CLINICAL ARTICLE „7

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Natalia López-Ampudia, James L Gutmann

Management of ‘S-shaped’ root canals –

technique and case report

Natalia
López-Ampudia
Universitat Internacional de
Catalunya, Barcelona, Spain

James L Gutmann.
DDS, PhD, FACD,
Key words anatomical irregularities, debridement, shaping, S-shaped canals FICD, FADI
Baylor College of Dentistry,
Texas A&M University,
Dallas, Texas, USA
The technical management of roots with S-shaped root canals to achieve both proper shaping and
thorough cleaning is difficult and demanding. Little has been written that specifically addresses the Correspondence to:
James L Gutmann
clinical challenges encountered in these anatomically irregular roots. The purpose of this article is 1416 Spenwick Terrace,
to detail techniques that can be used to efficiently and safely complete the entire root canal pro- Dallas, Texas, 75204-5529,
USA
cedure on teeth with S-shaped roots and to amplify this accomplishment using a case report and Tel: + 214-827-5378
treatment outcome. Fax: + 214-827-4848
Email:
jlgutmann@earthlink.net

„ Introduction ment and disinfection on this tooth very difficult,

A wide range of variability in root anatomy is found
in certain roots or teeth. In particular, certain roots
seem to have a propensity for an ‘S-shape’ config-
uration. Recent reports indicate that of 1163 roots
from 14 different types of teeth (700 total) exam-
ined, 17.5% exhibited secondary curvatures that
were classified as being S-shaped, with 12.3% of
maxillary teeth and 23.3% of mandibular teeth
exhibiting this anatomical characteristic1. A wide
variety of teeth can exhibit S-shaped root anato-
mies (Fig 1), with one of the most prominent and
challenging anatomies being found in maxillary
second premolars (Fig 2). The mesial-distal nar-
rowness of these teeth both coronally and apically,
along with the propensity for external root invagi-
nations, make enlarging, shaping and debride-
even with the use of nickel-titanium (NiTi) hand or
rotary instruments.
Very little has been published regarding the spe-
cific techniques required to shape, clean and obtu-
rate these canals, while preventing deviations from
the original canal anatomy, such as straightening the
canals, blockages, ledges, zips and strips2,3. More
often than not a hybrid technique of canal prepara-
tion is necessary and the chosen technique will vary
by both the root anatomy and clinician expertise4.
The purpose of this technique article and case
report is twofold: 1) to describe techniques that can
be used to manage S-shaped root canals, and 2) to
detail the use of one of these techniques in the man-
agement of a maxillary second premolar that has an
accentuated S-shape root configuration, along with
an assessment of treatment outcomes.

ENDO (Lond Engl) 2011;5(1):7–15

8„ López-Ampudia/Gutmann Management of ‘S-shaped’ root canals
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Fig 1 Examples of ub

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teeth with discernible lica
S-shaped roots: a) man- tio
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dibular second molar, b)
maxillary second molar,
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c) maxillary first premo-
lar, d) maxillary second
premolar.

a b

c d

Fig 2 Maxillary second „ General considerations for techniques

premolar requiring root
canal treatment exhibit- used in root canal treatment of teeth
ing an accentuated with S-shaped root canals
S-shaped root system.
S-shaped, sometimes referred to as bayonet-shaped,
canals can be troublesome and challenging because
they involve at least two curves, with the apical curve
being the most vulnerable to deviations in anatomy,
loss of working length and the potential for instru-
ment separation. These double-curved canals (in
two dimensions) that often have an additional curve
(three dimensions) are usually identified radiographi-
cally when they traverse in a mesial-distal direction;
however if they transverse in a buccal-lingual direc-
tion also (as seen commonly in the mesial roots of
mandibular molars), they may be identified with mul-
tiple-angled radiographs or when the initial apical file
is removed from the canal and it simulates multiple
curves. In these situations the additional use of cone-

