The Guidebook to Molar Endodontics

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Editor
Ove A. Peters
Department of Endodontics
University of the Pacific Arthur A. Dugoni School of Dentistry
San Francisco
California
USA

ISBN 978-3-662-52899-0 ISBN 978-3-662-52901-0 (eBook)

DOI 10.1007/978-3-662-52901-0

Library of Congress Control Number: 2016958572

© Springer-Verlag Berlin Heidelberg 2017

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Preface

Dear reader:
You may think, “Why another textbook on endodontics?” and you are absolutely
right to ask that question. The purpose of this book is in my view a bit different from
a typical textbook, and hopefully this becomes apparent when you read it.
Historically, the intention of a guidebook, according to several dictionaries that I
consulted, was to give information to travelers. Regardless of whether you are a
seasoned clinician or a beginner, you may want to travel deeper into molar endodon-
tics, and this book intends to give you support in your decision-making and execu-
tion of the treatment plan.
The idea for this book was born out of several pertinent findings in discussions
with endodontists, residents, general dentists, and fellow faculty members:

• Do we teach molar endodontics sufficiently to dental students or should they take

additional training to perform this procedure?
• Are modern technological developments, such as the use of the operating micro-
scope or cone beam computed tomography (CBCT), essential to successful
molar endodontics?
• Is avoiding a gross mistake as important as doing the little things right in achiev-
ing success?

The latter question came to the forefront when I considered the use of checklists
for clinical procedures [1]. While it would be dangerous to oversimplify endodon-
tics, it surely helps to step back occasionally and make sure that the right thing is
done. Better yet, one would like to use clinical evidence whenever available to sup-
port the course of action.
This is the reason that each chapter in this book has a number of references but
also one key citation that can help to directly address a clinical quandary. With this
comes the need to reevaluate the standard of practice periodically to include new
and pertinent information.
This task would be insurmountable if it were not for my coauthors who were
each responsible for a chapter in this book; I cannot thank each of them enough.
From a clinical standpoint, there are several key principles that can be cited for
procedural success in root canal therapy. The term “procedural success” is in my
view related to what the clinician can do to promote best patient-related outcomes.

v
vi Preface

It is my impression that outcomes in endodontics are discussed more and more in a

broader sense beyond the treatment of apical periodontitis; this is helpful so that we are
not primarily focusing on radiographically confirmed resolution of apical bone defects
but considering other outcomes that are relevant for our patients [2].
At a time where CBCT permits real-time imaging of apical conditions, without
clearly defining what a normal periradicular space looks like, an assessment of our
strategies is in order. I happen to believe the next step in this diagnostic paradigm
will be molecular tests for pulpal and periapical conditions.
Obviously, the practice of dentistry varies from country to country, continent to
continent, perhaps based on fee schedules and educational systems. This prompted
me to solicit the help of well-educated clinician-researchers with diverse back-
grounds for each of the central issues discussed in this book, ranging from molar
anatomy over diagnosis and clinical treatment to outcome assessment, retreatment,
and surgery.
It is my hope that you will enjoy the text as much as the supporting material in
bullet points and images and, ultimately, go on to travel the road to successful molar
endodontics.

San Francisco, CA, USA Ove A. Peters, DMD, MS, PhD

References
1. Gawande A. The checklist manifesto: how to get things right. New York: Metropolitan Books;
2009.
2. Azarpazhooh A, Dao T, Ungar WJ, Da Costa J, Figueiredo R, Krahn M, Friedman S. Patients’
values related to treatment options for teeth with apical periodontitis. J Endod. 2016;42:365–70.
Acknowledgments

At this point, I must thank all involved in my career for their interest and enthusiasm
for root canal treatment and all other aspects of endodontology; specifically, I am
grateful for the guidance and support from my mentors Dr. Fred Barbakow, Dr.
Harold Goodis, and Dr. Alan Gluskin.
I am greatly indebted to my coauthors and editors—their invaluable contribu-
tions made this book possible.
Most importantly, I would like to express my gratitude to my parents who started
me in life with their attitude of hard work, curiosity, and support for whatever new
project I came up with. Last but not least, my thanks go to my wife Christine. She
is not only an educator and endodontist in her own right but also my favorite line
editor; this book would not have been possible without her understanding and prac-
tical help.

