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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 83-86

Identification and clinical management of extra root in mandibular first molars: A series of case reports


Department of Conservative Dentistry and Endodontics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr Ashish Jain
Department of Conservative Dentistry and Endodontics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_15_18

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  Abstract 


The radix entomolaris/paramolaris is the major anatomical variant in mandibular first molars. If present, an awareness and understanding of this unusual root and its root canal morphology can contribute to the successful outcome of root canal treatment. Hence, it is essential to anticipate and find all roots and root canals during root canal treatment with the help of proper angulations and interpretation of intraoral periapical radiographs. This case series discusses the detection and clinical management of five mandibular molars with extra root and root canal anatomy.

Keywords: Anatomical variation, endodontic treatment, mandibular first molar, radix entomolaris


How to cite this article:
Jain A, Viola Solomon R, Karunakar P, Ranga Reddy M S. Identification and clinical management of extra root in mandibular first molars: A series of case reports. J Oral Res Rev 2018;10:83-6

How to cite this URL:
Jain A, Viola Solomon R, Karunakar P, Ranga Reddy M S. Identification and clinical management of extra root in mandibular first molars: A series of case reports. J Oral Res Rev [serial online] 2018 [cited 2018 Dec 14];10:83-6. Available from: http://www.jorr.org/text.asp?2018/10/2/83/240920




  Introduction Top


One of the main reasons for failure of root canal treatment in molars is because of missed canals.[1] Hence, it is of utmost importance that a clinician be familiar with root and root canal anatomy. In most cases, mandibular molars present with two roots; however, the major anatomical variant is the third root which if located distolingually is known as radix entomolaris (RE) and if located mesiobuccally is known as radix paramolaris (RP).[2]

The present case series describes the detection and management of five cases of mandibular first molar with three roots and four root canals.


  Case Reports Top


Case report 1

A 25-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with complaints of pain on chewing in the left lower posterior tooth. On clinical examination, there was a gross decay in the mandibular right first permanent molar (46). Intraoral periapical radiograph revealed a radiolucency involving pulp and periapical radiolucency beneath mesial and distal roots [Figure 1]a.
Figure 1: (a) Preoperative radiograph, (b) radiograph showing obturation with permanent coronal seal

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After achieving adequate local anesthesia with 2% lidocaine, conventional triangular access cavity was prepared. In the process of removing the remaining roof in the distolingual corner, a bleeding spot was observed (redline test) which when explored found to be an additional canal. The access cavity preparation was modified from a triangular to a trapezoidal form for proper accessibility of all the canals. The fourth canal was explored with DG 16 explorer (Dentsply, Switzerland). The canal lengths were determined electronically using an apex locator (SybronEndo, Germany). The canals were then cleaned with 3% sodium hypochlorite and shaped with ISO 6% ProTaper Rotary System (Dentsply, Maillefer). The canals were obturated with ISO 6% ProTaper gutta-percha points and AH Plus sealer using single-cone technique. The access cavity was restored with composite resin [Figure 1]b. The patient was recalled for full coverage restoration.

Case report 2

A 27-year-old female patient presented with a chief complaint of pain in the left lower back tooth region for 2 weeks. Pain was of intermittent type which aggravated on chewing food. Radiographs showed gross lesion involving pulp with periapical changes in relation to the mesial canal [Figure 2]a.
Figure 2: (a) Preoperative radiograph, (b) radiograph showing obturation with permanent coronal seal

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After locating three canals, the dentinal map seemed to be slightly extending in the distolingual direction which when tracked revealed a fourth canal. Access preparation was modified in that direction with a long shank round bur. Additional aids that help in location of orifices are DG 16 endodontic explorer, micro-openers, and sodium hypochlorite “bubble” test. Canal orifices were enlarged with Gates–Glidden drills, working length was determined radiographically, and the cleaning and shaping was performed with rotary ProTaper instruments in a crown-down technique. Glyde was used as a lubricant and the irrigants used were 3% sodium hypochlorite, 2% chlorhexidine gluconate, and 0.9% physiological saline. After the obturation was completed, the access cavity was restored with amalgam [Figure 2]b. The patient was recalled for full coverage restoration.

Case report 3

A 28-year-old male presented with a chief complaint of pain in the right lower back tooth region for 1 month. The tooth had extensive tooth decay on the distal part of the crown with tenderness on percussion. An extra cusp was present on the buccal side of the crown. Intraoral periapical radiographic finding reveals periapical radiolucency with respect to the distal root [Figure 3]a. On opening the pulp chamber, three root canals were found; these were enlarged coronally with Gates–Glidden drills. Since an extra canal was anticipated, inspection of the pulp chamber wall was done with loupes, and with the aid of a DG 16 probe, the extra canal was detected. After cleaning and shaping, the canals were obturated using 6% ProTaper gutta-percha points and AH Plus resin sealer. The access cavity was sealed with composite resin [Figure 3]b. The patient was given an appointment for full coverage restoration at a future date.
Figure 3: (a) Preoperative radiograph, (b) radiograph showing obturation with permanent coronal seal

