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CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 46-50

Endodontic management of bilateral mandibular canines with an unusual root canal anatomy


Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India

Date of Web Publication12-Jan-2015

Correspondence Address:
Amit Yadav
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Light House Hill Road, Mangalore 575 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.149088

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  Abstract 

This case report describes the endodontic management of bilateral mandibular canines with unusual root canal anatomy in a patient. The right mandibular canine had two separate roots (buccal and lingual), each root having a single canal. The left mandibular molar had two separate canals coronally joining into a single canal in the apical 3 rd (Vertucci Type II). While the presence of two roots and two canals in one root is not uncommon, finding a combination of these morphological variations in the same patient has not been reported previously. This emphasizes the perception of the clinician that a given tooth will contain a specific number of roots and/or root canals canal should be changed, and such variations should be kept in mind during the endodontic treatment of permanent mandibular canines.

Keywords: Bilateral, mandibular canine, root canal morphology, root canal treatment, two root canals


How to cite this article:
Rijal S, Yadav A, Shetty K. Endodontic management of bilateral mandibular canines with an unusual root canal anatomy. Saudi Endod J 2015;5:46-50

How to cite this URL:
Rijal S, Yadav A, Shetty K. Endodontic management of bilateral mandibular canines with an unusual root canal anatomy. Saudi Endod J [serial online] 2015 [cited 2019 Dec 7];5:46-50. Available from: http://www.saudiendodj.com/text.asp?2015/5/1/46/149088


  Introduction Top


Sterilization of the root canal space is of paramount importance with regard to root canal treatment. [1] Unless the canals have been sterilized or reached a phase where microorganism can no longer be cultivated, the prognosis is always going to be guarded. [2] To achieve this goal, a proper chemo-mechanical preparation and a sound knowledge of the root canal anatomy and its possible anatomic variations is essential. Anomalous root and root canal morphology can be found associated with any tooth with varying degree of and incidence. Failure to appreciate the anomalous root canal anatomy and thus identify/clean a canal in such cases is one of the main reasons for failure of endodontic treatment. [1]

Due to a knowledge of the general root canal anatomy associated with a particular tooth, many clinicians have the perception that a given tooth will contain a specific number of roots and/or canals. Such an approach often leads to failure to identify anomalous root canal anatomy and thus failure of the root canal treatment. Mandibular canals for instance usually present with a single root and a single canal (Vertucci Type I). [3] The occurrence a single root with two canals joining into a single canal apically (Vertucci Type II) and two roots in a mandibular canine is very rare ranging from 1% [4] to 5%. [5] Although the prevalence is low, a possible variation in the number of root/root canals should be kept in mind by the clinician while carrying out the endodontic treatment for a mandibular canine. This paper presents the endodontic management of a patient with aberrant root canal anatomy of the mandibular canine bilaterally, with right canine having two separate roots, each having a single canal, and the left canine having a single root with two canals coronally joining into a single canal apically.


  Case Report Top


A healthy 60-year-old Indian female reported to the endodontic clinic for replacement of missing lower left and right central and lateral incisors. She was very persistent on having the prosthesis of a fixed type. Her past history revealed extraction of the lower anterior teeth 6 years ago due to mobility. Intra-oral examination revealed missing lower anteriors and attrited lower canines and premolars with associated tenderness on percussion with mandibular left canine (#33) and mandibular right canine (#43) [Figure 1]. Radiographic examination revealed attrition on #33 and #43 approximating the pulp; the periapical area appeared normal with tooth #33, whereas a diffuse periapical radiolucency was seen associated with the buccal root of #43 [Figure 2] a. Pulp vitality in #33 and #43 gave a negative response. The diagnosis of necrotic pulp in relation to tooth #33 and necrotic pulp with associated symptomatic apical periodontitis in relation to tooth #43 was established, and a treatment plan of root canal treatment for #33 and #43 followed by fixed prosthetic replacement of the missing anteriors was planned and discussed with the patient.
Figure 1: Intra-oral picture showing the missing anterior teeth and generalized attrition

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Figure 2: Tooth no. 43 with two separate roots. Working length radiograph showing two separate roots with a single canal in each root (a). Post-obturation radiograph (b)

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After administration of local anesthesia, the teeth were isolated with rubber dam and access preparation was performed using a round diamond bur No. 2 and an Endo-Z bur (Dentsply, Maillefer, Ballaigues, Switzerland) in a high-speed airotor handpiece. Since there was attrition, access cavity preparation was done on the incisal surface to get a straight line access. Further modification and exploration of the access cavity demonstrated the presence of two separate root canal orifices in both #33 and #43 [Figure 2] a and [Figure 3] a. Canal patency was checked with #10 K-file (Mani, Inc., Tochigi, Japan). Initial exploration and negotiation of the canals were done with a size 15 K-file (Mani, Inc., Tochigi, Japan). Working length estimation was done using an electronic apex locater (PropexII, Dentsply, Maillefer, Switzerland).Working length was confirmed radiographically. The working length radiograph revealed separate buccal and lingual canal which joined in the apical third in tooth #33 and two separate roots in tooth #43 [Figure 2]a and [Figure 3]b.{Figure 2}
Figure 3: Access cavity in tooth no. 33 showing two separate canal orifi ces (buccal and lingual) (a). Working length radiograph showing a single canal with two roots joining at the apical third (b). Post-obturation radiograph (c)

