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Endodontic management of maxillary lateral incisor with palato-gingival groove - an innocuous culprit of endo-perio lesion.

Dr. Rafeza Sultana

MS-Resident, Phase-B

Dept. of Conservative Dentistry & Endodontics

BSMMU

Abstract:

Morphological defects occurring in dental structures can be sometime predisposing factor for the onset of inflamatory processes in the periodontal &/ pulpal tissue. Palato-gingival groove is one such defect, most frequently found on the palatal surface of the maxillary laterals. Recognition of such a defect is critical & important, especially because of its diagnostic complexity & further consequences.  This case repot is to describe the clinical management of tooth with palato-gingival groove (PGG) in a right maxillary lateral incisor with endo-perio lesion leading to dentoaiveolar abscess & sinus tact.

Keyword: Palato-gingival groove, Endo-perio lesion.

Introduction:

The region where the maxillary lateral incisors are located is considered to be an area of embryological hazard (J Dijalma et al, 1991). A great number of minor & major malformations occur in this area. For instance cleft palate, globule-maxillary cyst, missing or supernumerary tooth, dense in dente & peg lateral incisors. Another anomaly occurring in that region is PGG (Everetti FG et al, 1972).

The etiology of groove formation is not fully understood. But it is thought that the formation of PGG is by infolding of the enamel organ & the Hertwing’s root sheath (Walker & Jons, 1983) & has been speculated to an aborted formation of additional root (Keruzoudis et al, 2003).

The PPG has the similarity to dens  invaginatus, however it differs from dens invaginatus in such way that PGG occurs due to an infolding of the epithelium (resulting in a groove), rather than an invagination (resulting in a circular opening) (TG Ground 1988).

The anomaly has a variety of name, the PPG, the radicular lingual groove, the palato-radicular groove, the facial-radicular groove, the disto-lingual groove (Cacflia MS et al, 1998).

The PPG is the funnel shaped appearance which forms a niche for bacterial plaque & calculus accumulation making it difficult for the patients as well as professionals.

These grooves can be classified in to mild, moderate & complex based on its depth and extent. Mild one terminates at the CEJ whereas moderate grooves continue apically along the root surface. The complex forms are deeply grooved defects that separate an accessory root from the main root trunk (Goon WW et al, 1991).

                           

   Mild                                    Moderate                       Complex

                  Fig: Different types of palato-gingival groove.

Deferent studies have revealed a prevalence rate for palatal groove of about 2.8% to 8.5%, the most prevalent being the maxillary lateral incisor (D Rachana et al, 2007). In lateral incisors 43% of the grooves on the root extended less than 5mm. 47% between 6-10mm and only 10% more than 10mm (Kogan 1986).

Case report:

A 30 year old female patient came to the dept. of conservative Dentistry & Endodontics, BSMMU with the complaint of occasional episodes of swelling of gum & purulent discharge in relation to upper right lateral incisor. Her medical history was non contributory. There was no history of trauma, caries nor any discoloration of tooth. Intra-oral examination showed localized swelling & an intraoral draining sinus pointing on the labial gingiva at the apex of right lateral incisor. The palatal surface of lateral incisor showed fossa with mild calculus embedded in it. Periodontal examination revealed mild bleeding on probing & a narrow periodontal pocket (<5mm) alongside the groove & other aspects were revealed normal. There was no mobility associated with it. To locate the origin of the sinus, a gutta percha cone (no#25) was inserted in to its course & a radiograph was taken. The GP cone pointed towards the apex of the offending tooth. Radiograph also showed periapical radiolucency (about 3mm). On vitality test the tooth was found to be non vital. The findings were suggestive of primary pulpal lesion (Type-1 endo- perio lesion).

So, the case was diagnosed as type-I endo-perio lesion due to palato-gingival groove (Mild type).

Treatment plan comprised with of oral prophylaxis followed by primary endodontic management provided three dimensional obturation & repair of PGG with glass ionomer cement (Type-II).

The consent of the patient was taken. After mouth preparation, a straight line access cavity was done. The necrotic pulp remnants were removed & washed out by 2.5% NaOcl & normal saline. Working length (WL) measuring radiograph was taken & the WL was established as 20mm. Then the canal was prepared up to no #50 K file along with copious irrigation with NaOcl & normal saline. The canal was dried with paper point & Ca(0H)₂ paste was placed as an intracanal medicament for one week. The access was tightly sealed with ZOE cement. At the next visit the canal was found dry. Then the canal was irrigated with normal saline and dried with paper point. Before obturation a master point was inserted in to the canal & felt the tug back. Then the tooth was obturated with ZOE sealer & GP cone by lateral condensation technique and final restoration was made with GIC. The post-operative radiograph was taken at the same visit for obturation evaluation. The PPG was repaired with GIC as well. The patient was advised for follow up at 3, 6 & 12 months intervals.

