An unusual presentation of all the mandibular anterior teeth with two - - PDF document

J Indian Soc Pedod Prev Dent- December 2005 204

An unusual presentation of all the mandibular anterior teeth with two root canals - A case report

TIKU A. M.a, KALASKAR R. R.b, DAMLE S. G.c

Abstract

A rare case of two root canals in all mandibular anterior teeth is presented. The patient initially reported for the treatment of mandibular right central and lateral incisors. However, radiographic evaluation revealed variant root canal and apical foramen patterns. Key words: Anatomy, Endodontics, Mandibular, Retreatment, Two canals ISSN 0970 - 4388

aLecturer, bLecturer, cProfessor and Head of Department of Pediatric

Dentistry, Nair Hospital Dental College, Mumbai-08, India

days duration. On clinical examination, a zinc oxide eugenol temporary restoration was seen in mandibular right central and lateral incisors. Dental history revealed that the patient had undergone root canal treatment in these teeth one month back. Medical and family history was noncontribu-

• tory. Preoperative radiograph revealed an overextended,

poorly condensed root canal obturation in the mandibular right lateral incisor and periapical radiolucencies in man- dibular right central and lateral incisors respectively [Figure 1]. A closer observation of the same radiograph revealed two root canals in 41; 42; 43, a rare morphological varia-

• tion. As this was an unusual observation additional radio-

graphs for the left mandibular incisors and canines were taken after treating symptomatic teeth which also revealed two root canals in them [Figure 2]. In view of the clinical symptoms, faulty obturation and peri- apical pathology, an endodontic retreatment of both the teeth was planned. The teeth were isolated with rubber dam and the temporary restorations of zinc oxide eugenol were

• removed. The access cavities were modified and the previ-
• usly condensed gutta percha points were softened with

chloroform and removed using K and H files alternatively. Careful exploration of the root canals revealed two sepa- rate canals, buccally and lingully in both the teeth with vertucci type IV morphology of root canals. Working length was established radiographically. The canals were prepared using a step back instrumentation technique upto 40 # in-

• struments. A 2.5% of sodium hypochlorite and normal sa-

line (sodium chloride injection I.P 0.9% w/v core health care limited) were alternatively used as irrigants at every change

• f instruments. The canals were dried with sterile paper

points and were dressed with calcium hydroxide paste (pulpdent). The access cavities were then temporarily sealed with IRM. At 2 weeks follow up as the teeth were asymp- tomatic, obturation of the root canals was under taken with laterally condensed gutta-percha using lateral condensation

• technique. Post obturation radiograph was taken and the

access cavities were sealed with IRM. The teeth were later taken up for jacket crowns [Figure 2]. The patient was fol- Successful endodontic therapy of a tooth demands that the dentist, should have a thorough knowledge of the root ca- nal morphology, making it mandatory towards thorough radiographic evaluation and diagnosis of the status of the pulp canals as well as the periapical areas. Improper diag- nostic protocol may lead to the failure of endodontic treat- ment. A wide morphological divergence of the root canal systems is known to exist. Varying number of the root canals in dif- ferent teeth, their anatomy and interconnections have been studied and reported by several authors.[1,2,3] Vertucci has classified morphological patterns of the root canal systems into eight types.[4,5] Generally, the mandibular incisors have

• ne root canal with one apical foramen (Vertucci type I) or

two root canals with one apical foramen(Vertucci type II). However, the occurrence of two root canals with two sepa- rate foramina (Vertucci typeIV) in the mandibular incisors is very rare viz 3% and 2% in the mandibular central incisors and lateral incisors respectively, and in canines it is 6%.[5] Funato A has reported a case with two root canals and sepa- rate apical foramina in the mandibular central incisor.[6] This case report describes the successful endodontic retreatment of the mandibular right central and lateral inci- sors having vertucci type IV root canal morphological sys-

• tem. The case was followed up for period of thirty months.

The striking feature of this report however was the pres- ence of two root canals in all the mandibular anterior teeth which has not been reported earlier to the best of our knowl- edge.

Case Report

A 12 years old boy reported to the department of Pediatric Dentistry, Nair Hospital Dental College, Mumbai, with mild pain in the permanent mandibular right anterior teeth of 15

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J Indian Soc Pedod Prev Dent- December 2005 205

lowed up at regular interval of 1, 3, and 6 months respec-

• tively. At 6 months follow up, complete resolution of the

periapical pathology was observed [Figure 3]. The patient was observed for thirty months during which the patient was completely asymptomatic [Figure 4].

Discussion

Since the success of the endodontic treatment is related to a thorough debridment of the root canals and hermatic seal

• f the obturated materials, a good preoperative radiographic

evaluation is necessary. The anatomy of root canal systems dictates the condition under which root canal therapy is carried out and can di- rectly affect its prognosis. Extra root or root canals if not

Figure 1: Preoperative radiograph revealing an overextended poorly condensed root canal obturation in the mandibular right lateral incisor Figure 2: Radiograph of left mandibular incisors and canine showing two root canals Figure 3: Radiograph showing complete resolution of periapical pathology at 6 months follow up Figure 4: Radiograph of the teeth at 30 months follow up Two root canals in mandibular anterior teeth

detected are a major reason for failure of this treatment.[7] Incomplete removal of all the irritants from the pulp space may increase the possibility of treatment failure.[8,9] The main reasons for failure in endodontic treatment of mandibular incisors is the inability to detect the presence of a second root canal,which can then not be prepared and obturated during treatment.[10] The frequency of two root canals in the mandibular incisors is 45% as reported by Kartal and Yanikoglu,[10] whereas the

• ther reports give these percentages between 11.5% and

41.4% respectively.[10] The percentage of two root canals (type vertucci IV) with separate apical foramina in the mandibular central and lateral incisors are 3% and 2% respectively and in the canines it is 6%.[5] In present case, two root canals with separate foramina were distinctly observed in the mandibular right central incisors

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J Indian Soc Pedod Prev Dent- December 2005 206

which is very similar to a case presented by Funato etal, who reported a mandibular central incisor with two root canals and separate apical formina.[6] Holtzman reported mandibular canine with three root canals[11] and Arcangelo reported with two roots.[12] However, in the present case report two root canals appeared in all the mandibular teeth. Additionally except for the mandibular right central and lat- eral incisors, which were vertucci type IV, the classification

• f root canals system of the other anterior teeth was not

possible, as they were not indicated for root canal treat- ment. Numerous antimicrobial agents have been recommended as inter appointment dressings.[13] Calcium hydroxide paste is a simple and remarkably effective antimicrobial medicament. It has been shown to dissolve necrotic tissue and enhance the tissue dissolving effect of sodium hypochlorite solu- tion.[14] In the present case, calcium hydroxide (Pulpdent) was used as the intracanal medicament. At 15 days recall teeth were asymptomatic and thus taken up obturation. It is evident in the present case that faulty obturation of the root canals had led to the formation of periapical lesions. This could be attributed to the microleakage as the canals were not sealed properly. Careful radiographic examination

• f the root canal system are important prior to the root

canal preparation, so as to detect and be aware of varia- tions in root canal anatomy, before and during endodontic treatment procedures. Finally, it is also important that the endodontic treatment be reviewed periodically to ensure continuous healing without complications.

References

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• Dr. Amita M Tiku,

22 Milan apartments, Pali Road Bandra West, Mumbai.400050. India Two root canals in mandibular anterior teeth [Downloaded free from http://www.jisppd.com on Friday, April 21, 2017, IP: 104.249.178.54]