vii
Contents

1 Molar Root Canal Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Frank Paqué
2 Diagnosis in Molar Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
David E. Witherspoon and John D. Regan
3 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
John M. Nusstein
4 Vital Pulp Therapy for Permanent Molars. . . . . . . . . . . . . . . . . . . . . . 93
Lars Bjørndal
5 Molar Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Frank C. Setzer and Helmut Walsch
6 Shaping, Disinfection, and Obturation for Molars . . . . . . . . . . . . . . . 133
Ove A. Peters and Ana Arias
7 Considerations for the Restoration of Endodontically
Treated Molars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Julian G. Leprince, Gaetane Leloup, and Chloé M.F. Hardy
8 The Outcome of Endodontic Treatment . . . . . . . . . . . . . . . . . . . . . . . . 207
Thomas Kvist
9 Nonsurgical Root Canal Retreatment . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Elio Berutti and Arnaldo Castellucci
10 Endodontic Microsurgery for Molars . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Enrique M. Merino

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

ix
Contributors

Ana Arias, DDS, MS, PhD Conservative Dentistry, School of Dentistry,

Complutense University, Madrid, Spain
Elio Berutti, MD, DDS Department of Endodontics, University of Turin, Turin,
Italy
Lars Bjørndal, PhD Section of Cariology and Endodontics, Department of
Odontology, Faculty of Health and Medical Sciences, University of Copenhagen,
Copenhagen, Denmark
Arnaldo Castellucci, MD, DDS University of Naples Federico II, Naples, Italy,
University of Cagliari, Cagliari, Italy
Private Practice, Florence, Italy
Chloé M.F. Hardy, DDS School of Dentistry, Cliniques Universitaires Saint Luc –
Université catholique de Louvain, Brussels, Belgium
Thomas Kvist, PhD, DDS Department of Endodontology, Institute of Odontology,
The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Gaetane Leloup, DDS, PhD School of Dentistry, Cliniques Universitaires Saint
Luc – Université catholique de Louvain, Brussels, Belgium
Julian G. Leprince, DDS, PhD School of Dentistry, Cliniques Universitaires
Saint Luc – Université catholique de Louvain, Brussels, Belgium
Enrique M. Merino, MD, DDS European University, Madrid, Spain, Complutense
University, Madrid, Spain
Private Practice, Leon, Spain
John M. Nusstein, DDS, MS Division of Endodontics, The Ohio State University
College of Dentistry, Columbus, OH, USA
Frank Paqué, DMD, MSc Department of Preventive Dentistry, Periodontology
and Cariology, University of Zurich Center for Dental Medicine, Zurich, Switzerland
Private Practice, Zurich, Switzerland

xi
xii Contributors

Ove A. Peters, DMD, MS, PhD Department of Endodontics, University of the

Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, USA
John D. Regan, BDentSc, MA, MSc, MS, FICD Department of Endodontics,
Texas A&M, University Baylor College of Dentistry, Dallas, TX, USA
North Texas Endodontic Associates, Plano, TX, USA
Frank C. Setzer, DMD, PhD, MS Department of Endodontics, Penn Dental
Medicine, Philadelphia, PA, USA
Helmut Walsch, DMD, PhD, MS Department of Endodontics, Penn Dental
Medicine, Philadelphia, PA, USA
Private Practice, Munich, Germany
David E. Witherspoon, BDSc, MS, MFA, FICD Department of Endodontics,
Texas A&M University Baylor College of Dentistry, Dallas, TX, USA
North Texas Endodontic Associates, Plano, TX, USA
Molar Root Canal Anatomy
1
Frank Paqué

Abstract
Detailed understanding of root and root canal anatomy is the main prerequisite
for successful molar endodontics. Besides typical three-rooted and two-rooted
configurations for maxillary and mandibular teeth, respectively, there are specific
variations such as merged roots, additional roots, and completely different shapes
such as the C-shaped molars. Adding complexity, frequently small accessory
canals are found that can contribute to periapical pathosis.

Guiding Reference
Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal
configurations. J Endod. 1999;25:446–50.
This clinical study on first and second maxillary molars treated over an 8-year
period was made in an attempt to determine the percentage of second mesiobuccal
(MB2) canals that could be located routinely. 1732 maxillary molars were treated
and overall, the MB2 canal was found in about 73 % first molars, 51 % second
molars, and 20.0 % third molars. It occurred as a separate canal in about 55 % of first
molars, 45.646 % of second molars, and joined in all third molars. However, as the
operator became more experienced, scheduled sufficient clinical time, routinely
employed the dental operating microscope, and used specific instruments adapted
for microendodontics, MB2 canals were located in about 93 % of first molars and
60 % in second molars.

