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

MANAGEMENT . the prudent clinician will stop excavating dentin lest the tooth structure be weakened. 7-15 Radiograph of tooth in Figure 7-14 taken in 1989 reveals severe calcification of the pulp chambers and periapical and furcal radiolucencies. Painstaking removal of small amounts of dentin has proven to be the safest approach. Text Radiograph of a nonvital mandibular molar with calcified canals.followed to achieve the most successful result. There is no rapid technique for dealing with calcified cases. In the event of inability to locate the canal orifice{s). Retrograde procedures become conservative when compared with perforations or root fractures. FIG.

causing calcification and. At this phase of treatment the clinician must attempt to provide maximum visibility of the roof of the main chamber. FIG.FIG. calcified canals. and discolored dentin should be removed. necrosis of the pulp tissue. ultimately. cements. . 7-16 Mandibular first molar with a class I amalgam. The cavity preparation should be extended toward the assumed location of the pulp chamber. 7-17 Illustration showing excavation of amalgam and base material. All caries. and periapical radiolucency. The assumption is that a pulpal exposure has occurred.

loupes. The shape of the pulp chamber in the mandibular first molar will be roughly triangular or rectangular. 7-18 Using a long-shank no. Other landmarks are the cusp tips (if they remain). in the dentin. 4 or 6 round bur." or a retained outline.FIG. or the opcrating microscope are helpful in searching for anatomic landmarks. . The canal orifices are usually found closest to the points of the triangle or the corners of the rectangle. Even apparently totally calcified main pulp chambers leave a "tattoo. High-magnification eyeglasses. The orifices often lie directly beneath them. the assumed location of the main pulp chamber is explored.

One technique is to place warmed baseplate gutta-percha in the chamber floor with an . often being called upon to "flake away" calcified dentin. 7-21 As excavation proceeds apically. Reparative dentin is slightly softer than normal dentin. DG 16 (HU-Fricdy). is used to explore the region of the pulpal floor. A slight "tug back" in the area of the canal orifice often signals the presence of a canal. It is as important to the clinician doing endodontics as the periodontal probe is to the dentist performing periodontal diagnosis. FIG. it is advisable to check the proximity of the furcation.FIG. 7-19 The endodontic explorer. It is an examining instrument and a chipping tool.

7-24 Excavation extended apically in the direction of the root apices. following landmarks (removal of the rubber dam can often assist). . FIG.amalgam plugger. An angled bitewing radiograph reveals the amount of dentin remaining. 4 and 2 round burs. 7-22 Deeper excavation with no. FIG. will usually produce a small orifice.

The radiograph taken at right angles through the tooth will reveal the depth and the angulation of the search. the clinician should begin to feel concern about the loss of important tooth structure. the fiberoptic light can be applied to the buccal or lingual aspect of the crown.FIG. 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. FIG. which could lead to vertical root fracture. Transillumination often reveals landmarks otherwise invisible to the naked eye. 7-23 As an adjunct to maximum visibility with magnification. . 7-25 At this point in the search.

FIG. Calcinase. often produces some penetration. Glyoxide.. A slight pull. FIG. Careful file manipulation. the smallest instrument (a no. frequent recapitulation. and canal lubricants (e. 2 round bur helps to locate the orifice. The endodontic explorer is the first instrument to identify a pinpoint opening. signaling resistance. is usually an indication that one has located the canal. R-C Prep) will assist in gaining . 7-26 Further excavation apically with a long-shank no.g. 06 or 08 file) should be introduced. both apical and rotational. Gentle passive movement. 7-27 At the first indication of a space.

access to the apical terminus. or fourth canal once the first one has been located. third. 7-29 Final canal obturation and restoration revealing anatomic . 7-28 A larger instrument is shown passing two curvatures to the apex by locating one canal in a multicanal tooth. It is suggested that the access to (he canal orifice be widened until the clinician can readily relocate the orifice. It is usually possible to locate the second. FIG. FIG.

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

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