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Case report 4

A 42-year-old male patient presented with a chief complaint of throbbing pain in the lower right back tooth region for 1 week. On radiographic examination, a third root was observed with radiolucency in the apical region [Figure 4]a. On performing the vitality, test showed negative response. Access cavity preparation of trapezoidal shape was done to achieve straight line accessibility. The fourth canal was located using DG 16 explorer. Working length was determined radiographically followed by cleaning and shaping with ProTaper Rotary System. After obturation, the access cavity was sealed with composite resin as the final postobturation restoration of choice and the patient was recalled for full coverage restoration [Figure 4]b.
Figure 4: (a) Preoperative radiograph, (b) radiograph showing obturation with permanent coronal seal

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Case report 5

A 38-year-old female patient presented to the department with grossly decayed distal surface of the right back tooth. Pain was mild and continuous throughout the day which aggravated on chewing food. On radiographic examination, periapical changes were observed in the distal root apex along with extra root [Figure 5]a. After access opening, four canals were detected using 10# K-file, canal orifice was enlarged, and working length was determined. Cleaning and shaping was performed using ProTaper Rotary System in step-down fashion along with 3% sodium hypochlorite and 0.9% normal saline as irrigant. The canals were obturated with single-cone gutta-percha, and the pulp chamber was sealed with composite resin. The patient was recalled for full coverage restoration [Figure 5]b.
Figure 5: (a) Preoperative radiograph, (b) radiograph showing obturation with permanent coronal seal

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  Discussion Top


RE is first mentioned in the literature by Carabelli, and the term was coined by Mihaly Lenhossek (1922). The RE mostly has the Vertucci type I canal configuration.[3] The prevalence of these three-rooted mandibular first molars appears to be <3% in African populations, not to exceed 4.2% in Caucasians, to be <5% in Eurasian and Asian populations, and to be >5% (even up to 40%) in populations with Mongolian traits.[4]

A classification was given by Carlsen and Alexandersen based on the location of the cervical part as types A, B, C, and AC. Type A and Type B refer to a distally located cervical part, Type C refers to a mesially located cervical part, and Type AC refers to the location of the cervical part in the central location in between the mesial and distal components.[5] Another classification was given by De Moor et al. based on the curvature of the separate RE variants in three different buccolingual orientations. They are as follows: Type I refers to straight root/root canals, Type II refers to a curvature at the entrance of the orifice, and Type III refers to RE with two curvatures, one at the coronal level and the other at the middle third.[4]

To achieve a correct diagnosis, a minimum of two diagnostic radiographs are necessary using Clark's buccal object same-lingual, opposite-buccal (SLOB) rule. Additional 25° mesial horizontal-angled radiographs are essential for preoperative identification and evaluation of RE/RP (SLOB technique).[6] Even the presence of an extra cusp may sometimes indicate the presence of RE/RP. Additional canals can be located by following the laws of symmetry and laws of orifice location given by Krasner and Rashkow. Furthermore, the access cavity preparation should usually be modified from a triangular to a trapezoidal shape to accommodate the extra root and canal anatomy.

Additional aids that help in the location of orifices are DG 16 probe, micro-opener, sodium hypochlorite “bubble” test, white line test, redline test, methylene blue dye, fluorescein sodium ophthalmic dye, long shank burs, ultrasonic instruments, digital radiography, surgical loupes, fiberoptic illumination, dental endoscope and orascope, operating microscope, micro-CT, and visualization endogram using Ruddle's solution.[7] The clinician should be judicious to incorporate these aids to best achieve successful management of the complexity of the extra root and canals in three-rooted mandibular molar teeth.


  Conclusion Top


A number of anatomic variations occur which pose a challenge to the clinician. This particular variation of extra root in the mandibular first molar requires the clinician to possess thorough knowledge on the root canal anatomy and its variations. In addition, an accurate pretreatment diagnosis and a proper stepwise clinical protocol are important to facilitate the successful management of additional root/root canals.

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

A private clinic supported the study.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reyhani MF, Rahimi S, Shahi S. Root canal therapy of a mandibular first molar with five root canals: A case report. Iran Endod J 2007;2:110-2.  Back to cited text no. 1
    
2.
Calberson FL, De Moor RJ, Deroose CA. The radix entomolaris and paramolaris: Clinical approach in endodontics. J Endod 2007;33:58-63.  Back to cited text no. 2
    
3.
Segura-Egea JJ, Jiménez-Pinzón A, Ríos-Santos JV. Endodontic therapy in a 3-rooted mandibular first molar: Importance of a thorough radiographic examination. J Can Dent Assoc 2002;68:541-4.  Back to cited text no. 3
    
4.
De Moor RJ, Deroose CA, Calberson FL. The radix entomolaris in mandibular first molars: An endodontic challenge. Int Endod J 2004;37:789-99.  Back to cited text no. 4
    
5.
Carlsen O, Alexandersen V. Radix entomolaris: Identification and morphology. Scand J Dent Res 1990;98:363-73.  Back to cited text no. 5
    
6.
Wang Q, Yu G, Zhou XD, Peters OA, Zheng QH, Huang DM, et al. Evaluation of x-ray projection angulation for successful radix entomolaris diagnosis in mandibular first molars in vitro. J Endod 2011;37:1063-8.  Back to cited text no. 6
    
7.
Parolia A, Kundabala M, Thomas MS, Mohan M, Joshi N. Three rooted, four canalled mandibular first molar (Radix entomolaris). Kathmandu Univ Med J (KUMJ) 2009;7:289-92.  Back to cited text no. 7
    


    Figures

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



 

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