|Year : 2018 | Volume
| Issue : 2 | Page : 68-71
Nonsurgical endodontic retreatment of a two-rooted maxillary lateral incisor
Cangül Keskin1, Özgür Özdemir2
1 Department of Endodontics, Faculty of Dentistry, Ondokuz Mayis University, Samsun, Turkey
2 Miadent Oral Health Center, Ankara, Turkey
|Date of Web Publication||30-May-2018|
Department of Endodontics, Faculty of Dentistry, Ondokuz Mayis University, Samsun
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Maxillary incisor teeth have been known to have single root with a single root canal widely. The reports of anatomical variations regarding the root number of maxillary anterior teeth are limited. This case report describes the nonsurgical endodontic retreatment of a rare case of two-rooted maxillary lateral incisor tooth, emphasizing the importance of three-dimensional imaging techniques for the diagnosis of anatomical variations. A 32-year-old patient was referred for the endodontic evaluation of his tooth #22 because of failed root canal treatment. Cone-beam computed tomography revealed a palatally located extra root. Nonsurgical endodontic retreatment was performed. At the 4th month follow-up, the tooth was asymptomatic and functional.
Keywords: Anatomic variation, cone-beam computed tomography, imaging
|How to cite this article:|
Keskin C, Özdemir &. Nonsurgical endodontic retreatment of a two-rooted maxillary lateral incisor. J Interdiscip Dentistry 2018;8:68-71
| Clinical Relevance to Interdisciplinary Dentistry|| |
- Integration of oral radiology and endodontics ensured the correct diagnosis and identified reason to failure in this case report
- Usage of three-dimensional oral radiology tools leads to a better understanding of root canal configuration.
| Introduction|| |
Success of endodontic treatment depends on complete cleaning, shaping, and obturation of root canal system. Clinicians should consider possible anatomical variations in the number of root canals and/or roots, because any failure to recognize the actual root canal configuration and locate extra root canals may lead to treatment failure.
Maxillary incisor teeth have been reported to have a single root in 100% of the cases. However, there are case reports that presented maxillary lateral incisors with two roots and/or two separate root canals in the literature., Other reported anatomical variations related with maxillary lateral incisor are fusion, gemination, and dens invaginatus.,,
This case report aims to present successful nonsurgical endodontic retreatment of a maxillary lateral incisor tooth with two roots and asymptomatic apical periodontitis using diagnostic cone-beam computed tomography (CBCT).
| Case Report|| |
A 34-year-old male patient with no contributory disease was referred to the Endodontic Department with the diagnosis of failed root canal treatment of his left maxillary incisors [Figure 1]. A written consent form was obtained from the patient prior to examination. There was no history of trauma related to the maxillary region. The patient reported a history of swelling of the left side of his upper lip since the completion of previous root canal treatment of teeth #21 and 22. No swelling or abnormal findings were found during extraoral examination. Intraoral examination also showed no soft-tissue pathology. The tooth #21 was not tender to percussion whereas tooth #22 was painful to percussion and palpation. Both teeth had Miller Grade 2 mobility and periodontal pocket depths within 1–3 mm. Periodontal probing of the tooth #22 revealed a long oval-shaped root anatomy instead of a circular anatomy, which was a suggestion of a possible anatomical variation.
Examination of digital periapical radiographs revealed heterogeneous root canal filling of #22 and periapical radiolucency [Figure 2]. The root canal filling image was not at the center of the root, which also suggested the possibility of an extra root. To visualize the root canal anatomy, CBCT scan was planned. After written consent from the patient was obtained, CBCT examination confirmed the presence of an extra palatally located missed root [Figure 3]a and [Figure 3]b. The tooth was diagnosed to have asymptomatic apical periodontitis, and nonsurgical endodontic retreatment of #22 was planned.
