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http://www.journal-imab-bg.org. 2014, vol. 20, issue 1/ C-SHAPED CONFIGURATION OF THE ROOTCANAL SYSTEM – PROBLEMS AND SOLUTIONS Janet Kirilova, Snezhanka Topalova-Pirinska.Department of Conservative Dentistry, Faculty of Dental Medicine, Sofia, Bulgaria Journal of IMAB - Annual Proceeding (Scientific Papers) 2014, vol. 20, issue 1 Journal of IMABhttp://www.journal-imab-bg.orgABSTRACTIntroduction: The patients with C-shaped configu-ration of the root canal system are definitely a problem in http://dx.doi.org/10.5272/jimab.2014201.504 / J of IMAB. 2014, vol. 20, issue 1/http://www.journal-imab-bg.org 5. Category V (C5) - no canal lumen or there is oneclose to the apex.According to this classification, C4 includes teeth thathave only a single and very wide canal. In English literatureFig. 2. C-shaped configuration Category IV (C4) Fig. 3. Mandibular right second molar with one root canal category IV (C4): a - pulp chamber; b – post-treatmentFan suggests that 3 types of teeth with C-shaped con-figuration of the pulp chamber are included in the radiologi-cal classification [4]:1. Type I. Conical or square root with visible separa-tion of medial and distal part. Medial and distal canal merge2. Type II. Conical or square root with visible sepa-ration of medial and distal part. Medial and distal canal haveseparate apical foramen but run approximately in parallel and3. Type III. Conical or square root with visible sepa-ration of medial and distal part. Medial and distal canal haveseparate apical foramen, run approximately in parallel butone of them is longer than the other.MATERIAL AND METHODClinical case No 1 of a mandibular second molarnostic radiography of a mandibular right second molar withexacerbated chronic periapical periodontitis (Figure 3a). Af-ter opening the pulp chamber, the C-shaped configurationof the pulp chamber and a single root canal are confirmed(Figure 3b). It refers to category IV (C4) of Fan’s anatomicclassification. The lengths of the root canals are measuredelectrometrically with Raypex 4 apex locator. Due to the ex-cessive diameter of the root canal the treatment is performedcombined with irrigation with Smear Clear, 3% hydrogenperoxide and distilled water. Periapical lesions are influ-enced by physiotherapy with iodine-potassium iodide. Seal-plished by the technique of „continuous wave of conden-Clinical case No 2a of a mandibular second mo-lar with C-shaped configuration (two root canals)The clinical finding is a mandibular right second mo-lar with a C-shaped pulp chamber and two root canals - Cat-egory II (C2) according to Fan’s anatomic classification.Figure 4 shows the pulp chamber of the tooth before andThe extension of the endodontic cavity to the ves-tibular portion of the tooth is probably due to the search ofa mesiobuccal orifice of the root canal in the primary treat-ment, as this is not applicable to this anatomical variation (white arrow on figure 4). http://www.journal-imab-bg.org. 2014, vol. 20, issue 1/ C-shaped pulp chamber of mandibular second molar: a – C-shape of the open pulp chamber; b - clearlydefined C of the pulp chamber with filled canals - C2 or Category II according to Fan.Fig. 5. Mandibular right second molar with a C-shaped root canal system: a - X-ray prior to treatment; b – X-raywith gutta-points in the canals; c - X-ray after filling the canalsFigure 5 shows the diagnostic radiograph of the toothwhich refers to type III according to Fan’s radiological clas-sification. Figure 5 b is a radiographic image of the toothFigure 5c - after filling. The post obturation radiographypresents the filled root canal space and the existing anasto-mosing network between the main and the accessory canals.the technique of “continuous wave of condensation” byThermafill obturator and sealer for medial root canal.Clinical case No 2b of a mandibular second mo-lar with C-shaped configuration (two root canals)Figure 6 shows a madibular right second molar witha C-shaped pulp chamber and two root canals - CategoryII (C2) according to Fan’s anatomic classification. It is in-teresting that endodontic treatment was made through thecrown (as part of a bridge construction). The pulp cham-space is shown (Fig. 6a and b), as well as preoperative and Mandibular right second molar with a C-shaped root canal system: a-open and shaped pulp chamber; b –preoperative radiograph; c - pulp chamber after filling; d – post obturation radiograph. / J of IMAB. 2014, vol. 20, issue 1/http://www.journal-imab-bg.org Thermafill obturators and sealer.Clinical case No 3 of mandibular second molar withEndodontic retreatment of mandibular left secondis registered. Evidence for this case is presented in Figure7. In accordance with the radiograph, the tooth is classifiedas type I according to Fan’s radiological classification andas category III according to his anatomic classification (C3).Fig. 7. Mandibular left second molar with C-shaped configuration and three root canals: a - preoperative radio-graph; b - the pulp chamber during the treatment - the two canals with obturation (white arrows), a perforation at one ofthe ends of the pulp chamber (black arrow) and unfilled third root canal (red arrow); c – post obturation radiograph. Radiographs of mandibular right second molar: a – preoperative;curred in previous treatment (black arrow on figure 8b).Probably it was not taken into consideration that the toothhad C-shaped configuration and a mesiolingual orifice ofthe root canal was searched for. It is interesting to note thateral mandibular second molar, as well as the C-shaped pulpmolar are observed with the same patient.This confirms the conclusion of some authors [8, 9]for presence of similar