a novel clinical endodontic approach: radix entomolaris
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i n t e r n a t i o n a l j o u r n a l o f d e n t a l s c i e n c e an d r e s e a r c h 1 ( 2 0 1 3 ) 4 2e4 4
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Case Report
A novel clinical endodontic approach: Radix entomolaris
Kavita Dhinsa a,*, Firoza Samadi b, J.N. Jaiswal c, Sonali Saha a
aSenior Lecturer, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences,
Lucknow 226025, UP, Indiab Professor and Head of Department, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and
Medical Sciences, Lucknow 226025, UP, IndiacProfessor and Director, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical
Sciences, Lucknow 226025, UP, India
a r t i c l e i n f o
Article history:
Received 3 January 2013
Accepted 28 February 2013
Keywords:
Radix entomolaris
Root canal anatomy
Mandibular molars
* Corresponding author. Tel.: þ91 9721222260E-mail address: [email protected]
2213-9974/$ e see front matter Copyright ª 2013, Inter
http://dx.doi.org/10.1016/j.ijdsr.2013.04.001
a b s t r a c t
Aim: The present case report discusses the treatment of an endodontically treated
mandibular molar tooth with three roots and four canals. Two canals were present in the
mesial side and one each was present in the disto-buccal and disto-lingual side.
Background: Mandibular molars may have an additional root which may be located buccally
or lingually. When it is buccally located it is called as radix paramolaris and when lingually
located it is termed as radix entomolaris (RE). Hence, the presence of such a pulpal system
calls for challenges in providing endodontic treatment.
Case description: A female child of 13 years age, reported to the Department of Pedodontics &
Preventive Dentistry with a chief complaint of lancinating pain in the lower back region of
the right side of the mandible. The pain was present for last two months. On clinical ex-
amination, the mandibular first molar of right side was deeply carious with tenderness on
percussion. Intra oral periapical radiograph showed carious lesion involving enamel,
dentin and pulp along with an extra root between the distal and mesial roots. To confirm
that additional root is present, two intra oral periapical radiographs with different hori-
zontal angulations were taken. After taking radiographs, an additional root was confirmed
to be present on the disto-lingual side of the mesial root. Final diagnosis of irreversible
pulpitis was made. The treatment modality planned was root canal treatment.
Copyright ª 2013, International Journal of Dental Science and Research Published by Reed
Elsevier India Pvt. Ltd. All rights reserved.
1. Introduction Mostly mandibular first molars have two roots: one mesial
The complex nature of root canals and the pulpal system
provides a number of challenges in performing endodontic
treatment. Hence, it is very essential to identify any altered
anatomy of roots and root canals before starting endodontic
treatment.1
(mobile).(K. Dhinsa).national Journal of Dental Scie
and one distal, but the number of roots and root canals may
vary from person to person. This term was first coined by
Carabelli (1996). The extra root in RE is located on the disto-
lingual aspects of the mesial root and in radix paramolaris it
is located on the mesial aspect of the distal root.2
nce and Research Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
i n t e rn a t i on a l j o u r n a l o f d e n t a l s c i e n c e an d r e s e a r c h 1 ( 2 0 1 3 ) 4 2e4 4 43
The diagnosis of these complexes in root canals has been
described by Carlsen andAlexanderson (2007). When present,
complete diagnosis and treatment plan is necessary and
clinician should take it as an additional canal to fill.3
Fig. 2 e Two radiographs with different horizontal
angulations were made which confirmed that the
additional root was located disto-lingual to mesial root.
2. Case description
A female child of 13 years age reported to Department of
Pedodontics and Preventive Dentistry with a chief complaint
of throbbing pain in lower back region of right side of
mandible. She reported with intermittent pain which was
present from the last two months and increased in severity
since last 10 days. Clinical examination revealed a deeply
carious right mandibular first molar which was tender on
percussion (Fig. 1). The tooth when subjected to electrical and
thermal pulp testing revealed a negative response. Intra oral
periapical radiograph showed a deeply carious lesion
involving enamel, dentin and pulp along with an extra root
present between the distal and mesial roots. To confirm the
presence of extra root, two separate radiographs were taken
with different horizontal angulations, after which it was
confirmed that the extra root was located on the disto-lingual
side of the mesial root (Fig. 2). A diagnosis of pulpitis (irre-
versible) was made and treatment plan was decided.