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The coronal 3 rd was enlarged using SX file Protaper system (Maillefer, Dentsply). The canals were prepared with Protaper series nickel-titanium rotary instruments (Maillefer, Dentsply, Ballaigues, Switzerland), up to size F3 using a crown-down technique and irrigation with 5.25% sodium hypochlorite at each change of file. After completion of root canal cleaning and shaping, an intra- canal dressing of calcium hydroxide (Calcicur, VOCO, Cuxhaven, Germany) was placed and access cavity was restored with temporary dressing (Cavit G, 3M, ESPE, Germany). The patient was recalled after a week.

The patient was asymptomatic on next visit. The temporary dressing and intra-canal medicament were removed and root canals were irrigated with sodium hypochlorite followed by saline. The canals were subsequently dried with paper points. The canals were obturated using Protaper gutta-percha Size F3 and epoxy resin-based root canal sealer (AH Plus Sealer, Dentsply, Maillefer). The final radiograph shows two well-obturated root canals in both 33 and 43 [Figure 2]b and [Figure 3] c. Access cavity was restored with resin-based composite (Filtek TM Z 350XT, 3M ESPE, Minnesota, U.S.A) and patient was rescheduled for fixed prosthetic restoration.{Figure 2}{Figure 3}


  Discussion Top


The objective of root canal treatment is to debride any remaining pulp tissue, microorganism, bacteria and its byproducts from the root canal space prior to obturation, so as to harbor a conducive environment for the healing of periapical tissues. [1] Diagnosis and identification of total number of roots, roots canals and any possible permutation of the root canal morphology are of utmost importance for endodontic treatment. Failure to locate and disinfect an extra root canal is one of the most common cases for the failure of root canal treatment. [6]

Preoperative radiograph is extremely important as it allows for the diagnosis and identification of root and root canal anatomical variations. Though radiographs provide only two-dimensional image, radiographs taken with different horizontal angulations adequately reflect the morphological characteristics of the root and root canal system in the third dimension. [7] Care should be taken during the initial radiographic examination as well as during access cavity preparation because exploration and location of the canal orifice act as a guide to navigate the canals. [6] In this case, we found two root canal orifices, one buccal and one lingual, in both the mandibular canine. Radiographic examination revealed the presence of two roots in the right mandibular canine and a single root with two separate canals coronally joining into a single canal apically in the left mandibular canine. Since the clinical and radiographic examination clearly demonstrated the root canal anatomy, extra investigations such as CBCT were not planned because of concerns regarding radiation dosages. [8]

However, the presence of a second root or presence of bifurcation/extra canal is not always clearly evident. Identification of extra root is all the more difficult in the case of crowding due to superimposition. Therefore, radiographs should be carefully analyzed to identify details that may suggest presence of bifurcation or trifurcations, such as sudden discontinuity of the root canal. [9] Moreover, three-dimensional imaging techniques like cone beam computed tomography and spiral computed tomography will help us better understand the root and root canal morphology in such situations.

Mandibular canines usually have a single root with one canal; however, variation in the number of roots and root canals has been reported previously [10],[11],[12],[13],[14],[15],[16],[17] [Table 1]. Green [18] observed two canals in a single root in 13 out of 100 teeth examined. Hess [19] also observed two canals in 15% of the examined cases. Vertucci [18] reported the presence of two canals in 18% of the mandibular canines. Presence of two separate roots in a mandibular canine is even rarer. Laurichesse et al. [3] reported that 2% of mandibular canine presented with one root and two canals and that only 1% had two roots and two canals. Pecora JD [20] studied the internal anatomy, the direction and number of roots in mandibular canines on 830 mandibular canines, and found that only 1.2% had two canal with two orifice in a single root and 1.7% of the examined teeth had two separate roots thus showing the rarity of this type of root canal anatomy in mandibular canine. Moreover, a combination of these two types of root and root canal anatomy in a single patient as present in this case has never been reported.
Table 1: Case reports of number of root and root canals in permanent mandibular canine

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Root canal in a mandibular canine with a single root and single canal is quite large and usually does not cause much of technical problems during instrumentation. Mandibular canines presenting with two roots or two canals are very difficult to instrument and clean. Long axis of the canal meets the crown surface at the incisal edge or on the labial surface. This has to be taken into consideration; otherwise, it would lead to deviated preparations, the emphasis being on the labial side of the canal. In the present case, since there was attrition, access cavity preparation was done on the incisal surface, making straight line access and instrumentation of both the canals convenient and predictable.

