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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 322-324
Retreatodontics in maxillary lateral incisor with supernumerary root


Department of Conservative Dentistry and Endodontics, Government Dental College, Calicut, Kerala, India

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Date of Submission06-Dec-2010
Date of Decision20-Jan-2011
Date of Acceptance07-May-2011
Date of Web Publication10-Oct-2011
 

   Abstract 

Familiarity with the intricacies and variations of root canal morphology is essential for successful endodontic treatment. Maxillary central and lateral incisors are known to be single rooted with one canal. This case report describes endodontic retreatment of maxillary lateral incisors with two root canals, one of which was missed during the initial treatment.

Keywords: Endodontic retreatment; extra canals; maxillary lateral incisor; supernumerary root

How to cite this article:
Dexton AJ, Arundas D, Rameshkumar M, Shoba K. Retreatodontics in maxillary lateral incisor with supernumerary root. J Conserv Dent 2011;14:322-4

How to cite this URL:
Dexton AJ, Arundas D, Rameshkumar M, Shoba K. Retreatodontics in maxillary lateral incisor with supernumerary root. J Conserv Dent [serial online] 2011 [cited 2014 Jul 24];14:322-4. Available from: http://www.jcd.org.in/text.asp?2011/14/3/322/85827

   Introduction Top


Endodontic cavity preparations deal with both coronal and radicular cohorts that flow together into a single preparation. A root with gracefully tapering canal and a single apical foramen is more of an exception rather than a rule. Investigators have shown multiple foramina, deltas, accessory canals etc. in most of the teeth. Successful endodontic treatment depends upon the thorough knowledge of internal anatomy of pulp space and its variations. The practitioner should always be aware of the possible anatomical variations in the root canals of the teeth and try to correctly judge their location, length and relationship to one another.

The pulp chamber of maxillary lateral incisor is wider mesio distally than buccolingually. Cross section at the Cemento enamel junction (CEJ) shows a pulp chamber centred in the root; and its shape may be triangular, oval, or round. From the CEJ, the pulp canal usually becomes round in cross section in the midroot and apical areas. The lingual shoulder of dentin must be removed before instruments are used to explore the canals. Many anatomical studies have declared that maxillary incisors are always comprised of a single root, while case reports have been documented suggesting lateral incisor with two [1] and three root canals. [2] The term "supernumerary root" is used in describing the development of increased number of roots on a tooth compared with the classical description in dental anatomy. [3] The external access outline form for the maxillary lateral incisor may be rounded, triangle or an oval in shape.

This case reports a successful endodontic retreatment of maxillary lateral incisor with two roots and two root canals. The accessory root canal was not recognized in the initial endodontic treatment and hence failure of the treatment occurred. After an endodontic treatment, the case was reviewed at every six months interval for a period of two years.


   Case Report Top


A 25 year old male was referred to Department of Endodontics with a history of mild pain and swelling in the upper right lateral incisor of 10 days duration [Figure 1]. Dental history revealed root canal treatment done from a private clinic 7 months ago. Medical and family history was non contributory. Clinical examination showed normal number, size and colour of all teeth. A swelling in the palatal aspect of right lateral incisor was observed, but there was no fistulous tract. A temporary restorative material was seen in the palatal aspect of the lateral incisor. Radiographic examination revealed a poorly condensed overextended root canal filling, and an accessory root and canal which was not obturated. An occlusal radiograph and a second intra oral periapical radiograph with altered (mesial tube shift) horizontal angulations revealed an additional palatal root (same-lingual, opposite-buccal: SLOB rule) [Figure 2] and [Figure 3].
Figure 1: Preoperative photograph of the patient showing a swelling in the upper right lateral incisor region

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Figure 2: An occlusal radiograph taken preoperatively, showing the presence of an an accessory root canal in the upper right lateral incisor, which was not obturated

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Figure 3: Preoperative intra oral periapical radiograph with SLOB rule helps separate the two roots

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In view of the clinical symptoms, periapical pathology and faulty obturation, a non-surgical endodontic retreatment was planned to locate, debribe and obturate the missing root. The tooth was isolated with optra dam (Ivoclar Vivadent) [Figure 4], and the temporary restoration was removed with high-speed round diamond burs No. 1015 (KG-Sorensen, Barveri, SP). The overextended gutta percha was removed by chloroform and alternatively by Hedstrom (H) and K-file (Densply-Maillefer, Ballaigues, Switzerland). Careful exploration of root canals with DG 16 probe revealed two canals one mesial and distal. Both the canals were negotiated, patency was checked and working length was determined by electronic apex locator Root ZX (J.Morita MFG. Corporation, kyoto, Japan) and by files in radiograph [Figure 5]. Protaper files (Densply-Maillefer, Ballaigues, Switzerland) with alternate irrigation with 2.5% sodium hypochlorite and saline were used to clean and shape the canal. The temporary restoration was removed, and root canals were irrigated and dried with paper points. The obturation of the root canals was performed using lateral compaction technique with AH plus as the sealer. The access cavity was then restored with composites [Figure 6] and [Figure 7].
Figure 4: Optra dam isolation with temporary restorative material seen in the palatal aspect of the lateral incisor

