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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 36-40

Endodontic management of badly broken down tooth with radix entomolaris using the canal projection technique


Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College and Hospital, AMU, Aligarh, Uttar Pradesh, India

Date of Submission16-Jan-2019
Date of Acceptance19-Feb-2019
Date of Web Publication6-Mar-2019

Correspondence Address:
Huma Iftekhar
Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College and Hospital, AMU, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_4_19

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  Abstract 


The management of teeth with minimal coronal structure can be a challenging task when root canal treatment is required as a part of oral rehabilitation. Coronal leakage, isolation complexities, and risk of interappointment coronal-radicular fracture may be major contributors to endodontic failure. It is a great challenge to an endodontist to maintain root canal patency while isolating grossly destructed tooth with open pulp chamber, without blocking the root canals with restorative material. Pre-endodontic build-up of the coronal tooth structure following caries removal and identification of all the canal orifices while maintaining the canal patency can facilitate the endodontic process by providing a strong core and coronal seal. Hence, a restoration before endodontic treatment is mandatory during management of these teeth. This can be achieved successfully by the canal projection technique, wherein a tapered plastic sleeve is used to maintain the canal patency, projecting the canal from pulp chamber to cavosurface margin. Taking into consideration the limited worldwide availability and cost of original projectors, the aim of the present case is to highlight a simple yet effective method of placement of a pre-endodontic restoration using the canal projection technique by custom made plastic sleeves. This case report demonstrates the use of an innovative technique for canal projection, as an efficient method for managing complex cases.

Keywords: Broken down teeth, endodontic canal projection, isolation, pre-endodontic build-up, radix entomolaris


How to cite this article:
Iftekhar H. Endodontic management of badly broken down tooth with radix entomolaris using the canal projection technique. J Oral Res Rev 2019;11:36-40

How to cite this URL:
Iftekhar H. Endodontic management of badly broken down tooth with radix entomolaris using the canal projection technique. J Oral Res Rev [serial online] 2019 [cited 2019 Mar 25];11:36-40. Available from: http://www.jorr.org/text.asp?2019/11/1/36/253433




  Introduction Top


Advancement in endodontic techniques has resulted in retention of those teeth which were earlier considered unrestorable.[1] It is universally accepted that the preservation of a natural tooth is always superior to tooth loss and replacement.[2] The presence of minimal coronal structure can risk damage to the crown during rubber dam clamp placement compromising isolation thereby leading to coronal leakage.[3] Placing pre-endodontic restoration to achieve a strong coronal seal without compromising the canals patency is desirable when treating such cases. This can be achieved by the canal projection technique as suggested originally by Gerald N Glickmann and Roberta Pileggi, also known as “Projector Endodontic Instrument Guidance System” (PEIGS)[4] which provides pre-endodontic reconstruction of debilitated coronal and radicular tooth structure while preserving individualized access to canals. The technique helps to project the canal orifice from the floor of the pulp chamber to the cavosurface, enhancing visualization and access to the canals. Isolation is facilitated further by ease of clamp retention rendering many structurally debilitated teeth endodontically treatable.[5],[6]

A major anatomical variant of the two-rooted mandibular first molar is an additional distolingual third root, the radix entomolaris (RE).[7]

This case report describes the management of a case of an additional mandibular first molar with distolingual root (RE) restored using canal projection technique with custom made plastic projectors before endodontic treatment.

There are very few cases of canal projection reported in literature, since the original projector (PEIGS) is costly and not easily available.[5],[8],[9] In our case, we have utilized plastic disposable delivery tips of Metapex (Premixed root canal filling material, Calcium hydroxide Iodoform formulation, METABIOMED) which is readily available almost in every clinical setting.


