CaseReportsinDentistry

Volume2014(2014),ArticleID359438,6pages
http://dx.doi.org/10.1155/2014/359438

Case Report

S-Shaped Canals: A Series of Cases Performed by Four

Specialists around the World
Ricardo Machado,1 Antonis Chaniottis,2 Jorge Vera,3 Carlos
Saucedo,4 Luiz Pascoal Vansan,1 and Emmanuel Joo Nogueira Leal
Silva5
UniversityofSoPaulo,RibeiroPreto,Brazil
PrivatePracticeLimitedtoEndodontics,Kalithea,Greece
3
UniversityofTlaxcala,Puebla,Mexico
4
PrivatePracticeLimitedtoEndodontics,Monterrey,Mexico
5
GrandeRioUniversity,RiodeJaneiro,Brazil
1
2

Received18February2014;Revised21June2014;Accepted21June2014;Published
16July2014
AcademicEditor:JuanJosSeguraEgea
Copyright2014RicardoMachadoetal.Thisisanopenaccessarticledistributedunder
theCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,
andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Recognition of anatomical variations is a real challenge for clinicians undertaking
therapyregardlessoftheteeththataretobetreated.Theextentofthecurvatureisoneof
themostimportantvariablesthatcouldleadtoinstrumentfracture.Inclinicalconditions,
twocurvescanbepresentinthesamerootcanaltrajectory.Thistypeofgeometryis
denoted as the S shape, and it is a challenging condition. This report describes a
differentclinicalandeducationalscenariowherefourspecialistsaroundtheworldpresent
differentapproachesforthetreatmentofrootcanalswithdoublecurvaturesorSshaped
canals. Endodontic therapy is a very nuanced and challenging science and art. The
clinicalandteachingexperienceoftheauthorsshowdifferentapproachesthatcanbe
successfullyemployedtotreatchallengingteethhavingrootswithmultiplecurves.The
necessityofpreciseknowledgeoftherootcanalmorphologyanditsvariationisalso
underlined.

1. Introduction

Straightsimplerootcanalsystemsareexceptionsandnotrulesinthehumandentition.
Nature frequently demonstrates curved root canal systems of high complexity with
multiplecurvesindifferentplanes [1].Endodontic cleaningandshapingare difficult
whensuchsystemsarepresented[13].Recentstudieshavehighlightedthecomplexity
of the root canal system [46], which can create significant endodontic treatment
difficulties. Curves in multiple spatial orientations provide examples ofthese clinical
challenges [1, 7, 8] and an ideal preparation can be a difficult task to achieve,
especiallyincanalswiththesefeatures[9,10].
TheaimofthispaperistoshowfourcasesofSshapedcanalsperformedwithdifferent
approachesbyfourspecialistsfromdifferentclinicalscenarios.

2. Case Reports
2.1. Case 1
A40yearoldmalepatientwasreferredtotheclinicofoneoftheauthors(JorgeVera)
withseverepaintocoldstimuliinhisupperleftmaxillaryarch.Themedicalhistorywas
noncontributory.Allteethinthearearespondedwithinnormallimitstothermalcoldtests
exceptforthesecondleftmaxillarybicuspid.Probingdepthswerewithin3 mmforall
teethoftheregion.Preoperativeradiographrevealedadistaldecayinthesecondleft
maxillary bicuspid and a double curve or sshaped anatomy. After considering all
findings,adiagnosisofirreversiblepulpitiswasmade(Figure1(a)).

Figure 1: (a) Initial radiograph, (b) working length radiograph, and (c)
final radiograph.
Afteradministratinginfiltrationanesthesia(articaine1:100.000epinephrine),therubber
damwasplacedandtheaccesscavitypreparationwasperformedwithsize2roundburs
(KG Sorensen Zenith Dental Aps, AgerskovDenamark). Sizes .10 K and .08 K files
(Dentsply Maillefer, Ballaigues, Switzerland) were initially used with the Slick Gel
Lubricant(SybronEndo,OrangeCounty,CA)totrytoreachworkinglength.Thefiles
initially reached a very short length, so a stepback procedure using 360
counterclockwisemovementofeachfilewasperformedusingKfilessizes.15,.20,.25,
and.30(DentsplyMaillefer,Ballaigues,Switzerland)withslightapicalpressure.Atthe
completionoftheuseofthelargesizedfiles,5.25%NaOClwasirrigatedintotheroot