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Figure 5: Determination of working length by two 15 size k files placed in the mesial and distal root canals of upper right lateral incisor

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Figure 6: Master cone radiograph prior to obturation to determine if the correct working length has been reached and avoid over or under extensions in the root canals of the upper right lateral incisor

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Figure 7: Radiograph showing a two year follow up obturation of the root canals of the upper right lateral incisor

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   Discussion Top


The success of endodontic treatment depends on thorough debridement and hermetic seal of obturation material. Additional root canals or other parts of an infected root canal system that are not cleaned and obturated might provide a source of persistent irritation, compromising the long term success of the root canal therapy. Although the aetiology of the anomaly is unknown, an in growth of tissue from Hertwig's epithelial root sheath (HERS) has been claimed as a possible cause. [4] It is presumed that at the time of root formation the surface of the root or the forming periodontium (HERS) suffered some traumatic injury, and, as a result of that, a radicular shaped accessory formation developed. Presence of supernumerary root has a genetic penetrance. [3]

Diagnostic measures are important aids in the location of root canal orifices. These measures include obtaining multiple preoperative radiographs, examination of the pulp chamber floor with a sharp explorer, troughing grooves with ultrasonic tips, staining the chamber with dye, performing champagne bubble test and visualisation of bleeding points. [5] Careful examination of preoperative radiographs can aid in locating additional canals or roots. This might necessitate taking radiographs from different angulations. In cases with complex root canal anatomy, cone beam or spiral computed tomography can be used as an additional diagnostic tool. [6] Tracing the outline of the root surface cautiously can also help in the diagnosis. Locating the number and position of orifices on pulp-chamber floors can be difficult. This is especially true when the tooth being treated is heavily restored, malposed, or calcified. CEJ is an important landmark for locating pulp chamber and orifices. [7] Palpation of the attached gingival aids to determine the root location and direction. Considering the fact that so much of aberrations exist in these teeth, it becomes mandatory that when a patient comes with persistent pain or sensitivity to hot and cold after root canal treatment, the clinician must suspect the presence of missed canals. Judicious use of high-end diagnostic aids should also be considered in such complex situations. [6]

An endodontic microscope may be useful to locate the additional canal orifices. The experience from the present case demonstrates the variability of root canal morphology of maxillary lateral incisor. The clinician should be careful that even the most routine of cases might deviate from the usual.


   Conclusions Top


In conclusion, the clinician should be careful about the possible anatomical variations in the root canal configuration. The importance of careful preoperative evaluation with different diagnostic resources available cannot be overemphasized. The entire volume of the root canal space including accessory root canal and foramina should be filled so that a hermetic apical seal is obtained. Thus, this case report demonstrated the importance of a correct diagnosis for the endodontic practice. Finally, it is also important that the endodontic treatment be reviewed periodically to ensure continuous healing without complication.

 
   References Top

1.Pecora JD, Santana SV. Maxillary lateral incisor with two roots-case report. Braz Dent J 1992;2:151-3.  Back to cited text no. 1
[PUBMED]    
2.Walvekar SV, Behbehani JM. Three root canals and dens formation in a maxillary lateral incisor: A case report. J Endod 1997;23:185-6.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2 nd ed. Philadelphia: W.B. Saunders; 2002. p. 88.  Back to cited text no. 3
    
4.Kelly JR. Birooted primary canines. Oral Surg Oral Med Oral Pathol 1978;46:872.  Back to cited text no. 4
[PUBMED]    
5.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. 5
    
6.Sachdeva GS, Ballal S, Gopikrishna V, Kandaswamy D. Endodontic management of a mandibular second premolar with four roots and four root canals with the aid of spiral computed tomography: A case report. J Endod 2008; 34:104-7.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor. J Endod 2004; 30:5-16.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Antony Johns Dexton
Department of Conservative Dentistry and Endodontics, Government Dental College, Calicut, Kerala 673008
India
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DOI: 10.4103/0972-0707.85827

PMID: 22025843

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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