Home Print this page Email this page Users Online: 720
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 262-265

Nonsurgical re-treatment of a twin-rooted maxillary lateral incisor


Department of Conservative Dentistry and Endodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India

Date of Submission24-Apr-2020
Date of Decision11-May-2020
Date of Acceptance25-Jun-2020
Date of Web Publication8-May-2021

Correspondence Address:
Dr. Raju Chauhan
Department of Conservative Dentistry and Endodontics, Saraswati Dental College, Tiwariganj, Faizabad Road, Lucknow, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_92_20

Rights and Permissions
  Abstract 

An accurate diagnosis of the anatomy of the root canal system is a prerequisite for successful endodontic treatment. Morphological variations or additional roots/root canal should always be expected. These variations should be strongly considered before starting any endodontic treatment using various diagnostic aids for better outcome therapy. Nonsurgical endodontic re-treatment of a painful twin-rooted maxillary lateral incisor tooth of a 40-year-old female was carried out due to improper diagnosis of the extra root. The clinical examination and radiographic analysis confirmed the diagnosis of previously treated/necrotic pulp and symptomatic apical periodontitis. The patient remained asymptomatic at 6-month follow-up both clinically and radiographically. The case report emphasized on the need for clinicians to be extra careful while treating such teeth and use of cone-beam computed tomography for their diagnosis and management.

Keywords: Cone-beam computed tomography, extraroot, maxillary incisors, morphological variations, nonsurgical retreatment


How to cite this article:
Agarwal K, Samant PS, Chauhan R, Shreya. Nonsurgical re-treatment of a twin-rooted maxillary lateral incisor. Saudi Endod J 2021;11:262-5

How to cite this URL:
Agarwal K, Samant PS, Chauhan R, Shreya. Nonsurgical re-treatment of a twin-rooted maxillary lateral incisor. Saudi Endod J [serial online] 2021 [cited 2021 Jun 17];11:262-5. Available from: https://www.saudiendodj.com/text.asp?2021/11/2/262/315657


  Introduction Top


Thorough mechanical and chemical cleansing of the entire pulp cavity and its complete obturation is considered the main objective of the endodontic therapy.[1],[2] A tooth having canal with graceful tapering and a single apical foramen is more of an exception rather than a rule. Investigators have shown the presence of multiple foramina, deltas, accessory canals, etc., in most of the teeth.[3],[4] Maxillary lateral incisors have a high incidence of pulpal anatomical variations, most common of which are the palatogingival groove,[5] dens invaginatus,[6],[7],[8],[9] dens evaginatus,[6] fusion,[10] and gemination.[11],[12]

It is important for the clinicians to consider possible anatomical variations in the number of root canals and/or roots because any failure to recognize the actual root canal configuration may result in failed treatment.[12] Maxillary incisor teeth have been reported to have a single root in almost 100% of the cases,[13] but it can have two canals,[5],[14],[15] three canals,[7] four canals[8] and even five canals.[9] This case reports the successful endodontic re-treatment of twin-rooted maxillary lateral incisor which was diagnosed with conventional radiography and cone-beam computed tomography (CBCT).


  Case Report Top


A 40-year-old healthy female patient reported with the chief complaint of pain in the right maxillary lateral incisor (#12) for 20 days. The pain was intermittent and dull in nature initially but increased in severity from the past 1 week. Dental history revealed root canal treatment done by a private practitioner 2 years back. Intraoral examination showed that #12 was discolored [Figure 1]a and painful to percussion. The periodontal examination (CP 12 periodontal probe, Hu-Friedy, Chicago, IL, USA) showed the presence of a periodontal pocket with a probing depth of 4 mm. Pulp vitality test revealed nonvitality #12.
Figure 1: (a) Preoperative picture showing discolored tooth #12, (b) Preoperative radiograph showing an adequate root canal treatment #12 and presence of two separate roots, mesial and distal, (c) Isolation of tooth #12 under rubber dam, (d) Removal of old obturation material from the distal root

Click here to view


Radiographic examination of #12 depicted unusual morphology with two separate roots, i.e., mesial and distal. The radiograph also revealed poorly obturated mesial root and a missed distal root, both associated with periapical radiolucency [Figure 1]b. The final diagnosis was made on the basis of both clinical and radiographic examinations. The involved tooth had previously treated/necrotic pulp and symptomatic apical periodontitis.

After final discussion with the patient, informed consent was obtained for nonsurgical endodontic therapy. After administration of 2 ml local anesthesia with 2% lignocaine and 1:100000 epinephrine (Xicaine, ICPA Health Products Ltd, Gujarat, India), the tooth was isolated using rubber dam (Hygienic, Coltène Whaledent Inc., Cuyahoga Falls, USA) [Figure 1]c. Restorative material was removed from the access cavity, followed by the removal of previous root filling using Protaper retreatment files (Dentsply, Maillefer, Ballaigues, Switzerland) [Figure 1]d. However, the orifice of the accessory root canal was not negotiated. The patient was advised to have CBCT scan for better visualization of morphological variation and access the location of the orifice.