canalpreparationandasize.10Kfilewastakentoworkinglengthasconfirmedbythe
Elements Diagnostic Apex Locator (SybronEndo, Orange County, CA) and a check
radiograph(Figure1(b)).The.10and.15KfileswereusedatlengththenaCrownDown
instrumentationtechnique[11]wasperformedusingthesizes.25/.10and.25/.08twisted
files(SybronEndo,OrangeCounty,CA)toinstrumentthecervicalandmiddlethirdsof
thepreparation.Theapicalthirdwasshapedwithsizes.25/.06,.30/.06,and.35/.06 TF
instruments. 5.25% sodium hypochlorite was used to irrigate the root canal system
betweeneveryinstrumentandpatencywasmaintainedwitha.10 Kfilethroughoutthe
cleaning and shaping procedure. Passive ultrasonic irrigation was performed with an
Irrisafeultrasonictip(Satelec,Merignac,France)for1minutewiththecanalcompletely
floodedwith5.25%NaOCl;thecanalwasthenirrigatedwith17%EDTA,dried,and
filledwithgutta percha andKerrPulpCanalSealer(KerrCorporation, Orange,CA)
employingtheContinuousWaveofCondensationTechnique[12]usingtheElements
Obturation Device (SybronEndo, Orange County, CA). A down pack motion was
performedtofilltheapical4millimetersoftherootcanalandtheremainderofthegutta
perchawasinjectedwiththeguttaperchaextruder(Figure1(c)).
2.2. Case 2
A60yearoldfemalepatientwasreferredtotheclinicofoneoftheauthors(Antonis
Chaniottis) for the evaluation and possible treatment of her left maxillary second
premolar.Thetoothwassensitivetopalpationandpercussion.Thethermalandelectrical
pulp testing were negative. Thorough examination of the preoperative radiograph
revealedaperiapicallesionassociatedwiththeapexofthereferredtoothandadouble
curveorSshapedanatomy(Figure 2(a)).Afterconsideringallfindings,adiagnosisof
symptomaticapicalperiodontitiswasunequivocallymade.

Figure 2: (a) Initial radiograph showing periapical radiolucency, (b)

radiographic confirmation of the working length, and (c) immediate
posttreatment radiograph.
Afteradministratinginfiltrationanesthesia(articaine1:100.000epinephrine),therubber
damwasplaced.Accesswasachievedbyusingthesize2EndoAccessbur(Dentsply
Maillefer,Ballaigues,Switzerland).Refinementoftheaccesscavitywasachievedusing
the Endo Z bur (Dentsply Maillefer, Ballaigues, Switzerland). Coronal flaring of the

canals was performed by using the Protaper SX rotary file (Dentsply Maillefer,
Ballaigues,Switzerland).
ThelengthdeterminationradiographrevealedScurveapicalanatomy(Figure2(b)).The
initialnegotiationandscoutingoftheScurvedcanalswereachievedwithsizes.06,.08,
and.10Kstainlesssteelhandfiles(DentsplyMaillefer,Ballaigues,Switzerland).The
working length was verified using the Root ZX apex locator (J. Morita Inc., Kyoto,
Japan)andconfirmedradiographically(Figure2(b)).Handfilingwasachievedbyslowly
insertingtheKfiles(DentsplyMaillefer,Ballaigues,Switzerland)totheworkinglength
followed by gentle passive strokes upon withdrawal. This facilitated an unobstructed
glidepathtobecreatedalongtheScurvewithminimaltransportationduringshaping.
After handfiling, the sizes 1 and 2 Pathfinder rotary files (Dentsply Maillefer,
Ballaigues,Switzerland)wereusedtoworkinglength,followedbyscoutingwithsizes
10/.04 and 10/.06 Race files (FKG Dentaire, La ChauxdeFonds, Switzerland) to
working length. No further enlargement of the Scurved canals was performed. 6%
NaOClwasusedtoirrigatebetweeneachfileused.Canalblockingwaspreventedby
using multiple recapitulations with a precurved .08 stainless steel K files (Dentsply
Maillefer,Ballaigues,Switzerland)betweeneachrotaryfileuse.
The irrigation efficacy was enhanced after completion of the shaping procedures by
passive ultrasonic activation of the irrigant with a size .15 ultrasonic K file (Satelec
ActeonGroup,MerignacCedex,France).Thecanalswerenextfloodedwith17%EDTA
solutionfor2minutesfollowedbyafinalrinseofsterilewater.Thecanalsweredried
with size .20 sterile paperpoints and obturation was performed withthe Continuous
WaveofCondensationTechnique[12].
Twofinefeatheredtipguttaperchapoints(SybronEndo,Orange,CA,EUA)weregauged
to.20andfittedwithAHPlussealer(DentsplyDeTrey,Konstanz,Germany)toworking
length.AnextrafinetipmountedontheElementsObturationunit(SybronEndo,Orange
County,CA)wasusedatasettingof200C5mmshortoftheworkinglength.Theapical
guttaperchawascompactedbyusingasize35Dovganplugger(G.Hartzell&Son,
Concord, CA). Backfilling was performed using highspeed injection of
thermoplasticized gutta percha by the Extruder Elements Unit (SybronEndo, Orange
County,CA)througha.25gaugeneedle(Figure2(c)).
2.3. Case 3
A32yearoldfemalepatientwasreferredtheclinicoftheoneoftheauthors(Ricardo
Machado)withseverepaintocoldstimuliinherupperleftmaxillaryarch.Themedical
historywasnoncontributory.Allteethinthearearespondedwithinnormallimitstothe
thermalandelectricalpulptestingunlesstheleftmaxillaryfirstpremolarthatshoweda
considerable hypersensitivity. Probing depths were within 3mm for all teeth of the

