| Abstract|| |
Maxillary central incisor is considered the tooth with least anatomical variations. In literature, the prevalence of single root and single canal in maxillary central incisor has been reported as 100%. Only a handful of case reports suggesting more than one root or one canal are available and are mostly associated with developmental anomalies such as gemination and fusion. This article describes a rare case report of retreatment of a maxillary central incisor with two roots with normal clinical crown which was confirmed by cone-beam computer tomography (CBCT). A 50-year-old Indian male patient presented with pain and discomfort on a root canal-treated anterior tooth. Pulp sensibility testing of left maxillary central incisor was negative. Intraoral periapical digital radiograph revealed an obturated canal with suspected outline of a second root which got confirmed with cone shift technique. The tooth was treated under dental operating microscope during which two canals were located and retreatment was completed. Postobturation, CBCT was performed to study the root and canal morphology. Clinically and radiographically, all the follow-up examinations revealed an asymptomatic tooth without any active periapical lesion. The present case report emphasizes the fact that clinicians should approach each case with an open mind having a thorough knowledge of the normal tooth anatomy and should suspect variations in every case to ensure successful endodontic outcome.
Keywords: Cone-beam computer tomography; endodontic retreatment; maxillary central incisor; missed canal
|How to cite this article:|
Bhattacharyya A, Majumder G, Maity AB, Datta S. A rare case of persistent postendodontic symptomatic maxillary central incisor with aberrant canal configuration confirmed by cone-beam computer tomography and its nonsurgical management by retreatment. J Conserv Dent 2023;26:359-63
|How to cite this URL:|
Bhattacharyya A, Majumder G, Maity AB, Datta S. A rare case of persistent postendodontic symptomatic maxillary central incisor with aberrant canal configuration confirmed by cone-beam computer tomography and its nonsurgical management by retreatment. J Conserv Dent [serial online] 2023 [cited 2023 Sep 27];26:359-63. Available from: https://www.jcd.org.in/text.asp?2023/26/3/359/376916
| Introduction|| |
Alterations of the anatomy of root or canal configurations may influence endodontic treatment. The prognosis of endodontic treatment becomes challenging when complex internal anatomy is encountered.,,,
It is a well-known truism that maxillary central incisors are single-rooted single-canal teeth. Most dental anatomy and endodontic texts describe the maxillary central incisors as teeth with single root and single canal in 100% of cases., However, literature has very few published case reports of maxillary central incisor with two canals in a single root,,,,, or maxillary central incisor with two separate roots.,,,,, Hence, maxillary central incisors are generally considered to be simple teeth to treat endodontically having one root and one canal.
The purpose of this article is to report on the endodontic management of a root canal-treated symptomatic maxillary central incisor tooth having two roots, by nonsurgical retreatment procedure.
After reviewing the risk, benefit, and treatment options with the patient, informed consent was obtained for endodontic retreatment of maxillary left central incisor under dental operating microscope (DOM).
| Report|| |
This case report has been written according to CARE guidelines 2013.
A 50-years-old Asian male patient reported to the Department of Conservative Dentistry and Endodontics, with pain in the upper front tooth region for 2 weeks. The pain was throbbing in nature, and spontaneous. History revealed that he had visited a dentist 2 months ago with complaint of pain in the upper front tooth region and endodontic treatment was performed in relation to maxillary left central incisor. Medical history of the patient was noncontributory. The patient was informed about the various diagnostic and clinical investigation procedures to be conducted, and valid consent was taken. Proper consent was taken before clinical examination. On clinical examination, the tooth was found to be severely attrited, and with permanent restorative material on palatal aspect of the tooth. The tooth had a negative response when tested with Endo-Ice (Coltene, Cuyahoga, OH, USA) and warm gutta-percha and responded positively to both percussion and palpation. Periodontal probing exhibited probing depths that were <3 mm and mobility was within physiologic limits. The adjacent maxillary anterior teeth responded normally to thermal sensibility tests. On radiographic examination, it was found that the tooth was obturated, showing somewhat abnormal anatomy with suspected additional root and canal [Figure 1]. The additional palatal root was confirmed by altered horizontal angulated radiographs. Based on the findings, the tooth was diagnosed with incomplete endodontic treatment with necrotic pulp and apical periodontitis. A nonsurgical endodontic retreatment procedure was planned to locate the missing canal.
