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Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 61-65

A combined management of a rare case of a maxillary lateral incisor with accessory root and deep mesio-radicular groove

Centre for Restorative Dentistry, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Date of Web Publication8-Jan-2019

Correspondence Address:
Dr. Safura Anita Baharin
Unit of Endodontology, Centre for Restorative Dentistry, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_49_18

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This case report describes the combined nonsurgical endodontic retreatment and surgical intervention of a failed root canal treatment associated with a maxillary lateral incisor with an accessory root and deep mesio-radicular groove. A 42-year-old female Malay patient presented with persistent infection associated with deep mesial pocket from her maxillary left lateral incisor (#22). The medical history was noncontributory and the tooth was previously root treated. Following comprehensive clinical and radiographic examination, a combined nonsurgical endodontic retreatment and surgical management of tooth #22 were carried out. The inability to debride the periodontal defect necessitates the amputation of the accessory root, and surgical debridement of the deep radicular groove was carried out. The clinical and radiographic examination 1 year after completion of treatment revealed evidence of healing. The early recognition of root and canal variation, correct diagnosis, and appropriate management of tooth with accessory root and deep radicular groove is essential to ensure favorable treatment outcome.

Keywords: Accessory root, intraoral radiograph, maxillary lateral incisor, radicular groove

How to cite this article:
Baharin SA, Razali M. A combined management of a rare case of a maxillary lateral incisor with accessory root and deep mesio-radicular groove. Saudi Endod J 2019;9:61-5

How to cite this URL:
Baharin SA, Razali M. A combined management of a rare case of a maxillary lateral incisor with accessory root and deep mesio-radicular groove. Saudi Endod J [serial online] 2019 [cited 2020 Jul 7];9:61-5. Available from: http://www.saudiendodj.com/text.asp?2019/9/1/61/249596

  Introduction Top

A comprehensive clinical and radiographic assessment followed by correct diagnosis and appropriate management is important to ensure satisfactory treatment results. Failure to recognize and eliminate the source of disease would lead to persistence of infections and subsequent treatment failure. The ability to locate and completely debride the entire root canal system is a prerequisite for successful treatment. One of the reasons for treatment complications arises from clinician's failure to recognize the presence of canal variations associated with the tooth, leading to persistence of residual pathogenic microorganisms in uncleaned and infected root canals.[1],[2],[3] Thorough knowledge of typical and potential variations of root and canal anatomy is important in ensuring a favorable treatment outcome.[4],[5] Various studies have shown that the majority of the maxillary lateral incisors have only one root and one root canal, but variations associated with this tooth does exist.[3],[4],[5],[6]

The radicular groove is one of the most commonly reported developmental anomalies associated in maxillary lateral incisors with a reported incidence between 2.8% and 18%.[7] It usually originates near the cingulum and extends apically at varying lengths and depths along the root which may act as a niche for plaque accumulation and thus results in periodontal breakdown.[2],[7],[8],[9] The presence of long and deep radicular grooves posed challenges in the: (i) diagnosis as it may mimic localized chronic periodontitis due to the presence of deep periodontal pocket and (ii) treatment as it may require surgical intervention to allow eradication of infection associated with the groove.[7],[10]

The existence of accessory root in maxillary lateral incisor is rare and its presence, together with a deep radicular groove may result in severe periodontal breakdown.[2] This report presents a combination of nonsurgical root canal retreatment and surgical management of a maxillary lateral incisor with an accessory root and deep mesio-radicular groove.

  Case Report Top

A 42-year-old Malay female patient was referred to the Endodontic Specialist Clinic, Faculty of Dentistry, Universiti Kebangsaan Malaysia, with a chief complaint of persistent discharge and bad taste from the maxillary left lateral incisor (#22) region since the past 2 years. The patient's medical history was noncontributory. Past dental history revealed that the maxillary left lateral incisor had been root-treated 6 years ago. However, the symptoms persisted, with the occasional manifestation of gingival swelling around the tooth.

