Root canal therapy of C-shaped mandibular second molar: A Case report Presented by Dr.

Tahsina Nishat
Abstract: Aims: This clinical report presents the endodontic treatment of a mandibular second molar with a Cshaped canal systems. Summary: A C-shaped root canal is most frequently seen in mandibular second molar. Once recognised, the C-shaped canal is a challenge with respect to debridement and obturation. C-shaped root canal is an important anatomic variation which presents a thin fin or web connecting the root canals. We observed this configuration in a case and successfully treated the tooth by using conventional methods of obturation. Key learning points: C-shaped root canal, canal configurations, Calcium Hydroxide. Introduction The C-shaped canal system is an anatomical variation that may occur in mandibular first molars and maxillary molars but is most commonly found in mandibular second molars. Typically, this canal configuration is found in teeth with fusion of roots either on its buccal or lingual aspect. In such teeth, the floor of the pulp chamber is usually situated deeply and may assume an unusual anatomical appearance. C Shaped canal which presents many difficulties in removing pulp tissue and necrotic debris persistent discomfort during instrumentation because of large volumetric capacity of the C shaped canal system along with transverse anstomoses, irregularities and lateral canals make it difficult to clean and seal the root canal system. The purpose of this report is to present the root canal treatment of a mandibular second molar with a C Shaped canal system.

Case Report: A 25 years old female reported to the Department of Conservative Dentistry and Endodontics, in CIDCH with the chief complaint of pain in lower right posterior region. Clinical examination revealed deeply carious occlusal lesion in lower right mandibular second molar. Pain on percussion was present. No significant findings were recorded in the medical history. Intra-oral periapical radiograph showed coronal radiolucency involving the pulp chamber as well as a peri apical radiolucency. Therefore, the patient was diagnosed with chronic periapical periodontitis. The radiograph showed a fused root with outline of two root canals (Illustration 1).

Illustration 1 : Pre-Operative radiograph After the access cavity was prepared and removal of tissue from the pulp chamber was done and after careful probing with small files and irrigation with sodium hypochlorite, the canal system appeared C shaped. Canal orifice extending from mesiobuccal canal to mesiolingual canal and the other orifice of distal canal separately. Canal system identification was confirmed from radiograph. Though the tooth was non vital at first working length was determined (Illustration 2).

Illustration 2 : Working length radiograph

Distal, mesiobuccal and mesiolingual canal spaces were prepared normally. In between the instrumentation, the canal was irrigated with sodium hypochlorite. Calcium hydroxide intracanal medicament was placed for one week. During the second visit, patient was totally asymptomatic.

Distal canal was prepared by 40 master apical file & mesiolingual & mesiobuccal canal was prepared up to 30 no master apical file. Master cone intraoral periapical radiograph was taken (Illustration 3).

Illustration 3: Master cone radiograph The canal was obturated with lateral compaction gutta-pearcha technique and slurry mixed zno eugenol was used as sealer & final radiograph was taken ((Illustration 4). Permanent restoration was done after a week the patient was advised for follow up after a month.

Illustration 4: Post Obturation radiograph

Discussion:

C-shape configuration is known to present a complex canal anatomy where it is easy to retain residual pulp tissue, bacteria, and dentin debris, thus requiring supplementary effort to accomplish a successful treatment. Radiographic identification of this phenomenon is difficult. Most radiographs revealed radicular fusion or proximity, a large distal canal, a narrow mesial canal. In this case endodontic treatment of a mandibular second molar, type II (Meltons classification), C-shaped root canal is presented where the semicolon-shaped (;) orifice in which dentine separates a main C-shaped canal from one mesial distinct canal, (Illustration 5)

Illustration 5: Meltons classification (Category II) In this case sodium hypochlorite was used as irrigant because of large amount of Pulp tissue and transverse anastomoses copious amounts of sodium hypochlorite is necessary for maximum tissue removal and disolve tissue debris. It is better to use MTAD as an irrgant because it allowes prolong anti bacterial effect, it also opens dentinal tubules because it allows the anti microbial agent to penetrate. However, it was not possible to use in this case.. Placement of Calcium Hydro-oxide between appoinments was used because it increases tissue removal and has anti bacterial effect and stimulate periapical healing. Use of vertical compaction technique is better for obturating C shaped canal as this technique leads to better flow of gutta percha into the canals but there was no option 0f using this so lateral compaction technique was used and got a good result.