|Figure 1: Intraoral digital radiographs: (a) Preoperative (b) Master cone selection. (c) Immediate postoperative|
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In the first appointment, the treatment procedure was explained to the patient and written consent was taken. Proper consent was taken before starting the treatment. After obtaining anesthesia with 2% lidocaine hydrochloride (Septodont, France), the tooth was isolated using rubber dam (Coltene, Germany). On re-entering the tooth under high speed using No. 4 round diamond bur (Mani, Japan) with water coolant, the presence of an orifice with gutta-percha corresponding to the previously obturated canal was seen. Since the diagnostic intraoral radiograph suggested the presence of a missed palatal canal (utilizing SLOB rule), the access cavity was modified accordingly to locate the missed canal using Endo-Z bur (Dentsply Maillefer). The pulp chamber was explored under DOM (Global Surgical G6 series, USA) using DG16 Endo Explorer (Hu-Friedy, USA) during which a catch was felt palatal to the already obturated canal which was not previously negotiated. The site of the catch was scouted with No. 3 Start-X Tip (Dentsply Maillefer, Switzerland) using Biosonic Ultrasonic Scaler (Coltene, USA). Once the orifice was clearly visible, the presence of a canal was confirmed by placing a No. 10 K-file (Mani, Japan) and exposing a radiograph. The old gutta-percha filling from the facial orifice was removed with the help of HyFlex Remover file system (Coltene, France). The facial canal was irrigated with warm 5.25% sodium hypochlorite solution (Septodont, France) to flush the gutta-percha and sealer remnants. The working length was re-established with CanalPro electronic apex locator (Coltene, Germany).
Instrumentation was done in both the canals up to size F3 using ProTaper Gold file system (Dentsply Maillefer, Switzerland) and irrigation with copious amount of 5.25% sodium hypochlorite (Septodont, France). The canals were then dried with corresponding paper points and CalciCure Calcium Hydroxide paste (SafeEndo Dental, India) was placed as an intracanal medicament. The access cavity was sealed with noneugenol temporary cement Cavit-G (3M ESPE, USA).
The patient was recalled after 1 week for further follow-up and was found totally asymptomatic on examination. The tooth was again re-entered and re-instrumented with F3 ProTaper Gold file while irrigating with 5.25% sodium hypochlorite (Septodont, France), followed by 17% EDTA (Septodont, France) for 1 min and finally with 2% chlorhexidine (CHX) gluconate (Septodont, France). The canals were dried with F3 paper points (Dentsply Maillefer, Switzerland), following which they were coated with GuttaFlow 2 (Coltene, Germany) sealer. Obturation was done using F3 gutta-percha cones (Dentsply Maillefer, Switzerland) using warm vertical condensation technique [Figure 2]. Post this, the access cavity was restored with ParaCore dual cure resin (Coltene, Switzerland) and a postoperative cone-beam computer tomography (CBCT) (SIRONA ORTHOPHOS XG3D Machine, India) examination was carried out to confirm the presence of two roots and two canals in the tooth of interest and to evaluate the contralateral tooth for the same feature [Figure 2]. The patient was observed for 6 months through clinical and radiographic examination during which the tooth remained asymptomatic.
|Figure 2: (a) Intraoral clinical examination of a 50-years-old Indian male presenting with pain in maxillary left central incisor showing normal clinical crown. (b) A CBCT scan of the involved tooth was performed as confirmatory examination (SIRONA ORTHOPHOS XG3D Machine, India. Field of View (FOV) - 5.1 × 5.7 cm, Voxel size - 100 mm width × Height of section: 512 × 512, No. of slices 568), where axial section showing buccal and palatal root of left maxillary central incisor. (c) Sagittal view of CBCT showing well-obturated buccal and palatal canal of left maxillary central incisor. CBCT: Cone-beam computer tomography|
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| Discussion|| |
The internal anatomy of maxillary central incisor is usually considered well known. Despite the abundance in the published literature with regard to the incidence of extra canals in different teeth, the reported incidence of additional canal in maxillary central incisor is found to be as low as 0.6%.
The most common root canal morphology in maxillary central incisor is single root and single canal and is reported to be as high as 100%., However, some case reports show exceptions wherein there is more than one canal or one root, but are extremely rare and is mostly associated with gemination, fusion, dens invaginatus or with the presence of supernumerary roots. [Table 1]. Usually maxillary central incisor with such variations present with an unusually large crown surface either labially or palatally. Sert and Bayirli reported the presence of additional canal in 3 of the 200 maxillary central incisors examined using demineralization. The summary of the demineralization studies on maxillary central incisors is shown in [Table 2].,,,,,
|Table 1: Summary of case reports of the maxillary central incisor with more than one root|
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|Table 2: Summary of demineralization studies on the maxillary central incisors|
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In this present report, we described a case wherein retreatment was performed on maxillary central incisor where the crown was clinically normal in shape with two separate canals having two roots, which was later confirmed with CBCT.