An intraoral examination revealed the presence of a sinus tract buccally with clear exudate oozing from the mesial aspect of tooth #22 [Figure 1]a. A 9 mm pocket was discovered on the mesiobuccal aspect of the involved toot which coincided with the presence of a groove on the mesial aspect of the root that clinically visible and can be felt with a periodontal probe. The tooth had a yellowish discoloration and its incisal edge was 3 mm longer than the adjacent maxillary left central incisor (#21). The diagnostic intraoral periapical radiograph showed the presence of an accessory root on the mesial aspect of the tooth surrounded by a large radiolucent lesion which extends apically [Figure 1]b. The existing root filling was approximately 3 mm short of the radiographic apex. The periapical radiograph with a size 30 gutta-percha point inserted into the opening of the sinus tract showed the gutta-percha cone pointing into the mesial pocket of the tooth. A diagnosis of previously treated, symptomatic apical periodontitis was made, and the treatment decided on was to perform nonsurgical root canal retreatment followed by surgical debridement of the radicular groove.
Figure 1: Clinical examination revealed the presence of a sinus tract between tooth #21 and #22. The coronal aspect of the mesio-radicular groove is visible on the mesial aspect of tooth #22 (a). Radiographic assessment showed the presence of a root filling approximately 3 mm short of the radiographic apex, and large radiolucent area extending apically on the mesial aspect (b). Postretreatment radiograph (c). Presence of an accessory root on mesial aspect of tooth #22 with a deep bony defect with approximately 9 mm pocket (d). Removal of overlying bone revealing the whole length of the accessory root and mesio-radicular groove palatal to it (e). Amputation of the accessory root followed by debridement of the root surface (f). Radiographic assessment revealed a reduction of the radiolucency on the mesial aspect of the root (g)

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Stage 1: Nonsurgical stage – Root canal retreatment

Under local anesthesia and dental dam isolation, the access cavity was made and the gutta-percha was completely removed using hand files and solvent (Chloroform, Sultan Healthcare, Edgewood, New Jersey, USA). The working length was determined, and the canal was prepared in a crown-down manner using hand ProTaper files (ProTaper®, Dentsply Maillefer, Germany). Exploration of the pulp chamber under magnification (Global Surgical, St. Louis, MO, USA) failed to locate the canal orifice of the accessory root. The canal was irrigated with 2.5% sodium hypochlorite, dried with paper points, and calcium hydroxide medicament (CALASEPT® Plus, Directa AB, Upplands Väsby, Sweden) was placed. Canal was sealed with temporary restoration Cavit® (3M ESPE, Seefeld, Germany). One week later, the canal was disinfected with 5% sodium hypochlorite, dried with paper points, and obturated by cold lateral condensation using gutta-percha cone and Sealapex sealer (Kerr, Romulus MI). The tooth was double sealed with glass ionomer cement (Fuji II, GC) internally and coronally with composite resin restoration (3M ESPE, St. Paul, MN, USA). A posttreatment radiograph was taken to ensure canal was completely obturated to the working length [Figure 1]c.

Stage 2: Surgical stage – Root amputation and debridement of the radicular groove

Surgical intervention was carried out 1 month after the completion of root canal treatment. Under local anesthesia, a full mucoperiosteal flap utilizing intrasulcular incisions was raised. Upon exposure of the surgical site, an osseous fenestration was evident on the facial surface approximately 5 mm above the interproximal bone crest between tooth 21 and 22 [Figure 1]d. After debridement of the granulation tissues, it was apparent that the intrabony defect was rather extensive which affect almost half of the mesial surface of the root and the tip of the accessory root was clearly visible [Figure 1]e. A deep radicular groove was noticed on the mid-mesial aspect of the main root but was partly obscured by the accessory root. This mesio-radicular groove coincides with the deep periodontal pocket and vertical radiolucent line seen on the radiograph.

The overlying bone covering the coronal aspect of the root was removed to ease the amputation of the accessory root and the accessory root was amputated and the granulation tissue was thoroughly curetted, followed by thorough debridement of the bony defect and meticulous root planning of the main root [Figure 1]f. No filling was placed in the amputated root area as there was no canal orifice located clinically after examination under dental microscope. The bony defect was filled with natural bone substitute (Bio-Oss, Geistlich Pharma AG, Switzerland). Primary closure of the wound was secured using a 4–0 silk suture, and hemostasis was obtained. Examination at 12-month follow-up revealed a 4 mm periodontal pocket on the mesial aspect of tooth 22, a completely healed sinus, and the patient was satisfied with the outcome of the treatment. Review radiograph revealed increasing radiodensity of surrounding bone on the mesial aspect of the root of tooth 22 demonstrating regeneration of the osseous tissue [Figure 1]g.

  Discussion Top

Establishing an accurate diagnosis is very critical to the success of the treatment as it will influence the management and prognosis of the case. Failure to correctly diagnose a disease may result in treatment complication, procedural error, the persistence of infection, and ultimately, failure of treatment. Therefore, comprehensive clinical and radiographic examination is necessary to ensure all aspects of the potential contributing and complicating factors were identified, and correct diagnosis can be made. In this case, the inability of the clinician to recognize: (i) the contributing factor, i.e., the presence of mesio-radicular groove and (ii) the complicating factor, i.e., the accessory root has resulted in incorrect diagnosis and management of the case. Consequently, it resulted in unfavorable treatment outcome as the source of infection was not eradicated.