   

Fig: exploration of sinus tract

  

Fig: Detection of PGG

Fig: Shallow periodontal pocket alongside the grioove

Fig: Pre-operative x-ray

Fig: Sinus trakcking x-ray

Fig: WL-measurring x-ray

Fig: Obturation x-ray

Discussion:

Palato-gingival groove is a developmental anomaly that has the predilection for the maxillary lateral incisor. The PGG presents of variable extent & depth that may or may not involve a communication between pulp cavity & periodontal tissue. These grooves are deep initially after root formation & become shallow with age due to deposition of dentin (Anderregg CR, 1993). The PPG is one of the important entities & could manifest either as true endodontic lesion, periodontal disease or may appear as a combined endo-perio lesion.

For anatomical region, the PGG is an ideal plaque trap for promoting periodontal break down & pulp necrosis. Reasons for the occurrence of combined lesion are existence of communication between the pulp chamber and the periodontium. Friedman & Goultschin have suggested pulpal necrosis followed by apical periodontitis is often earliest manifestation of PPG.

Clinician should be aware of the incidence & method for treating PPG. Rrarely the PGG can be seen on radiographic examination in the form of a parallel radiolucent vertical line (RW Lee 1968) or in other cases not following the root canal (DS August 1978).

The PGG requires early diagnosis and treatment as it may result in radicular & pulpual pathosis. This fissure like channel is a locus of plaque & calculus accumulation, which acts as a secondary local etiologic factor encouraging the development of periodontitis (Kozlovsky A 1988). A patient with PGG may have the symptoms of a periodontal or acute dento-alveolar abscess or may show no symptoms at all. Frequently a lesion related to a groove is characterized by recurrent symptomatic episodes (Robinson SF 1988).

The pulp is also affected by bacteria which are situated in the radicular groove. Bacteria and their products may enter in to the pulp through the accessory foramen and lateral canals situated along the floor or side walls of the groove. Another groove of the bacterial invasion into the pulp is via the exposed dentinal tubules on the side of the groove where surface resorption as a result of inflamatory process (N P Kerezoudis 2003).

Treatment may vary from case to case. Early diagnosis of the case is very much important for preventive measure. Teeth with deep palatal groove should be treated with fissure sealant before plaque and food impaction & breakdown of the periodontal structures (M Hulsmann 1997).

Although several modalities have been suggested for the treatment of this condition. There is general consensus that these are predictable failures. Many treatment regimen have been suggested such as conventional root canal treatment, combined root canal therapy followed by saucerization of the defect with flowable composite, intentional replantation and guided tissue regeneration according to severity.

In the last decades, with extensive knowledge of guided tissue regeneration, mechanical barrier have been used to halt the epithelium down growth along the root surface, allowing periodontal ligament, cementum and bone to regenerate along periodontally diseased roots. Calcium sulphate, collagen methyl cellulose acetate, enamel matrix protein etc have used as mechanical barrier to allow periodontal regeneration (S Andreana 1998).

The prognosis of a tooth with PPG mainly depends on location of the groove, severity of the periodontal problem, accessibility of the defect & the type of groove ie shallow or deep, long or short.

In this case report, patient presented with true endodontic involvement (type-1 endo-perio lesion), as an earlier manifestation of PGG. So non surgical endodontic treatment was done provided three dimensional obturation & the groove was repaired with GIC & advised for periodic follow up.

GI cement was used because of its antibacterial activity & the property of chemical adhesion to the tooth structure. Clinical & histological studies have been shown that there is an apical & CT adherence to the GI cement during the healing process.

Conclution:

Palato-gingival groove is an enigma & it is considered as a silent killer that can pose dilemmas for diagnosis & clinical management. The PGG might escape detection until patient presents with advanced pulpal pathosis with secondary periodontal involvement. So the evaluation of clinical signs & appropriate diagnostic tests are of paramount important to prevent incorrect diagnosis & treatment. Endodontists must be capable of performing advanced periodontal regeneration techniques during endo-surgery for the successful treatment of those lesions.

References:

Anderegg CR, Meitzer DG (1993) Treatment of the palato- gingival groove with guided tissue regeneration. Report of 10 cases. J Periodontol 64:72-4

Andreana S A (1998) Combined approach of treatment for developmental groove associated periodontal defect. A case report J periodontal 69: 601-7

August DS (1978) The radicular ligual groove: an overlooked differential diagnosis J Am Dent Assoc 90: 1037-9

Cecflia MS, Lara VS, Moraes IG, Paolo S, Brazil (1998) The palato-gingival groove a cause of failure in root canal treatment. Oral Surg Oral Med Oral pathol Oral radiol Endod 85:94-8).

D. Rachana, Prasannalatha Nadig, Gururaj Nadig (2007) The palata groove: Application of computed tomography in its detection – A case report. Journal of conservative dentistry 10: 83-43(6): 353-361.