  Case Report Top


A 22-year-old male reported to the Department of Conservative Dentistry and Endodontics Dr. Z. A. Dental College and hospital AMU Aligarh, India, complaining of a dull, mild pain in the left mandibular posterior region for 2 months. Intraoral examination revealed the presence of a grossly decayed mandibular left first molar with three walls missing [Figure 1]. Pulp sensibility testing elicited a negative response. The preoperative radiograph [Figure 2] revealed deep occlusal caries involving the pulp and widening of the periodontal ligament space with the apical contour of roots indicating some possibility of the extra root. An angled radiograph of the tooth was taken which revealed the presence of at least three distinct roots, but a confirmatory diagnosis was still needed to rule out the possibility of any missed root or canals. After taking informed consent from the patient, Spiral computed tomography (SCT) scan was done with SCT scanner (Somatom Balance, Siemens, Erlangen, Germany). All the protective measures were taken to protect the patient from radiation. Slices of the mandibular first molar were obtained at different level coronal third, middle third, and apical third, which confirmed three distinct roots with four separate canals and four separate orifices [Figure 3]a-c]. A diagnosis of RE with pulpal necrosis and chronic periradicular periodontitis was made. Root canal treatment was planned using canal projection technique. The projectors were made using plastic delivery needles of Metapex (Premixed root canal filling material, calcium hydroxide iodoform formulation, METABIOMED). The cut conical projectors were slid onto endodontic files [Figure 4].
Figure 1: Preoperative photograph showing severely broken down mandibular left molar

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Figure 2: Preoperative radiograph showing deep occlusal caries and periradicular periodontitis

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Figure 3: Slices of molar at (a) coronal, (b) middle, and (c) apical third revealing four separate canals and four separate orifices

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Figure 4: Projectors prepared with delivery tips of metapex and cut projectors slided onto K files

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After securing adequate anesthesia and application of rubber dam with a clamp with apically inclined beaks, caries was excavated. Access cavity preparation was performed, and four root canal orifices were identified (mesiobuccal, mesiolingual, distobuccal, and distolingual) [Figure 5]. The canals were enlarged to a size 30 k file using the standardized method of cleaning and shaping. A stainless steel automatrix band was placed followed by the application of phosphoric acid gel to etch the exposed dentine and enamel. Rinsing and drying were accomplished after 20 s. The Projectors were placed on four endodontic files and slid up toward the file handles so that 5–8 mm of each file tip protruded beyond the tip of the projector. Different sizes of files were used to aid in the identification of the projected orifices. Size 25 k file was used for the mesiobuccal canal, size 25 for the distobuccal, size 30 for the mesiolingual, and size 20 for the distolingual. Each file with a Projector was then inserted into its respective orifice. A dentine bonding agent was then applied and light cured. The build-up was placed in increments using a nanohybrid composite (Filtek Z350 XT, 3M ESPE) and light-cured [Figure 6]. Following curing, the files were removed, leaving the projectors in place. A size 50 Hedstrom hand file was engaged in projectors and projectors removed from the core. A high-speed diamond bur was used to level the occlusal surface providing ideal endodontic reference points. Thus, a pre-endodontic build-up with individualized access to each canal was achieved successfully [Figure 7].
Figure 5: Access opening completed under rubber dam, four orifices detected

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Figure 6: Composite built-up around projectors to occlusal surface

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Figure 7: Orifices projected to occlusal surface

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The original hand file was introduced into each projected orifice, and a working length radiograph was taken [Figure 8] and confirmed with an electronic apex locator (Raypex 5, VDW GmbH, Munchen, Germany). Canals were instrumented with protaper rotary files and were medicated with calcium hydroxide preparation (Metapex, BIOMED) and temporarily sealed with Cavit (3M ESPE). At the subsequent visit, obturation was performed with protaper gutta-percha and sealer (Endoflas, Colombia) [Figure 9], and canals were sealed with glass ionomer cement. The pre-endodontic build-up itself was used as a core, and full crown preparation was performed followed by crown cementation at a subsequent appointment. Follow-up radiographs at subsequent appointments revealed completely asymptomatic tooth [Figure 10].
Figure 8: Working length radiograph

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Figure 9: Postobturation radiograph

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Figure 10: Follow-up radiograph

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  Discussion Top


Frequently endodontist encounter severely compromised teeth which requires pre-endodontic build-up of lost coronal structures to ensure a strong core, good coronal seal, placement of rubber dam clamp and to act as reservoir for irrigating solutions.[10] Pre-endodontic build-up can be achieved by a variety of materials as amalgam, composites, or glass ionomer cements. It can also be facilitated by the application of copper bands, orthodontic bands, or temporary crown.[11] Surgical exposure of subgingival tooth structure to aid clamp placement, usage of serrated clamps, clamps with gingivally oriented prongs are helpful during the isolation of severely destructed tooth. The usage of orthodontic bands, pin-retained amalgam, and adhesive restorations are also advocated.[12] However, these restorative methods are time-consuming; they can impede endodontic access and may require replacement when they are weakened by endodontic access procedures.