ENDO (Lond Engl) 2011;5(1):7–15

 López-Ampudia/Gutmann
Fig 3 Two distinct mandibular second molars (left: radio-
graph; right: extracted tooth) with S-shaped mesial roots;
arrows indicate root invaginations that are prone to poten-
tial perforations during canal shaping that is not done in a
thoughtful manner.
beam computerised tomography (CBCT) may be of
assistance5. To manage these root canal systems, the
clinician must approach them with knowledge of the
anatomical challenges, experience in the use of con-
temporary and traditional instruments, and a thor-
ough assessment of the case at hand.
„ Traditional technique –
use of stainless steel instruments
When using a traditional approach to the cleaning
and shaping of S-shaped root canals with hand stain-
less steel instruments, the following guidelines or
directives should be considered:
• Visualise mentally the three-dimensional nature
of the S-shaped canal using the radiographic evi-
dence available.
• Anticipate the presence of multiple concavities or
invaginations along the external surfaces of the
root to prevent a strip perforation along with the
approximate position of both the curves (Fig 3).
• Develop an unrestricted approach to the first or
coronal curve by skewing the access prepara-
tion to the mesial or distal if necessary (see Fig 4
for skewing concept). This can be done with an
Endo Z bur in the crown of the tooth (Dentsply
Maillefer, Ballaigues, Switzerland), which should
eliminate any potential for gouging tooth struc-
ture. This will not permit better access to the
Management of ‘S-shaped’ root canals „9
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Fig 4 Left: maxillary second premolar with an accentuated S-shaped root. Centre: blue
line indicates the long axis of the root coronally, while the red arrow indicates the direc-
tion of the skewed access opening. Right: altered long axes of the root in the middle
(blue line) and apical (yellow arrow) portions of the root.
altered long axis of the root in the middle and
apical portions of the root.
• Shape the coronal curve passively as access
through this will facilitate the cleaning and shap-
ing of any other curvatures. Irrigate frequently
and recapitulate as necessary with small files.
• Overcurve the apical 2 to 3 mm of the stain-
less steel file to maintain the curvature the apical
portion of the canal. In this process the master
apical file should be in the smaller size range (20
to 25) and smaller file sizes are used in this mid-
to-apical region with short-amplitude strokes to
manage these anatomical challenges effectively
and to prevent stripping, zipping and ledging in Fig 5 Diagrammatic
representation of the po-
the root curvatures (Fig 5). Anticurvature or re- tential errors that could
verse filing in the coronal curve is used with pri- occur in the premolar
in Figure 4 when using
mary pressure being placed away from the curve stainless steel files for
of the coronal curvature to prevent stripping6,7. canal shaping. Blue =
stripping; yellow = zip-
Each case will vary depending on the nature of ping; black = ledging.
the curvatures, position of the tooth and skill/
experience of the clinician.
If either the loss of working length or deviations
in anatomy are identified during the enlarging and
shaping, the same principles of error management
apply as those with a straightforward canal sys-
tem2,3. However, focusing on a problem that has
occurred in the apical curvature can easily produce
an additional problem in the coronal curvature. Thus,
careful clinical judgment is necessary when manag-
ENDO (Lond Engl) 2011;5(1):7–15
10 „ López-Ampudia/Gutmann Management of ‘S-shaped’ root canals
Fig 6 Division of the S-shaped root into thirds, which allows the clinician to approach
shaping incrementally as opposed to trying to manage the entire root length all at one
time (anatomical data extrapolated from Hopewell-Smith A. An Introduction to Dental
Anatomy & Physiology. London, J & A Churchill, 1913, who measured the teeth in inch-
es). In looking at the data from the teeth that most commonly exhibit an S-shaped root
configuration, the mean root measurement for the maxillary first molar was 12.9 mm;
maxillary second premolar 13.97 mm; maxillary first premolar 12.19 mm; and mandibu-
lar second molar 12.7 mm and first molar 12.9 mm. This does not account for teeth