Everatt FG, Kermer GM (1972) The disto-lingual groove in the maxillary lateral incisor. J Endod 1991: 17:244-8.

Goon WW, Carpenter WM, Braces NM, Ahlfeld RJ, Complex facial radicular groove in a maxillary lateral incisor. J Endod 1991; 17:244-8.

Jesus Dijalma Pecora, Manoel Damia O Sousaneto Et AI (1991) Invitro Study Of redicular Grooves In Maxillary Incisors. Braz Dent J 2(1):69-73.

Kogan S (1986) The prevalence, location and conformation of palato radicular grooves in maxillary incisors. J Peridontol 57:231.

Kozlovsky A, Tal H, Yechezkiely N, mozes O (1988) Facial radicular grooves in a maxillary central incisor – A case report. J Periodontol September 59(9):615-617.

Lee RW, Lee EC, Poon RY (1968) Palato gingival grooves in maxillary incisors: a possible predisposing factoto localized periodontal disease. Brit dent J 2:14-8

M hulsmann (1997) Dens invaginatus: aetiology, classification, prevalence, diagnosis and treatment considerations. Int Endod J 79-90.

N.P. Kerezoudis, G.J. Siskos & V. Tsatsas (2003) Bilateral buccal radicular groove in maxillary incisors: case report. Int Endo Jour 36:898-906.

Robinson SF, Cooley RI (1988) Palato-gingival groove lesions: recognition and treatment. Gen Dent 36:340-342.

Tom G. Gound, Glenn I. Mze (1998) treatment options For The Redicular Lingual Groove A Review & Discussion. Pract Periodont Aesthetic Dent 10(3):369-375.

Reattachment of fractured coronal tooth fragment of maxillary central incisor by using fiber reinforced post- Regaining back to normal.

Dr. Rafeza Sultana

MS- Resident, phase-B

Dept. of Conservative Dentistry & Endodontics

Bangabandhu Sheikh Mujib Medical University, Dhaka.

Abstract:

Dental trauma is such a situation where in the patient is affected both socially and psychologically. Such patients are quite apprehensive because of impaired function, esthetics and phonetics. The prime objective while handling such cases is immediate restoration of function, esthetics and phonetics as well. The advances in adhesive dentistry have allowed dentist to use the patient’s own fragment to restore the fractured tooth. Reattachment of tooth fragment is such an ultraconservative technique which provides safe, fast & esthetically pleasing results. This case report presents a 27 year male patient with a complicated crown fracture of maxillary right central incisor tooth; where fracture fragment luted with reattachment technique. The procedure used to repair the fracture fragment included endodontic treatment & after root canal obturation a glass fiber post is used for reinforcement and fragment was luted with composite resin. On word assessment showed a stable reattachment, good esthetic and periodontal health.

Key word: Coronal fracture, fragment reattachment, Composite resin, fiber post.

Introduction:

Almost every dental expert is familiar with the patient having traumatized tooth at their regular practice. The most affected teeth are maxillary incisors due to their anterior position and protrusion and the common etiological factor of crown or crown root fracture in the permanent dentition are injuries caused by fall, contact sports, automobile accident and foreign body striking the teeth. Esthetic rehabilitation of crown fractures of the maxillary anterior teeth is one of the greatest challenges to the dental specialist. The patients are very conscious about their appearance where as the specialist has to consider long term biological function of that tooth in addition to esthetic. Traditionally such injuries have been restored with composite resin¹, but they have some disadvantages of colour match and variable wear.⁶ On the other hand reattachment of fractured fragment may offer following advantages (1) Better esthetic and achievement of lifelike translucency (2) Require less time (3) A positive emotional and social response from the patient’s side⁵ (4) Relatively inexpensive procedure.

Moreover several factors influence the management of coronal tooth fracture including extend of fracture, pattern of fracture and restorability of fractured tooth, secondary trauma, presence/absence of fractured tooth fragment and it’s condition for use, occlusion, esthetic, finances and prognosis.^3,15,18 With the recent improvement in the dental materials, resin based restorative materials with the use of tooth coloured fiber reinforced polymer posts are of choice for such treatment protocol. Because the biomechanical properties of fiber reinforced polymer post are reported close to those of dentin⁸ like esthetic, bonding to tooth structure, modulus of elasticity and cause fewer tooth fracture.²⁰

If a broken tooth fragment is available and in a good condition the restoration of the tooth using its won fragment has been suggested.²¹

Case Report:

A 27 year old male patient reported to the Dept. of Conservative Dentistry and Endodontics BSMMU with the chief complaint of broken upper front tooth following trauma due to hard substance striking while taking food 7 days back.

