J Indian Soc Pedod Prev Dent- December 2005 204

An unusual presentation of all the mandibular anterior teeth with two rootcanals - A case reportTIKU A. M.a, KALASKAR R. R.b, DAMLE S. G.c

Abstract

A rare case of two root canals in all mandibular anterior teeth is presented. The patient initially reported for the treatment ofmandibular right central and lateral incisors. However, radiographic evaluation revealed variant root canal and apical foramenpatterns.

Key words: Anatomy, Endodontics, Mandibular, Retreatment, Two canals

ISSN 0970 - 4388

aLecturer, bLecturer, cProfessor and Head of Department of PediatricDentistry, Nair Hospital Dental College, Mumbai-08, India

days duration. On clinical examination, a zinc oxide eugenol

temporary restoration was seen in mandibular right central

and lateral incisors. Dental history revealed that the patient

had undergone root canal treatment in these teeth one

month back. Medical and family history was noncontribu-

tory. Preoperative radiograph revealed an overextended,

poorly condensed root canal obturation in the mandibular

right lateral incisor and periapical radiolucencies in man-

dibular right central and lateral incisors respectively [Figure

1]. A closer observation of the same radiograph revealed

two root canals in 41; 42; 43, a rare morphological varia-

tion. As this was an unusual observation additional radio-

graphs for the left mandibular incisors and canines were

taken after treating symptomatic teeth which also revealed

two root canals in them [Figure 2].

In view of the clinical symptoms, faulty obturation and peri-

apical pathology, an endodontic retreatment of both the

teeth was planned. The teeth were isolated with rubber dam

and the temporary restorations of zinc oxide eugenol were

removed. The access cavities were modified and the previ-

ously condensed gutta percha points were softened with

chloroform and removed using K and H files alternatively.

Careful exploration of the root canals revealed two sepa-

rate canals, buccally and lingully in both the teeth with

vertucci type IV morphology of root canals. Working length

was established radiographically. The canals were prepared

using a step back instrumentation technique upto 40 # in-

struments. A 2.5% of sodium hypochlorite and normal sa-

line (sodium chloride injection I.P 0.9% w/v core health care

limited) were alternatively used as irrigants at every change

of instruments. The canals were dried with sterile paper

points and were dressed with calcium hydroxide paste

(pulpdent). The access cavities were then temporarily sealed

with IRM. At 2 weeks follow up as the teeth were asymp-

tomatic, obturation of the root canals was under taken with

laterally condensed gutta-percha using lateral condensation

technique. Post obturation radiograph was taken and the

access cavities were sealed with IRM. The teeth were later

taken up for jacket crowns [Figure 2]. The patient was fol-

Successful endodontic therapy of a tooth demands that the

dentist, should have a thorough knowledge of the root ca-

nal morphology, making it mandatory towards thorough

radiographic evaluation and diagnosis of the status of the

pulp canals as well as the periapical areas. Improper diag-

nostic protocol may lead to the failure of endodontic treat-

ment.

A wide morphological divergence of the root canal systems

is known to exist. Varying number of the root canals in dif-

ferent teeth, their anatomy and interconnections have been

studied and reported by several authors.[1,2,3] Vertucci has

classified morphological patterns of the root canal systems

into eight types.[4,5] Generally, the mandibular incisors have

one root canal with one apical foramen (Vertucci type I) or

two root canals with one apical foramen(Vertucci type II).

However, the occurrence of two root canals with two sepa-

rate foramina (Vertucci typeIV) in the mandibular incisors is

very rare viz 3% and 2% in the mandibular central incisors

and lateral incisors respectively, and in canines it is 6%.[5]

Funato A has reported a case with two root canals and sepa-

rate apical foramina in the mandibular central incisor.[6]

This case report describes the successful endodontic

retreatment of the mandibular right central and lateral inci-

sors having vertucci type IV root canal morphological sys-

tem. The case was followed up for period of thirty months.

The striking feature of this report however was the pres-

ence of two root canals in all the mandibular anterior teeth

which has not been reported earlier to the best of our knowl-

edge.

Case Report

A 12 years old boy reported to the department of Pediatric

Dentistry, Nair Hospital Dental College, Mumbai, with mild

pain in the permanent mandibular right anterior teeth of 15

[Downloaded free from http://www.jisppd.com on Wednesday, September 16, 2015, IP: 36.81.31.93]

J Indian Soc Pedod Prev Dent- December 2005205

lowed up at regular interval of 1, 3, and 6 months respec-

tively. At 6 months follow up, complete resolution of the

periapical pathology was observed [Figure 3]. The patient

was observed for thirty months during which the patient

was completely asymptomatic [Figure 4].

Discussion

Since the success of the endodontic treatment is related to

a thorough debridment of the root canals and hermatic seal

of the obturated materials, a good preoperative radiographic

evaluation is necessary.