that are genetically short or exhibit unusual crown-to-root ratios. The specific numbers
in this situation are not as important as recognising that the instruments are working in
a confined space that has irregular anatomy, that the root canal instruments are NOT
cutting coronal tooth structure and that by dividing the roots in smaller sections that
relate to the nature of the curves, the process of canal penetration, shaping and clean-
ing can be done more efficiently with less chance for errors. Clinicians commonly refer
to their entire working length of the tooth, when in reality the true ‘working length of
the instrument’, while in the canal it is much shorter.
ing problems in the apical curve. Once enlarging,
shaping and cleaning have been completed, NiTi
finger or hand compactors are used with either a cold
or warm gutta-percha technique to obturate these
delicate canal systems. However, in these cases,
core-carrier obturators would be ideal.
„ Contemporary technique –
use of NiTi rotary instruments
Initial skewing of the access cavity to the mesial or
distal is of benefit for a better entry into the coronal
part of the S-shaped curve based on the position of
the tooth in the arch. Endo Z burs are especially ef-
fective in accomplishing this goal.
When contemplating the use of NiTi rotary in-
struments in these teeth, both the angle and radius
of root curvature are extremely important1. The ra-
dius of curvature impacts greatly on the cyclic fatigue
of engine-driven rotary instruments, because as the
ENDO (Lond Engl) 2011;5(1):7–15
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radius of curvature decreases, the cycles ofPNiTi
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strument failure also decreases. ti
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From an anatomical perspective for anyss e n c e
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of canal penetration that uses rotary instruments is the
recognition that most roots and root canals are 9 to
14 mm from the orifice to the desired apical position
and not the full tooth length (Fig 6). This means that
when working around multiple curves, the clinician
has to only think in terms of achieving penetration of
approximately 1/3 of the root length at a time, or, for
example, in the case of a root that is only 12 mm long,
4 mm at a time for safe penetration. In severe curves,
penetration of only 1, 2 or 3 mm may be indicated.
Therefore, penetration of the entire length immedi-
ately may not be necessary, however the application
of sound principles of crown-down preparation tech-
niques to achieve the desired goal is always essen-
tial. Development of a pathway for all instruments
requires the initial use of small K-files to determine
the degree of patency. However, safe penetration
through the first curve (mostly coronal) of the root is
essential to open the canal system for further clean-
ing and shaping. Options for this procedure include
hand NiTi shaping instruments (ProTaper S1 and SX)
or the use of orifice shapers (both from Dentsply
Maillefer), Gates Glidden drills (Dentsply Maillefer),
LA Axxess (SybronEndo, Orange, CA, USA), Light-
Speed CRX (Discus Dental, Culver City, CA, USA),
ultrasonic instruments or larger tapered rotary instru-
ments to open the coronal third to the first curve (Fig
7). These instruments are generally safe to develop
the initial coronal canal flare.
Once penetration and shaping to or slightly
around the first curve occurs, additional penetra-
tion can occur to the second curve or slightly be-
yond that anatomical challenge, as the coronal
pathway should not impact on this procedure. This
can be done with small K-files, small variably ta-
pered NiTi instruments or instruments designed for
this purpose, such as a rotary PathFile™ in small
diameter sizes (0.02) (Dentsply Tulsa Dental Spe-
cialities, Tulsa, OK, USA). Once the pathway has
been cleared into the third curve, sufficient space
has usually been developed to enhance the use
of irrigants for tissue dissolution and disinfection,
although full penetration of the irrigant may not
always occur until larger apical sizes are achieved
or there is sufficient coronal flare. However, even
 López-Ampudia/Gutmann
if a small instrument can go around both curves
successfully, full canal cleaning and shaping should