His medical history was all right. Clinical examination revealed a clean fracture horizontally mesial to distal and angulated incisally from palatal to labial with pulp exposure on the labial surface of right maxillary central incisor. Fracture was not evident labially. There no apparent trauma to the adjacent teeth and soft tissues. On radiographic examination revealed an oblique fracture palato-labially. After routine history taking, examination and based upon patient’s desire, a treatment plan was formulated that included endodontic treatment and reattachment of fractured portion of tooth with composite resin using a fiber reinforced post.

In the first appointment a single visit endodontic treatment was performed. Under local anesthesia, the pulp was extirpated and the working length was determined by working length measuring X-ray. Then the root canal was prepared as standardized technique at 17mm working length up to 70 H file and obturated with Gutta Percha by lateral condensation technique.

The fractured fragment was completely separated, dehydrated and chalky white in appearance. In order to prevent dehydration and to get the natural appearance, the fractured fragment was preserved in normal saline for 7 days. After 7 days, in the next visit the GP was partially removed by pesos-reamer (No-1) leaving 5 mm GP at the apex to maintain a tight apical seal. A post hole was prepared within the canal and a perfect diameter sized glass fiber composit post(Glassix, Nordin) was cemented with the root canal using glass ionomer luting cement (GC corporation). An internal groove was made both in fractured fragment and the palatal aspect of the tooth where the fiber post and composite will occupy. Acid etching was done on both the fragment and the tooth using 37% orthofhosforic acid for 15 seconds and thoroughly rinse off. A bonding agent (Beautibond, sofu) was applied to both the substrates and cured according to manufacturer instruction.

Then the fragment was reattached with flowable composite resin (Beautifil flow, Sofu). The excess resin was removed with an excavator and light cured for 30 seconds from both buccal and palatal aspect. Final finishing and polishing was done. Occlusion was cheeked and post operating instructions were given and patient was recalled after 7 days for evaluation. Clinical and radiological examination carried out after 1 month, 3 months, 6 months and 1 year to confirm the satisfactory esthetic and functional outcome of the treatment with no associated endodontic or periodontal problem.

Discussion:

Up to date, a lot of deferent approaches were proposed for treatment of fractured tooth depending on location of the fracture such as (1) Reattachment of the fractured fragment (2) Composite restoration (3) Orthodontic extrusion (4) Surgical extrusion (5) Crown lengthening.¹¹

In recent years due to remarkable advancements of adhesive systems and resin composites, it is now possible to achieve excellent results with reattachment of tooth fragments provided that the biological factors, materials, and techniques are logically assessed and managed.¹⁶ As with the conventional restoration, restorative success depends on proper case selection, strict adherence to sound principles of periodontal and endodontic therapies, and the techniques and materials for modern adhesive dentistry.^10,12,14

In the presented case of complicated crown fracture requiring endodontic therapy, the fractured fragment was available and reattachment of the fragment with fiber post is performed to retain the fractured segment and reduce the stress on the luting material. The posts interlock the two separate fragments and minimize the stress on the remaining tooth structure. The use of the natural tooth substance offers a conservative, esthetic, and economical option that provides good and long lasting esthetics, restores function, results in a positive psychological response, and is certainly a simple procedure. Adhesive post is used as it has the potential for increased retention, is more flexible, and has modulus of elasticity approximately same as dentin, and when bonded with resin cement it distributes forces evenly along the root.¹⁷

The most common complication of post and core system is debonding;⁴ another reason for failure is root fracture.⁹ Restoration with cast metal posts can cause wedging forces coronally that may result in irreversible failure because of fracture of an already weakened root.² Whereas fiber-reinforced composite resin post has demonstrated negligible root fracture. Studies have indicated that dentin-bonded resin post-core restorations provide significantly resistance to fracture than cemented custom cast posts and cores.^7,19 In addition; the fiber-reinforced posts are used with minimal preparation because it uses the undercuts and surface irregularities to increase the surface area for bonding, thus reducing the possibility of tooth fracture during function or traumatic injury.¹³

Various studies reported that sectional obturation of root canal (at the apex) and use of dual cure resin play an important role in the successful treatment outcome of reattachment technique. Use of a fiber post luted with dual cure resin increase the retention of the segment and provides a monoblock effect by locking the core material (fiber post) with the dentinal wall of root canal without leaving any gaps.

Most concerns about reattachment technique have been directed towards the fractured strength of the restored tooth. There are several reinforcement techniques adapted to strengthen the tooth structures like – i) Circumferential bevel, ii) External chamfer, iii) ‘V’ shaped bevel, iv) Placement of internal grooves, v) superficial over contour of restorative material over the fracture line and pulp chamber, in case of complicated fracture.¹⁸  

The clinician must consider that a dry and clean working field and proper use of bonding protocols and bonding materials is the key to achieve success in adhesive dentistry.

