Endodontic Treatment of a Mandibular Canine with Three Root Canals and Periradicular Lesion – Case Report

Knowledge of morphological variations of the root canal system is essential for successful endodontic treatment. Thorough debridement of the root canals, followed by an appropriate three− dimensional obturation prevents the leakage of residual bacteria and their by−products into the periradicular area. To achieve this aim the clini− cian should never assume that a given tooth will contain a specific number of canals [1]. He should

be aware of possibility of existing the additional root canals, which must be detected; otherwise treatment failure is extremely possible [2].

There were some studies that reported on the morphological variations associated with man− dibular canines. The incidence of two canals with separate foramina was stated by Green in 3% of cases [3] and by Vertucci in 6% of cases [4], whereas the occurrence of a third canals was no

DAMIAN

LICHOTA

_{, ALICJA}

_NOWICKA

_{, JADWIGA}

_{BUCZKOWSKA−RADLIŃSKA}

_,

KRZYSZTOF

WOŹNIAK

_{, MARIUSZ}

_LIPSKI

Endodontic Treatment of a Mandibular Canine

with Three Root Canals and Periradicular Lesion

– Case Report

Leczenie endodontyczne kła żuchwy z trzema kanałami korzeniowymi

i zmianami okołowierzchołkowymi – opis przypadku

1_{Department of Conservative Dentistry, Pomeranian Medical University, Szczecin, Poland} 2_{Department of Orthodontics, Pomeranian Medical University, Szczecin, Poland}

3_{Department of Preclinical Conservative Dentistry and Preclinical Endodontics, Pomeranian Medical University,}

Szczecin, Poland

Dent. Med. Probl. 2009, 46, 1, 131–133 ISSN 1644−387X

CLINICAL CASE

© Copyright by Wroclaw Medical University and Polish Stomatological Association

Abstract

A thorough diagnosis of the anatomy of the root canal system is a prerequisite for successful root canal treatment. Careful observing of the preoperative radiographs and examination of the pulp chamber floor help the location of root canal orifices. It is important during endodontic treatment of all teeth, even if possibility of occurrence of addi− tional root canals is extremely low. This clinical article presents and describes successful endodontic treatment of a mandibular canine with two roots, three root canals with three separate foramina and periradicular lesion. After biomechanical preparation using rotary NiTi instruments the root canals were obturated using cold lateral conden− sation of gutta−percha cones and AH plus sealer. Two−years recall showed complete bone healing (Dent. Med.

Probl. 2009, 46, 1, 131–133).

Key words: mandibular canine, three root canals.

Streszczenie

Szczegółowe poznanie anatomii systemu kanałów korzeniowych jest warunkiem powodzenia leczenia endodontycz− nego. Wnikliwa analiza zdjęć radiologicznych wykonanych przed rozpoczęciem leczenia oraz badanie dna komory zęba pomagają umiejscowić ujście kanałów korzeniowych. Jest to ważne podczas leczenia endodontycznego wszystkich zębów, nawet wtedy, kiedy prawdopodobieństwo wystąpienia dodatkowych kanałów korzeniowych jest bardzo małe. W artykule opisano udane leczenie endodontyczne dolnego kła żuchwy z dwoma korzeniami, mającego trzy kanały korzeniowe o oddzielnych otworach anatomicznych oraz zmiany okołowierzchołkowe. Po biomechanicznym opracowaniu z użyciem rotacyjnych narzędzi niklowo−tytanowych kanały korzeniowe zostały wypełnione metodą bocznej kondensacji gutaperki i pasty AH plus jako sealera. Po dwóch latach od leczenia stwierdzono całkowite wygojenie kości (Dent. Med. Probl. 2009, 46, 1, 131–133).

stated in studies mentioned above, as well as it was no stated in study of Pineda and Kuttler [5].

The aim of this study was to present a very rare case of treatment of mandibular canine with two roots, three root canals with three separate foramina and periradicular lesion.

Case Report

A 53−year−old female patient with noncontrib− utory medical history was referred to the endodon− tic specialist for endodontic treatment of the mandibular left canine before projected prosthetic treatment. At presentation the tooth was symptom free. Clinical examination revealed a prosthetic crown covering mandibular left canine. Preoperative radiograph indicated the presence of the post and two separate roots with no obturated canals, as well evidence of periradicular radiolu− cency (Fig. 1).

The prosthetic crown and the post were removed and appropriate access to the pulp cham− ber was made. Two orifices situated lingually and buccally were found immediately. After careful inspection of the chamber floor connecting both orifices the third orifice was located near the buc− cal canal and close to the mesial pulp chamber wall. All three canals were investigated with a size 10 K−file (Mani, Tochigi, Japan). The canals buccal and „third” were instrumented to a size 15 whereas lingual canal was wider than two others and initial− ly was instrumented to a size 20. Working length was estimated using an apex locator Apit (Osada, Tokyo, Japan) and a radiograph with reamers inserted into root canals was taken (Fig. 2). The buccal and „third” canals were enlarged with the hand K−files (Mani, Tochigi, Japan) to a size 20 and than all root canals were prepared in a crown− down method using ProFile rotary NiTi instru− ments (Maillefer/Dentsply, Ballaigues, Switzerland)

powered by the endodontic micromotor Endostep− per (S.E.T., Olching, Germany) to a size 35 and taper.06. During preparation copious irrigation was performed with 2% natrium hypochloride and File− Eze (Ultradent, South Jordan, UT, USA) was used as a lubricant. The canals were dried with paper points and obturated with AH plus root canal seal− er (Dentsply/DeTrey, Konstanz, Germany) and a gutta−percha cones using cold lateral condensa− tion. A temporary filling was placed and a postop− erative radiograph was taken to assess the quality of obturation (Fig. 3). Four weeks later the pros− thetic treatment has been performed. It was made the post and prosthetic crown. Two−year follow−up examination revealed in complete bone repair (Fig. 4).