still be applied using the 1/3 or even ¼ guideline,
taking small lengths at a time to minimise or pre-
vent deviations, which can even occur with rotary
NiTi instruments; and certainly with stainless steel
K-files. Instruments such as the variably tapered
S1, SX and S2 of the ProTaper® Universal series
(Dentsply Tulsa Dental Specialties) are exception-
ally effective in helping to create a tapered pathway
with minimal to no deviations in the curves of these
canals, due to the location of the cutting on the in-
strument (primarily coronal), with the non-cutting
apical portion serving as a pathfinder.
As long as smaller tapered, rotary instruments,
such as a 0.02 or 0.04 are used with minimal pressure
in the canal to minimise cyclic fatigue, their applica-
tion in the canal, taking one curve at a time, is usually
successful. In some cases where the curvatures are
not extreme (> 20 to 30 degrees), these instruments
may work well shaping the entire curved system, as
long as they do not go beyond a size of a No. 25.
Beyond that size, deviations are likely, especially as
the taper increases.
Some of the newer rotary NiTi files, such as the
Sequence file (Brasseler, Savannah, GA, USA), the
Twisted file (SybronEndo), the GTX file and Vor-
tex™ file (Dentsply Tulsa Dental Specialities) and
LightSpeed (Discus Dental) may be used effectively
in small sizes (15–20) using one to shape the canal
over its entire length, or two used incrementally,
going around each curved 1 to 2 mm before ad-
vancing to the next size. Even these approaches,
if used excessively or if used in higher sizes, may
create a deviation from the canal anatomy. The
use of NiTi rotary instruments may have to be fol-
lowed by small hand stainless steel files to ensure
patency and absence of any ledge formation. If the
entire canal is prepared with small NiTi files only
(size 20 or less with tapers of 0.04 to 0.06) tapers
of these smaller sized instruments may be insuffi-
cient to facilitate both canal cleaning and thorough
obturation8.
Most if not all S-shaped canals will have curva-
tures in three dimensions, especially in the molar
teeth. These variances will not be seen readily on
two-dimensional radiographs; however these types
of variations must be anticipated as the degree and
Management of ‘S-shaped’ root canals „ 11
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Fig 7 PUse
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instrumentsl(orange
ica SX
tiothe
and purple S1 from
te ot n
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ProTaper series) can be
n c ethe coro-
ss eopen
fo r
used to
nal portion of the root
canal safely.
radii of curvature will impact greatly on the choice
of instruments and their usage in each particular
situation1. For example, one of the most challeng-
ing S-shaped root configurations is the mesial-
lingual canal of a mandibular molar that curves to
the lingual, returns to the buccal, while at the same
time curving distally. In this regard separated instru-
ments or blocked/ledged canals are often seen in
this root.
„ Case report – application of
contemporary principles in the
management of a S-shaped
root canal system
A 51-year-old male patient was referred from the
undergraduate student clinic at the Universitat In-
ternacional de Catalunya, Barcelona, Spain, to the
postgraduate endodontic program with a history of
pain during mastication with an associated periapi-
cal lesion on the maxillary right second premolar.
There were no medical contraindications to dental
treatment. The tooth in question had a Class II deep
resin restoration that appeared intact. The tooth did
not respond to a cold stimulus (Endo-Frost, Roeko,
Langenau, Germany); the contralateral tooth served
as a control. While the tooth was symptomatic to
palpation and to vertical percussion, no sinus tract
was found. Periodontal probing was within normal
limits and no evidence of occlusal trauma was iden-
tified. A preoperative periapical radiograph con-
firmed the presence of a periapical radiolucent lesion
around the apex and the S-shaped root anatomy
(Fig 2). A bitewing radiograph was also taken in
ENDO (Lond Engl) 2011;5(1):7–15
12 „ López-Ampudia/Gutmann Management of ‘S-shaped’ root canals
Fig 8 Bitewing radio-
graph of the maxillary
second premolar seen
in Figure 2. This type
of radiograph is helpful