The tooth was anesthesized, carious lesion was removed
and composite build up was done giving tooth its normal
anatomical structure. Preparation of access cavity was done
using round bur and endodontic explorer was used to locate
the canal orifices (Fig. 3). Upon clinical examination, the orifice
of distal canal and the disto-lingual corner of pulp chamber
were separated by a dark line. On this aspect a diamond bur
was used to remove the overlying dentin, which revealed the
orifice of the second distal canal. The working lengths of root
canals were determined using K-files and intra oral periapical
radiograph (Fig. 4). Biomechanical preparation of the canals
was done using EDTA (Glyde) together with 2.5% sodium hy-
pochlorite and normal saline (Fig. 5). Drying of canals was
done with paper points while obturation was done with zinc
Fig. 1 e Right mandibular first molar was deeply carious
and tender on percussion.
oxide eugenol together with gutta-percha. The access cavity
was filled with glass ionomer cement followed by composite
resin restoration.
3. Discussion
The correct reason for the formation of RE is not clear. In
Europeans the association of RE in first molars (mandibular)
was found to be 3.4e4.2%, in Indians less than 5% and in
Caucasians it was found to be 4.2%.1
In dysmorphic, supernumerary roots, a number of external
factors may contribute during the formation of tooth, while in
eumorphic roots the genetic factors plays an important role.
According to Curzon (1974) ‘three-rooted molar’ trait has a
high genetic predominance.4
The RE may be located on the disto-lingual aspect of the
distal root while its length may vary from short conical to a
Fig. 3 e Access preparation done and canal orifices located
using endodontic explorer.
Fig. 4 e Canal lengths determined using radiographs.
i n t e r n a t i o n a l j o u r n a l o f d e n t a l s c i e n c e an d r e s e a r c h 1 ( 2 0 1 3 ) 4 2e4 444
mature root. The extension of pulp in RE is visible in an intra
oral periapical radiograph, but always the RE is smaller than
themesial and distal roots.5 Theremay be four different types
of RE as classified by Carlsen and Alexanderson (1990):
� Type A e distally located cervical part of the RE with two
normal distal root components.
� Type B e distally located cervical part of the RE one normal
distal root components.
� Type C e mesially located cervical part.
� Type AC e central location, between the distal and mesial
root components.
This classification allows for the identification of separate
and nonseparate RE.6
De Moor et al (2004) classified RE according to their cur-
vature as:
� Type I e straight root/root canal.
� Type II e initially curved entrance which continues as a
straight root/root canal.
Fig. 5 e Canals obturated using gutta-percha and zinc
oxide eugenol sealer.
� Type III e initial curve in the coronal third of the root canal
and a second curve beginning in the middle and continuing
to the apical third.4
Apart from radiographic diagnosis the presence of addi-
tional root can be identified by clinical examination of the
crown and visual inspection of the cervical morphology of the
roots using a periodontal probe.2 An additional cusp or very
prominent disto-lingual lobe together with cervical convexity
may indicate presence of extra root.7 If a diagnosis of RE is
made before commencement of endodontic treatment we can
be aware of the correct morphology of the pulp chamber once
it has been opened.8
The morphology of the pulp chamber shows a rectangular
outline formwhile a dark line in the floor of the pulp chamber
may confirm the exact location of the orifice of the RE canal.9
After initial exploration of the root canal and radiographic
examination of the root canal length, precautions should be
taken to avoid any accidental error.10
4. Conclusion
Justastheappearanceofall individual isnotalikesamegoestrue
for thedentition. Lotofvariations isseen in theanatomyof tooth
structure. Amongst all RE may be a challenge for all clinicians
who do not have proper diagnostic aids and lack proper knowl-
edge of the anatomy of tooth. With all proper skills, knowledge
and correct diagnosis these cases canbewell handledwith ease.
Conflicts of interest
All authors have none to declare.
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