Conclusion:

Because of larger incidence of trauma to dental tissues and their supporting structures, it is important to have proper knowledge of the techniques available and their indications, along with risk benefit ratio. The reattachment of the tooth fragment is possible only when the fragment is available and can be improved with different adhesive techniques and restorative materials. The main concern is to educate the population to preserve the fractured fragment and seek immediate dental care.

References:

1.       Attila IO, Cenk MHA, Serdar MT. Multidisciplinary approach to the rehabilitation of a crown –root fracture for immediate esthetics. Dent Traumatol 2006; 22:48-52.

2.       A. S. Deutsch, J. Cavallari, B. L. Musikant, L. Silverstein, J. Lepley, and G. Petroni, “Root fracture and the design of prefabricated posts,” The Journal of Prosthetic Dentistry, vol. 53, no. 5, pp. 637–640, 1985. 

3.       Andreasen FM, Noren JG, Andreasen JO, et al. long term survival of fragment bonding in the treatment of fractured crowns. Quintessence Int 1995; 26:669-81.

4.       A. Torbjörner, S. Karlsson, O. Dr, and P. A. Ödman, “Survival rate and failure characteristics for two post designs,” The Journal of Prosthetic Dentistry, vol. 73, no. 5, pp. 439–444, 1995. 

5.       Baratieri LN, Monteiro S. tooth fracture reattachment: Case reports. Quint Int 1990; 21:261-270.

6.       Badami A, Dunnes, Scheer B. As in vitro investigation into shear bond strengths of two dentine bonding agents used in the reattachment of incise edge fragments. Endo Dent Traumat 1995; 11:29-135.

7.       B. Akkayan and T. Gülmez, “Resistance to fracture of endodontically treated teeth restored with different post systems,” The Journal of Prosthetic Dentistry, vol. 87, no. 4, pp. 431–437, 2002.

8.       Duret B, Duret F, Reynaud M. Long-life physical property preservation and postendodontic rehabilitation with the composipost. Compend Contin Educ Dent Suppl. 1996;20:50–56.

9.       E. Asmussen, A. Peutzfeldt, and T. Heitmann, “Stiffness, elastic limit, and strength of newer types of endodontic posts,” Journal of Dentistry, vol. 27, no. 4, pp. 275–278, 1999.

10.   F. M. Andreasen, U. Steinhardt, M. Bille, and E. C. Musksgaard, “Bonding of enamel-dentin crown fragments after crown fracture. An experimental study using bonding agents,” Endodontics & Dental Traumatology, vol. 9, no. 3, pp. 111–114, 1993.

11.   Georgia. V. Macedo, Patrica Diaz, Carlos augusto. Reattachment of anterior tooth fragment: A conservative approach. Journal of Esthetic and Restorative dentistry 2008; 20:5-20.

12.   G. Cavalleri and N. Zerman, “Traumatic crown fractures in permanent incisors with immature roots: a follow-up study,” Endodontics & Dental Traumatology, vol. 11, no. 6, pp. 294–296, 1995.

13.   K. C. Trabert, A. A. Caputo, and M. Abou-Rass, “Tooth fracture—a comparison of endodontic and restorative treatments,” Journal of Endodontics, vol. 4, no. 11, pp. 341–345, 1978.

14.   M. N. Lowey, “Reattachment of a fractured central incisor tooth fragment,” British Dental Journal, vol. 170, no. 8, article 285, 1991.

15.   Olsburgh S, Jacoby T, Krejci I. crown fractures in the permanent dentition: pulpal and restorative consideration. Dent traumatol 2002; 18(3): 103-15.

16.   P. Vashisth, M. Mittal, and A. P. Singh, “Immediate reattachment of fractured tooth segment: a biological approach,” Indian Journal of Dental Research and Review, pp. 72–74, 2012.

17.   P. Lokesh and M. Kala, “Management of mild-root fracture using MTA and fiber post to reinforce crown—a case report,” Indian Journal of Dental Research and Review, vol. 3, pp. 32–36, 2008.

18.   Reis A, Francci C, Loguercio AD, et al. Re-attachment of anterior fractured teeth: fracture strength using different techniques. Oper Dent 2001; 26(3):287-94.

19.   R. T. Beg, M. W. Parker, J. T. Judkins, and G. B. Pelleu, “Effect of dentinal bonded resin post-core preparations on resistance to vertical root fracture,” The Journal of Prosthetic Dentistry, vol. 67, no. 6, pp. 768–772, 1992.

20.   Salameh Z, Sorrentino R, Papacchini F, Ounsi HF, Tashkandi E, Goracci C, Ferrari M. Fracture resistance and failure patterns of endodontically treated mandibular molars restored using resin composite with or without translucent glass fiber-post. J Endod. 2006;32:7752–7755. 

21.   Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. evaluation of success in the reattachment of control fractures, Dent Traumatol 2008; 24:151-8.

Figures of various steps of reattachment technique.

