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DIFFICULT CASES IN ENDODONTICS – PROGNO-SIS AND PROPHYLAXIS OF COMPLICATIONS

Janet Kirilova, Snezhanka Topalova-Pirinska.Department of Conservative Dentistry, Faculty of Dental Medicine, Sofia, Bulgaria

Journal of IMAB - Annual Proceeding (Scientific Papers) 2014, vol. 20, issue 1Journal of IMABISSN: 1312-773X (Online)http://www.journal-imab-bg.org

ABSTRACTIntroduction: There are cases in the endodontic

treatment which are a real challenge. There are teeth withtaurodontism and radix entomolaris. Patients usually losetheir teeth because these anatomical features are less familiar.

Purpose: The aim of this study is to investigate severalcases with taurodontism and radix entomolaris.

Material and methods: Two cases with taurodontismand one with radix entomolaris that are described in thefollowing article. Careful exploration of the grooves betweenall orifices with magnification, use of ultrasonic irrigation;and a modified filling technique are of particular use.

Results: Results are observed after several years. Inperforming a root canal treatment on such teeth, one shouldappreciate the complexity of the root canal system, canalobliteration and configuration, and the potential for additionalroot canal systems.

Conclusions: Knowledge of the phenomenon oftaurodontism and radix entomolaris will improve the medicalpractice of the general dental practitioner.

Key words: Anatomical variation, taurodontism, radixentomolaris, endodontic treatment

INTRODUCTIONThe endodontic cases for treatment can be

conditionally divided into: simple, moderately difficult anddifficult. The group of difficult cases concerns the aberrationsof dental roots - taurodontism; C-shaped configuration of thepulp chamber and the root canal system; radix entomolarisof first mandibular molar; dens evaginatus and densivaginatus.

The purpose of this article is to discuss some difficultcases for treatment in the endodontic practice in order toforesee and prevent complications. Such are rare cases oftaurodontism of lower premolars and radix entomolaris of thefirst mandibular molar.

MATERIAL AND METHODSCase with taurodontism of the mandibular second

left premolarA patient (19 years old) is referred to us for

endodontic treatment after having been placed a necrotizingagent and an unsuccessful attempt for extirpation of the pulptissue by a general dental practitioner.

A bleeding wide open pulp chamber of the mandibular

second left premolar was found while examining the patient.The patient reported pain and we observed symptoms of painon probing. The tooth to be treated has a deviation in the toothposition (marginal rotation). The accompanying X-ray showsthat it is a rare case with hypotaurodontism of mandibularsecond left premolar (Figure 1).

Fig.1. Mandibular second left premolar withhypotaurodontism and communication with the dental pulp

The X-ray shows that the mandibular first leftpremolar is also with taurodontism, but the dental pulp is notaffected.

Taurodontism is also described as an abnormalityassociated with a common disease, but in this case suchdisease is not found [13]. Nowadays, it is assumed thattaurodontism is an anatomical variation that occurssporadically in the human population [10].

The pulp tissue in the pulp chamber was removedunder anesthesia. When looked at under a microscope it wasfound that a perforation of the distal pulp chamber toothwas made, possibly in an attempt to locate the orifice of theroot canal. Two orifices, vestibular and lingual, were found(Figure 2).

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Fig.2. “C” shaped pulp chamber of tooth 35. The littlewhite arrow indicates the location of the perforation.Bleeding can be seen nearby due to the perforation. The bigwhite arrow indicates the vestibular orifice with a crescentshape.

After obturation of the root canal system a treatmentof the perforation in the distal part of the pulp chamber wasperformed using mineral trioxide aggregate (MTA). A liningof glass ionomer cement was placed at the next visit and thepatient was referred to the treating general dental practitionerto place the final filling (obturation).

Case with taurodontism of the mandibular firstright premolar

Endodontic treatment of the mandibular first rightpremolar was conducted on a 32-year old patient. The toothwas with a destroyed clinical crown, periapical changes(chronic granulomatous diffuse periodontitis PAI 2) and adeviation in the tooth position (marginal rotation). The X-rayshowed that it was a rare case of tooth withhypotaurodontism. Endodontic treatment was completed witha filling with cold lateral condensation. The post endodonticrecovery was with a post (February 2005). Due to the toothrotation the control X-ray for filling is made with medialdisplacement of about 30 degrees (Figure 5).

Fig.5. X-ray after filling of the mandibular first rightpremolar with hypotaurodontism.

