CALCIFIED CANALS

Calcification in the root canal, whether isolated or continuous, can make treatment very difficult for the most skilled clinician. The use of chelating agents, magnification, fiberoptic transillumination, and pathfinding files can help the dentist find and treat calcified canals.

Therefore, in calcified cases when the bur does not drop easily into the chamber, the clinician should change to smallerdiameter burs and, keeping the long axis in mind, direct the cutting action in apical-lingual version. If the canal orifice still does not materialize after cutting in an apical direction, the clinician should remove the bur, place it in the access cavity, and expose a radiograph; the resultant film will reveal the depth of cutting and the angulation of cutting from mesial to distal.

Electronic apex locators are especially useful when treating teeth with calcified pulp chambers, as a minute perforation can be discerned before it is enlarged.

METHODS OF LOCATING CALCIFIED CANALS Preoperative radiographs (Fig. 7-10) often appear to reveal total, or nearly total, calcification of the main pulp chamber and radicular canal spaces. Unfortunately, the spaces have adequate room to allow passage of millions of microorganisms. The narrowing of these pulpal pathways is often caused by chronic inflammatory processes such as caries, medications, occlusal trauma, and aging. Despite severe coronal calcification, the clinician must assume that all canals exist and must be cleaned, shaped, and filled to the canal terminus. It has been demonstrated that caFIG. 7-10 Radiograph of a nonvital mandibular molar with calcified canals. nals become less calcified as they approach the root apex. There are many methods of locating these spaces (Figs. 7-11 to 7-29). It is recommended that the illustrated sequences be

followed to achieve the most successful result. In the event of inability to locate the canal orifice{s), the prudent clinician will stop excavating dentin lest the tooth structure be weakened. Retrograde procedures become conservative when compared with perforations or root fractures. There is no rapid technique for dealing with calcified cases. Painstaking removal of small amounts of dentin has proven to be the safest approach. Text

Radiograph of a nonvital mandibular molar with calcified canals.

FIG. 7-15 Radiograph of tooth in Figure 7-14 taken in 1989 reveals severe calcification of the pulp chambers and periapical and furcal radiolucencies.

MANAGEMENT

FIG. 7-16 Mandibular first molar with a class I amalgam, calcified canals, and periapical radiolucency. The assumption is that a pulpal exposure has occurred, causing calcification and, ultimately, necrosis of the pulp tissue.

FIG. 7-17 Illustration showing excavation of amalgam and base material. The cavity preparation should be extended toward the assumed location of the pulp chamber. At this phase of treatment the clinician must attempt to provide maximum visibility of the roof of the main chamber. All caries, cements, and discolored dentin should be removed.

FIG. 7-18 Using a long-shank no. 4 or 6 round bur, the assumed location of the main pulp chamber is explored.

High-magnification eyeglasses, loupes, or the opcrating microscope are helpful in searching for anatomic landmarks. Even apparently totally calcified main pulp chambers leave a "tattoo," or a retained outline, in the dentin. The shape of the pulp chamber in the mandibular first molar will be roughly triangular or rectangular. The canal orifices are usually found closest to the points of the triangle or the corners of the rectangle. Other landmarks are the cusp tips (if they remain). The orifices often lie directly beneath them.

FIG. 7-19 The endodontic explorer, DG 16 (HU-Fricdy), is used to explore the region of the pulpal floor. It is as important to the clinician doing endodontics as the periodontal probe is to the dentist performing periodontal diagnosis. It is an examining instrument and a chipping tool, often being called upon to "flake away" calcified dentin. Reparative dentin is slightly softer than normal dentin. A slight "tug back" in the area of the canal orifice often signals the presence of a canal.

FIG. 7-21 As excavation proceeds apically, it is advisable to check the proximity of the furcation. One technique is to place warmed baseplate gutta-percha in the chamber floor with an

amalgam plugger. An angled bitewing radiograph reveals the amount of dentin remaining.

FIG. 7-22 Deeper excavation with no. 4 and 2 round burs, following landmarks (removal of the rubber dam can often assist), will usually produce a small orifice.

FIG. 7-24 Excavation extended apically in the direction of the root apices.

FIG. 7-23 As an adjunct to maximum visibility with magnification, the fiberoptic light can be applied to the buccal or lingual aspect of the crown. Transillumination often reveals landmarks otherwise invisible to the naked eye.

FIG. 7-25 At this point in the search, the clinician should begin to feel concern about the loss of important tooth structure, which could lead to vertical root fracture. The bur may be removed from the handpiece and placed in the excavation site. Packing cotton pellets around the shaft maintains the position and angulation of the bur. The radiograph taken at right angles through the tooth will reveal the depth and the angulation of the search.

FIG. 7-26 Further excavation apically with a long-shank no. 2 round bur helps to locate the orifice. The endodontic explorer is the first instrument to identify a pinpoint opening.

FIG. 7-27 At the first indication of a space, the smallest instrument (a no. 06 or 08 file) should be introduced. Gentle passive movement, both apical and rotational, often produces some penetration. A slight pull, signaling resistance, is usually an indication that one has located the canal. Careful file manipulation, frequent recapitulation, and canal lubricants (e.g., Calcinase, Glyoxide, R-C Prep) will assist in gaining

access to the apical terminus. It is suggested that the access to (he canal orifice be widened until the clinician can readily relocate the orifice.

FIG. 7-28 A larger instrument is shown passing two curvatures to the apex by locating one canal in a multicanal tooth. It is usually possible to locate the second, third, or fourth canal once the first one has been located.

FIG. 7-29 Final canal obturation and restoration revealing anatomic

complexities. This drawing appeared on the cover of the fifth edition of Pathways of the Pulp. (The simulations of the prepared and filled canals are courtesy of Dr. Clifford Ruddle.)