Fig: Pre-Operative photograph

Fig: Fracture fragment (labial view)  

Fig: Fracture fragment (palatal view)  

Fig: Fiber reinforced post 

Fig: post placement  

Fig: post placement  

Fig: Groove preparation  

Fig: Trial of fragment reattachment 

Fig: Trial of fragment reattachment 

Fig: Check occlusion  

Fig: Light curing of composite resin 

Fig: Light curing of composite resin 

Fig: Post operative occlusion check 

Fig: After treatment

Radiographic assessment.

Fig: Pre-operative 

Fig: per-operative 

Fig: per-operative 

Fig: post-operative

Fluoride seal to forbid dental cavity in children and teenagers

Objective

High dental cavity commons disease affecting a big part of the world wide population, including around 65% to 80% of school-age children. In general, levels of dental cavity varies substantially between and breast of the several countries, but in low socio-economic position (SES), children have higher levels of dental cavity than those in higher SES groups. Treatment of cavity causes of the teeth accompanied by suffering and pain. Repair and alternate of dental cavity is costly, that represents a significant drain on resources for health care systems.

Fluoride seal is a potential option to prevent dental cavity in children. This developed in the 1960s and has been widely used in Europe and Canada. Use in other countries appears to be increasing, including in the US, where it can be used outside of the label as preventive agents of decay.

Two large meta-analysis reviews indicated significant reductions in caries in deciduous and permanent teeth. However, there was significant heterogeneity among the studies within each body of meta-analysis of the evidence for the two meta-analyses of average quality.

Thirteen tests allowed data for meta-analysis of the surface of the permanent tooth, and the fraction bundle of FS (M) prevented estimate comparing fluoride seal with placebo or no treatment was 43% (95% confidence interval (CI) 30-57%). d (e/m) to prevent the perceptiveness of the falling out was 36% (90% CI(: 25% to 52%) Ten tests provided data for meta-analysis of the surface of the tooth. Prevents any significant correlation between the d (M) FS or FS fractions d (e/m) has been found on the baseline of caries risk of infection factors. It was background exposure to fluoride, the capacities of the application such as prevention, fluoride concentration, and continually of application. It there was also no significant association in models meta-regression between estimates of d (M) FS or FS d (e/m) prevents fractures and after special factors such as whether the use of a placebo or no treatment control, duration of follow-up, or whether to use individual or randomized cluster. There was little information on potential adverse effects or accept treatment.

This updated review conclusions remain the same when you appear first, but are enhanced by the addition of various more recent studies. The analysis suggests significant effect prevents caries of primary and permanent dental varnish fluoride, but the quality of the evidence was considered to be moderate, because they included mainly studies present a high risk of bias and heterogeneity.

Endodontic management of Mandibular first molar with five canals

Dr. Rafeza Sultana

Ms- Resident, Department of Conservative Dentistry & Endodontic.

BSMMU

Abstract: The purpose of this study was to demonstrate the importance of knowledge of the internal anatomy of root canals for the success of endodontic treatment. Lack of knowledge of anatomic variations & their characteristics in different teeth has been pointed out as one of the causes of endodontic therapy failure. The present report  describes a right mandibular first permanent molar requiring root canal therapy, found to have three separate canals ( type-1 configuration) in the mesial  root & two separate canals ( type-1 configuration) in the distal root . So emphasizes the need for the clinicians to be aware of & look out for such variation & use adequate diagnostic methodologies prior to & during therapy to detect such variations. The operator experience has also shown to be a key factor in negotiation & management of this aberrant canal configuration.

Key Word: Mandibular 1^st Molar, Middle Mesial canal, % root canal, Root canal anatomy.

Introduction: Knowledge of internal dental anatomy is fundamental to the success of endodontic treatment. Incomplete instrumentation, inadequate cleaning & shaping, & the subsequent defective obscuration of root canals are the main causes of endodontic treatment failure¹. Anatomical characteristics of the different types of teeth and their possible variations are challenges routinely faced by practitioners performing endodontic treatment.

The correct access into the pulp chamber, which should allow access to the orifices of the root canals and an optimum view of the chamber floor, is a fundamental step in endodontic therapy as it enables the identification of any variation in the number and position of root  canals² .

The middle mesial canal has been more commonly located in mandibular 1^st molar¹⁰.  Several studies have evaluated the degree of variation in the number of roots and root canals in mandibular 1^st molars¹⁰ .  Fabra  campons¹⁰ studies 145 mandibular 1^st molars & found that 2.75% of the teeth had five canals. Martinez-burna and Badanelli⁵ conducted a canal investigation & found 29 teeth with five root canals in a sample of 2362 mandibular permanent molars and reported that 12 out of 100 molars studied had a third mesial canal.