After treatment with rotary nickel titanium instrumentsusing the crown-down methodology and multiple irrigations,the ultrasound activated (according to various literaturesources [4, 11, 14]) root canals were obturated with aThermafil obturator and a sealer (Figure 4).

Fig.4. X-ray after filling of the mandibular second leftpremolar.

The shape of the vestibular orifice, as shown in Figure2, is a crescent, which is an evidence of either a wide largevestibular root canal or possibly a second root canal.

On an X-ray used to establish the length of the rootcanals two vestibular root canals located very close to eachother are well seen (Figure 3).

Fig.3. X-ray with gutta percha points in the root canalsof tooth 35. The second canal is indicated with a white arrow.

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We observed an intact periapical bone and excellenthealing results (Figure 6) after seven years, at a radiographycheck-up of the same tooth 44 - mandibular first rightpremolar with a normal centering,

Fig.6. Mandibular first right premolar withtaurodontism 7 years later.

When a rectangular or a trapezoidal pulp chamber isidentified on the X-ray, it is difficult to locate the orificesconnected to radix entomolaris. This is the tooth treated byus and presented on a preoperative radiograph in Figure 8.

Fig. 8. X-ray of the mandibular first molar with radixentomolaris.

Case with radix entomolaris of the first mandibularmolar

Another root aberration affecting the mandibular firstmolar is the radix entomolaris. It occurs infrequently and isdifficult for endodontic treatment.

The sixth lingual tubercle in the crown of the firstmandibular tooth is considered a sign of such root aberration(Figure 7).

Fig.7. Crown of the mandibular first molar with radixentomolaris.

The case is difficult because it is difficult for theendodontic clinician to locate the orifice of the radixentomolaris and because of the fact that there is a narrow rootcanal with a large curvature. A therapy was carried out withthe help of nickel titanium instruments using crown-downmethodology and multiple irrigations, and the root canalswere obturated with a Thermafil obturator and a sealer(Figure 9).

Fig.9. X-ray of the root canal filling of the mandibularfirst molar with radix entomolaris.

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Address for correspondence:Dr Janet Kirilova, PhDDepartment of conservative Dentistry, Faculty of Dental Medicine1, St. George Sofiiski Str., 1431 Sofia, BulgariaE-mail: janetkirilova@gmail.com,

RESULTS AND DISCUSSIONAccording to G. Tomov (2010) in Bulgaria the

frequency of taurodontism ranges from 2.9% in 15-35-yearold individuals to 37.5% in individuals with hypodontia[13].

Sometimes locating, cleaning and filling root canalsof teeth with taurodontism create major problems.Individual approach, precise planning and implementationof health activities are essential for the endodontic result [2,7, 8 and 11].

It is necessary to work under anesthesia rather thanwith devitalizing agents, as heavy bleeding may occur.Moreover, it is risky to make perforation when detectingroot canals [14]. It is recommended to use passive ultrasonicirrigation with hypochlorite for irrigation (no irrigation withsyringes), because the endodontic volume contains greateramount of infected channel contents and extrusion of debrisor irrigant is possible. A combination of lateral and verticalcondensation [1] is required for the successful filling of theroot canal system.

The rare root aberration radix entomolaris isassociated with certain ethnic groups. In the Africanpopulation the frequency of entomolaris is 3% while in

Europeans the frequency is less than 5% (3.4% to 4.2%).In the Mongoloid race the frequency is more than 5% andmay reach more than 30% (Chinese, Eskimos and AmericanIndians). Radix Entomolaris is considered normalmorphology among these populations due to the identifiedhigh frequency [3, 4, 5]. For Europeans, it is unusualmorphology.

Ethnicity is a predisposing factor for anatomicalabnormalities such as the number of tooth roots. TheMongoloid population shows significantly more often firstmandibular molar with three roots with a 3:1 ratio whencompared to Caucasians and Afro-Americans. This is thereason this variation to be discussed as geneticallydetermined characteristic [6, 9, 13, 14].

Its size can range from short conical to very narrowroot canal with large curvature. Generally, the radixentomolaris has a smaller size than the distal andmesiovestibular root. In most cases these root canals arevery narrow and with a large curvature [13, 14].

It is important to recognize and diagnose teeth withtaurodontism and radix entomolaris for the successfultreatment of such cases. This gives a good estimate of thetreated teeth and may prevent complications.

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