in both diagnosis and
treatment planning the
final restoration.
order to determine the restorability of the tooth
(Fig 8).
The diagnosis was pulpal necrosis with symp-
tomatic apical periodontitis. The patient was
thoroughly informed about the high degree of
case difficulty and the possible risk of instrument
failure or irreversible alteration of the root canal
anatomy.
„ Root canal treatment
All root canal procedures were performed under
local anaesthetic and dental dam isolation. Follow-
ing initial access opening preparation with a small
round diamond bur, margins and the depth of the
access were redefined with an Endo-Z bur. A DG-16
endodontic explorer was use to locate the buccal
and palatal canals. Subsequently the coronal por-
tions of the canals were gently probed with small
K-files (sizes 06 and 08) (Dentsply Maillefer) to
establish an initial pathway and patency to the esti-
mated apical terminus of the root canal. In this case
it was determined to be at the radiographic apex
until a working length was taken. Then the coronal
portions of the canals were flared using SX and
S1 files (ProTaper Universal, Dentsply Maillefer)
(Fig 9). Once the coronal pathway was established,
the working length was determined using the Den-
taport ZX (J. Morita, Tokyo, Japan) and confirmed
radiographically using a size 15 K-file at 23 mm for
each canal (Fig 10).
Canal enlargement and shaping was performed
using a hybrid technique. Initially the S1 (ProTa-
per Universal) was used, followed by the S2 and
ENDO (Lond Engl) 2011;5(1):7–15
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F1. Due to the increase in taper and size uofb the
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subsequent finishing files and the abrupt canal cur- ti
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vatures, subsequent enlarging and shaping
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®
complished with a ProFile instrument (#25/.04;
Dentsply, Maillefer). During all the enlarging and
shaping, the cleaning process was facilitated with
sodium hypochlorite (NaOCl 4.2%). Apical patency
was maintained with a size 10 K-file.
A final irrigation protocol consisted of sonic ac-
tivation of the irrigants with the Vibringe® device
(Vibringe B.V., Amsterdam, The Netherlands), fol-
lowing the manufacturer’s instructions, using each
irrigant with a frequency of 150 MHz. The irrigants
used were, in order, 10 ml of 10% citric acid and
10 ml of 4.2% NaOCl. The canals were rinsed with
96% ethanol and dried with assorted paper points
(Dentsply, Maillefer).
Prior to obturation, the final canal size was veri-
fied, using #25/04 ProFile to the working length
in lieu of the ThermaFil verifiers provided by the
manufacturer (Dentsply, Maillefer) (Fig 11). Ther-
maFil core-carriers (size 25) were used for obtura-
tion due to the severe curvature. The use of the
core-carrier facilitates flow of both sealer and gutta-
percha around the curves and enhances obturation
in teeth with challenging anatomies. The root canal
sealer (AH-plus®; Dentsply, Maillefer) was mixed
and applied using a size 25 paper point. The obtura-
tors were heated in the ThermaPrep® Oven (Dent-
sply, Maillefer) and inserted into the canal with a
smooth and firm movement without rotation, until
the working length was reached. The coronal por-
tion of the carriers was removed with an Endo Z bur
and after cleaning the pulp chamber, a thin layer
of flowable composite was placed over the carriers
to prevent leakage until a coronal restoration was
placed. This was covered with Cavit™ (3M ESPE,
Seefeld, Germany) as a temporary restoration and a
final radiograph was taken to assess the obturation
(Fig 12). The tooth was restored with an indirect
resin restoration (Adoro, Ivoclar-Vivadent, Schaan,
Liechtenstein) providing cuspal coverage to prevent
tooth fracture.
At 3-month and 10-month re-examinations, the
patient was symptom-free. The 10-month radio-
graph showed a breakdown of the extruded sealer
and the formation of new bone around the root apex
(Fig 13).
 López-Ampudia/Gutmann Management of ‘S-shaped’ root canals „ 13
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Fig 9 Access preparation with en- Fig 10 Working length determina- Fig 11 Verification of the final apical
larged orifices in the coronal portion of tion. sizes.
the root.