|Figure 3: (a) Cone-beam computed tomography examination; transversal (b) cone-beam computed tomography examination; sagittal|
Click here to view
Following the administration of 4% articaine with epinephrine 1/100,000 local anesthetic and isolation with a rubber dam, previous restoration was removed and endodontic access cavity was modified to access the extra root canal. Coronal root canal filling was mechanically removed using H-files (Dentsply Maillefer, Switzerland). Any remnants of root canal filling were removed by flushing with sterile saline solution. Entire content of the root canal was removed and confirmed radiographically. The second root canal was introduced with inspection through loupe (×4). The working lengths were determined using an electronic apex locator (Raypex 5, VDW, Munich, Germany) and confirmed with periapical digital radiographs [Figure 4]. The canals were chemomechanically prepared with ProTaper Next (Dentsply, Maillefer, Switzerland) rotary system files with size X1-X5 to a master apical file with size 50 in conjunction with 5.25% NaOCl irrigation. The root canals were dried with sterile paper points and dressed with calcium hydroxide paste, and the access cavity was restored with temporary restorative material. One week later, the tooth was asymptomatic. After isolation with a rubber dam, the restorative material and cotton pellet were removed. EndoActivator (Dentsply, Tulsa Dental Specialties, Tulsa, OK, USA) and 5.25% NaOCl irrigation were used to remove the calcium hydroxide paste. The root canals were irrigated with 5.25% NaOCl, distilled water, and 17% ethylenediaminetetraacetic acid solutions, and then, sterile paper points were used to dry the root canals. The root canals were obturated with gutta-percha and AHPlus (Dentsply Detrey, Konstanz, Germany) using the cold lateral compaction technique [Figure 5]. The tooth was then restored with composite resin (Charisma; Heraeus Kulzer, Hanau, Germany) permanently. Postoperative periapical radiographs were carried out to evaluate the obturation.
Follow-up examinations revealed no pathology [Figure 6], and all clinical findings were consistent with treatment success after 4 months.
| Discussion|| |
The aim of endodontic treatment is to eliminate infections from the root canal system and prevent its reinfection. Untreated root canal spaces act as a nidus for bacterial growth and lead to root canal treatment failure. Treatment success requires the identification of all root canals to disinfect and obturate whole root canal system. Therefore, clinicians must have adequate knowledge about the possible root canal configuration anomalies. In the present case report, the patient was referred with a failed root canal treatment due to a clinical error of a missed extra canal and inadequate root filling of the main root canal.
The presence of more than one root in maxillary incisor teeth is a rare finding. Vertucci reported that just 2% of maxillary incisor teeth have two separate root canals. De Deus also reported that 3% of maxillary lateral incisors might have two separate root canals. Case reports described the presence of more than two root canals related with tooth anomalies, such as fusion, gemination, or dens invaginatus.,,,, In the present case report, there was no anomaly regarding the crown appearance. A previous study stated that 9%–10% of maxillary lateral incisors show more than one root canal in the Turkish population. Another study examined 1400 teeth in Turkish population and reported the presence of more than one root canal in 22% of maxillary lateral teeth.
In the present case report, uncommon root canal configuration of maxillary lateral incisor was detected preoperatively with the aid of CBCT. Radiographic examination is essential in many aspects of endodontic treatment. However, the amount of information gained from conventional periapical radiographs is limited in the case of superimposition and geometric distortion of anatomical structures. CBCT is widely used in dentistry to overcome the limitations of conventional two-dimensional imaging techniques by resulting in better understanding of root canal configuration. In light of the data obtained from CBCT scans, nonsurgical root canal treatment was performed.
| Conclusion|| |
The present case demonstrates the variability of root canal configuration of maxillary lateral incisor and emphasizes the importance of three-dimensional imaging tools in the diagnosis of such variations. Utilizing proper diagnostic tools will lead to a more conservative treatment plan and predictable results.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saleh IM, Ruyter IE, Haapasalo M, Ørstavik D. Survival of Enterococcus faecalis
in infected dentinal tubules after root canal filling with different root canal sealers in vitro
. Int Endod J 2004;37:193-8.
Wong M. Treatment considerations in a geminated maxillary lateral incisor. J Endod 1991;17:179-81.
Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101-10.
Collins IJ. Maxillary lateral incisor with two roots. Aus Endod J 2001;27:37-8.
Gandhi A, Kathuria A, Gandhi T. Endodontic-periodontal management of two rooted maxillary lateral incisor associated with complex radicular lingual groove by using spiral computed tomography as a diagnostic aid: A case report. Int Endod J 2011;44:574-82.
Libfeld H, Stabholz A, Friedman S. Endodontic therapy of bilaterally geminated permanent maxillary central incisors. J Endod 1986;12:214-6.
Cimilli H, Kartal N. Endodontic treatment of unusual central incisors. J Endod 2002;28:480-1.
Michanowicz AE, Michanowicz JP, Ardila J, Posada A. Apical surgery on a two-rooted maxillary central incisor. J Endod 1990;16:454-5.
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99.
De Deus QD. Endodontia. 5th
ed. Medsi: Rio de Janeiro; 1992.
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.
Calişkan MK, Pehlivan Y, Sepetçioǧlu F, Türkün M, Tuncer SS. Root canal morphology of human permanent teeth in a Turkish population. J Endod 1995;21:200-4.
Huumonen S, Kvist T, Gröndahl K, Molander A. Diagnostic value of computed tomography in re-treatment of root fillings in maxillary molars. Int Endod J 2006;39:827-33.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]