Aminsobhani et all studied the occurrence and location of the middle mesial canal of mandibular 1^st molar & second molar in relation to other two mesial canals that were treated in private practice that middle mesial canalwas located in the middle of the distance between the mesiobuccal and mesiolingual canals. The canal configuration  was found in 6 2^nd molars & 21 1^st molars. Middle mesial canals in all of the cases joined to mesiobuccal or mesioligualcanals. None of the teeth consisted  of three independent canals with three apical foramina . Beatty & krell described  a mandibular 1^st molar with three independent canals in the mesial root . Author Dr. carlos Heibom et  al reported the number of roots, total number of canals, the number of middle mesial canals & number of foramina in the following chart

Number of roots Number of molars studied                  18,781                        3-rooted molars in %                  13 % (2,450)

Total number of canals Number of molars studied                   4,745         61.3 % 3 canals        35.7 % 4 canals       0.8 % 5 canals

Number of canals in mesial root Number of mesial roots studied           4,535         3.3 % 1 canal            94.2 % 2 canals      2.6 % 3 canals

Mesial and distal roots. Canal system configuration                                                                            Type I (1-1)   Type II (2-1)   Type IV (2-2)   Type VIII (3-3) Number of mesial roots studied           4,331                               35 %               52.3 %                0.9 % Number of distal roots studied             2,992         62.7 %           14.5 %            12.4 %

Number of foramina in mesial and distal roots                                                                                    1 foramen                2 foramina                   3 foramina Number of mesial roots studied          4,817                  38.2 %                      59.2 %                         1.6 % Number of distal roots studied            3,378                  77.2 %                      22.2 %

Intercanal communications. Type V isthmuses                                                                                               Mesial root                                 Distal root Number of molars studied                   1,615             54.8 % middle & apical 1/3              20.2 % middle 1/3

According to ingle¹² one of the most important causes of endodontic treatment failure is the incomplete obturation of the root canal system. Therefore, the correct location, instrumentation & obturation of all canals are indispensable procedures. 

Case report: A 19 years old male patient reported to the department of conservative dentistry & endodontics BSMMU with decayed tooth & associated pain over his right mandibular region. Intra oral examination revealed class 1 deep carious lesion in mandibular right 1^st molar. The tooth exhibited no mobility, was mildly tender to percussion and gives a negative respond to vitality test. The pre operative diagnostic radiograph of the tooth revealed a deep carious lesion involving the pulp with widening of apical periodontal space. A diagnosis of necrotic pulp with apical periodontitis was made and endodontic treatment was scheduled. After administration of local anesthesia & isolation, the carious lesion was removed and an

Endodontic access was made. Inspection of pulp chamber floor showed orifices corresponding to mesiobuccal, mesioligual, distobuccal abd distolingual canals. On careful examination of the groove between the mesiobucccl and mesiolingual canal orifice was identified and subsequently negotiated. The working length was established (MB-20mm, ML-20mm, Middle Mesial-19mm,DB-19.5mm,DL-19mm).The canals were instrumented with NiTi  file and irrigation was done with  2.5% NaOCl solution. After preparation the canal was finally flushed with normal saline & dried with sterile paper points and Ca(OH)2 was given at the full length of the canals with Lentulo-spiral  for 1 week. At the subsequent visit the Ca(OH)2 dressing was removed, the master cone fit was cheeked and the root canal was dried with absorbent paper point and was obturated with GP cone.

Discussion: Before root canal treatment clinician should adequate knowledge of the pulp chamber and anatomy of teeth. All root canals should be accessed, cleaned and shaped to achieve a hermetic obturation of the entire root canal space.

There is an abundant amount of reports that relate the anatomic variations of the mandibular molars. This should induce the clinician to observe the pulp chamber floor to locate possible canal orifices. This will increase the long term prognosis of endodontic therapy. Searching for additional canal orifice should be standard practice for clinician. A round bur or ultrasonic tip can be used for removal of any protuberance from the mesial axial wall would prevent direct access to the developmental groove between MB & ML orifices. This developmental groove should be carefully cheeked with sharp endodontic explorer (DG-16, JW-17). If orifices are located the groove can be troughed with ultrasonic tip, its mesial aspect until small file can negotiate this intermediate canal^{4 .} New technology such as dental operating microscopes and dental loupes offer magnification and illumination of the operating field and substantially improved the visualization of the root canal orifices^5-6. But we did not use these new technologies during treatment session.

Numerous studies in the past decade have described the morphology of teeth including mandibular molars⁷. The morphology of mesial root canals in mandibular molar is complex and high frequency of intercanal communication and or isthmuses ^{(7,8,9,10-13)}.

The presence of third canal (middle mesial) in the mesial root of the mandibular molars has been reported to have an incidence of 0.95% to 15%^{(4,7,11,14,15,19)}.In almost all of the clinical cases  reported until today these canals joined the mesiobuccal & mesiolingual canal in the apica third²⁰.

