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June 2006 – Hand Files and Warm Gutta Percha Provide Optimal Results

The anatomy of this Mandibular molar suggested that it was actually a second molar that drifted into position of the previously extracted first molar. The apex had an unusual radiolucency at the terminus that suggested the roots may be buccally or lingually tilted.

The patient presented with a history of large MOD amalgam restoration that had a crack in the occlusal surface as well as buccal composite restorations. Caries was visible on the distal occlusal aspect and the patient was exhibiting signs of irreversible pulpitis.

M y initial working length files seemed to be joined at the apex, which would be unusual for a first molar but not uncommon for a second molar that had not yet evolved into a “full C-Shape” fused root configuration.  The distal canal was larger and fairly easy to negotiate. However, the single mesial canal required repeated bends at the end of the hand files to negotiate past the apical buccal curvature. This meant that attempting to negotiate Ni-Ti rotaries would be very risky or would lead to ledging of the canal. The straighter more coronal portiosn did lend themselves to Ni-Ti use but they could be more easily, quickly, economically and safely negotiated with simple use of Gates Glidden burs to the point of curvature. At that point repeated recapitulation of prebent hand files was required in order to get around the extreme curve. Even still, the junction presented problems because the glide path could not be easily reproduced at the wider joined section.

A chloroform dip technique was used to adapt the gutta percha cones to the canal. The distal cone was placed in the canal first (since it had a straighter path) and then the mesial cone was applied to the point of junction. The canal was packed with classic warm gutta percha technique and two pluggers were used simultaneously in both canals to get maximum packing pressure. Some excess is visible at the apex but overall the results were good. We can clearly see the “curtain” effect that occurs where the canals join. This also indicates that our irrigants have done a fairly good job of digesting the tissue and allowing for the reproduction of the canal anatomy in the junction area during the pack.

Even with the repeated instrument bends we can still see a bit of ledging of the mesial canal at the junction. (arrow)