Tooth wear due to attrition, erosion and abrasion is frequently observed in dental practice. The stage of tooth wear affects the choice of treatment, in severely affected teeth, the progressive loss from tooth wear may result in pulp involvement. [21] Meister and colleagues have indicated that reparative dentine formation is the most common sequelae and the pulp chambers have calcified. [22] The most common complications resulting from irritation of the pulp are pulpal inflammation, pulp necrosis, and periapical inflammation. The pulp need not be exposed for these problems to occur, as was seen in this case. Histological examination has discovered that the layer of attrited or eroded dentine overlying the pulp may be thin enough to permit bacterial entry. [23] When pulp damage is severe, as seen in this case endodontic treatment becomes necessary.


  Conclusion Top


Although the occurrence of two root canals with a single root or two canals with two roots in the mandibular canine have been reported, the combination of these as reported in the present case is rare. It is very important to detect such anatomical variations in the permanent teeth. Inability to detect such aberrations in anatomy will result in uninstrumented areas of the root canal space and subsequent failure of the root canal treatment.


  Acknowledgment Top


The authors would like to acknowledge Dr. Shreya Hegde, Assistant Professor, Manipal College of Dental Sciences, Mangalore for her professional assistance.



 
  References Top

1.
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2.
Chugal NM, Clive JM, Spãngberg LS. A prognostic model for assessment of the outcome of endodontic treatment: Effect of biologic and diagnostic variables. Oral Surg Oral Med Oral Pathol 2001;91:342-52.  Back to cited text no. 2
    
3.
Vertucci FJ. Root canal anatomy of the mandibular anterior teeth. J Am Dent Assoc 1974;89:369-71.  Back to cited text no. 3
    
4.
Laurichesse JM, Maestroni J, Breillat J. Endodontie Clinique. 1 st ed. Paris, France: Cdp; 1986. p. 64-6.  Back to cited text no. 4
    
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Ouellet R. Mandibular permanent cuspids with two roots. J Can Dent Assoc 1985;61:159-61.  Back to cited text no. 5
    
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Haapsalo M, Udanes T, Endal U. Persistant, recurrent, and aqcuired infection of the root canal system post treatment. Endod Topics 2003;6:151-2.  Back to cited text no. 6
    
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Walton RE. Endodontic radiographic technics. Dent Radiogr Photogr 1973;46:51-9.  Back to cited text no. 7
    
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Roberts JA, Drage NA, Davies J, Thomas DW. Effective dose from cone beam CT examinations in dentistry. Br J Radiol 2009;82:32-40.  Back to cited text no. 8
    
9.
Shanna R, Pecora JD, Lumley PJ, Walmsley AD. The external and internal anatomy of human mandibular canine with two roots. Dent Traumatol 1998;14:88-92.  Back to cited text no. 9
    
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Heling I, Gottlieb-Dadon I, Chandler NP. Mandibular canine with two roots and three root canals. Endod Dent Traumatol 1995;11:301-2.  Back to cited text no. 10
    
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Holtzman L. Root canal treatment of a mandibular canine with three root canals. Case report. Int Endod J 1997;30:291-3.  Back to cited text no. 11
    
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Bhardwaj A, Bhardwaj A. Mandibular canines with two roots and two canals-a case report. Int J Dent Clin 2011;3:77-8.  Back to cited text no. 12
    
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Tiku AM, Kalaskar RR, Damle SG. An unusual presentation of all the mandibular anterior teeth with two root canals-A case report. J Indian Soc Pedod Prev Dent 2005;23:204-6.  Back to cited text no. 13
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Victorino FR, Bernardes RA, Baldi JV, de Moraes IG, Bernardinelli N, Garcia RB, et al. Bilateral Mandibular Canines with Two Roots and Two Separate Canals-Case Report. Braz Dent J 2009;20:84-6.  Back to cited text no. 14
    
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Andrei OC, Margarit R, Daguci L. Treatment of a mandibular canine abutment with two canals. Romanian J Morphl Embryol 2010;5:565-8.  Back to cited text no. 15
    
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Gaikwad A. Endodontic treatment of mandibular canine with two root canal- a case report. Int J Dent Clin 2011;3:118-9.  Back to cited text no. 16
    
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Arora V, Nikhil V, Gupta J. Mandibular canine with two root canals-an unusual case report. Int J Stomatol Res 2013;2:1-4.  Back to cited text no. 17
    
18.
Green D. Double canal in single roots. Oral Surg, Oral Med Oral Pathol 1973;35:689-96.  Back to cited text no. 18
    
19.
Hess W. The anatomy of the root canals of teeth of the permanent dentition. New York: Williams Wood Co; 1925.  Back to cited text no. 19
    
20.
Pécora JD, Sousa Neto MD, Saquy PC. Internal anatomy, direction and number of roots and size of human mandibular canines. Braz Dent J 1993;4:53-7.  Back to cited text no. 20
    
21.
Eccles JD. Tooth surface loss from abrasion, attrition and erosion. Dent Update 1982;9:373-81.  Back to cited text no. 21
    
22.
Meister F, Braun RJ, Gerstein H. Endodontic involvement resulting from dental abrasion or erosion. J Am Dent Assoc1980;101:651-3.  Back to cited text no. 22
    
23.
Jones RR, Cleaton-Jones P. Depth and area of dental erosions, and dental caries, in bulimic women. J Dent Res 1989;68:1275-8.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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Discussion
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Acknowledgment
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