anatomical facts in contralateral teethThermall obturators and sealer.Clinical case No 4 of mandibular second molar withC-shaped configuration (four root canals)The demonstrated case of mandibular right secondmolar with chronic periapical periodontitis. The clinicalcrown is almost completely destroyed. The configurationPreoperative radiograph shows a root canal type II accord-ing to Fan’s radiological classification (Figure 8).The typical C-shaped configuration of the pulpchamber is seen in Figure 9a. In Figure 9b shows the pulpchamber with filled root canals of the same tooth and in Fig- http://www.journal-imab-bg.org. 2014, vol. 20, issue 1/ Mandibular right second molar with C-shaped configuration of the pulp chamber and four root canals: a -C-shaped pulp chamber; b - pulp chamber with Termafill obturators in canals; c – post obturation radiograph.bined technique of filling a „continuous wave of conden-sation” using System B and Obtura II and ThermafillRESULTS AND DISCUSSIONScanal system show that this root canal aberration occurs ina wide variety and variability with a single root canal up totwo, three and four separate root canals. The diameter ofthe root canal themselves also varies from very wide to suchwith a small diameter.In literature have found single publications of caseswith a C-shaped canal [1, 7, 9, 11, 12]. According to dif-ferent authors their frequency varies from 2.7% [5, 16] to8% [9]. The teeth with C-shaped root canal configurationare usually mandibular second molars, and more rarely themandibular first premolars, the maxillary first molars, aswell as the mandibular wisdom-teeth (third molars). The C-shaped configuration of the pulp chamber and the root ca-nal system affects more often Asians than Caucasians [11]with frequency of distribution up to 30%. The probabilityof finding C-shaped configuration in the contralateral toothalateral toothSuccessful endodontic treatment of a tooth with a C-shaped configuration is difficult and a real challenge con-sidering decontamination and successful filling of the rootcanal system. The canal instruments, which use, mainly ro-tating and the processing of an elliptical canal is difficultand inefficient. The creation of systems, with reciprocalmotion for machine preparation, is a significant step for-ward. It is inappropriate to apply separately the standardtechnique, step-back or crown-down technique for thecleaning of such type of root canals require knowledge ofvarious techniques for instrumentation and their combina-Qualitative filling of teeth with a C-shaped root ca-nique or cold lateral condensation is impossible. The diffi-culties arise from the fact that with the C-shaped root ca-nals it is the possible to have a thin net of anastomoses ine a thin net of anastomoses inAll this requires good knowledge of and combiningdifferent techniques of root canal extension from manual to It is important to choice the method of irrigation,tomosis. Ultrasonic activation of the irrigation solution with2.5 sodium hypochlorite may be advantageous in remov-volume endodont contains greater amount of infected chan-nel contents and extrusion of debris or irrigant is possiblee Regarding the filling of root canal system onebined technique of filling the continuous wave of conden-sation using System B and Obtura II and ThermallThermallIt is recommended that cases with C-shaped configu-dodontic space, it’s necessary to know and learn differenttechniques of filling and appropriate equipment with suit- / J of IMAB. 2014, vol. 20, issue 1/http://www.journal-imab-bg.org 1. Bolger WL, Schindler WG. Amandibular first molar with a C-shapedroot configuration. [ PubMed] [ CrossRef] canal configurations in mandibular sec-ond molar. J Am Dent Assoc. Nov; 99(5): 836-9. [ PubMed] 3. Fan B, Cheung GS, Fan M,system in mandibulary second molars:Part I - Anatomical features. J Endod. [ PubMed] 4. Fan B, Cheung GS, Fan M,Gutman JL, Fan W. C-shaped canalsystem in mandibulary second molars:Part II - Radiographic features. [ PubMed] [ 5. Haddad GY, Nehme WB, QuinsHF. Diagnosis, classification and fre-quency of C-shaped canals in man-dibular second molars in the Lebanese 1999 Apr;25(4): PubMed] [ 6. Jafarzadeb H, Wu Y-N. The C-shaped root canal canfiguration: A re- REFERENCES: view. J Endod. 2007 May;35(5):517- PubMed] [ 7. Kirilova J. The cases with rareconfigurations of root canals of themandibular second molar. Problems of 2009; 35(part II): 73-9. [in Bulgarian]8. Kuzmanova Y. Prospective appli-Stomatology80(1):63-68. [in Bulgarian]9. Kuzmanova Y. Rare endodonticvariations in the permanent molars inthe Bulgarian population. cine. 2014; 96(1):30-41. [in Bulgarian]of the mandibular second molar inSingaporen Chinese. Austr Dent J. anatomy of second molars. Part II. C-Int Dent J. 1990 Jan; 12. Rahimi S, Shahi S, Lotfi M,Zand V, Abdolrahimi M, Es’haghi R.Root canal configuration and preva-lence of C-shaped canajs in mandibu-J Oral Sci. PubMed] [ CrossRef] 13. Seo MS, Park DS. C-shapedroot canals of mandibular second mo-lar in a Korean population: clinical ob-servation and in vitro analysis. Endod J. 2004 Feb;30(2):391-8. [ PubMed] [ 14. Wang Y, Guo J, Yang HB, HanX, Yu Y. Incidence of C-shaped rootcanal systems in mandibular secondmolars in the native Chinese popula-Int J Oral Sci. PubMed] [ CrossRef] 15. Weine FS. The C-shaped man-dibular second molar: incidence and [ 16. Weine FS, Pasiewicz RA, RiceRT. Canal configuration of the man-dibular second molar using a clinicallyoriented in vivo method. J Endod. PubMed][ CrossRef] Address for correspondence:Dr Janet Kirilova, PhDDepartment of conservative Dentistry, Faculty of Dental Medicine1, St. George Sofiiski Str., 1431 Sofia, BulgariaE-mail: janetkirilova@gmail.com ,