During the second appointment, the patient reported with CBCT scan which revealed an untreated root which was placed mesiopalatally, fused to the main root at the cervical level [Figure 2]a and [Figure 2]b. The accessory root canal was negotiated with sharp endodontic explorer (DG 16, Hu-Friedy, Chicago, IL, USA) under magnification using dental loupes 3.0x (Zumax Medical, Suzhou, China). The working length was determined by electronic apex locator (Root ZX, J Morita, Tokyo, Japan) and verified radiographically [Figure 2]c. Canal preparation was done with hand k-files (Dentsply, Maillefer, Ballaigues, Switzerland) and protaper rotary Ni-Ti instruments (Dentsply, Maillefer, Ballaigeus, Switzerland) along with copious irrigation using 5.25% sodium hypochlorite. An intracanal medicament of calcium hydroxide paste (Iodotin, TehnoDent, Belgorod, Severny, Russia) was placed up to the working length [Figure 2]d. The tooth was sealed with the temporary restoration (Cavit, 3M ESPE, Seefeld, Germany), and the patient was recalled after 2 weeks.
Figure 2: (a) Cone-beam computed tomography sagittal view showing two distinct roots (arrows) in tooth #12, the extra root is located somewhat mesiopalatally, (b) cone-beam computed tomography axial view showing approximate root length of the main root and accessory root of tooth #12, (c) Working length radiograph, (d) Radiograph showing intracanal calcium hydroxide dressing

Click here to view


In the recall appointment, the patient was found to be asymptomatic; the tooth appeared in normal condition with no tenderness to percussion. Temporary restoration was removed, and canals were cleaned. An apical mineral trioxide aggregate (MTA ProRoot, Dentsply, Tulsa, Switzerland) plug was placed in both canals, followed by placement of moisted cotton and temporary restoration (Cavit, 3M ESPE, Seefeld, Germany). Next day, after the removal of temporary filling and cotton pellet, root canals were obturated with gutta percha (Meta Biomed Co., Chungcheongbuk-do, Korea) and AH Plus sealer (Dentsply, Maillefer, Ballaigues, Switzerland) using cold lateral compaction technique. The tooth was sealed with composite restoration (Charisma, Heraeus Kulzer, GmbH, Hanan, Germany), and a postoperative radiograph was taken [Figure 3]a.
Figure 3: (a) Radiograph taken immediately after obturation of both roots in tooth #12, (b) 6-month follow-up radiograph showing resolution of periapical radiolucency in tooth #12, (c) radiograph taken after fiber post and core done in tooth #12, (d) postoperative picture after placement of PFM crown

Click here to view


The 6-month follow-up examination of the patient revealed no clinical abnormalities, and the tooth was completely asymptomatic with no tenderness. Satisfactory healing was appreciated radiographically with the resolution of periapical lesion and moderate bone formation [Figure 3]b. During this visit, fiber post cementation (Para Post, Coltène Whaledent Inc., Cuyahoga Falls, USA) and core buildup was done using dual-cure composite (Grandio Core, Voco, Cuxhaven GmbH, Germany) [Figure 3]c, followed by placement of full-coverage porcelain fused to metal. (PFM) crown [Figure 3]d.


  Discussion Top


Thorough debridement of the canals and the hermetic seal is the key for the success of any endodontic treatment. Additional missed root canals that are not cleaned or incomplete root canal therapy might provide a nidus for bacterial growth, persistent irritation, compromising the long-term success, and lead to root canal treatment failure.[16],[17] When there is the presence of two roots or two root canals in a maxillary incisor, it is important to consider conditions such as fusion,[10] gemination,[11],[12] dens in dente,[6],[7],[8],[9] and palatogingival or distolingual groove.[5] In this case, clinical examination as well as the pretreatment radiographs revealed a crown of normal size and shape when compared with the contralateral side with no evidence of enamel or dentinal invagination and palatogingival or distolingual groove. Although it is very rare to have more than one root in maxillary incisors, the presence of two separate root canals is also reported by Vertucci in 2% of the maxillary incisors.[18] In the present case report, endodontic treatment failure occurred because of a lack of knowledge of the two roots as mostly maxillary lateral incisor is associated with a single root. Due to an unknown etiology behind this variation, a disturbance in the development of Hertwig's epithelial root sheath and consequent formation of a horizontal flap is considered.[19] The various diagnostic aids in the location of root canal orifices include obtaining multiple preoperative radiographs, an examination of the pulp chamber floor using sharp endodontic explorer, performing champagne bubble test, visualization of bleeding points, and troughing grooves with ultrasonic tips.[20] As an additional diagnostic tool, CBCT can be used in cases with complex root canal anatomy. This advanced radiographic technique is very helpful to explore the internal and external morphological variations.

