ABSTRACT : Mandibular premolars have earned the reputation for having an aberrant anatomy. Literature is

replete with reports of extra canals in mandibular second premolars, but reports about the incidence of extra roots

in these teeth are quite rare. This case is reported a rare case of successful endodontic management of a two-rooted

mandibular first and second premolar (tooth #44, #45) and radix paramolaris in mandibular molars (tooth #46,

#47) using cone beam computed tomography (CBCT)

1 2 3 4 5Himadri Sharma, Ajay Nagpal, Rohit Paul , Manoj Hans, Amit Kumar Garg1 2 3 4,5Post graduate student, Reader, Professor and Head , Professor

Department of Conservative Dentistry and Endodontics,

K D Dental College and Hospital. Mathura

INTRODUCTION :

The main objective of root canal treatment is thorough

mechanical and chemical debridement of all root canals and

their complete obturation with an inert filling material and a

c o r o n a l f i l l i n g , p r e v e n t i n g t h e i n g r e s s o f

microorganisms.1Root canal anatomy and the confounding

nature of the human pulpal system pose significant challenges

in rendering endodontic treatment, so thorough

understanding of root canal anatomy and morphology is

required for achieving high levels of success in endodontic

treatment. [2]

It is known that the mandibular first and second molars and

premolars can display several anatomical variations. Vertucci

in his series of studies conducted on extracted teeth, reported

2.5% incidence of a second canal.[2] Zilich and Dawson

reported 11.7% occurrence of two canals and 0.4% of three

canals in mandibular premolars.[3] According to Ingle,

mandibular second premolars have only 12% chance of a

second canal, 0.4% of a third canal and Harty has reported

11% possibility of second canal. In most instances

mandibular premolars have one canal, but teeth with two or

more canals have also been reported.[4-8]

Supernumerary roots in the mandibular molars is associated

with certain ethnic groups as follows: Europeans, 3.4–4.2%9

Africans, 3%10 Eurasians and Indians, less than 5%11

Caucasians, 4.2%12 Mongoloids such as Chinese, Eskimos,

and American Indians have 5% to more than 30%13 the

overall incidence in German patients was 1.35%14 and

among the Asiatic Indians, Taiwanese and Koreans were

about 5.97%, 21% and 24.5% respectively.[15] Because of its

high frequency, it may be considered as the Asiatic trait.

Conventional intra-oral periapical radiographs are an

important diagnostic tool in endodontics for assessing the

canal configuration. However, it is not completely reliable

owing to its inherent limitations. Cone beam computed

tomography (CBCT) is useful in order to overcome the

disadvantages of radiographs by providing three-dimensional

ENDODONTIC MANAGEMENT OF TWO ROOTED

MANDIBULAR PREMOLARS AND RADIX PARAMOLARIS

IN MANDIBULAR MOLARS DIAGNOSED WITH CBCT.

A CASE REPORT

Journal of Dental Sciences

University

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University J Dent Scie 2018; Vol. 4, Issue 2

Case Report

Keywords :

Mandibular first premolar;

Mandibular second premolar;

Mandibular molars; radix

paramolaris; cone beam

computed tomography.

Conflict of interest: Nil

No conflicts of interest : Nil

images. These imaging techniques have emerged as powerful

tools for the evaluation of root canal morphology.[16]

CASE REPORTS :

An 40-year-old female patient reported to the Department of

Conservative Dentistry and Endodontics (K.D. Dental

College, Mathura) with a chief complaint of pain in right

lower back tooth region since 10 days. The tooth was tender

on percussion, and cold test showing negative response, with

referred pain. The patient's medical history was

unremarkable. The radiograph revealed the deep carious

lesion encroaching the pulp and double periodontal lining.

Fig.1

After extensive clinical and radiographical examination, the

diagnosis of symptomatic irreversible pulpitis with apical

periodontitis was made and the tooth was prepared for non-

surgical endodontic treatment.

The radiograph revealed the presence of at least three distinct

roots in molars and two distinct roots in premolar, but the

confirmation of the number of roots or root canals could not

be made with the help of intraoral periapical radiograph alone.

Hence, to ascertain this rare and complex root canal anatomy

of the tooth in a three-dimensional manner, dental imaging

with the help of a CBCT was planned. Informed consent from

the patient was obtained. CT scan was done with CBCT

scanner (3D Imaging Centre Agra ,India). CBCT revealed

three distinct roots with four separate canals and four separate

orifices in mandibular first and second molars . Two distinct

roots with two separate canals and two separate orifices in

mandibular first and second premolars. Fig 2 & 7 (A , B).