region.Preoperativeradiographrevealedthepresenceofdecayallaroundthecrownand
a double curve or sshaped anatomy (Figure 4(a)). After considering all findings, a
diagnosisofirreversiblepulpitiswasmade.
Afteradministratinginfiltrationanesthesia(articaine1:100.000epinephrine),therubber
damwasplaced.Initialaccesswasachievedbyusinga1016HLbur(DentsplyMaillefer,
Ballaigues, Switzerland) and refinement of the access cavity was achieved using the
EndoZbur(DentsplyMaillefer,Ballaigues,Switzerland).Coronalflaringofthecanals
was achievedbyusingthe ProtaperSX, S1,andS2rotaryfiles(DentsplyMaillefer,
Ballaigues,Switzerland).
InitialnegotiationandscoutingoftheScurvedcanalswereachievedwithasize.10
stainlesssteelKfile(DentsplyMaillefer,Ballaigues,Switzerland).Workinglengthwas
verified by using the Elements Diagnostic Apex Locator (SybronEndo, Orange, CA,
EUA).HandfilingwasachievedbyslowlyinsertingtheKfilestotheworkinglength
followedbypassivegentle,withdrawalstrokes.Thisallowedanunobstructedglidepath
tobedevelopedalongtheSshapedcurvaturewithminimaltransportation.
Afterhandfiling,aCrownDowninstrumentationtechnique[13]wasperformedbyusing
size.04through.30profiles(DentsplyMaillefer,Ballaigues,Switzerland).Asyringeof
2.5%NaOClwasusedtoirrigatethecanalsbetweeneachfileuse.Blockingofthecanal
was prevented by using multiple recapitulations with a size .10 K file (Dentsply
Maillefer,Ballaigues,Switzerland)betweeneachrotaryfileuse.Nofurtherenlargement
oftheScurvedcanalswasperformed.Thecanalswerefloodedwith17%EDTAsolution
for 3 minutes and dried with number 30 sterile paper points and the obturation was
performedbytheTaggerHybridTechnique[14].
Two gutta percha master cones (Profile .04Dentsply Maillefer, Ballaigues,
Switzerland)werefittotheradiographicterminuswithfirmtugback.Theconeswere
coatedwithAHPlussealer(DentsplyDeTrey,Konstanz,Germany)andfittoworking
length with the aid of a size 30 finger spreader (Dentsply Maillefer, Ballaigues,
Switzerland). Subsequently, three accessory cones were added. Next a size 40/.02
McSpaddencondenserwasusedlimitedtoplacementinthecoronaltwothirdsofthe
root.ThetoothwastemporizedwithCavit(ESPE,SeefeldOberb,Germany)andthe
patientwasreferredbacktothereferringdentistforthedefinitiverestoration(Figures
3(b)and3(c)).

Figure 3: (a) Initial radiograph, (b) final periapical radiograph (straight

view), and (c) final radiograph (mesial view).

Figure 4: (a) Initial radiograph showing an access previously performed,

(b) radiographic confirmation of the working length, (c) radiograph
taken to check master cone, and (d) final radiograph.
2.4. Case 4
A37yearoldmalepatientwasreferredtotheclinicoftheoneoftheauthors(Carlos
Saucedo)fortheendodontictreatmentofhisrightmaxillarysecondpremolar.Treatment
had been previously attempted at an endodontists office and was incomplete. The
medical history was noncontributory. As the initial access had already been
accomplished, thermal tests were not performed. The adjacent teeth exhibited
unremarkable findings. Probing depths were within 3mm. Preoperative radiograph
demonstratedthataccesshadbeenpreviouslyperformedandadoublecurveorSshaped
anatomy(Figure4(a)).
Afteradministratinginfiltrationanesthesia(articaine1:100.000epinephrine)therubber
damwasplaced;theprevioustemporarymaterialwasremovedbyusinga1016HLbur
(DentsplyMaillefer,Ballaigues,Switzerland)andrefinementoftheaccesscavitywas
achievedusingtheEndoZbur(DentsplyMaillefer,Ballaigues,Switzerland).Asonly
onecanalhadbeenpreviouslyfoundtowardthebuccalaspect,theaccesspreparationwas
extended toward the palatal side finding the palatal canal. Initial negotiation was
performed with C+ .06K files (Dentsply Maillefer, Ballaigues, Switzerland) 34 mm
shortoftheradiographicapex.Irrigationwith17%EDTAwasperformedandthecoronal
twothirdswasflaredusingtheTFSystem(SybronEndo,Orange,CA,EUA)starting
withthe.25/.10fileentering34mmintotheorificefollowedwiththe.25/.08proceeding
to57mmdepths.Next,theMiniApexLocator(SybronEndo,Orange,CA,EUA)was
usedtoestablishtheworkinglengthwhichwasalsovalidatedusingadigitalradiograph
(Figure4(b)).
AfterachievingtheworkinglengthwithaC+10Kfile(DentsplyMaillefer,Ballaigues,
Switzerland) the HyflexCM System was used (ColteneWhaledent, Allstetten,
Switzerland)finishingtheinstrumentationwitha.30/.04file.Blockingofthecanalwas
preventedbyusingmultiplerecapitulationswithaKfilesize.10(DentsplyMaillefer,