Radiographic examination using intraoral periapical view is important for the evaluation of the canal configuration. However it has its inherent limitation to access the root canal system completely. Digital radiography at different angles with subsequent image analysis can be used effectively. Computed tomography (CT) imaging has been widely used in medicine since the 1970s and was introduced in the endodontic field in 1990. Recently cone beam CT (CBCT) and RVG imaging has been shown to provide comparable images at reduced dose and cost to be considered as an alternative to multi detector CT imaging in endodontic. La et al. 2010 suggested clinical detection and management of an independent middle mesial  canal in mandibular molar by using CBCT imaging.

Various diagnostic aids like dyes, champagne bubble test , ultrasonic’s, micro openers and transillumination  aids, irrigators to improve pulp chamber visibility (Stropko) and observing the chamber for bleeding spots could be used by the clinician as an effective means to locate additional canal orifices.

Conclusion: knowledge of dental anatomy in fundamental for good endodontic preparation. Identification of these extra canals and their instrumentation is one of the key factors in the prevention of unsuccessful treatment outcomes. In addition to the various diagnostic aids, operator experience has also been identified as a key factor in locating these aberrant canals. The clinician should be aware of the incidence of this type of variation in the mandibular first molar tooth and perform a preoperative radiological assessment from different angles, a proper access preparation, and thorough examination of the pulp chamber to locate and debride all the canals. An accurate clinical evaluation of root canal and morphology in mandibular first molar should be done using various diagnostic methodologies with magnification and illumination, which would pave the way for long-term success of endodontic therapy.

References

1. Leonardo MR. Aspectos anatômicos da cavidade pulpar:

relações com o tratamento de canais radiculares. In:

Leonardo MR, Leal JM, eds. Endodontia: tratamento de

canais radiculares. 3rd ed. São Paulo: Panamericana;

1998. p. 191.

2. Balleri P, Gesi A, Ferrari M. Primer premolar superior

con tres raíces. J Endod Pract 1997; 3: 2.

3. Hess W. The anatomy of the root canals of the teeth of

the permanent dentition. Part 1. New York: Williams

Wood; 1925.

4. De Deus QD. Endodontia. 5th ed. Rio de Janeiro: Medsi;

1992.

5. Martinez-Berna A, Badanelli P. Investigación clinica de

molares inferiores con cinco conductos. Boletín de

Information Dental 1983; 43: 27–41.

6. Okumura T. Anatomy of the root canals. JADA 1927;

632–6.

7. Skidmore AE, Bjorndal AM. Root canal morphology of

the human mandibular first molar. Oral Surg 1971; 32:

778–84.

8. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic

investigation of 7,275 root canals. Oral Surg

Oral Med and Oral Path 1972; 33: 101–10.

9. Hartwell G, Bellizzi R. Clinical investigation of in vivo

endodontically treated mandibular and maxillary molars.

J Endod 1982; 8: 555–7.

10. Fabra-Campos CH. Unusual root anatomy of mandibular

first molars. J Endod 1985; 11: 568–72.

11. Jacobsen EL, Dick K, Bodell R. Mandibular first molars

with multiple mesial canals. J Endod 1994; 20:

610–13.

12. Ingle JI. Endodontics. 3rd ed. Philadelphia, PA:

Saunders; 1985.

13. Vertucci FJ. Root canal anatomy of the human permanent

teeth. Oral Surg Oral Med Oral Pathol 1984; 58:

589–99.

14. De Grood ME, Cunningham CJ. Mandibular molar

with 5 canals: report of a case. J Endod 1997; 23:

60–2.

15. Marshall FJ, Papin J. A crown-down pressureless preparation

root canal enlargement technique. Technique

manual. Portland: Oregon Health Sciences University;

1980.

16. Tagger M. Use of thermo-mechanical compactors as an

adjunct to lateral condensation. Quintessence Int 1984;

15: 27–30.

17. Vande Voorde HE, Odendahl D, Davis J. Molar 4th

canals: frequent cause of endodontic failure. III. Dent J

1975; 44: 779–86.

Figure 4 Final radiograph of obturation of five canals.

F. B. Barletta et al. Mandibular Molar with Five Root Canals

© 2007 The Authors 3

Journal compilation © 2007 Australian Society of Endodontology

18. Badanelli P, Martinez-Berna A. Obturacion de un molar

inferior con cinco conductos. In: Lasala A, ed. Endodoncia.

Barcelona: Salvat S. A.; 1979. p. 407.

19. Carvalho MC, Zuolo ML. Orifice locating with a microscope.

J Endod 2000; 26: 532–4.

20. Bueno CE, Cunha RS, Dotto SR, Ferreira R. Um molar

inferior com cinco canais – caso reportado. Rev Fac

Odontol Univ Passo Fundo 2002; 7: 51–3.

Mandibular