What is a calcium silicate–based sealer?
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