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Endodontic Retreatment of Two Mandibular Molars with Radix Entomolaris

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Endodontic Retreatment of Two Mandibular Molars with Radix Entomolaris CASE REPORT 213 Sabine Oberländer Endodontic retreatment of two mandibular molars with radix entomolaris Sabine Oberländer, Dr med dent Heidenheim, Germany Correspondence to: Sabine Oberländer Zahnarztpraxis Dr Gerhard Key words radix entomolaris, retreatment, three-rooted mandibular first molar Grüninger, Ausgust-Lösch Str 6, 89522 Heidenheim, This report presents a case with unusual root morphology on both first mandibular molars. Normal Germany Tel: 0049/7321 21 652 root canal anatomy of mandibular first molars is characterised by a birooted tooth with three root Email: [email protected] canals. A peculiarity that may occur, however, is radix entomolaris (RE). An endodontic retreatment was carried out on the two mandibular molars of a female patient. In both cases, an additional distally located root was found and treated. Consequently, both teeth had three roots, each with four canals. Looking for accessory roots, root canals, and unusual anatomy of the canal system is decisive for a successful root canal treatment. Knowing that they exist enables a successful treatment to be pro- vided, even in complicated cases. Introduction Treatment of the entire root canal system is required in order to ensure the success of therapeutic meas- Pulp horn ures and to prevent recurrent infection of the root canal system by untreated root canals1-3. In addition to not reaching the full working length, the main rea- Root canal sons for endodontic failures are lack of knowledge of orifice anatomic structures, and consequently leaving root canals uninstrumented and undisinfected4. Mesial root In individual cases, mandibular molars may have Distal root an additional, distolingually located root (radix Radix Ento- entomolaris) (Fig 1). Radix entomolaris was first molaris mentioned by Carabelli5. A prevalence of 3–4% in the European population is as low as in the Afri- Apical foramen with apical delta can population6. In the American Indian population and in the Asian population, the prevalence rate of Fig 1 Schematic drawing of a mandibular molar with radix radix entomolaris (RE) is considerably higher, ranging entomolaris. ENDO (Lond Engl) 2012;6(3):215–219 214 Oberländer Endodontic retreatment of two mandibular molars Fig 2 Diagnostic radiograph of tooth 36 showing a frac- Fig 3 Working length radiograph of tooth 36 with silver tured instrument in the mesial root, with apical and inter- points. radicular radiolucency. between 5% and 40%7-9. Schäfer et al10 reported 46 had undergone root canal treatment 3 months an incidence of RE of 1.35% in a group of German earlier. Since then, she had noticed increasing pain, patients. Some studies recorded a bilateral occur- increasing discomfort on chewing, and an evolving rence of RE in 50–67% of the cases11-12. swelling in the left mucobuccal fold. The first molar The definitive quality of radix entomolaris is the on the right side was also tender on percussion, but far distolingual position of the canal orifice13. Radix not as much as the first left molar. Tooth 36 clini- entomolaris can often only be radiographically veri- cally showed severe percussion sensitivity, and at the fied by angled radiograph images14. In addition to buccal aspect the probing depth was found to be the existence of an accessory cusp (tuberculum 10 mm. In the radiograph, an apical radiolucency praemolare), also periodontal probing for cervical was observed in addition to an incomplete root canal prominences can provide an indication of an ad- filling and a fractured instrument in one of the mesial ditional root. root canals (Fig 2). The radiograph of tooth 46 also Different manifestations of RE have been de- showed an incompletely obturated root canal system scribed in the literature. De Moor et al7 classified RE and an apical radiolucency (Fig 8). From these diag- into three sub-groups, depending on the curvature nostic radiographs, the tentative diagnosis of radix of the root canal: entomolaris on both teeth was already established. t Type I: straight root/root canal The patient was informed in detail about the t Type II: initially curved canal, which continues as treatment planning for nonsurgical retreatment of a straight root/root canal both teeth. The patient refused alternative therapies, t Type III: initial curvature in the coronal third, fol- such as the extraction of tooth 36 due to the severe lowed by a second curvature beginning in the symptoms, or a merely surgical procedure in the middle and continuing to the apical third of the form of an apicectomy. root. After administration of the anaesthetic (1.5 ml UDS, Sanofi-Aventis, Berlin, Germany) and appli- cation of a rubber dam, the retreatment was car- ried out on tooth 36 using a surgical microscope Case report (Zeiss, OPMI pico, Aalen, Germany). After removal A 19-year-old female patient came to the