ORIGINAL RESEARCH
Journal of Case Reports in Dental Medicine (J Case Rep Dent Med) May 2020, Volume 2, Number 2: 36-39
University of Medical Sciences
and Technology, Sudan
Correspondence to:
*
sowaraldahb@gmail.com
Received: 6 December 2018
Revised: 20 January 2019
Accepted: 25 March 2019
Available Online: 1 May 2020
 © 2019 JCRDM. Published by Faculty of Dentistry, Hasanuddin University. All rights reserved.
Root canal treatment for a lengthy maxillary canine of 37 mm.
Case Report
Shahad E. Hussain 1, Elhadi M. Awooda1*
Abstract
Objective: Very long teeth present challenging in endodontic treat-
ment. It necessitates modification of the instruments and techniques
to negotiate the canal and to obturate to the full working length.
This case aims to perform root canal treatment (RCT) of a lengthy
maxillary canine of 37 mm length.
Methods: A 75-year old man came for a filling of decayed upper front teeth.
Radiographically, the right canine showed an abnormality in length. Clinically,
it was carious, not tender to percussion, and diagnosed as asymptomatic irrever-
Keywords: CBCT, Hand H-file, Lengthy Root Canals, Maxillary cuspid
Cite this Article: Hussain SE, Awooda EM. 2020. Root canal treatment for a lengthy maxillary canine of 37 mm. Case Report. Journal of Case
Reports in Dental Medicine. 2(2): 36-39. DOI: 10.20956/jcrdm.v2i2.108
Introduction
The outcomes of the root canal treatment depend
on the technical quality and rigorous allied of the
principles and procedure to achieve the objectives
of cleaning, shaping, and obturation. Good
knowledge of the root canal morphology and its
variations is crucial. The clinician should have a
thorough understanding of the detailed anatomy
of the root canal to be able to utilize the most
appropriate treatment techniques and protocols,
thereby increasing the percentage of success
rate.1
From the literature; a number of studies and
case reports have investigated the length of human
maxillary canine. In 1902, G.V Black stated that
the longest maxillary cuspid was 32.0 mm,2 while
Bjorndal et al. reported the longest maxillary canine
at 33.3 mm in 1974.3 In 1979, Wiene reported a
surgically extracted human maxillary canine of 39.5-
mm length.4 While in 1982, Gray came up with an
extracted upper canine of 41-mm.5 Also, a maxillary
canine length of 47-mm has been reported.6
Extremely long maxillary canines present
challenges when an RCT is indicated, especially
during canal preparation. Endodontic instrument
consists of cable and body (intermediate and active
part) and the longest file available is 31- mm length.
7
Only a few authors have experienced endodontic
treatment of long maxillary canine.7-12 Although
it is very rare to face such critical situation, an
unusual mechanical alteration and modification
sible pulpitis with normal apical tissues.
Results: This case illustrated the use of hand H-files (ISO) with the
removal of the plastic cable and preparation of the canal by push - pull
movement and obturation conventionally through vertical and lateral
condensation techniques. CBCT was used to assess treatment outcome.
Conclusion: RCT of a very long tooth can be performed by instrument
cable removal technique (ICRT) to achieve good quality and better
outcomes.
of the instruments and techniques should be
implemented to achieve the objectives of RCT.
Our aim of this case report was to accomplish
biomechanical preparation and obturation of a very
long maxillary canine of a 37-mm length and to
discuss the treatment modifications that must be
considered to successfully manage such very rare
cases.
Case Report
A 75-year-old Sudanese man with no significant
past medical history was presented with a chief
complaint of multiple decayed teeth and food
impaction on the upper right canine. Visually,
the intra-oral clinical examination revealed dental
caries on all upper anterior teeth. The tooth of.
chief complaint showed mesial proximal dental
caries. It responded negatively to cold sensibility
test, without tenderness to vertical or horizontal
percussion, and its crown width and length were
within the average normal dimension of maxillary
canines with slight attrition of up to 1mm. Normal
physiological mobility and no swelling or palpation
on the soft tissues over the apex area. Soft t issues
examination revealed marginal gingivitis of all
anterior teeth with normal pocket depth, and extra-
oral examination no abnormality detected. Intra oral
periapical radiographic for the tooth of complaint
(##13) showed abnormal length of 37 mm figure 1.
36
ORIGINAL RESEARCH
The diagnosis reached was asymptomatic
irreversible pulpitis with normal apical tissues.
We utilized the available facilities by removing
of the whole cable of the longest hand files
(31 mm) to negotiate root canal.
The patient was anesthetized (lidocaine 2%
with epinephrine 1:100,000 local anesthetics, Box
of 50-1.7 ml Cartridges, Septodent, UK), a rubber
dam was applied, all carious tissues were removed
carefully, and access cavity was prepared figure
2.
We made a modification to the existing hand H-
file size 30, 35 and 40 of 31 mm length (Dentsply-
Maillefer, Ballaigues, Switzerland) by heating the
plastic cable over flame and when it became soft
before melting it was pulled away by dental tweezer
figure 3.
Figure 1 Preoperative intra oral periapical radiograph of the
upper right maxillary canine.
Figure 2 Access cavity preparation
Figure 3 File Length of 37 mm after removal of the plastic cable.
37 Journal of Case Reports in Dental Medicine (J Case Rep Dent Med) May 2020; 2(2): 36-39. DOI: 10.20956/jcrdm.v2i2.108
They were grasped by a tweezer (figure 4) in an
inverted pen grasp (figure 5) and the canal was
biomechanically prepared by push-pull movement
to the full working length of 36 mm figure 6.
The canal was prepared by the step
back technique which started by an initial H-file
size 30, followed by size 35 as a master file, then
step back and flaring by H-file size 40. Calcium
hydroxide and iodide paste was placed as an
inter-appointment medicament I  CAL Plus- 
Calcium Hydroxide Paste with Iodoform (I- 
DENTAL Dental Supplies), and the tooth was
temporized using Cavit G (3M, ESPE, Germany).
One week later the tooth was asymptomatic; the
calcium hydroxide flushed out by an irrigant
(sodium hypochlorite 1%) and the canal dried
using paper points. obturation was done first by
vertically condensing size 35 gutta percha cone
(Gapadent, Henan, China). The Gutta Percha
cone was gripped by the dental tweezer then
loaded with mixed Endodontic sealer
(Endomet plain, Septodent, Pennsylvania,
USA) and pushed inside the canal. Endodontic
plugger of size 50 (Finger Pluggers - Plastic
Handle, 4/Pkg - Dentsply, Maillefer) gently
condensed the gutta percha vertically. Then a
hand Endodontic spreader size A (Dentsply-
Maillefer, Ballaigues, Switzerland) condensed the
gutta percha laterally creating space for
accessories Gutta Percha and the obturation
completed by lateral condensation technique
figure 7. The tooth was restored permanently
by Nanohybrid composite resin (EsCom 100,
SPIDENT Co., Ltd, Incheon, Korea).
The six-month follow up was assessed by a
clinical examination and radiographically by CBCT
figure 8. It revealed no periapical abnormality and
the patient had been asymptomatic since treatment
was completed with a successful outcome.
Discussion
The accurate working length determination is a
prerequisite for successful root canal therapy,
which reduces the chances of insufficient cleaning
of the canal or damaging the periapical tissues from
over instrumentation.13,14 The conventional way of
determining working length of very long teeth
through hand endodontic files of maximum length
of 31 mm is difficult.15
The length of the endodontically treated
canine (37-mm) of this case deviated so greatly
from the normal length of teeth.4 The abnormal
length of human teeth seems to not be relevant to
the tallness or shortness of human; as our patient
height was 182-cm. Wilkie & Chambers suggests
that tooth length is not necessarily related to
height of the patient and emphasizes the need
 ORIGINAL RESEARCH

