27 endodontic treatment treatment4j.pdf · disadvantages of radiographs by providing...

ABSTRACT : A case is reported documenting successful treatment of radix entomolaris (tooth #36). The

purpose of this article is to report the successful endodontic treatment of mandibular first molars with RE

by using cone beam computed tomography (CBCT).

1 2 3 4Suresh Pandey, Amit Kumar Garg, Manoj Hans, Rohit Paul1 2,3 4Post graduate student, Professor, Professor and Head

Department of Conservative Dentistry and Endodontics,

K D Dental College and Hospital. Mathura-281006. India

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 coronal filling, preventing the ingress of

microorganisms.1

One of the main reasons for the failure of root canal treatment

is the inadequate removal of pulp tissue and microorganisms

from the root canal system. Root canal anatomy and the

confounding nature of the human pulpal system pose

significant challenges in rendering endodontic treatment.

Therefore, it is imperative that the aberrant anatomy is

identified before and during the root canal treatment of three-

rooted mandibular first molars.2 Mandibular molars typically

have two roots placed mesiodistally, but they sometimes have

an additional root, a radix entomolaris (RE), usually on the

distolingual aspect.1

This supernumerary root in the mandibular first molar is

associated with certain ethnic groups as follows: Europeans,

3.4–4.2%3-6 Africans, 3%7 Eurasians and Indians, less than

5%8 Caucasians, 4.2%1, 2, 9 Mongoloids such as Chinese,

Eskimos, and American Indians have 5% to more than

30%10-13 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-

17 Because of its high frequency, it may be considered as the

Asiatic trait.2, 11 The RE mostly has Vertucci type I canal

configuration.18 The RE, which in general is smaller than

distobuccal and mesial roots, can be separate from or partially

fused with these other roots.2, 19 Recently, Song et al. have

classified the RE into five types according to their

morphological characteristics.17

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

images. These imaging techniques have emerged as powerful

tools for the evaluation of root canal morphology.20

CASE REPORTS : An 50-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 left lower back tooth region since 10

days.. The tooth was percussion sensitive, 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 around the distal root with periapical

changes (Fig.1A). ]

ENDODONTIC TREATMENT OF RADIX

ENTOMOLARIS DIAGNOSED WITH CONE BEAM

COMPUTED TOMOGRAPHY: A CASE REPORT

Journal of Dental Sciences

University

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 130

University J Dent Scie 2018; Vol. 4, Issue 1

CaseReport

Keywords:

Mandibular first molars;

radix entomolaris; cone beam

computed tomography.

Conflict of interest: Nil

No conflicts of interest : Nil

(Fig.1A). Preoperative radiograph

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, 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).

Also, all the protective measures were taken to protect the

patient from radiation. Slices of the mandibular first molar

were obtained at different levels –coronal third, middle third

and apical third in order to determine the canal morphology.

CBCT revealed three distinct roots with four separate canals

and four separate orifices. The distance of distolingual (DL)

canal orifice was 4.1 mm from distobuccal (DB) canal orifice

and 4.0 mm from mesiolingual (ML) canal orifice.

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). Two distal and two mesial canal orifices

were located using an endodontic explorer (DG-16, Dentsply,

Gloucester, UK).

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.

The root canals were shaped with Hyflex CM rotary

instruments (Coltene Whaledent, Germany) up to the 30, 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). Calcium hydroxide dressing was

given for two weeks .After two weeks calcium hydroxide

dressing was removed and copious irrigation was done. Maser

cone were taken. The canals were dried and obturated with

30,4% gutta-percha. (Fig.1E) and AH Plus sealer (Dentsply

Maillefer, North America) and the tooth was restored with

miracle mix. After one months follow up, the tooth was

asymptomatic and crown was given .

Figure 1(a) Preoperative radiograph. (Fig.1b). Axial view and

3D image of 36(CBCT image), (Fig.1c).

CBCT image of root and root canal of 36, (Fig.1d). Occlusal

view of the pulp chamber floor with the orifice of RE,

(Fig.1e). Working length, (Fig.1f). Calcium hydroxide

dressing,

(Fig.1g)Maste cone, (Fig.1h). Post endo, (Fig.1i).Crown

i.r.t. 36 .

(Fig.1b). Axial view and 3Dimage of 36(CBCT image)

(Fig.1c).,CBCT image of root and root canal of 36

(Fig.1d). Occlusal view of the pulp chamber floor with the

orifice of RE.

Fig.1e). Working length



(Fig.1f). Calcium hydroxide dressing

(Fig.1g). Master cone

(Fig.1h). Post endo

(Fig.1i). PFMCrown i.r.t. 36

DISCUSSION : The presence of RE 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.21 Apart from

complicating the root canal procedure, RE has been found to

be a contributing factor to localized periodontal

destruction.22 In addition, reports correlate significantly

higher probing depths with attachment loss at the distolingual

aspect of three-rooted molars.23 . The bilateral occurrence of

three-rooted mandibular first molars was 37.14% .24 The

inability to find and obturate a root canal has been shown to be

a major cause of failure in endodontic therapy.25

Based on previous studies performed by Ballal et al.,26

Gopikrishna et al.,27 and Robinson et al.28wherein CBCT

was used for confirmatory diagnosis of morphological

aberrations in the root canal anatomy, CBCT of the

mandibular first molar was planned in the present study. The

initial diagnosis of RE before root canal treatment is

important in order to facilitate endodontic procedure, and to

avoid 'missed' canals and roots. If the RE canal entrance is not

clearly visible after removal of the pulp chamber roof, a more

thorough inspection of the pulp chamber floor and wall,

especially in the distolingual region, is necessary. Visual aids

such as a surgical loupe, intra-oral camera or dental

microscope can be useful.

With the distolingually located orifice of the RE, a

modification of the classical triangular opening cavity to a

trapezoidal form to locate and access the root canal better is

essential; straight line access must be established.1, 2

According to Walker and Quackenbush29 , normally a third

root should readily be evident in about 90% of cases

radiographically, but occasionally it might be difficult to see

because of its slender dimensions. More recently, with the

advent of CBCT in endodontics, more accurate information

can be obtained about root forms of individual teeth. These

could be used routinely to investigate any thing suggestive of

the presence of the RE for obtaining conclusive results.25

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. 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.

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FIGURE LEGENDS

Figure 1(a) Preoperative radiograph.,(Fig.1b). Axial view and

3Dimage of 36(CBCT image), (Fig.1c). CBCT image of

root and root canal of 36, Fig.1d). Occlusal view of the

pulp chamber floor with the orifice of RE, (Fig.1e).

Working length, (Fig.1f). Calcium hydroxide dressing,

(Fig.1g). Master cone, (Fig.1h). Post endo and

(Fig.1i).Crown i.r.t. 36.

CORRESPONDENCE AUTHORS :

Dr. Suresh Kumar Pandey

Post Graduate Student,

Department of Conservative Dentistry and Endodontics,

K.D. Dental College and Hospital ,Mathura-281006.India.

[email protected]



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