During root formation, Hertwig's epithelial root sheath is bent horizontally at cementoenamel junction causing the cervical opening of the tooth germ to narrow. Due to any trauma or any unknown factor, the fusion of the horizontal diaphragm may remain incomplete resulting in the development of accessory roots and canals. Multiple angulated radiographs usually aid in identification of the anomalies or variations. Endodontic diagnosis is correctly obtained in 90% of cases with three radiographs that included an angled one rather than 74% of cases with only one radiograph. So, clinicians should always take multiple angulated radiographs and cautiously trace outline of the root surface to identify aberrations of root anatomies.
Intraoral radiography is usually routinely used in endodontics; however, CBCT is an advanced diagnostic aid which provides more comprehensive three-dimensional information during complex endodontic procedures. There are case reports available where spiral Computer Tomography (CT) was used to detect extra canals.
In this case, CBCT was advocated to confirm the rarely reported root canal anatomy of the tooth of interest and to rule out the same in the adjacent teeth as the patient was planned for full mouth rehabilitation. Sabala et al. reported that root canal aberrations occur 90% bilaterally. However, Lin et al. mentioned that two rooted maxillary central incisors were mostly unilateral. In the present case also, right maxillary central incisor had single root and single canal as confirmed by CBCT.
In this present case, morphological abnormality of the root canal was evident by the assessment of the initial X-ray. Although the second root and canal were evident in the radiograph, the previous root canal treatment only included one canal. Additional tools such as the use of DOM greatly improved visibility and the ability to adequately retreat the tooth. Removal of gutta-percha can be done with solvents, heat, or endodontic instruments. In this case, the HyFlex Remover file has been used which is specifically designed to remove the gutta-percha obturation material during a nonsurgical endodontic retreatment, without the use of any solvent.
As a final irrigant, 2% CHX was used as it is bactericidal and routinely used in retreatment endodontic procedures for its substantivity action. The canals were obturated with a warm thermomechanical technique as it has been proven to be superior to standard cold lateral compaction.
The patient was followed up for a period of 6 months, after which the patient was referred to the Department of Prosthodontics for prosthetic rehabilitation. At that time, radiographs showed healthy and normal periapical structures and the patient was free of pain or any discomfort.
It must be noted that a pretreatment CBCT would have been ideal for diagnosing any aberrant root canal morphology. Furthermore, in cases of retreatment, long-term periodic recall to evaluate the tooth in question clinically and radiographically is necessary to ensure the successful outcome of the treatment.
| Conclusion|| |
This is a rare case report describing the existence of persistent symptoms in an unusual case of a maxillary central incisor with two roots and two canals with a normal clinical crown in which one canal was missed out during initial treatment. The experience from the present case demonstrates the variability of root canal morphology of maxillary central incisor. The clinician should be careful during exploration and treatment procedure in order to avoid missing extra canals. Finally, it should be always kept in mind that even the most routine of cases might deviate from the usual.
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Conflicts of interest
The first author of this case reports personal affiliation with Coltene/Whaledent which however is in no way related to the present case report. The other authors state clearly that there is no conflict of interest that is directly or indirectly linked to this case report.
| References|| |
Peikoff MD, Trott JR. An endodontic failure caused by an unusual anatomical anomaly. J Endod 1977;3:356-9.
Greenfeld RS, Cambruzzi JV. Complexities of endodontic treatment of maxillary lateral incisors with anomalous root formation. Oral Surg Oral Med Oral Pathol 1986;62:82-8.
Libfeld H, Stabholz A, Friedman S. Endodontic therapy of bilaterally geminated permanent maxillary central incisors. J Endod 1986;12:214-6.
Wang J, Zhang W, Zhou L. A maxillary center incisor with three independent roots and three root canals: A case report. Medicine (Baltimore) 2020;99:e21761.
Weine FS, Izquierdo O, Hayashi A. Endodontic Therapy. Saint Louis, MO: Mosby; 2004.
Laurichesse JM, Maestroni F, Breillat J. Endodonzia Clinica. Milano: Masson; 1994. p. 60.