for good radiographs before tooth removal or

endodontic treatment.16
Endodontic treatment of long maxillary
canines has been experienced by a few authors.
Venokur and Fink., in 1976 canine length was
estimated to be 41 mm to 42 mm, but they did
not document obturation radiographically. 8 In
1982, Bellizzi documented and reported a case in
Figure 4 File size 35 grasped by dental tweezer for which the maxillary canine was obturated to a
biomechanical preparation. working length of 38 mm.9 Also, in 1992, Vargo
and Hartwell modified endodontic treatment of a
40-mm long maxillary canine.10 Literature search
revealed a gap from 1992 without documentation
of RCT of a long maxillary canine, until recently
Al-Dahman et al., in 2017 treated a tooth of 32-
mm. 11 In 2019 Cardoso et al., implemented a
new technique titled “Instrument Cable Cutting
Technique” (ICCT).12
The cleaning and shaping of maxillary
canines longer than 31 mm length is extremely
Figure 5 Inverted pen grasp for push pull movement difficult, because the longest endodontic canal
biomechanical preparation. preparation instrument available commercially,
is 31-mm length.7 The length of 31-mm makes it
difficult to flare the canal to the full working
length. Some have tried widening the access
cavity and using the cingulum or the cervical
limit of the access cavity as a reference point.
7,10,11
Other should still be possible using 31mm
instruments and having the crown hollowed out
or cut of. 5 It is important to point out that
Maillefer (Dentsply, Ballaigues, Switzerland)
produces the Vetinox series of endodontic
instruments, designed for veterinary use, with
higher lengths, reaching 40 mm and even 60
mm. 7 In this case, due to the age of the patient
and loss of some posterior teeth, attrition was a
result that wearied approximately up to 1 mm
from the incisal surfaces of the anterior teeth
Figure 6 Estimated working length by Initial H-file size 30,
including the cuspids. It is also expected that
showing 3 mm short from the radiographic apex.
the tooth becomes brittle and will be more liable
to fracture if over reduced to use cervical limit
as reference point.9,10,11 The whole cable removal
from the hand file and grasping by the dental
tweezer seems appropriate for canal preparation
of lengthy tooth. The instrument cable removal
technique (ICRT) we used in this case; is based
on removing the whole plastic part of the cable
in order to gain additional millimeters during
the root canal preparation to reach the proposed
apical constriction stop area. It is important to
note that, movement of files for canal prepara-
tion should be limited to push-pull to facilitate
control grasping of the instrument by the
Figure 7 Obturation to the full working length of 36 mm. tweezer and to better shaping of the canal so as
to facilitate obturation.

Journal of Case Reports in Dental Medicine (J Case Rep Dent Med) May 2020; 2(2): 36-39. DOI: 10.20956/jcrdm.v2i2.108 38
ORIGINAL RESEARCH
Figure 8 A&B views of CBCT Six months follw up, full hermatic
obturation to the full working length of 36 mm with
normal periapical tissues.
Conclusion
A lengthy canine of more than 31 mm can be
biomechanically prepared for root canal
treatment by removing the cable of longest ISO
hand files, grasping by tweezer and push- pull
movement for flaring.
Aknowledgment
The authors would like to express sincere gratitude to
Britaria Theressy for her help during case treatment.
Conflict of Interest
The authors report no conflict of interest.
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