DOI: 10.7860/JCDR/2014/7780.

4074
Case Report

Re-treatment of a Two-Rooted Maxillary

Dentistry Section

Central Incisor - A Case Report

Roopadevi Garlapati1, Bhuvan Shome Venigalla2, Rammohan Chintamani3, Jayaprakash Thumu4

ABSTRACT
This case report is on endodontic retreatment of a maxillary central incisor with two roots. A twenty-year-old male patient presented with
pain in maxillary left central incisor. Radiographic examination showed an incompletely filled canal and an additional palatal root with periapi-
cal radiolucent lesion. Conventional cleaning and shaping of both the roots i.e., buccal and additional palatal root canals was performed and
obturation was done. After one year recall examination, the tooth was asymptomatic and periapical lesion had healed.

Keywords: Additional Root, Maxillary Central Incisor, Root Canal

CASE REPORT cal) was used as an intracanal medicament and the access cavity
A 20-year-old male patient was referred to the Department of was closed with Zinc oxide eugenol temporary cement. Patient was
Conservative Dentistry and Endodontics with pain and labial prescribed antibiotics and analgesics to manage pain and swelling.
swelling in the upper anterior region since two weeks. The pain was Patient was recalled after one week for further followup. At the
continuous and throbbing. His past dental history revealed that he second visit patient was totally asymptomatic. Temporary restorative
visited the dentist two months ago with a complaint of pain in the material was removed, facial and distopalatal canals were irrigated
upper front teeth region. Root canal treatment was planned and and dried with paper points. Master cone radiograph was taken to
performed in relation to the maxillary left central incisor. His medical confirm the length [Table/Fig-4]. Canals were coated with AH Plus
history was non-contributory. On clinical examination all the teeth sealer and obturation of both the canals was done with gutta-percha
were normal in number, size and color. A swelling was observed on and AH Plus as the sealer using cold lateral compaction technique.
the labial aspect of maxillary left central incisor and the tooth was The access cavity was restored with composite resin (Filtek Z 250,
tender on percussion. A permanent restorative material was seen 3M Dental Products) [Table/Fig-5]. After two weeks, the patient was
on the palatal aspect of maxillary left central incisor. Radiographic recalled to give metal ceramic crown for maxillary left central incisor
examination revealed the previous root canal treatment with for the enhancement of esthetics. Crown preparation was performed
incomplete obturation and periapical radiolucency. Along the middle in relation to the maxillary left central incisor and impressions were
third of the root, an abnormal anatomical anomaly was seen which made with a low viscosity material (Aquasil,Dentsply). Patient was
was suggestive of an additional root. Presence of an additional palatal recalled after one week for the cementation of crown. Re-treatment
root was confirmed by second intraoral periapical radiograph with of maxillary left central incisor and restoring it with a crown was
altered (mesial tube shift) horizontal angulations [Table/Fig-1]. Based completed in a period of one month and the patient was periodically
on the above clinical and radiographic findings, maxillary left central reviewed after three months, six months and one year. Patient was
incisor was diagnosed as having necrotic pulp and chronic apical asymptomatic during one year follow-up and he was satisfied with
periodontitis. A nonsurgical endodontic re-treatment procedure was esthetics and function. At one year follow-up, a radiograph was
planned for the maxillary left central incisor to locate the missing taken in relation to maxillary left central incisor, which confirmed the
root canal and the patient was informed about the procedure. healing of periapical lesion [Table/Fig-6].
Under rubber dam isolation, the access cavity was re-entered using
a No.1015 high speed round diamond bur and the permanent DISCUSSION
restorative material was removed. Entire gutta-percha was removed Maxillary central incisors are usually considered to have single root
from the facial canal with the help of chloroform and alternatively and one root canal [1]. While some case studies reported with two
by Hedstrom (H) files. Facial canal was irrigated with saline to flush to four canals, two roots and two root canals [2,3]. Other variations
the gutta-percha and sealer remnants. Entire gutta-percha removal like fusion, gemination, presence of dens invaginatus are also seen
from the facial canal was confirmed by radiographs [Table/Fig-2]. [4]. Usually maxillary central incisor with such variations present with
Additional distopalatal canal was located with a DG 16 endodontic an unusually large crown or defective crown surface either labially
explorer using endodontic loupes. For the enhancement of or lingually. In the present case, the crown was clinically normal in
accessibility and instrumentation the access cavity was extended size and shape.
on to the distopalatal aspect. The distopalatal canal was located Sabala et al., reported that root canal aberrations occurring in less
and the patency was checked with No.15 K-file. Working length than 1% of the cases were 90% bilateral [5]. In the present case,
was determined by an apex locator (Propex-II, Dentsplymallifer, the right maxillary central incisor was also seen with the presence
Ballaigues, Switzerland) and confirmed by files in the radiograph of two roots.
[Table/Fig-3]. Cleaning and shaping was performed by hand During normal root formation, the Hertwig’s epithelial root sheath
instruments with step-back technique using Glyde as a chelating (HERS) is bent horizontally at the Cemento Enamel Junction causing
agent and with copious irrigation in between the instrumentation. the cervical opening of the tooth germ to narrow. Due to any
The facial canal and the distopalatal canal were instrumented up traumatic injury or any unknown factor the fusion of the horizontal
to master apical size of 60 ISO size K-file with alternate irrigation of extensions of the diaphragm remains incomplete, which leads to the
3% sodium hypochlorite solution and saline. Finally the canals were development of accessory root canals opening on the periodontal
rinsed with 2% Chlorhexidine (CHX). Calcium hydroxide paste (RC surface of the root [6].

