Pierre Pizem Endodontics

05/27/2026

Calcified mandibular first molars can quickly become some of the most demanding cases in endodontics. 🔬🦷
This distal root presented a challenging Vertucci Type V configuration with a very late apical split in the last 3 mm. Under high magnification, the bifurcation could be identified and negotiated, allowing each apical branch to be shaped and obturated individually.
👉 Clinical pearl: in calcified cases with suspected apical bifurcation, precurved small hand files combined with continuous microscopic inspection can help confirm whether you are dealing with a true apical split rather than a single eccentric foramen. Once both branches are independently negotiated to length, maintaining patency and creating separate glide paths greatly improves shaping and obturation control.
The microscope is not just about seeing better — it changes the way we understand root canal anatomy.

05/25/2026

Five years later… asymptomatic, functional, and showing excellent healing.
The pre-operative radiograph clearly revealed a Vertucci Type V configuration in this mandibular premolar. High magnification and coaxial illumination were essential to precisely locate, negotiate, and treat both canals conservatively and predictably.
Modern endodontics is all about seeing more to preserve more. 🔬
A great reminder that careful radiographic interpretation combined with microscope-enhanced dentistry leads to long-term success.

05/13/2026

A 18 years follow up on my work: https://www.endomontreal.com/2008/10/15/cleaning-shaping-and-filling-of-a-canal-subdivision-in-the-apical-third-of-distal-root-canal-case-125546/
18 years ago, I treated this mandibular first molar with a rare Vertucci Type V canal configuration — and today, the tooth is still fully functional and going strong. 🔥🦷
An intricate endodontic case involving a rare Vertucci Type V canal configuration in the distal root of a mandibular first molar.
In this anatomy, one canal exits the pulp chamber and divides near the apex into two distinct canals with separate foramina (1–2 configuration).
According to Vertucci’s landmark 1984 study, this configuration occurs in only about 8% of distal roots in mandibular molars.
The challenge in this case was managing the apical split while maintaining complete access to both branches. Each canal division was individually obturated using Pulp Canal Sealer and gutta-percha with lateral and vertical condensation techniques.
To regain access to the vestibular branch apex after filling the lingual branch, gutta-percha had to be selectively removed from the coronal, middle, and apical thirds of the distal canal — a delicate and highly controlled procedure.
Cases like this remind us that understanding root canal anatomy is everything in endodontics. Precision, patience, and respect for complexity lead to long-term success.
18-year follow-up. Functional. Asymptomatic. Stable. 🙌

An intricate root canal procedure on a mandibular first molar distal root canal. Case Study Number 125546. A Vertucci type V pulp space configuration can be described as follow: One canal leaves the pulp chamber and divides short of the apex into two separate distinct canals with distinct foramina (...

05/07/2026

A challenging follow-up on a maxillary first molar with exceptionally long roots (TOOTH LENGTH: 26MM) and severe canal curvature. Cases like this remind us that anatomy still dictates everything in endodontics.
Initial treatment required meticulous negotiation, glide path management, and controlled shaping to preserve the original canal trajectory while minimizing procedural errors. Despite the complexity, long-term follow-up demonstrates stable healing and retention of the tooth.
In this case, all canals were shaped using rotary NiTi instrumentation — my preferred approach over reciprocating systems for highly curved anatomy. Continuous rotation, when paired with a reproducible glide path and controlled torque, offers excellent tactile feedback and tends to maintain canal patency more predictably in complex molars.
One concern I personally encounter with reciprocating systems in difficult curved canals is the increased tendency for debris accumulation and blockage, particularly in long narrow canals with limited coronal enlargement. Several studies have suggested that reciprocating instrumentation may extrude more debris apically and can produce greater debris compaction within the canal system compared with continuous rotary techniques.
Literature worth reviewing:
• Bürklein & Schäfer – debris extrusion with reciprocating vs rotary systems
• De-Deus et al. – shaping behavior and debris transportation in reciprocating files
• Robinson et al. – canal transportation and shaping outcomes in curved canals
Cases like this are a reminder that technology never replaces respect for anatomy.

05/02/2026

Pushing boundaries in general practice 💪🦷
This mandibular first molar ( #36) presented with irreversible pulpitis following crown preparation, but what made it truly challenging was the anatomy and structural compromise:
• 26 mm long canals
• Four narrow, calcified canals
• Missing lingual wall → compromised isolation
Careful negotiation, controlled instrumentation (MAF 30 mesial / 35 distal), and strict irrigation protocols allowed full working length management and a clean obturation outcome.
This case is a reminder that with the right case selection, magnification, and respect for anatomy, even complex endodontics can be successfully managed in general practice.
Final step: proper coronal seal and cuspal coverage to ensure long-term success.
📍Precision. Patience. Respect for biology.