F. Paqué, DMD, MSc

Department of Preventive Dentistry, Periodontology and Cariology,
University of Zurich Center for Dental Medicine, Zurich, Switzerland
Private Practice, Rennweg 58, 8001 Zurich, Switzerland
e-mail: [email protected]

© Springer-Verlag Berlin Heidelberg 2017 1

O.A. Peters (ed.), The Guidebook to Molar Endodontics,
DOI 10.1007/978-3-662-52901-0_1
2 F. Paqué

1.1 Introduction

A central goal of cleaning and shaping procedures in endodontics is to obtain a

debrided root canal system that is in its entirety free of microbiota and debris.
Therefore, detailed knowledge about root canal anatomy prior to any access to the
root canal system is absolutely mandatory [1]. Moreover, complex root canal anat-
omy in molar roots should be expected in every single case. Root and root canal
anatomy directly impacts practice and procedures for access cavity preparation,
canal shaping and obturation, and in fact most procedures in molar endodontics (see
Chaps. 5, 6, 7, 9, and 10 in this book).
It is well established that intraradicular microflora is the main cause for develop-
ing, or persisting, apical periodontitis [2]. Unfortunately, the intraradicular infection
mainly consists not of planktonic bacteria but of well-organized biofilms. The bac-
teria in biofilms show a higher pathogenicity compared to their planktonic counter-
parts [3]. More than 400 different bacterial species were found in root canal systems
of teeth with necrotic pulps [4]. Interactions between different species within end-
odontic biofilms lead to enhanced stress resistance [5]. Their location within com-
plex molar root canal configurations makes complete eradication of endodontic
biofilms virtually impossible; even reducing the microbial burden below a biologi-
cally acceptable threshold demands careful canal debridement. It is safe to say that
in depth understanding of root canal anatomy is of upmost importance for success-
ful molar endodontics.

1.2 Components of the Root Canal System

and Classifications

In roots with round cross-sectional shapes, the number of root canals corresponds in
most cases to the number of roots. However, an oval shaped root may have more
than one canal [1]. The immense complexity of molar canal configurations is based
on a wide range of root canal curvatures, different root canal sections, different
accessory canals, fins, and isthmuses. Different attempts of classification contrib-
uted to a deeper understanding of root canal anatomy. There are numerous classifi-
cations for anatomical variations in root canals. Weine and coworkers [6] examined
in a laboratory study the mesiobuccal roots of maxillary molars and classified these
into four and later into five types as shown in Fig. 1.1.
A more detailed classification is recommended to more accurately describing the
internal root canal configurations of individual molar roots. One of the most com-
monly used classifications is the one by Vertucci [7] with eight different canal mor-
phologies (Fig. 1.2a).
However, if there are more than two canals within one root, this classification
again is limited. Gulabivala et al. [8] further developed this classification to addi-
tional nine morphology types. Especially for describing the root canal formation of
the mesial root in mandibular molars types 1, 2, and 3 of this classification is mean-
ingful (Fig. 1.2b).
1 Molar Root Canal Anatomy 3

Fig. 1.1 Classification of multiple canals in one root by Weine et al. [6]. The original classifica-
tion of four types was later expanded to the five configurations shown

Another research group [9] extended Vertucci’s classification with additional 14

configurations examining 2800 extracted human teeth. These further developments
contribute to the understanding of substantial complexity in root canal configuration.

1.3 Complexity of Root Canal Systems

As Vertucci [1] stated, a root with a tapering canal and a single foramen is the
exception rather than the rule. Great complexity of root canal anatomy can be found
at every level of the root canal space. It is the result of tooth development mainly
after eruption of the tooth to the oral cavity and apical closing [10] due to the appo-
sition of secondary dentin. The primary apposition of root dentin has determined the
external shape of the root, and therefore the internal shape will be the very similar:
if the external shape is round, the canal will also be round; if the external shape is
long oval or kidney shaped, the canal will be long oval or kidney shaped too.
4 F. Paqué

Fig. 1.2 Expanded root canal classifications by Vertucci [7] (eight types) (a) and by Gulabivala
et al. [8] (seven types) (b)

Kidney-shaped roots, like in mandibular molars, mainly develop two root canals
(Fig. 1.3).
For example, in mandibular first and second molars the root canal systems were
completely defined at 30–40 years of age [10]. Various intercanal communications
can still remain and represent one main component of complex root canal anatomy
(Fig. 1.3). Others are wide ranges of root canal curvatures, different root canal cross
sections, accessory canals, secondary canals, lateral canals, furcation canals, fins
and multiple apical foramina, and so-called apical deltas.
More than two decades ago when rotary Nickel-Titanium instruments were
introduced to the endodontic market, root canal curvatures have been stated as one
of the most common endodontic complexity [11]. With the further development of
these instruments and the experience gained by the practitioners, the difficulties of
shaping even severely curved root canals have mainly been overcome over the past
1 Molar Root Canal Anatomy 5

Fig. 1.2 (continued)

few years (Fig. 1.4). Taking into consideration that complex root canal systems
require proper cleaning and disinfection, the main challenge remains to debride the
spaces of the root canal system that cannot be reached by mechanical instrumenta-
tion. Especially in mandibular and maxillary molars, the above-mentioned compo-
nents of complex root canal anatomy are a common finding. In a literature review
about tooth survival after nonsurgical root canal treatments [12], the tooth type or
specifically nonmolar teeth were found to significantly increase tooth survival.

