|Year : 2016 | Volume
| Issue : 1 | Page : 40-42
Nonsurgical endodontic management of a two-rooted maxillary lateral incisor
Sukhwant Singh Yadav1, Naseem Shah2
1 Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
2 Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||16-Dec-2015|
Sukhwant Singh Yadav
3rd Floor, Department of Conservative Dentistry and Endodontics, MAIDS, MAMC Complex - 110 002,
Source of Support: None, Conflict of Interest: None
Thorough debridement is the key to the success of nonsurgical endodontic treatment in teeth with periapical lesions. Missed canals harbor bacteria which lead to treatment failure. This case report presents an unusual case of two rooted maxillary lateral incisors with the periapical lesion and emphasizes the importance of knowledge of the variability of root canal morphology. The tooth was treated with nonsurgical endodontic therapy. The patient was asymptomatic and bony healing was evident on radiograph at 12 and 18 months follow-up.
Keywords: Anatomical complexity, nonsurgical treatment, two rooted maxillary lateral incisor
|How to cite this article:|
Yadav SS, Shah N. Nonsurgical endodontic management of a two-rooted maxillary lateral incisor. Saudi Endod J 2016;6:40-2
| Introduction|| |
The knowledge of root canal morphology and its frequent variation is a basic requirement for endodontic success. The anatomical complexities of root canal anatomy have been highlighted in the literature and clinician's necessity of understanding probable aberrations has been emphasized. The majority of anatomic studies found that maxillary lateral incisor is a single rooted tooth.,,, However, numerous case reports demonstrate significant variability in anatomy. Most reported cases of two-rooted maxillary lateral incisors are a result of fusion or gemination and are usually associated with a macrodont crown. There are a few reported cases of two roots associated with normal crown dimensions.,, Anomalous two-rooted maxillary lateral incisors with a developmental radicular lingual groove  and dens formation  are also reported in the literature. The purpose of this article is to report a two-rooted maxillary lateral incisor with a periapical radiolucent lesion that was successfully managed by nonsurgical endodontic treatment.
| Case Report|| |
A 27-year-old man was referred to the Department of Conservative Dentistry and Endodontics, All India Institute of Medical Sciences, New Delhi from a private practitioner for root canal treatment of the left maxillary central (#21) and lateral (#22) incisors. The patient gave the history of trauma 4 years back and recurrent swelling, which subsided on medication for the past 1½ years. On clinical examination, both teeth were sensitive to percussion but responded normally to palpation. An intra-oral sinus was present in relation to #22 [Figure 1]a. Radiographic examination revealed unusual root morphology of the left maxillary lateral incisor with two separated roots one mesial and the other distal. Large, diffuse periapical radiolucency was evident on intra-oral radiograph [Figure 1]b. Based on the above clinical and radiographic findings, a diagnosis of necrotic pulp and chronic apical periodontitis of tooth #22 was established. A nonsurgical endodontic therapy was planned after discussion with the patient and informed consent was taken. After rubber dam application (Hygienic Dental Dam, Coltène/Whaledent Inc., Cuyahoga Falls, USA), temporary restoration was removed and endodontic access was modified. Two canal orifices (mesial and distal) were located with an endodontic explorer (DG-16) in #22 [Figure 2] while single canal orifice was found in tooth #21. The working length was determined with electronic apex locator (J. Morita USA, Inc.: Root ZX II) and confirmed radiographically. The root canals were cleaned and shaped using ISO K files (SybronEendo, Mexico City, Mexico) with the crown down pressure-less technique. The mesial canal was instrumented to a master file size of 40 and distal canal to the size of 60. The root canals were copiously irrigated with 5.25% sodium hypochlorite solution (Hyposol, Prevest Denpro Limited, Jammu, India). An intracanal medicament of calcium hydroxide (Super Dental Products, New Delhi, India) and distilled water (Shree Krishna Keshav Lab Ltd., Ahmedabad, India) paste was then placed. After 2 weeks, the teeth were asymptomatic. The root canals were obturated with gutta-percha and AH Plus (Dentsply Limited, Surrey, United Kingdom) using a lateral compaction technique and permanently restored with composite restoration (Beautifill II Dental Hybrid Composite, San Marcos, United States). Follow-up at 18 months showed symptom-free #21 and 22. Radiographic examinations showed evident periapical bony healing [Figure 3].