practice of a few dentine overhangs, four root canal orifices for the first time in 2009 because of severe discom- were visualised, of which the distolingual orifice fort caused by tooth 36. The general medical his- of the radix entomolaris was unprepared. The ex- tory was unremarkable. According to the informa- isting root canal filling was removed using Gates tion provided by the patient, this tooth and tooth Glidden burs (Sendoline, Täby, Sweden) and ro- ENDO (Lond Engl) 2012;6(3):215–219 Oberländer Endodontic retreatment of two mandibular molars 215 Table 1 Data of the root canal treatment of tooth 36. Root canal Length determined Length in Corrected Final preparation size with Raypex radiograph working length ProTaper, Hedstroem files Mesiobuccal (MB) 20 mm 20 mm 20 mm F3, ISO size 35 Mesiolingual (ML) 22 mm 22 mm 20.5 mm F3, ISO size 35 Distobuccal (DB) 20 mm 20 mm 20 mm F3, ISO size 35 Distolingual (DL) 22.5 mm 22 mm 20.5 mm F3, ISO size 45 tary ProTaper revision files (Maillefer, Ballaigues, second dressing was placed for 2 months, due to an Switzerland). The fractured root canal instrument upcoming stay abroad. (Hedström file) was located in the mesiolingual The patient presented 2 months later, free of canal and removed using ultrasound tips (CPR3, symptoms. The initial probing depth of 10 mm at the Spartan, Fenton, MI, USA). Working lengths of the buccal aspect had decreased to 2 mm. After admin- root canals were determined using an apex locator istration of the anaesthetic and isolation by rubber (Raypex, VDW, Munich, Germany). All root canals dam, all root canals were chemically debrided once were intermittently irrigated with NaOCl solution again using ultrasound files (IRI S 2½5, VDW, Mu- (5%), and enlarged using ProTaper instruments nich, Germany) and abundant irrigation with NaOCl of sizes S1 to F1. The instruments were set into solution in order to remove the calcium hydroxide rotation using the Endo IT motor (VDW, Munich, dressing and to clean the canal walls. After fitting the Germany). After a final irrigation with alcohol and gutta-percha masterpoints (Hygienic ADA medium, chlorhexidine (CHX) solution (2%), the root canals Coltène/Whaledent, Altstätten, Switzerland), a were dried with paper points, and a calcium hydro- master cone radiograph was taken. The following xide dressing (freshly mixed with CHX 2%) was final irrigation sequence was carried out before ob- placed. The access cavity was provisionally sealed turation: NaOCl (5%) – ethanol (70%) – ethylen- with Cavit (3M Espe, Seefeld, Germany). ediaminetetraacetic acid (EDTA) (17%) – ethanol One week later, the patient presented again. (70%). Subsequently, the root canals were dried She was free of discomfort, the swelling was clearly with paper points. The gutta-percha cones were regressive, and the tooth was no longer tender on covered with sealer (Pulp Canal Sealer, SybronEndo, percussion. After administration of the anaesthetic Orange, CA, USA) and placed into the respective (UDS) and application of a rubber dam, a radio- root canal. The heat-activated System B Heat Source graph was taken with silver points (ISO 15) placed (SybronEndo, Orange, CA, USA) was fitted to work- in the root canals for length determination (Fig 3). ing length minus 3 mm, by means of a silicone stop- Subsequently, the working lengths were corrected per and inserted into the root canal. Following the as follows: ML 20.5 mm, MB 20 mm, DL 20.5 mm down-pack, the thermoplasticised gutta-percha and DB 20 mm (Table 1). In the further course of was compacted with pluggers (Buchanan Plugger, treatment, the root canals were cleaned and shaped SybronEndo, Orange, CA, USA). After radiographic with ProTaper instruments up to size F3 for the control of the down-pack (Fig 4), the root canal planned warm vertical obturation technique. Also space was gradually back-filled using the Obtura during this treatment session, the root canals were pistol (SybronEndo, Orange, CA, USA), and the irrigated with a NaOCl solution (5%) with a tem- warm gutta-percha was compacted using pluggers perature of approximately 50°C. A final irrigation of increasing size up to approximately 1 mm below with alcohol and chlorhexidine solution was made the canal orifices. The pulp chamber was cleansed and the root canals were dried with paper points. with alcohol of residual sealer, and an adhesive filling Once again, a calcium hydroxide suspension freshly with Tetric Flow and Ceram (Ivoclar Vivadent, Ell- mixed with CHX was placed, and the access cav- wangen, Germany) was placed. The postoperative ity was provisionally sealed with Cavit and Tetric control radiography revealed a minor extrusion of Ceram (Ivoclar Vivadent, Ellwangen, Germany). A sealer at the distolingual root canal (Fig 5). ENDO (Lond Engl) 2012;6(3):215–219 216 Oberländer Endodontic retreatment of two mandibular molars Fig 4 Radiographic control of tooth 36 after down-pack, Fig 5 Radiographic control of tooth 36 after back fill and showing an apical puff at the distolingual root.
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