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Accessory Mesial Roots and Root Canals in Mandibular Molar Teeth: Case Reports, SEM Analysis and Literature Review

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Accessory Mesial Roots and Root Canals in Mandibular Molar Teeth: Case Reports, SEM Analysis and Literature Review REVIEW ARTICLE 195 Hany Mohamed Aly Ahmed, Norhayati Luddin Accessory mesial roots and root canals in mandibular molar teeth: Case reports, SEM analysis and literature review Hany Mohamed Aly Ahmed Department of Restora- tive Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Key words accessory root, accessory root canal, mandibular molar, middle mesial canal, root, Malaysia root canal Norhayati Luddin Department of Restora- Adequate knowledge on the root and root canal morphological variations is essential for successful tive Dentistry, School of Dental Sciences, Universiti endodontic treatment. Mandibular molar teeth show considerable variability and complexity in their Sains Malaysia, Kelantan, external and internal radicular morphology that require special attention from dental practitioners to Malaysia provide the best clinical outcomes for the patients. This report aims to describe two clinical cases of Correspondence to: Dr Hany Mohamed Aly mandibular molar teeth with accessory mesial roots/root canals. The first case demonstrates a suc- Ahmed cessful identification and endodontic management of a three-rooted mandibular second molar with Department of Restorative Dentistry, an accessory mesial root, and the second case presents a mandibular first molar with five root canals, School of Dental Sciences, in which three separate mesial root canals were identified. With the aid of SEM and radiographic Universiti Sains Malaysia, Kubang Kerian, 16150, examination, both external and internal radicular morphological analysis were also performed on Kelantan, Malaysia an extracted mandibular second molar tooth having an apical mesial root bifurcation. In addition, Tel: 00-601-29857937 Email: hany_endodontist@ a review on the literature was undertaken to identify the available in vitro and in vivo studies that hotmail.com demonstrated these anatomical aberrations in the mesial root of mandibular molar teeth. Introduction molar tooth with an accessory mesial root can be rather common4,12-18. In addition, some studies and Thorough knowledge on root and root canal morph- reported cases demonstrated the occurrence of four- ology is a fundamental prerequisite for successful rooted mandibular molar teeth having double mesial root canal treatment1. Accessory roots in mandibular roots4,5,16,18-22. permanent molar teeth have been comprehensively Apart from this external anatomical aberration, investigated in previous studies2-7, and it can be mandibular molar teeth show an increased likelihood concluded that the occasion of this anatomical ab- for internal morphological variations including root erration varies according to ethnicity, gender and canals with unusual configurations, lateral and furca- association with some diseases4, 8-10. While the oc- tion canals and inter-canal communications1,23-25. currence of radix entomolaris (accessory disto lingual Within this complex anatomy of the root canal sys- roots) and radix paramolaris (accessory buccal roots) tem, the increased prevalence of additional root is usually mentioned as the typical clinical finding canals, which is significantly influenced by ethnicity for three-rooted mandibular permanent molar and age1,26, is considered at the forefront of chal- teeth6,11, the occasion of three-rooted mandibular lenges facing clinicians while performing endodontic ENDO (Lond Engl) 2012;6(3):195–205 196 Ahmed/Luddin Accessory mesial roots and root canals in mandibular molar teeth therapy. Even though mandibular molar teeth are shaped using sizes 2 and 3 Gates-Glidden drills (Mani, usually presented with double mesial root canals, as Tochigi, Japan ). The working length was determined many as four canals have been reported in the mesial using electronic apex locator (Element Diagnostic root of mandibular molar teeth27-30. Unit, SybronEndo, Orange, California, USA), and the Because of these external and internal anatom- canals were initially instrumented using hand K-Flex- ical discrepancies, it is of prime importance for the ofiles (Dentsply Maillefer, Ballaigues, Switzerland) up clinicians to clearly identify their morphological land- to sizes 25 and 30 for the mesial and distal canals, marks. Hence, this article aims to present two clin- respectively. Subsequently, with the aid of a NaviTip ical cases and one extracted mandibular molar tooth needle gauge 29 (Ultradent, South Jordan, Utah, having these anatomical aberrations in the mesial USA), the canals were injected with an aqueous root. In addition, a literature search for the available radiopaque calcium hydroxide paste (UltraCal XS, and relevant articles, cited in PubMed and Google