Discussion

An occurrence of a canine with three root canals is a great curiosity. A review of the litera− ture revealed in only few case reports. Heling et al. [6] described a case of a root canal retreatment in a mandibular canine with two roots and three canals. Holtzman [7] reported an endodontic treat− ment of mandibular canine with three root canals. Orguneser and Kartal [8] described a case of endodontic treatment of mandibular canine with three root canals and two foramina.

The variability of the root canal system repre− sents a challenge to both endodontic diagnosis and treatment. The tooth described in the present study possessed three root canals with three separate foramina. In result of observation of the preopera− tive radiograph the possibility of presence of two roots and two canals was taken into consideration. However, initial radiographs alone are not suffi− cient to give a complete image of the internal anatomy of the tooth [9]. In presented study pre− operative radiograph did not suggest that the D. LICHOTAet al. 132

Fig. 1. Preoperative radiograph of tooth 33 shows two

roots and periradicular radiolucency

Ryc. 1. Przedoperacyjne RTG zęba 33 uwidacznia dno

korzenie i zmiany okołowierzchołkowe

Fig. 2. Length−determination radiograph with instru−

ments inserted into root canals

Ryc. 2. Pomiarowe zdjęcie radiologiczne z narzędzia−

„third” canal exist and it was found in conse− quence of a thorough examination of the pulp chamber and pulp chamber floor. England et al. [10] stated that the preoperative radiographs of good quality, tactile examination of both the pulpal floor and pulpal chamber as well as detailed knowledge of the morphology of the root canal system are prerequisite for successful root canal treatment. In our opinion mentioned factors are of equal importance too.

In teeth with aberrant anatomy the more apical is situated pulp chamber floor, the more difficul− ties with identification of the orifices and insertion of the instruments into canals may occur. In pre− sent case the pulp chamber floor was situated in the coronal part of the root canal what made the treatment relatively easier. However, initial prepa− ration with hand files and enlarging to a size 20 facilitate subsequent instrumentation with NiTi rotary instruments.

Endodontic Treatment of a Mandibular Canine

133

Fig. 3. Radiographic control following obturation of

three root canals. Note that right canine possess two roots as well

Ryc. 3. Kontrolne RTG wykonane po wypełnieniu

3 kanałów korzeniowych, prawy kieł również ma 2 korzenie

Fig. 4. Two−year follow−up radiograph of tooth 33

showing complete bone repair

Ryc. 4. Kontrolne RTG wykonane 2 lata po zakończe−

niu leczenia uwidacznia całkowite wygojenie kości

References

[1] D’ARCANGELOC., VARVARAG., DEFAZIOP.: Root canal treatment in mandibular canines with two roots: a report of two cases. Int. Endod. J. 2001, 34, 331–334.

[2] HOENM. M., PINKF. E.: Contemporary endodontic retreatments: an analysis based on clinical treatment findings. J. Endod. 2002, 28, 834–836.

[3] GREEND.: Double canals in single roots. Oral Surg. Oral Med. Oral Pathol. 1973, 35, 689–696.

[4] VERTUCCIF. J.: Root canal anatomy of the human permanent teeth. Oral Surg. Oral Med. Oral Pathol. 1984, 58, 589–599.

[5] PINEDAF., KUTTLERY.: Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg. Oral Med. Oral Pathol. 1972, 33, 101–110.

[6] HELINGI., GOTTLIEB−DADONI., CHANDLERN.P.: Mandibular canine with two roots and three root canals. Endod. Dent. Traumatol. 1995, 11, 301–302.

[7] HOLTZMANL.: Root canal treatment of a mandibular canine with three root canals. Case report. Int. Endod. J. 1997, 30, 291–293.

[8] ORGUNESERA., KARTALN.: Three canals and two foramina in a mandibular canine. J. Endod. 1998, 24, 444–445. [9] TZANETAKISG.N., LAGOUDAKOST.A., KONTAKIOTISE.G.: Endodontic treatment of a mandibular second premolar

with four canals using operating microscope. J. Endod. 2007, 33, 318–321.

[10] ENGLANDM.C., HARTWELLG.R., LANCEJ.R.: Detection and treatment of multiple canals in mandibular premolars. J. Endod. 1991, 17, 174–178.

Address for correspondence:

Damian Lichota

Department of Conservative Dentistry Pomeranian Medical University Al. Powstańców Wlkp. 72 70−111 Szczecin Poland Tel.: 48 91 466 16 48 Fax: 48 91 466 17 71 E−mail: atol@sci.pam.szczecin.pl Received 24.04.2009 Revised: 29.04.2009 Accepted: 29.04.2009

Praca wpłynęła do Redakcji: 24.04.2009 r. Po recenzji: 29.04.2009 r.