|Figure 1: (a) Clinical picture depicting normal anatomic form of lateral incisor along with buccal sinus (arrow), (b) preoperative radiograph showing an extra root (arrow) in relation to lateral incisor|
Click here to view
|Figure 2: Clinical picture showing access opening with 2 canals (arrows)|
Click here to view
|Figure 3: Follow-up radiographs, (a) 12 months and (b) 18 months showing significant healing of periapical lesion (arrows)|
Click here to view
| Discussion|| |
The main objective of endodontic treatment is the elimination of infection from the root canal system and prevention of re-infection. Endodontic treatment can fail for many reasons including the presence of untreated missed canal. Finding more than one canal in maxillary lateral incisors is a rare condition. Vertucci  has reported that maxillary incisors present single root and single canal in 100% of the cases, though there were few case reports describing two,, three  and even four canals. When a maxillary incisor presents two roots or two root canals, conditions such as fusion, gemination, dens in dent, palato-gingival, or disto-lingual groove must be considered. There was no possibility of fusion or gemination in the present case, which commonly result in either a single larger crown or two crowns or roots fused together., The pretreatment radiograph showed no evidence of enamel or dentinal invagination, thus making dens in dente or dens invagination as unlikely causative factors. Sabala et al. reported that aberrations occurring less than 1% of the time were 90% bilateral. Most of the case reports of two rooted lateral incisors are found unilateral. The probable etiology for unilateral accessory root may result from traumatic injury of primary teeth. Root duplication may occur following intrusive luxation of primary teeth. Cone beam computed tomography is used as a diagnostic tool by many authors  for evaluation of extra canal or root in teeth. This is beneficial when two root canals are superimposed on each other such as buccal and lingual canals and are not clearly detectable on radiographs. In the present clinical report, it was possible to visualize the canals through evaluation of the initial X-ray as the roots were mesial and distal. The access cavity was extended mesially to locate the mesial canal, improve the visibility, and access for the endodontic instrumentation. Surgical loupes or dental operating microscope can sometimes be required if there is difficulty in canal location or the extra canal is present deeper in the pulp chamber. The clinician should be careful that even the most routine of cases might deviate from the usual. Lack of knowledge of aberrant anatomy and variations can result in failure of endodontic treatment due to necrotic debris and irritants in missed canals.
| Conclusion|| |
This article demonstrates the importance of having a thorough knowledge of variability in root canal morphology in endodontic management and effectiveness of nonsurgical approach even in the presence of root canal morphology aberrations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99.
Caliskan MK, Pehlivan Y, Sepetçioglu F, Türkün M, Tuncer SS. Root canal morphology of human permanent teeth in a Turkish population. J Endod 1995;21:200-4.
Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30:391-8.
Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101-10.
Hatton JF, Ferrillo PJ Jr. Successful treatment of a two-canaled maxillary lateral incisor. J Endod 1989;15:216-8.
Sykaras SN. A two-rooted maxillary lateral incisor. Oral Surg Oral Med Oral Pathol 1972;34:349.
Ravindranath M, Neelakantan P, Subba Rao CV. Maxillary lateral incisor with two roots: A case report. Gen Dent 2011;59:68-9.
Peikoff MD, Trott JR. An endodontic failure caused by an unusual anatomical anomaly. J Endod 1977;3:356-9.
Zillich RM, Ash JL, Corcoran JF. Maxillary lateral incisor with two roots and dens formation: A case report. J Endod 1983;9:143-4.
Patil AA, Patil SA, Dodwad PK. Endodontic management of a supernumerary tooth fused to the maxillary permanent lateral incisor. Saudi Endod J 2014;4:28-31.
Walvekar SV, Behbehani JM. Three root canals and dens formation in a maxillary lateral incisor: A case report. J Endod 1997;23:185-6.
Kottoor J, Murugesan R, Albuquerque DV. A maxillary lateral incisor with four root canals. Int Endod J 2012;45:393-7.
Sabala CL, Benenati FW, Neas BR. Bilateral root or root canal aberrations in a dental school patient population. J Endod 1994;20:38-42.
Maghsoudlou A, Jafarzadeh H, Forghani M. Endodontic treatment of a maxillary central incisor with two roots. J Contemp Dent Pract 2013;14:345-7.
[Figure 1], [Figure 2], [Figure 3]