Ultradent, South Jordan, Utah, USA), and the access Scholar from 1971 to 2011, was undertaken to iden- cavity was then temporized using a fast set highly tify the available in vitro and in vivo studies that viscous conventional glass ionomer cement (Ionofil demonstrated this aberrant anatomy. Molar AC Quick, Voco, Cuxhaven, Germany). In the following visit, the hand mechanical instrumentation was continued up to sizes 35 and 45 for the mesial Case 1 and distal root canals, respectively. Finally, the canals A 30-year-old male patient was referred with the were obturated using the lateral compaction tech- chief complaint of a dull pain while chewing on nique (Figs 1c and d). the mandibular right side. The medical history was noncontributory. The clinical examination revealed Case 2 a large and deep carious cavity related to the man- dibular right second molar with slight pain on per- A 40-year-old male patient presented with the main cussion. There was no evidence of current swelling or complaint of severe pain while chewing on man- tooth mobility. Radiographically, the tooth showed dibular left side of the jaw. Clinical and radiographic widening of the periodontal ligament spaces around examinations revealed a large proximal carious le- the mesial and distal roots (Fig 1a). A second mesial sion related to his mandibular left first molar with root was identified (Fig 1a). The pulp of the tooth severe pain on percussion and loss of periapical was provisionally diagnosed as necrotic with asym- periodontal ligament space (Fig 2a). Following tomatic apical periodontitis. Following caries excava- l ocal anaesthesia, the caries was excavated, and tion, the pulp was confirmed to be necrotic and a root canal treatment was initiated after the pulp root canal treatment was scheduled. exposure was confirmed. All endodontic procedures were performed with Similar to the previous case, all treatment steps the aid of magnification using 4× prismatic dental were employed with the aid of assisted magnifi- loupes (Heine, Herrsching, Germany), accessory cation and accessory illumination. The tooth was light emitting diode illumination (LED) (3S, Heine, isolated and the access cavity was prepared, after Herrsching, Germany) and rhodium plated front restoring the distal wall using a fast set highly vis- surface mirror (Hahnenkratt, Königsbach-Stein, Ger- cous conventional glass ionomer cement (Ionofil many). After the administration of local anaesthesia Molar AC Quick, Voco). The working lengths were and rubber dam isolation, the access cavity prep- determined for the four root canals (MB – mesio- aration was completed. During exploration of the buccal; ML – mesiolingual; DB – distobuccal; DL – pulp chamber, a wide buccolingual dimension of the distolingual) using electronic apex locator (Element mesial access cavity wall was noted, indicating the Diagnostic Unit, SybronEndo). The DB and DL root complete division of the mesial root into two well- canals were connected at the apical third of the root separated mesial root components (Fig 1b). by one apical foramen. The canals were coronally Following this, the mesiobuccal (MB), mesio- shaped using Gates-Glidden drills (Mani) (sizes 2 lingual (ML) and distal (D) root canals were coronally and 3) and apically instrumented to a flexible file ENDO (Lond Engl) 2012;6(3):195–205 Ahmed/Luddin Accessory mesial roots and root canals in mandibular molar teeth 197 Fig 1 (a) Periapical radiograph showing the external outlines of the two mesial roots (white arrows). (b) An intraoral photograph showing the wide buccolingual dimension of the me- sial orifices. (c and d) Postoperative periapical radiograph. a b c d size 25 (Mani). Then, an aqueous radiopaque cal- arate apical foramen (Fig 2c). The orifice and about cium hydroxide paste (UltraCal, Ultradent) was in- 2 mm of the coronal third of the MM canal were troduced into the canals as intracanal medicament flared using a Gates-Glidden drill (Mani) (size 2), and using NaviTip needles gauge 29 (Ultradent), and the mechanical instrumentation was continued using the access cavity was then temporized using glass stainless steel flexible hand files (Mani) until only size ionomer cement (Ionofil Molar AC Quick, Voco). 30 to reduce the risk of perforation, while the MB In the subsequent visit, a thorough exploration and ML canals were prepared at size 35. The distal of the mesial groove between the MB and ML canal root canal was instrumented up to size 50. Finally, orifices was performed using an endodontic explorer the canals were obturated using the lateral compac- under magnification and a middle mesial (MM) root tion technique (Fig 2d). canal was located (Fig 2b). The canal showed a sep- ENDO (Lond Engl) 2012;6(3):195–205 198 Ahmed/Luddin Accessory mesial roots and root canals in mandibular molar teeth Fig 2 (a) Preoperative radiograph showing large proximal cavitation and loss of periapical periodontal
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