04/20/2026

“Non-restorable” is sometimes just a perspective.
This second maxillary molar was initially deemed hopeless due to:
▪️ Severe loss of remaining tooth structure
▪️ Complex, partially obliterated root canal system
▪️ Poor long-term prognosis following prior assessment

The patient sought a second opinion — and instead of extraction, we opted for a carefully planned endodontic approach.

🔬 Key considerations in this case:
▪️ Negotiation of calcified/obliterated canals under magnification
▪️ Conservative access to preserve what little coronal structure remained
▪️ Use of advanced irrigation protocols to compensate for limited mechanical debridement
▪️ Careful working length control in a challenging anatomy
▪️ Three-dimensional obturation despite canal irregularities
▪️ Reinforcement with a cast post to support the final restoration and distribute functional load
▪️ Close radiographic follow-up to monitor periapical healing and structural stability

📸 Serial radiographs (2018 → 2026) demonstrate:
✔️ Stable periapical status
✔️ Maintained bone levels
✔️ Functional integrity of the restoration
✔️ No clinical symptoms

⏳ 8 years later — the tooth remains functional and asymptomatic.

Sometimes, with the right strategy, patience, and respect for biology… even “hopeless” teeth can surprise us.

04/18/2026

Challenging calcified maxillary molar with severe curvature.
Negotiation and glide path were the key hurdles, but full canal system was located, centered preparation maintained, and 3D obturation achieved to length.
Sealer extrusion consistent with apical rarefaction—expecting favorable healing.
Cases like this are all about patience, control, and respecting anatomy.

04/08/2026

🦷 14-Year Follow-Up — When Hidden Anatomy Meets Long-Term Success
Fourteen years ago, this mandibular molar looked simple:
➡️ Two canals. Straightforward case.
But endodontics is rarely that simple.
Under the microscope, the reality changed:
A hidden split — a Vertucci Type V configuration.
One canal… dividing into two at the apex.
👉 Miss it, and you leave infection behind.
👉 Find it, and you give the tooth a real chance to last.
Fast forward 14 years:
✔️ Asymptomatic
✔️ Fully functional
✔️ Radiographically stable
No retreatment. No compromise.
Takeaway:
Hidden anatomy isn’t rare — it’s just missed.
And true endodontic success is measured in decades, not days.

03/24/2026

🔬 Fibre post removal — precision over force
In this case, a 13 mm fibre post was removed under high magnification using a Buc #3 diamond-coated ultrasonic tip — but with a slightly different strategy 👇
Instead of circumferential troughing (which risks unnecessary dentin loss in thin posts), the approach was:
➡️ Direct, centered pe*******on through the post
➡️ Continuous visualization of the circumferential post margin (see yellow arrow)
➡️ Using the margin as a real-time safety boundary to stay perfectly within the post
Ultrasonic activation was performed in short, controlled bursts, always followed by:
💧 Frequent irrigation
– flushing debris
– improving visibility
– minimizing heat
As the tip progressed apically, the post was internally degraded and hollowed, allowing it to collapse rather than be pulled out — no Stieglitz, no force, no stress on the root.
✅ Stay centered
✅ Let ultrasonics do the work
✅ Trust what you see under the scope
Key takeaway:
Fibre posts are best managed by controlled internal destruction, not aggressive removal.

03/19/2026

11 YEARS. Same tooth. Same challenge. Different perspective. 🔬🦷
This case showcases a Vertucci Type V root canal configuration in a maxillary premolar, complicated by a heavily calcified coronal third — a scenario that tests patience, precision, and persistence.
📍 2015: Initial presentation with complex anatomy and limited canal visibility due to calcification. Careful negotiation and respect for the original canal pathway were critical to avoid procedural errors.
📍 Treatment phase: Conservative access, magnification, and meticulous scouting allowed identification of the bifurcating system — classic Type V splitting apically.
📍 2026 (11-year follow-up):
✔️ Stable periapical condition
✔️ Maintained structural integrity
✔️ Functional and asymptomatic
✨ Takeaway:
Even in calcified canals, biology rewards respect. When anatomy is understood and preserved — long-term success follows.
💡 Never underestimate:
• The importance of pre-operative assessment
• Tactile feedback during canal negotiation
• Long-term follow-up as the real measure of success