Ballaigues,Switzerland)betweeneachrotaryfileusewhilecopiouslyirrigatingwith5%
NaOCl using the Endovac irrigation system (SybronEndo, Orange, CA, EUA). The
canalswerefloodedwith17%EDTAsolutionfor2minutesandthecanalsweredried
withsize.20sterilepaperpointsandobturationwasperformedwiththecontinuouswave
ofcondensationtechnique[12].Asize.30/.04Hyflexmastercone(ColteneWhaledent,
Allstetten,Switzerland)wasplacedtoworkinglengthandfit(Figure4(c)).Asize.25/06
System B plugger was preselected (SybronEndo, Orange, CA, EUA) and was used
approximately5mmshortoftheworkinglength.PulpCanalSealerEWT(SybronEndo,
Orange, CA, EUA) was the sealer used to coat the cone and the down pack was
performed at 200C with a number 2 Buchanan Plugger (SybronEndo, Orange, CA,
EUA).ThebackfillwasperformedwiththeSystemBCordlessunit.Glassionomer(Fuji
IXGCAsiaDentalPtvLtd,CityMadhapur,Hyderabad,India)wasplacedintheaccess
andthepatientwasreferredfordefinitiverestoration(Figure4(d)).

3. Discussion
Anatomicalcomplexitiesanddoublecurvatureshavebeenreportedbyseveralstudies
[1517].Complexrootcanalssystemsthatarenotcleanedandfilledadequatelymight
provideasourceofpersistentirritation,compromisingthelongtermsuccessoftheroot
canaltherapy[18,19].
The diagnosis and management of double curvatures, or Sshaped canals, present an
endodontic challenge. Careful examination of preoperative radiographs is clinically
helpful[2022].Baseduponthedentalliteratureandasshowninthesedescribedcases,it
is suggested that knowledge of root anatomy is essential for endodontic treatment
success. The different clinicians highlighted in this paper demonstrate useful and
differentclinicalprotocolsservingasaguideforallphasesofendodontictreatment.The
important treatment strategy requires that careful attention is paid to anatomical
complexitiesandthatanatomicalvariationscanbefoundinanyportionofahumantooth
root[23,24].Acareful,meticulous,andthoughtfulmethodavoidsincompleterootcanal
preparationandfailure.
Thereisaconsensusintheliteraturethatinstrumentationincurvedcanalsconsideringa
great degree of curvature predisposes higher risks of accidents [2527]. The four
extremelycurvedcasesdetailedinthispapershowhowstrategicplanningcanleadto
successful achievement of objectives. The authors of this paper described different
cleaningandshapingprotocolsanddifferenttechniquesofwarmingguttapercha.
Ingeneral,endodonticsisaverycomplexdisciplineandaneducationalchallengefor
thoseinstitutionsteachingthespecialty.Studieshaveshownunsatisfactoryendodontic
treatmentswithpreventableerrorsperformedbyundergraduatestudents[2831].This
paperprovidesusefulclinicalsuggestionsprovidedbyfourgeographicallyandculturally

diversecliniciansexperiencedinperformingendodontictherapy.Theiruniqueinsights,
experiences,andknowledgemayhelptoeducatedentistswhowouldliketosuccessfully
treatcomplicatedendodonticcases.

4. Conclusion
Endodontictherapyisaverynuancedandchallengingscienceandart.Theclinicaland
teachingexperienceoftheauthorsshowdifferentapproachesthatcanbesuccessfully
employed to treat challenging teeth having roots with multiple curves. Technical
principlesofendodontictreatmentrequireconstantassessment,revisions,anddefinition.

Conflict of Interests
JorgeVera,inthepast,hasreceivedhonorariumfromSybronendospecialties.Theother
authors declare that there is no conflict of interests regarding the publication of this
paper.

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