(A) Patient information

  • Age: 40 
  • Gender: female
  • Medical history: non-contributory

(B) Tooth

  • Identification: 17 maxillary right molar
  • Dental history: mesial decay;”pain to sweets and temperature differences “ (sic).
  • Clinical examination findings: Pain on percussion; no sinus tract and soft tissue within normal limits; probing depths within 3mm: severe pain in the cold test.
  • Preoperative radiological assessment: mesial decay
  • Diagnosis: symptomatic irreversible pulpitis

(C) Treatment plan

  • Preliminary procedures: local anaesthesia (4% articaine with 1:100,000 epinephrine); rubber dam; access performed with a round bur; removal of the decayed tissue; cavity margins refined with ultrasonic tips (CPR  #2, #3; Obtura Spartan ®️); dental microscope ( Semorr G4,)  for all the procedures.
  • Canal preparation: Initial shaping with Flash  25.06 (Bondent, Shangai, China ) without previous hand file scouting or glide path; when reached the first 2/3 of the canal, the 8 and 10 C-file were used for glide path and to confirm the patency; the working length was taken with a help of 10 C-file and apex locator; shaping finished with Flash 25.06.
  • Irrigation: 6% NaOCl (manual dynamic activation); 10% Citric acid (MDA); ultrasonic activation 3×20 seconds (PUI).
  • Final irrigation protocol: 6% NaOCl ; PUI 60 seconds; Salin solution; 95% alcohol.
  • Obturation: bioceramic sealer (bio-c sealer) and gutta-percha; warm vertical compaction.

(D) Technical Aspects 

Pre-operative periapical radiographs in different angulations or tomography favour the establishment of a correct treatment plan. In this particular case the distal buccal canal was out of its normal position making it difficult to find the entrance. Although under microscope visualization we had to follow root fusion line to find the canal. It was near the palatal. The ultrasonic tips were very important to reach the distal buccal canal at this stage. Another important factor was the common entrance of the two channels, which made difficult both a correct approach and the obturation. Clinicians should be aware of this anatomical conformation before starting the treatment. A straight irrigation protocol is imperative in this these cases. Only experience and knowledge can avoid errors that may be irreversible.

A. Previous apical Rx<br />
Figure A

Previous apical Rx 

B. Cbct for searching the distal bucal<br />
Figure B

Cbct for searching the distal bucal

C. Image of DB close to the palatal
Figure C

Image of DB close to the palatal

D. The white spot in the place of DB
Figure D

The white spot in the place of DB

E. Obturation with bioceremic cement and Gutta Percha
Figure E

Obturation with bioceremic cement and Gutta Percha

F. Final Rx to check everything
Figure F

Final Rx to check everything

G. Final rx in a different angle
Figure G

Final rx in a different angle