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Case Report

A novel clinical endodontic approach: Radix entomolaris

Kavita Dhinsa a,*, Firoza Samadi b, J.N. Jaiswal c, Sonali Saha a

aSenior Lecturer, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences,

Lucknow 226025, UP, Indiab Professor and Head of Department, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and

Medical Sciences, Lucknow 226025, UP, IndiacProfessor and Director, Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical

Sciences, Lucknow 226025, UP, India

a r t i c l e i n f o

Article history:

Received 3 January 2013

Accepted 28 February 2013

Keywords:

Radix entomolaris

Root canal anatomy

Mandibular molars

* Corresponding author. Tel.: þ91 9721222260E-mail address: grover.kavita@gmail.com

2213-9974/$ e see front matter Copyright ª 2013, Inter

http://dx.doi.org/10.1016/j.ijdsr.2013.04.001

a b s t r a c t

Aim: The present case report discusses the treatment of an endodontically treated

mandibular molar tooth with three roots and four canals. Two canals were present in the

mesial side and one each was present in the disto-buccal and disto-lingual side.

Background: Mandibular molars may have an additional root which may be located buccally

or lingually. When it is buccally located it is called as radix paramolaris and when lingually

located it is termed as radix entomolaris (RE). Hence, the presence of such a pulpal system

calls for challenges in providing endodontic treatment.

Case description: A female child of 13 years age, reported to the Department of Pedodontics &

Preventive Dentistry with a chief complaint of lancinating pain in the lower back region of

the right side of the mandible. The pain was present for last two months. On clinical ex-

amination, the mandibular first molar of right side was deeply carious with tenderness on

percussion. Intra oral periapical radiograph showed carious lesion involving enamel,

dentin and pulp along with an extra root between the distal and mesial roots. To confirm

that additional root is present, two intra oral periapical radiographs with different hori-

zontal angulations were taken. After taking radiographs, an additional root was confirmed

to be present on the disto-lingual side of the mesial root. Final diagnosis of irreversible

pulpitis was made. The treatment modality planned was root canal treatment.

Copyright ª 2013, International Journal of Dental Science and Research Published by Reed

Elsevier India Pvt. Ltd. All rights reserved.

1. Introduction Mostly mandibular first molars have two roots: one mesial

The complex nature of root canals and the pulpal system

provides a number of challenges in performing endodontic

treatment. Hence, it is very essential to identify any altered

anatomy of roots and root canals before starting endodontic

treatment.1

(mobile).(K. Dhinsa).national Journal of Dental Scie

and one distal, but the number of roots and root canals may

vary from person to person. This term was first coined by

Carabelli (1996). The extra root in RE is located on the disto-

lingual aspects of the mesial root and in radix paramolaris it

is located on the mesial aspect of the distal root.2

nce and Research Published by Reed Elsevier India Pvt. Ltd. All rights reserved.

i n t e rn a t i on a l j o u r n a l o f d e n t a l s c i e n c e an d r e s e a r c h 1 ( 2 0 1 3 ) 4 2e4 4 43

The diagnosis of these complexes in root canals has been

described by Carlsen andAlexanderson (2007). When present,

complete diagnosis and treatment plan is necessary and

clinician should take it as an additional canal to fill.3

Fig. 2 e Two radiographs with different horizontal

angulations were made which confirmed that the

additional root was located disto-lingual to mesial root.

2. Case description

A female child of 13 years age reported to Department of

Pedodontics and Preventive Dentistry with a chief complaint

of throbbing pain in lower back region of right side of

mandible. She reported with intermittent pain which was

present from the last two months and increased in severity

since last 10 days. Clinical examination revealed a deeply

carious right mandibular first molar which was tender on

percussion (Fig. 1). The tooth when subjected to electrical and

thermal pulp testing revealed a negative response. Intra oral

periapical radiograph showed a deeply carious lesion

involving enamel, dentin and pulp along with an extra root

present between the distal and mesial roots. To confirm the

presence of extra root, two separate radiographs were taken

with different horizontal angulations, after which it was

confirmed that the extra root was located on the disto-lingual

side of the mesial root (Fig. 2). A diagnosis of pulpitis (irre-

versible) was made and treatment plan was decided.