The anatomy of root canal systems dictates the condition

under which root canal therapy is carried out and can di-

rectly affect its prognosis. Extra root or root canals if not

Figure 1: Preoperative radiograph revealing an overextendedpoorly condensed root canal obturation in the mandibular rightlateral incisor

Figure 2: Radiograph of left mandibular incisors and canineshowing two root canals

Figure 3: Radiograph showing complete resolution ofperiapical pathology at 6 months follow up

Figure 4: Radiograph of the teeth at 30 months follow up

Two root canals in mandibular anterior teeth

detected are a major reason for failure of this treatment.[7]

Incomplete removal of all the irritants from the pulp space

may increase the possibility of treatment failure.[8,9] The main

reasons for failure in endodontic treatment of mandibular

incisors is the inability to detect the presence of a second

root canal,which can then not be prepared and obturated

during treatment.[10]

The frequency of two root canals in the mandibular incisors

is 45% as reported by Kartal and Yanikoglu,[10] whereas the

other reports give these percentages between 11.5% and

41.4% respectively.[10] The percentage of two root canals (type

vertucci IV) with separate apical foramina in the mandibular

central and lateral incisors are 3% and 2% respectively and in

the canines it is 6%.[5]

In present case, two root canals with separate foramina were

distinctly observed in the mandibular right central incisors

[Downloaded free from http://www.jisppd.com on Wednesday, September 16, 2015, IP: 36.81.31.93]

J Indian Soc Pedod Prev Dent- December 2005 206

which is very similar to a case presented by Funato etal,

who reported a mandibular central incisor with two root

canals and separate apical formina.[6] Holtzman reported

mandibular canine with three root canals[11] and Arcangelo

reported with two roots.[12] However, in the present case

report two root canals appeared in all the mandibular teeth.

Additionally except for the mandibular right central and lat-

eral incisors, which were vertucci type IV, the classification

of root canals system of the other anterior teeth was not

possible, as they were not indicated for root canal treat-

ment.

Numerous antimicrobial agents have been recommended as

inter appointment dressings.[13] Calcium hydroxide paste is

a simple and remarkably effective antimicrobial medicament.

It has been shown to dissolve necrotic tissue and enhance

the tissue dissolving effect of sodium hypochlorite solu-

tion.[14] In the present case, calcium hydroxide (Pulpdent)

was used as the intracanal medicament. At 15 days recall

teeth were asymptomatic and thus taken up obturation. It

is evident in the present case that faulty obturation of the

root canals had led to the formation of periapical lesions.

This could be attributed to the microleakage as the canals

were not sealed properly. Careful radiographic examination

of the root canal system are important prior to the root

canal preparation, so as to detect and be aware of varia-

tions in root canal anatomy, before and during endodontic

treatment procedures. Finally, it is also important that the

endodontic treatment be reviewed periodically to ensure

continuous healing without complications.

References

1. Pineda F, KutlerY. Mesiodistal and buccolingualroentgenographic investigations of 7,275 root canals.OralSurgery, Oral Medicine, Oral Pathology 1972;33:101-10.

2. Bellizzi R Hartwell G. Clinical investigation of in vivoendodontically treated mandibular anterior teeth. Journal ofEndodontics 1983;9:246-8.

3. Caliskan MK, Pehivan Y, Sepetcioglu F, Tuncer SS. Root canalmorphology of human permanent teeth in a Turkish population.Journal of Endodontics 1995;21:200-4.

4. Vertucci FJ. Root canal anatomy of mandibular anterior teeth.Journal of American Dental Association 1974;89:369-71.

5. Vertucci FJ. Root canal anatomy of the human permanent teeth.Oral Surgery, Oral Medicine, Oral Pathology 1984;58:589-99.

6. Funato A, Funato H, Matsumoto K. Mandibular central incisorwith two root canals. Endodontics and Dental Traumatology1998;14:285-6.

7. Slowey RR. Radiographic aids in detection of extra root canals.Oral Surgery Oral Medicine Oral Pathology 1974;37:762-71.

8. Nair R, Sjogren U, Kreg G, Khanberg KE, Sandquist G.Intraradicular bacteria and fungi in root filled asymptomatichuman teeth with therapy resistant periapical lesion- a long termlight and electron microscope follow up study. Journal ofEndodontics 1990;16: 580-8.

9. Sjogren U, Hagglund B, Sundquist G, Wing K. Factors affectingthe long term results of endodontic treatment. Journal ofEndodontics 1990;16:498-504.

10. Kartal N, Yanikoglu F C. Root canal morphology of mandibularincisors. Journal of Endodontics 1992;11:562-564.

11. Holtzman L. Root canal treatment of a mandibular canine withthree root canals. Case report.International Endodontic Journal1997;30:291-3.

12. 7.DArcangelo C, Varvara G, De Fazio P. Root canal treatmentin mandibular canines with two roots- A report of two cases.International endodontic Journal 2001;34:331-4.

13. Bystrom A, Claesson R, Sundquist G. The antibacterial effect ofcamphorated paramonochlorophenol, camphorated phenol,andcalcium hydroxide in the treatment of infected root canals.Endodontics and Dental Traumatology 1985;1:170-5.

14. Hasselgren G, Olsson B, Cvek M. Effects of calcium hydroxideand sodium hypochlorite on the dissolution of necrotic porcinemuscle tissue.Journal of Endodontics 1988;14:125-7.

Reprint requests to:Dr. Amita M Tiku,22 Milan apartments, Pali RoadBandra West, Mumbai.400050.India

Two root canals in mandibular anterior teeth[Downloaded free from http://www.jisppd.com on Wednesday, September 16, 2015, IP: 36.81.31.93]