Fig 12 Root canal obturation using
ThermaFil obturators.
Fig 13 Radiograph at the time of the
10-month re-examination. The patient
was symptom-free and a final restora-
tion had been placed. Good bony heal-
ing is evident with the dissolution of
the overextended root canal sealer.

„ Discussion ever, while the use of these types of simulated root

Key to the successful root treatment of teeth with
S-shaped roots is the recognition of the challenges
that will be encountered in the enlarging, shaping
and cleaning of the root canal system in the clinical
setting. Heretofore, studies have only focused on
these procedures in simulated S-shaped root canal
systems9-12, with a focus primarily on comparing
shaping ability and efficacy of multiple, new and
innovative nickel-titanium root canal files. How-
canal systems may have some validity13 they can-
not account for the three-dimensional changes en-
countered in the human dentition, the ability to as-
sess debridement, and the dissimilar nature of the
model’s material from root canal dentine. While the
intricacies of canal management must ultimately be
demonstrated on human teeth, the use of a hybrid
technique was identified as being the best when
using the models, integrating instruments from vary-
ing manufacturers that had different cross sections,

ENDO (Lond Engl) 2011;5(1):7–15

14 „ López-Ampudia/Gutmann Management of ‘S-shaped’ root canals
greater flexibility and reduced tapers. On human
teeth, a recent study showed that combining differ-
ent file systems did not lead to increased levels of
apical (canal) transportation and that this approach
may actually be a valid alternative to achieving larger
apical diameters without a higher risk of procedural
errors4. Furthermore, with larger apical sizes and the
use of devices that agitate the irrigant, canal cleanli-
ness may be enhanced14.
Concern has been expressed in related literature
as to how large the apical preparation must be to 1)
enable the instrument to contact the walls circum-
ferentially and clean the dentine, and 2) permit the
flow of irrigant effectively into the apical few mil-
limetres to enhance the removal of debris and bac-
teria. Historically there have been recommendations
to prepare the apical extent of the canal to a size 25
to 3515,16. However histological studies indicate that
15 to 30% of the root canal walls remain untouched
by instruments when using these recommended
sizes17,18. Apical preparations to larger sizes have
shown better debridement and dentine wall contact,
however they also risk perforations or lacerations of
the apical foramen19 or for that matter even small
apical fractures20,21. Even with the use of a rotary
instrument in curved canals, as much as 25% of the
apical wall may be untouched, even up to an apical
size of 4522,23, and in some teeth in particular, ex-
cessively large sizes may be necessary, which are not
compatible with the external root anatomy24.
The application of rotary instruments in curved
canals has proven to be successful as compared to
stainless steel hand instruments; however, the ability
of the rotary instrument to provide better cleaning has
not been substantiated. In fact, with the contempo-
rary clinical guideline of an apical size of #20/.06 or
even #40/.06, debris still remains, although the larger
sizes have significantly less debris25. With an increase
in taper, even the smaller sizes, such as #20/.10 may
be as clean as a #40/.1026, but debris still remains.
ENDO (Lond Engl) 2011;5(1):7–15
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There also appears to be an impetus forularger
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apical preparations based on better irrigant pen- i
tebetter api- on
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etration (minimum of a #30/.06)27 and ss e n c e