Ingle JI, Bakland LK, Baumgartner JC. Endodontics. Hamilton: Decker; 2008.
Todd H. Maxillary right central incisor with two root canals. J Endodon 1976;2:227-9.
al-Nazhan S. Two root canals in a maxillary central incisor with enamel hypoplasia. J Endod 1991;17:469-71.
Cabo-Valle M, González-González JM. Maxillary central incisor with two root canals: An unusual presentation. J Oral Rehabil 2001;28:797-8.
Rodrigues EA, Silva SJ. A case of unusual anatomy: Maxillary central incisor with two root canals. Int J Morphol 2009;27:827-30.
Zhang B, Wang J, Zhou Z, Ge X, Cheng G, Chen Y, et al.
Treatment of a young maxillary central incisor with two root canals: A case report. Int J Gen Med 2021;14:419-23.
Patterson JM. Bifurcated root of upper central incisor. Oral Surg Oral Med Oral Pathol 1970;29:222.
Sinai IH, Lustbader S. A dual-rooted maxillary central incisor. J Endod 1984;10:105-6.
Lambruschini GM, Camps J. A two-rooted maxillary central incisor with a normal clinical crown. J Endod 1993;19:95-6.
González-Plata-R R, González-Plata-E W. Conventional and surgical treatment of a two-rooted maxillary central incisor. J Endod 2003;29:422-4.
Maghsoudlou A, Jafarzadeh H, Forghani M. Endodontic treatment of a maxillary central incisor with two roots. J Contemp Dent Pract 2013;14:345-7.
Al-Madi EM. Maxillary central incisor with two roots – A case report. Saudi Endod J 2020;10:162. [Full text]
Emmanuel, Indira R, Kandaswamy D. Maxillary incisor with two roots - a case report. J Conserv Dent 2007;10:74-6.
Vertucci FJ, Haddix JE, Britto LR. Tooth morphology and access cavity preparation. In: Cohen S, Hargreaves KM, editor. Pathways of the Pulp. 9th
ed. St. Louis, MO: Mosby Elsevier; 2006. p. 148-232.
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.
Roshan P. Root and canal morphology of human permanent teeth in a Sri Lankan and Japanese population. Anthropol Sci 2008;116:123-33.
Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al.
Root canal morphology of permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: A new modified root canal staining technique. J Endod 2009;35:651-6.
Rahimi S, Shahi S, Yavari HR, Reyhani MF, Ebrahimi ME, Rajabi E. A stereomicroscopy study of root apices of human maxillary central incisors and mandibular second premolars in an Iranian population. J Oral Sci 2009;51:411-5.
Kasahara E, Yasuda E, Yamamoto A, Anzai M. Root canal system of the maxillary central incisor. J Endod 1990;16:158-61.
Calişkan MK, Pehlivan Y, Sepetçioğlu F, Türkün M, Tuncer SS. Root canal morphology of human permanent teeth in a Turkish population. J Endod 1995;21:200-4.
Tayaar AS. Development and Growth of Teeth. In: Kumar GS, editor. Orban's oral histology and Embriology. 12th ed. India: Elsevier; 2009. p. 30–31.
Brynolf I. Roentgenologic periapical diagnosis. IV. When is one roentgenogram not sufficient? Sven Tandlak Tidskr 1970;63:415-23.
Subha N, Prabu M, Prabhakar V, Abarajithan M. Spiral computed tomographic evaluation and endodontic management of a maxillary canine with two canals. J Conserv Dent 2013;16:272-6.
] [Full text]
Sabala CL, Benenati FW, Neas BR. Bilateral root or root canal aberrations in a dental school patient population. J Endod 1994;20:38-42.
Lin WC, Yang SF, Pai SF. Nonsurgical endodontic treatment of a two-rooted maxillary central incisor. J Endod. 2006;32:478-481.
Masiero AV, Barletta FB. Effectiveness of different techniques for removing gutta-percha during retreatment. Int Endod J 2005;38:2-7.
Lea CS, Apicella MJ, Mines P, Yancich PP, Parker MH. Comparison of the obturation density of cold lateral compaction versus warm vertical compaction using the continuous wave of condensation technique. J Endod. 2005;31:37-39.
Dr. Anirban Bhattacharyya
Department of Conservative Dentistry and Endodontics, Haldia Institute of Dental Sciences and Research, Haldia, West Bengal
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2]