To overcome these challenges, the canal projection technique was developed by Gerald N Glickmann and Robert Pileggi also known as PEIGS which used plastic sleeves for pre-endodontic rehabilitation of a badly mutilated teeth. However, due to its limited availability and high cost, alternatives such as greater taper gutta-percha[5] and hypodermic needles[8],[9] were tried with effective outcomes. These alternative techniques of canal projection offered all the benefits of conventional PEIGS, without any extra learning curve and they were economical, easily available yet equally effective.

However, gutta-percha is flexible, and there may be a possibility that it may get mechanically retained to the resin material thus creating difficulties during removal after the composite core build-up. Similar is the case with sleeves of hypodermic needles as there are chances of sticking of composite onto it and the parallel needles do not perfectly adapt to the conical roots. The present case focuses on the use of plastic delivery tips of metapex which has some inherent taper when cut, and it does not adhere composite onto it as well as it can be easily removed post core build up.

Since in the above case apical contour of roots some possibility of extra roots thorough inspection of preoperative radiographs coupled with spiral computed tomography examination was done which provided us three-dimensional observation of roots to avoid the possibility of missed root or canal and possibility of endodontic failure.

The present case demonstrates the use of an innovative technique of canal projection offering similar benefits of conventional PEIGS, using plastic disposable delivery tips as an efficient method for managing teeth with minimum coronal tooth structure to maintain canal patency and for successful rehabilitation of grossly mutilated teeth.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johns BA, Brown LJ, Nash KD, Warren M. The endodontic workforce. J Endod 2006;32:838-46.  Back to cited text no. 1
    
2.
Lazarus JP. Provisionally restoring a necrotic tooth while maintaining root canal access. J Am Dent Assoc 2004;135:458-9.  Back to cited text no. 2
    
3.
Jeffrey IW, Woolford MJ. An investigation of possible iatrogenic damage caused by metal rubber dam clamps. Int Endod J 1989;22:85-91.  Back to cited text no. 3
    
4.
Glickman GM, Pettiette MT. Preparation for treatment. In: Cohen S, Hargreaves KM, Keiser K, editors. Pathways of the Pulp. 9th ed. St. Louis, MO, USA: Mosby; 2006. p. 120-32.  Back to cited text no. 4
    
5.
Tanikonda R. Canal projection using gutta-percha points: A novel technique for pre-endodontic buildup of grossly destructed tooth. J Conserv Dent 2016;19:194-7.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Weathers AK. Endodontics from access to success, part 1. Access, the important first step. Dent Today 2004;23:78-80, 82, 84-5.  Back to cited text no. 6
    
7.
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. 7
    
8.
Velmurugan N, Bhargavi N, Lakshmi N, Kandaswamy D. Restoration of a vertical tooth fracture and a badly mutilated tooth using canal projection. Indian J Dent Res 2007;18:87-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Mangat P, Tomer AK, Bhardwaj G, Singh A, Muni S, Sneha. Pre-endodontic rehabilitation of badly mutilated teeth with canal projection technique. Int J Appl Dent Sci 2016;2:65-7.  Back to cited text no. 9
    
10.
Scott GL, Walton RE, Torabinejad M. Principles and Practice of Endodontics. 3rd ed. Philadelphia, PA, USA: W.B. Saunders; 1996. p. 118-29.  Back to cited text no. 10
    
11.
Ingle JI, Walton RE, Malamed SF. Preparation for endodontic treatment. In: Ingle JL, Bakland LK, editors. Endodontics. 5th ed. Hamilton, Ontario, Canada: B. C. Decker; 2002. p. 357-404.  Back to cited text no. 11
    
12.
Carrotte P. Endodontics: Part 7. Preparing the root canal. Br Dent J 2004;197:603-13.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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