1.4 The Anatomy of Maxillary Molars

A sufficient root canal treatment in maxillary molars is based on an optimal access to

and preparation of all existing root canals. The goal of the treatment is to present the
existing anatomy as comprehensive as possible and to widen the root canal system to
6 F. Paqué

Fig. 1.3 Micro-computed tomography images of extracted teeth from patients of different ages.
Three-dimensional reconstructions and corresponding cross sections from the middle third of the
roots are shown. Images from left to right: extracted tooth of a young-aged, middle-aged, and older
patient, respectively. Note the width of the main canals and the number and size of various ramifi-
cations and communications

enable a sufficient disinfection and filling. The anatomy of maxillary molars is very
complex and the root canal treatment of this particular group of teeth represents a major
challenge for dentists [1]. Carabelli documented the particular anatomy of maxillary
molars as early as 1844 [13]. Numerous subsequent publications discussed the com-
plexity of maxillary molar anatomy; most often the mesiobuccal root and the occur-
rence of a second mesiobuccal (MB2) canal have been in the main focus. In 1917,
Walter Hess [14] presented the anatomical complexities with multitude of branches
and accessory canals by illustrating in detail the number and formation of root canals.
He was the first to relate age and gender of the patients to root canal complexity.
Many studies have shown the anatomy of the upper first molar and especially the
presence of a MB2 canal using different techniques [15]. Failures in root canal treat-
ment of this tooth type are often based on untreated MB2 canals [6, 16]. The clinical
prevalence of the MB2 canal in maxillary first molars and in second molars is
reported up to 93 % and 60 %, respectively [17].
Results from laboratory micro-computed tomography (micro-CT) studies are of
special interest for molar anatomy, because this technique allows a three-dimensional
presentation and analysis of the root canal system without damaging the tooth
1 Molar Root Canal Anatomy 7

Fig. 1.4 Micro-computed tomography images of an extracted mandibular and a maxillary molar.
Note the severe canal curvatures in both roots of the mandibular molar and in the MB root of the
maxillary molar

structures [18]. Due to modern treatment methods like the use of dental micro-
scopes, options for a successful therapy of difficult root canal anatomies have sig-
nificantly improved [19]. The location of MB2 canals during root canal treatment of
maxillary molars is much more likely by applying the dental microscope and
through the use of specialized tools than without [17].
The first maxillary molar is the most voluminous of all teeth: it has four pulp
horns and the pulp chamber has usually a rhomboid cross-sectional shape [1]. The
second maxillary molar in principle is of similar shape (Fig. 1.5a). However, the
pulp chamber is often more long oval, sometimes it is ribbon shaped (Fig. 1.5b).
A maxillary first molar has typically three separate roots and in only about 4 %
of the cases just two roots are found. Two or more merged roots occur in about 5 %
of all cases. The presence of four roots is extremely rare [15]. In second maxillary
molars, merging of roots is much more common. Interestingly, the distobuccal (DB)
root canal in second maxillary molars is often difficult to negotiate because an
S-shaped DB root is a quite common finding.
Cleghorn et al. [15] evaluated laboratory studies from the years 1914 to 2004 in
a literature review of the anatomy of the first maxillary molar. The occurrence of a
MB2 was reported to range from 25 to 96 %. Pooled data of 21 studies gave an
overall prevalence of roughly 60 %.
8 F. Paqué

Fig. 1.5 (a) Micro-computed tomography images of an extracted first (right) and second maxil-
lary molar (left). Note the in general similar shape but the overall smaller volume of the second
maxillary molar. Typically, the buccal roots of the second maxillary molar seem to be fused. (b)
Clinical images of cases after preparation of all canals in a first (right) and second (left) maxillary
molar with rotary instruments. The access cavities provide an overview of all four canal orifices.
Note the ribbon-shaped pulpal floor in the second maxillary molar, the entrance of MB2 is located
very close to the palatal orifice, a common finding in these kinds of teeth