Preoperative assessment involves two important procedures which are a clinical examination and radiographic interpretation. During the clinical examination stage, systematic and careful examination of the tooth and its surrounding structure is important to identify any landmarks or clue to potential contributing or complicating factors such as the presence of deep grooves, crown or root fracture, or unusual tooth structure.[5] In the present case, the existence of deep mesio-radicular groove was visible clinically and can be felt with a sharp probe. The use of magnification such as dental operating microscope allows the clinician to better assess and visualize the area of interest. In addition, meticulous tactile examination with a sharp probe enables the clinician to feel the presence of any irregularities on the crown or root surface. When there is a presence of deep pocket around the tooth, a sharp probe is used to feel the root surface for irregularity or defect that may be present.

In addition, a preoperative intraoral radiograph is essential to facilitate the assessment of the root and its surrounding structure. Clinicians must be very attentive, especially in treating a tooth with an established potential of having an anatomical aberration. A good quality preoperative radiograph and thorough assessment of this radiograph are important to avoid overlooking the existence of root and canal aberration that may be present. Whenever the dentist is in doubt, he/she should take another periapical radiograph at a different angulation to confirm the existence of canal aberration or root fracture. It was shown that taking several radiographs at a different angle increases the ability of the clinician to make a correct diagnosis.[11] With the advent of dental three-dimensional imaging, it provides superior accuracy and the clinician able to perform a better assessment of the root and canal anatomy. Therefore, the clinicians should consider taking additional diagnostic radiographs using three-dimensional imaging technique such as cone-beam computed tomography (CBCT) or spiral CT to confirm their finding.[7] In the presented case, the presence of additional root was clearly visible on the diagnostic periapical radiograph; unfortunately, it was missed during the previous diagnostic phase, thus resulted in the persistent infection of the tooth. Hence, we feel that it does not justify the taking of the CBCT scan. The clinician should assess the size, shape, extent, and location of the radiolucent lesion. A radiolucent periapical lesion is always associated with the radiographic apex of the affected tooth and has a round shape. However, in certain cases, the lesion may extend to the lateral side of the root which may indicate the presence of lateral canal, root fracture, or periodontal disease. In this case, the initial radiograph revealed a more radiopaque image on the mesial aspect of the root surface of tooth 22 surrounded by the radiolucent lesion.

The radicular groove is one of the commonly reported developmental anomalies associated with maxillary lateral incisors.[3],[7],[10],[12],[13],[14] In this case, clinical examination revealed the presence of a deep groove on the mesial aspect of the tooth that was clearly visible and was associated with deep periodontal pocket. However, the presence of an accessory root complicates the treatment as it hinders adequate nonsurgical debridement of the groove and hence necessitates the surgical intervention to be carried out. The membrane was considered initially, which primarily to prevent apical migration of epithelium and second to prevent displacement of the bone graft granules. However, due to the defect was small, that bone graft granules contained within the defect and the soft-tissue flap was quite thick; thus, no concern on tissue perforation and therefore membrane was not placed. It is ascertained that, by adding the membrane, patient would probably be benefitted from the primary outcome, i.e., improvement in clinical attachment level, yet it probably not cost-effective in certain cases.[15] The use of Emdogain®, in this case, would offer better clinical outcomes[16] yet not considered due to religious issue.

The presence of accessory root in maxillary lateral incisor has been reported previously, but its occurrence is rare with limited endodontic cases have been reported.[2],[3],[10],[14],[17],[18] A study using microcomputed tomographic analysis of extracted maxillary lateral incisors with radicular groove showed that a Type III groove with deep invagination may divide the root, forming an accessory root.[7] When the presence of accessory root is confirmed, the clinician must explore the internal aspect of the pulp chamber using the dental operating microscope to locate the canal orifice. The access cavity may need to be widened laterally toward the additional canal.[17],[19] Failure to locate and clean this canal will result in treatment failure as infection may persist as bacteria remains in the canal. In this case, exploration of the internal pulp chamber area under the dental operating microscope had failed to locate the orifice of the accessory canal. The inability to locate the accessory canal may be confounded by two factors, i.e., (a) the canal does not exist or (b) the canal orifice has been obliterated by the restorative material used to seal the access cavity. In cases of teeth with aberrant anatomy whereby the objectives cannot be achieved, surgical intervention or extraction of the affected tooth is often necessary.[2],[18],[20]

  Conclusion Top

This case showed that thorough clinical examination and meticulous assessment of the diagnostic preoperative periapical radiograph are important in ensuring the correct diagnosis is made and hence adequate management of a tooth with developmental anomalies is provided. The ability to recognize the presence of developmental anomaly earlier will ensure treatment success.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

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