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cal cleaning and therefore better management of
bacterial populations apically. In fact, larger apical
sizes have been identified as being more effective
in bacterial elimination in simple root canal systems.
However the significance of the extent of the api-
cal preparation in specific clinical situations has not
been clarified, such as canal systems with highly
irregular branching. Furthermore, studies have in-
dicated that unwarranted or excessively large apical
enlargement may not be necessary in the presence
of suitable coronal tapers for the efficient irrigation
of the canal system28. However, when viewed from
an outcomes standpoint, there does not appear to
be an ideal canal size or taper that influences ulti-
mate success29.
The proper use of a gutta-percha core-carrier
would seem to be highly desirable for thorough
canal obturation. This method would allow for
the flow, movement and more thorough distribu-
tion of both sealer and thermally-softened gutta-
percha easily around the multiple curves, while at
the same time penetrating any lateral communica-
tions and dentinal tubules following smear layer
removal30-34.
Management of these types of anatomical
shapes by the skilled and experienced clinician may
be an everyday challenge for which they have al-
ready developed a successful, technical approach.
However for the less experienced, this type of
anatomical configuration can be most perplexing
and can lead ultimately to a number of problems
if not approached in a knowledgeable and con-
fident manner. Knowledge of three-dimensional
anatomy, the use of the CBCT when available, and
practice on extracted teeth will help the practitioner
to achieve positive outcomes when faced with this
clinical challenge.
 López-Ampudia/Gutmann
„ References
1. Schäfer E, Diez C, Hoppe W, Tepel J. Roentgenographic
investigation of frequency and degree of canal curvatures
in human permanent teeth. J Endod 2002;28:211-216.
2. Hülsmann M, Schäfer E. Problems in Endodontics: Etiology,
Diagnosis and Treatment. London: Quintessence Publish-
ing, 2009.
3. Gutmann JL, Lovdahl PE. Problem Solving in Endodontics,
ed 5. St. Louis: Elsevier Mosby, 2011.
4. Setzer FC, Kwon T-K, Karabucak B. Comparison of apical
transportation between two rotary file systems and two
hybrid rotary instrumentation sequences. J Endod 2010;36:
1226-1229.
5. Michetti J, Maret D, Mallet J-P, Diemer F. Validation of
Cone Beam Computed Tomography as a tool to explore
root canal anatomy. J Endod 2010;36:1187-1190.
6. Abou-Rass M, Frank AL, Glick DH. The anticurvature filing
method to prepare the curved root canal. J Am Dent Assoc
1980;101:792-794.
7. Roig Cayón M, Basilio Monne J, Canalda Sahli C. Manual
instrumentation of root canals. Review of the last decade.
[Article in Spanish] Av Odontoestomatol 1991;7:49-57.
8. Thompson SA. Dummer PM. Shaping ability of Lightspeed
rotary nickel-titanium instruments in simulated root canals.
Part 1. J Endod 1997;23:698-702.
9. Yoshimine Y, Ono M, Akamine A. The shaping effects of
three nickel-titanium rotary instruments in simulated S-
shaped canals. J Endod 2005;31:373-375.
10. Ding-ming, H, Hong-xia L, Cheung GS et al. Study of the
progressive changes in canal shape after using different
instrument by hand in simulated S-shaped canals. J Endod
2007;33:986-989.
11. Bonaccorso A, Cantatore G, Condorelli GG, Schäfer E, Tripi TR.
Shaping ability of four nickel-titanium rotary instruments in
simulated S-shaped canals. J Endod 2009;35:883-886.
12. Ersev H, Yilmaz B, Ciftçioğ lu E, Ozkarsli SF. A comparison of
the shaping effects of 5 nickel-titanium rotary instruments
in simulated S-shaped canals. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2010;109:86-93.
13. Lim KC, Webber J. The validity of simulated root canals
for the investigation of the prepared root canal shape. Int