The tooth was anesthesized, carious lesion was removed

and composite build up was done giving tooth its normal

anatomical structure. Preparation of access cavity was done

using round bur and endodontic explorer was used to locate

the canal orifices (Fig. 3). Upon clinical examination, the orifice

of distal canal and the disto-lingual corner of pulp chamber

were separated by a dark line. On this aspect a diamond bur

was used to remove the overlying dentin, which revealed the

orifice of the second distal canal. The working lengths of root

canals were determined using K-files and intra oral periapical

radiograph (Fig. 4). Biomechanical preparation of the canals

was done using EDTA (Glyde) together with 2.5% sodium hy-

pochlorite and normal saline (Fig. 5). Drying of canals was

done with paper points while obturation was done with zinc

Fig. 1 e Right mandibular first molar was deeply carious

and tender on percussion.

oxide eugenol together with gutta-percha. The access cavity

was filled with glass ionomer cement followed by composite

resin restoration.

3. Discussion

The correct reason for the formation of RE is not clear. In

Europeans the association of RE in first molars (mandibular)

was found to be 3.4e4.2%, in Indians less than 5% and in

Caucasians it was found to be 4.2%.1

In dysmorphic, supernumerary roots, a number of external

factors may contribute during the formation of tooth, while in

eumorphic roots the genetic factors plays an important role.

According to Curzon (1974) ‘three-rooted molar’ trait has a

high genetic predominance.4

The RE may be located on the disto-lingual aspect of the

distal root while its length may vary from short conical to a

Fig. 3 e Access preparation done and canal orifices located

using endodontic explorer.

Fig. 4 e Canal lengths determined using radiographs.

i n t e r n a t i o n a l j o u r n a l o f d e n t a l s c i e n c e an d r e s e a r c h 1 ( 2 0 1 3 ) 4 2e4 444

mature root. The extension of pulp in RE is visible in an intra

oral periapical radiograph, but always the RE is smaller than

themesial and distal roots.5 Theremay be four different types

of RE as classified by Carlsen and Alexanderson (1990):

� Type A e distally located cervical part of the RE with two

normal distal root components.

� Type B e distally located cervical part of the RE one normal

distal root components.

� Type C e mesially located cervical part.

� Type AC e central location, between the distal and mesial

root components.

This classification allows for the identification of separate

and nonseparate RE.6

De Moor et al (2004) classified RE according to their cur-

vature as:

� Type I e straight root/root canal.

� Type II e initially curved entrance which continues as a

straight root/root canal.

Fig. 5 e Canals obturated using gutta-percha and zinc

oxide eugenol sealer.

� Type III e initial curve in the coronal third of the root canal

and a second curve beginning in the middle and continuing

to the apical third.4

Apart from radiographic diagnosis the presence of addi-

tional root can be identified by clinical examination of the

crown and visual inspection of the cervical morphology of the

roots using a periodontal probe.2 An additional cusp or very

prominent disto-lingual lobe together with cervical convexity

may indicate presence of extra root.7 If a diagnosis of RE is

made before commencement of endodontic treatment we can

be aware of the correct morphology of the pulp chamber once

it has been opened.8

The morphology of the pulp chamber shows a rectangular

outline formwhile a dark line in the floor of the pulp chamber

may confirm the exact location of the orifice of the RE canal.9

After initial exploration of the root canal and radiographic

examination of the root canal length, precautions should be

taken to avoid any accidental error.10

4. Conclusion

Justastheappearanceofall individual isnotalikesamegoestrue

for thedentition. Lotofvariations isseen in theanatomyof tooth

structure. Amongst all RE may be a challenge for all clinicians

who do not have proper diagnostic aids and lack proper knowl-

edge of the anatomy of tooth. With all proper skills, knowledge

and correct diagnosis these cases canbewell handledwith ease.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

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10. Madhuram K, Keerthana S, RajKumar S, Sankar SL. Radixentomolaris: report of two cases. Indian J Dent.2011;1(4):227e230.