Local anesthesia was induced with 2% lidocaine containing

1:80,000 epinephrine (Lignox 2% A, Indoco Remedies, Goa,

India). A rubber dam was applied and coronal access was

made with Endo Access bur and Endo-Z bur (Dentsply Tulsa

Dental, OK, USA).

The root canals were explored with a K-file #10 (Dentsply

Maillefer, Ballaigues, Switzerland). The working length

measurement was performed with an electronic apex locator

(Root ZX, J. Morita ,USA) and confirmed with taking

radiograph. Fig. 4 (A&B), Fig. 9 (A&B)

The root canals were shaped with Hyflex CM rotary

instruments (Coltene Whaledent, Germany) up to the 25, 4%.

During preparation, EDTA (Glyde File Prep, Dentsply

Maillefer, North America) was used as lubricant and the root

canals were disinfected with sodium hypochlorite solution

(3%) (Cmident, India). Master cone were taken. Fig.5, Fig.

10 (A&B) .The canals were dried and obturated with 25,4%

gutta-percha. and AH Plus sealer (Dentsply Maillefer, North

America) and the tooth was restored with miracle mix. Fig. 6,

Fig. 11.

Fig.1 Preoperative radiograph

Fig:2 CBCT image of root and root canals of #44 and# 45

Fig.3 Occlusal view of pulp chamber with the orifice of

#44and #45

Fig.4 (A & B) Working length of #44 and #45

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Fig.5 Master cone #44&#45 Fig.6 Post endo

Fig.7 (A) CBCT image of root and root canal of # 46

Fig.7 (B) CBCT image of root and root canals of # 47

Fig. 8 (A&B) Occlusal view of pulp chamber with the orifice

of #46 and #47

Fig. 9 (A&B) Working length of #46&#47

Fig. 10 (A) Mastercone #46

Fig. 10 (B) Mastercone #47 Fig.11 Post endo

DISCUSSION :

The presence of extra roots in mandibular premolars and

molars has clinical implications in endodontic treatment. An

accurate diagnosis of these supernumerary roots can avoid

complications or missing a canal during the root canal

treatment. Apart from complicating the root canal procedure,

extra roots has been found to be a contributing factor to

localized periodontal destruction.[8] The inability to find and

obturate a root canal has been shown to be a major cause of

failure in endodontic therapy.[18]

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University J Dent Scie 2018; Vol. 4, Issue 2

The presence of extra roots or canals in mandibular premolars

is undoubtedly an endodontic challenge. The mandibular

premolars showed the highest failure rate of all types of

teeth.[19] Conceivably, these findings could be due to the

complex root canal anatomy of a large number of these teeth.

A wide range of opinions are reported in the literature

regarding the number of root canals, but there are very few

reports on the variations in the number of roots that occur in

the mandibular second premolars.

CONCLUSION :

Although the incidence of root and canal variation is rare,

every effort should be made to find and treat all roots and

canals for successful clinical results. The clinician should be

astute enough to identify the presence of unusual numbers of

roots and their morphology. A thorough knowledge of root

canal anatomy and its variations, careful interpretation of the

radiograph.

This paper highlights the role of CBCT as an objective

analytical tool in order to ascertain root canal morphology.

The dental CBCT is a wonderful tool for examination and

diagnosis in clinical endodontics.[20]

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2. Vertucci FJ. Root morphology of mandibular premolars.

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15. Tu MG, Tsai CC, Jou MJ, Chen WL, Chang YF, Chen SY, et al. Prevalence of three-rooted mandibular first molars among Taiwanese individuals. J Endod 2007;33:1163- 6.

16. Song JS, Choi HJ, Jung IY, Jung HS, Kim SO. The prevalence and morphologic classification of distolingual roots in the mandibular molars in a Korean population. J Endod 2010;36:653-7.

17. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod 2004;30:559-67

18. Bains R, Loomba K, Chandra A, et al. The radix entomolaris: a case report. ENDO (Lond Engl) 2009;3:121-5

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CORRESPONDENCE AUTHOR :Dr. Himadri sharmaPost Graduate Student,Department of Conservative Dentistry and Endodontics,K.D. Dental College and Hospital ,Mathura-281006.India.himadrisharma44@gmail.com

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