Mastering Challenging Endodontic Cases with Dr. Pietro Mannino

Mastering Challenging Endodontic Cases with Dr. Pietro Mannino

24 March 2025

At Monkfield Dental, we understand that some endodontic cases present unique challenges that require specialized skills, advanced technology, and extensive experience. Our Dentist with Special Interest in Endodontics, Dr. Pietro Mannino, routinely handles complex cases that might otherwise result in extraction.

In this article, we showcase two particularly challenging treatments performed on the same patient – illustrating how specialized endodontic care can preserve natural teeth that are critical for both aesthetics and function, even when the prognosis seems questionable.

Patient Case Overview

Our patient presented with multiple endodontic issues requiring attention. After comprehensive examination including CBCT imaging, we identified two teeth with failed previous endodontic treatments that were particularly concerning: the UL3 (upper left canine) and UL5 (upper left second premolar). Both teeth were strategically important for the patient’s smile aesthetics and proper function.

Rather than recommending extraction and prosthetic replacement, Dr. Pietro determined that with his advanced training in endodontics, these natural teeth could be saved. The case illustrates the value of advanced endodontic intervention for preserving natural dentition, even in situations where the anatomy presents significant challenges.# Beyond the Ordinary: Complex Endodontic Cases at Monkfield Dental

Case Study 1: The Hidden Canal

The Challenge

Our patient’s UL5 presented with temperature sensitivity despite previous endodontic treatment. The heavily restored tooth required a crown, but first needed comprehensive endodontic retreatment to establish a solid foundation for the final restoration. CBCT imaging revealed complex canal anatomy, including a second canal (buccal) that hadn’t been previously treated and a canal that has been shortly filled and could benefit from a retreatrment.

Figure 1: Pre-operative CBCT slice of UL5 revealing the previously untreated buccal canal.

Diagnostic Precision

A standard radiograph might have missed the issue, but CBCT imaging revealed what conventional X-rays couldn’t show: a missed buccal canal that had never been treated and a root filling of the palatal canal which was relatively short. This untreated canal was the source of the patient’s ongoing discomfort.

The Solution

Using magnification for enhanced visualization, Dr. Pietro carefully accessed the tooth and located the previously missed buccal canal. The procedure involved:

1. Careful removal of the previous filling material using reciprocating instruments
2. Location and measurement of both the palatal canal and the elusive buccal canal
3. Thorough cleaning and shaping with R25 files and irrigation with sodium hypochlorite and ultrasonic activation
4. Filling both canals with bioceramic sealer and gutta-percha

The post-operative radiograph showed complete obturation of both canals, addressing the anatomy that had been previously missed.

Figure 2: Post-operative radiograph showing complete obturation of both the palatal and previously missed buccal canals of UL5.

Case Study 2: The Extraordinarily Long, Thin Root

The Challenge

The second case involved a UL3 (upper left canine) requiring re-treatment. What made this case particularly demanding was the exceptional anatomy of the root – measuring 26.5mm in length (significantly longer than average) and extremely thin at the apical portion.

Figure 3: Pre-operative CBCT of UL3 showing the exceptionally long, thin root with previous inadequate root canal treatment.

Technical Precision

Working with such unusual anatomy required specialized equipment and techniques:

1. Long endodontic instruments capable of reaching the full 26.5mm length
2. Careful measurement using an apex locator to confirm the extraordinary working length
3. Delicate instrumentation to avoid perforating the thin apical region
4. Enhanced visualization with magnification to navigate the challenging anatomy

The Solution

Dr. Pietro systematically removed the old filling material using S1 ProTaper files at slow speed with eucalyptus oil to soften the gutta-percha. After confirming the working length with both apex locator and radiographic verification, he shaped the canal using a sequence of ProTaper files (S2-F1-F2).

The canal was thoroughly disinfected using sodium hypochlorite with ultrasonic activation to enhance penetration into the narrow apical region. Bioceramic sealer was selected for its excellent sealing properties and biocompatibility, particularly important in this case where periapical healing was essential.

Figure 4: Left – Working length determination with file at the 26.5mm length. Right – Post-operative radiograph showing complete obturation of the extraordinarily long canal.

When to Consider Referral

These cases highlight situations when referral for advanced endodontic treatment can significantly improve outcomes:

1. Previous treatment failure – When conventional root canal treatment has failed to resolve symptoms
2. Complex anatomy – Extremely long, curved, or thin roots that require specialized techniques
3. Missed canals – Cases where CBCT reveals additional canals that were not treated initially
4. Periapical pathology – Large lesions that require specialized approaches to promote healing

The Technology Advantage in Advanced Endodontics

At Monkfield Dental, Dr. Pietro Mannino utilizes advanced technology to achieve predictable results in complex cases:

• CBCT imaging for precise 3D diagnosis of canal anatomy
• Magnification for enhanced visualization of canal entrances and anatomy
• Advanced Endodontic Instruments designed for challenging cases
• Ultrasonic activation for superior irrigation and disinfection
• Bioceramic materials for optimal sealing and healing

Preserving Natural Dentition: Functional and Aesthetic Benefits

By successfully treating both the UL3 (canine) and UL5 (premolar) for this patient, we preserved teeth that serve critical functions. The canine provides guidance during lateral movements and plays a vital role in the patient’s smile aesthetics, while the premolar is essential for proper mastication and supports the posterior occlusion.

Dr. Pietro noted that the UL3 case with the extraordinarily long, thin root is particularly rare: “We don’t see often a root that long and that thin,” he observed. Yet despite these challenges, both teeth were successfully treated in a single visit each, with excellent prognosis thanks to the complete cleaning, shaping, and filling of the canal systems.

The patient will now retain these natural teeth rather than requiring extractions and prosthetic replacements, maintaining both function and aesthetics. Additionally, Dr. Pietro identified potential issues with the adjacent UL1 and UL2, which will need attention in the future – highlighting the comprehensive approach taken to the patient’s overall endodontic health.

Referral Process

To refer patients to Dr. Pietro Mannino for advanced endodontic treatment, please contact us on 01954 774 540, or refer online on:

We welcome your referrals and are committed to providing excellent communication throughout the treatment process.did you

About Dr. Pietro Mannino

Dr. Pietro Mannino is our dentist with special interest in Endodontics at Monkfield Dental. With over ten years of experience practicing dentistry in the UK and a Master’s Degree in Endodontics from Bologna University, Italy, Dr. Pietro focuses in saving teeth that might otherwise require extraction. His methodical approach ensures optimal care for all patients, from standard root canal treatments to the most complex cases.