Endod J 1985:18:240-246.
14. de Gregorio C, Estevez R, Cisneros R, Paranjpe A, Cohenca N.
Efficacy of different irrigation and activation systems on the
penetration of sodium hypochlorite into simulated lateral
canals and up to working length: an in vitro study. J Endod
2010;36:1216-1221.
15. Ingle JI, Bakland LK, Peters DL, Buchanan LS, Mullaney TP.
Endodontic Cavity Preparation. In: Ingle JI, Bakland LK.
Endodontics, ed 4. Baltimore, Williams & Wilkins, 1994.
16. Walton RE, Rivera EM. Cleaning and shaping. In: Walton RE,
Torabinejad M (eds). Principles and Practice of Endodontics,
ed 2. Philadelphia: WB Saunders, 1996.
17. Walton RE. Histologic evaluation of different methods of
enlarging the pulp canal space. J Endod 1976;2:304-311.
Management of ‘S-shaped’ root canals „ 15
pyrig
No Co
ht
t fo
rP
by N
18. Bolanos OR, Jensen JR. Scanning electron microscope com- ub
Q ui
parisons of the efficacy of various methods of root canal lica
preparation. J Endod 1980;6:815-822. tio
te ot n
n
19. Weiger R, Bartha T, Löst C. An approach to determine the
individual apical preparation size. Int Endod J 2002;35:107.
ss e n c e
fo r
20. Weller PJ, Svec TA, Poweres JM, Ludington JR, Suchina JA.
Remaining dentin thickness in the apical 4 mm following
four cleaning and shaping techniques. J Endod 2005;31:
464-467.
21. Adorno CG, Yoshioka T, Suda H. The effect of working length
and root canal preparation technique on crack development in
the apical root canal wall. Int Endod 2010;43:321-327.
22. Paqué F, Musch U Hülsmann M. Comparison of root canal
preparation using RaCe and ProTaper rotary Ni-Ti instru-
ments. Int Endod J 2005;38:8-16.
23. Hülsmann M, Schade M, Schäfers F. A comparative study
of root canal preparation with HERO 642 and Quantec SC
rotary Ni-Ti instruments. Int Endod J 2001;34:538-546.
24. Gani O, Visvisian C. Apical canal diameter in the first upper
molar at various ages. J Endod 1999;25:689-691.
25. Usman N, Baumgartner JC, Marshall JG. Influence of instru-
ment size on root canal debridement. J Endod 2004;30:
110-112.
26. Albrecht IJ, Baumgartner JC, Marshall JG. Evaluation of api-
cal debris removal using various sizes and tapers of Profile
GT files. J Endod 2004;30:425-428.
27. Khademi A, Yazdizadeh M, Feizianfard M. Determination
of the minimum instrumentation size for penetration of
irrigants to the apical third of root canal systems. J Endod
2006;32:417-420.
28. Coldero LG, McHugh S, MacKenzie D, Saunders WP.
Reduction in intracanal bacteria during root canal prepa-
ration with and without apical enlargement. Int Endod J
2002;35:437-446.
29. Ørstavik D, Qvist V, Stoltze K. A multivariate analysis
of the outcome of endodontic treatment. Eur J Oral Sci
2004;112:224-230.
30. Weis MV, Parashos P, Messer HH. Effect of obturation
technique on sealer cement thickness and dentinal tubule
penetration. Int Endod J 2004;37:653-663.
31. De-Deus G, Maniglia-Ferreira CM, Gurgel-Filho ED, Pa-
ciornik S, Machado AC, Coutinho-Filho T. Comparison of
the percentage of gutta-percha-filled area obtained by
Thermafil and System B. Aust Dent J 2007;33:55-61.
32. Ordinola-Zapata R, Bramante CM, Bernardineli N, et al.
A preliminary study of the percentage of sealer penetra-
tion in roots obturated with the Thermafil and RealSeal-1
obturation techniques in mesial root canals of mandibular
molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2009;108:961-968.
33. Anbu R, Nandini S, Velmurugan N. Volumetric analysis of
root fillings using spiral computed tomography: an in vitro
study. Int Endod J 2010;43:64-68.
34. De-Deus G, Maniglia-Ferreira CM, Gurgel-Filho ED,
Paciornik S, Machado AC, Coutinho-Filho T. Comparison
of the percentage of gutta-percha-filled area obtained by
Thermafil and System B. Aust Endod J 2007;33:55-61.
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