In the present case, CBCT was used to know the exact location of the root canal orifice of the extra root in order to avoid excessive cutting of tooth structure, as the tooth was already compromised due to previous endodontic treatment. Three-dimensional imaging techniques such as CBCT can be useful in diagnosing teeth with unusual root canal morphology.[15] The missed canal was negotiated carefully using the information of CBCT scan and the magnification. The extra root canal orifice was located by extending the access cavity slightly toward mesiopalatal direction. Intracanal calcium hydroxide dressing was given for 2 weeks because of its known bactericidal effects, its ability to create favorable condition for periapical repair, and stimulate hard-tissue formation.[21] MTA plug was created to get perfect apical seal as some amount of apical root resorption was evident in the preoperative radiograph. MTA provides an excellent apical seal as it expands on setting, also it has a potential for tissue regeneration and mineralization.[22] The tooth was later restored using fiber postcore and crown as it was having compromised crown structure.


  Conclusion Top


This case report explains the importance of preoperative assessment of the number of roots and canal configuration with different angulated radiographic and needs of CBCT in special circumstances. All of these are considered to be the prerequisite for successful endodontic treatment.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
European Society of Endodontology. Quality guidelines for endodontic treatment: Consensus Report of the European Society of Endodontology. Int Endodontic J 2006;39:921-30.  Back to cited text no. 1
    
2.
American Association of Endodontists. Treatment standards; 2018. Available from: https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/04/TreatmentStandards_Whitepaper.pdf. [Last accessed on 2020 Jun 20].  Back to cited text no. 2
    
3.
Makade CS, Shenoi PR, Gunwal M. Maxillary lateral incisor with two roots and two canals: A case report. Indian J Dent 2014;5:45-7.  Back to cited text no. 3
    
4.
Dexton AJ, Arundas D, Rameshkumar M, Shoba K. Retreatodontics in maxillary lateral incisor with supernumerary root. J Conserv Dent 2011;14:322-4.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Hasan A, Ali Khan J. Combined endodontic and surgical management of twin rooted maxillary lateral incisor with a palatogingival groove. Iran Endod J 2018;13:413-9.  Back to cited text no. 5
    
6.
Mupparapu M, Singer SR, Goodchild JH. Dens evaginatus and dens invaginatus in a maxillary lateral incisor: Report of a rare occurrence and review of literature. Aust Dent J 2004;49:201-3.  Back to cited text no. 6
    
7.
Jung M. Endodontic treatment of dens invaginatus type III with three root canals and open apical foramen. Int Endod J 2004;37:205-13.  Back to cited text no. 7
    
8.
Nosrat A, Schneider SC. Endodontic management of a maxillary lateral incisor with 4 root canals and a dens invaginatus tract. J Endod 2015;41:1167-71.  Back to cited text no. 8
    
9.
Jaikailash S, Kavitha M, Ranjani MS, Saravanan B. Five root canals in peg lateral incisor with dens invaginatus: A case report with new nomenclature for the five canals. J Conserv Dent 2014;17:379-81.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Yagci A, Cantekin K, Buyuk SK, Pala K. The multidisciplinary management of fused maxillary lateral incisor with a supernumerary tooth in cleft lip adolescence. Case Rep Dent 2014;2014:459416. DOI: 10.1155/2014/459416.  Back to cited text no. 10
    
11.
Yücel AC, Güler E. Nonsurgical endodontic retreatment of geminated teeth: A case report. J Endod 2006;32:1214-6.  Back to cited text no. 11
    
12.
Wong M. Treatment considerations in a geminated maxillary lateral incisor. J Endod 1991;17:179-81.  Back to cited text no. 12
    
13.
Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101-10.  Back to cited text no. 13
    
14.
Yadav SS, Shah N. Nonsurgical endodontic management of a two-rooted maxillary lateral incisor. Saudi Endod J 2016;6:40-2.  Back to cited text no. 14
  [Full text]  
15.
Elbay M, Kaya E, Elbay ÜŞ, Sarıdağ S, Sinanoğlu A. Management of two-rooted maxillary central and lateral incisors: A case report with a multidisciplinary approach involving CAD/CAM and CBCT technology. J Pediatr Dent 2016;4:51-4.  Back to cited text no. 15
  [Full text]  
16.
Peikoff MD, Perry JB, Chapnick LA. Endodontic failure attributable to a complex radicular lingual groove. J Endod 1985;11:573-7.  Back to cited text no. 16
    
17.
Al-Madi E. Maxillary central incisor with two roots: A case report. Saudi Endod J 2020;10:162-164.  Back to cited text no. 17
  [Full text]  
18.
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99.  Back to cited text no. 18
    
19.
Khojastehpour L, Khayat A. Maxillary central incisor with two roots: A case report. J Dent (Tehran) 2005;2:74-7.  Back to cited text no. 19
    
20.
Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics 2005;10:3-29.  Back to cited text no. 20
    
21.
Fernandes M, Ataide ID. Non-surgical management of periapical lesions. J Conserv Dent 2010;13:240-5.  Back to cited text no. 21
[PUBMED]  [Full text]  
22.
Torabinejad M, Parirokh M. Mineral trioxide aggregate: A comprehensive literature review-part II: Leakage and biocompatibility investigations. J Endod 2010;36:190-202.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed130    
    Printed0    
    Emailed0    
    PDF Downloaded36    
    Comments [Add]    

Recommend this journal