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[Table/Fig-1]: Pre-operative radiograph of maxillary left central incisor

[Table/Fig-2]: Post-Guttapercha removal
[Table/Fig-3]: Working length radiograph with files placed in two root canals

[Table/Fig-4]: Mastercone radiograph

[Table/Fig-5]: Post-obturation radiograph of maxillary left central incisor
[Table/Fig-6]: Radiograph of maxillary left central incisor with crown

In order to identify these anomalies or variations the radiographs CHX has antibacterial substantivity in dentine for up to 12 weeks.
should be taken in different angulations. Brynolf reported that Irrigating the root canals with CHX delays the contamination of
endodontic diagnosis is correctly obtained 74% of the time with obturated root canals by bacteria which enters through the coronal
one radiograph and 90% of the time with three radiographs that restoration or tooth interface [11].
included an angled view [7]. So, the clinician should always take Calcium hydroxide Ca(OH)2 was used as an intracanal medicament
more than one radiograph from different angulations. Cautiously of choice because of its effective antibacterial properties and it
tracing the outline of the root surface also helps in the diagnosis. causes healing of periapical tissues. Calcium hydroxide is a strong
Intraoral radiography is commonly used method for diagnosis and base with a high pH of approximately 12.5 -12.8. Ca(OH)2 powder is
treatment planning in endodontics, which may mislead the clinician mixed with saline and is placed as intracanal dressing for few days or
into false positive results. So,with the advent of digital radiography weeks. Antibacterial action of Ca(OH)2 is by the ionic dissociation of
and CT Scans the errors were minimized in the clinical cases. In Ca+2 and OH- ions and their effects on vital tissues, which generates
complex root canal anatomy cases, Spiral Computed Tomography induction of hard tissue deposition and being antibacterial [12].
can be used as an additional tool [8]. Cone-Beam Computed The major reason for the failure of this case was incompletely
Tomography (CBCT) is an advanced diagnostic aid which is used obturated facial canal and missed additional distopalatal canal.
in endodontics for diagnosis, treatment planning and for follow-up. When a patient reports with persistent pain after endodontic
Main advantage of using CBCT in endodontics is reduced radiation treatment, suspect for missed canals. For locating the orifices of
exposure with added diagnostic information during complex root canal diagnostic aids are very important. These include careful
endodontic procedures. CBCT is mainly useful to observe the examination of floor of the pulp chamber using sharp explorer,
expansion of periapical lesions, differentiation of periapical lesions, troughing the grooves with ultrasonic tips, staining the pulp chamber
confirming the number of root canals [9,10]. with dye and performing champagne bubble test using Sodium
In the present case, 2% Chlorhexidine (CHX) was used as a final hypochlorite (NaOCl). Explore for the missed canals using multiple
irrigating solution, as it has wide range of activity against both gram- angled radiographs. As the untreated root canal spaces acts as
positive and gram-negative bacteria. CHX is bactericidal, used in nidus for bacterial contamination,causing the failure of treatment.
endodontics routinely during retreatment procedures, as it adsorbs The present case was successfully managed with the help of
to dental tissue and mucous membrane, resulting in its prolonged multiple angled radiographs and proper usage of irrigants and
gradual release at therapeutic levels. Many studies reported that intracanal medicaments which eliminated the drug resistant bacteria

254 Journal of Clinical and Diagnostic Research. 2014 Feb, Vol-8(2):253-255

www.jcdr.net Roopadevi Garlapati et al., Two-rooted Maxillary Central

during re-treatment procedure. A three dimensional obturation with Treatment of a Two-Rooted Maxillary Central Incisor. J Endod. 2006;32:478-81.
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PARTICULARS OF CONTRIBUTORS:
1. Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India.
2. Professor, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India.
3. Reader, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India.
4. Professor, Department of Conservative Dentistry and Endodontics, Sibar Institute of Dental Sciences,Guntur, Andhra Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Roopadevi Garlapati,
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sibar Institute of Dental Sciences, Date of Submission: Sep 29, 2013
Takkellapadu, Guntur-522509, Andhra Pradesh, India.
Date of Peer Review: Dec 8, 2013
Phone: 09052073309, E-mail: [email protected]
Date of Acceptance: Dec 22, 2013
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Feb 03, 2014

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