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Radix Entomolaris - Mansi

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BY – Mansi Punjabi MDS 2 nd Yr (2013-16) MODERATOR-Dr. Ruchika Dewan Case Presentation RADIX ENTOMOLARIS
Transcript

BY – Mansi Punjabi

MDS 2nd Yr (2013-16)

MODERATOR-Dr. Ruchika Dewan

Case PresentationRADIX ENTOMOLARIS

• Introduction• Prevalence of RE• Etiology• Morphology of RE• Case report• Discussion• Conclusion• References

Contents

INTRODUCTION

Molars are frequently affected by caries at an early age and require successful endodontic treatment

Mandibular molars can have an additional root located lingually (the Radix Entomolaris) or buccally (the Radix Paramolaris)

Failure to diagnose and treat the extra roots in molars may lead to the endodontic treatment failure

Radix entomolaris (RE) is one of the anatomical variant found in a permanent Mandibular molar

First described by carabelli in 1844 and described by various terms, such as “extra third root” or “distolingual root” or “extra distolingual root”

It can be found in the first, second and third mandibular Molars, occurring the least frequently in the second molar

Radix entomolaris (RE) Characterized by the presence of an additional or extra third root, which is typically found disto-lingually

Radix paramolaris (RP) is known as the “mesiobuccal root” (Carlsen et al, 1991) and was first described by Bolk in

1915

Radix paramolaris is seen buccally to the mesial root and may found separate or fused with the mesial root

The prevalence of Radix entomolaris is reported to differ significantly with races and ranges from 0-33.1%

African population -- 3% (Int Endod J 1998;31:112-6)

Eurasian and Indian populations -- 5% (Br Dent J 1938;64:264-74)

Mongoloid traits such as Eskimo, Chinese, and American Indians -- 5–30% (Br Dent J 1985;159:298-9 and Community Dent Oral Epidemiol 1981;9:191-2)

Because of its high prevalence in these populations, the RE is considered to be a normal morphological variant (Eumorphic root morphology)

Caucasians -- 3.4–4.2% (Braz Dent J 1992;3:113-7 and J Dent Res

1973;52;181) considered to be unusual or dysmorphic root morphology

Prevalence of Radix Entomolaris

The prevalence of Radix paramolaris as observed by Visser (1948) was found to be –

0% for the first mandibular molar 0.5% for the second molar 2% for the third molar

Prevalence of Radix Paramolaris

The etiology behind the formation of the Radix entomolaris is still unknown

In dysmorphic supernumerary roots -- its formation could be related to external factors during odontogenesis, or to penetrance of an atavistic or polygenetic system (atavism is the reappearance of a trait after several generations of absence)

In eumorphic roots -- racial genetic factors influence the more profound expression of a particular gene that results in the more pronounced phenotypic manifestation

ETIOLOGY

De Moore et al. (Int Endod J 2004;37:789-99) classified RE based on the curvature of the root or root canal in bucco-lingual orientation

Morphology of the Radix Entomolaris

In 1991, Carlson and Alexandersen (Scand J Dent Res

1990;98:363-73) classified four types of RE (A, B, C, and AC) based on the location of the cervical portion of the root

Recently in 2010 Song et al. (J Endod 2010;36:653- 7) have suggested a new classification based on morphologic characteristics assessed from cross-sectional computed tomography technique

Carlsen and Alexandersen (Scand J Dent Res 1991;99:189-95) classified Radix paramolaris (RP) into two types

OPD NO : - 248343

NAME : - Dinesh

AGE : - 29 years

GENDER : - Male

ADDRESS : - Greater Noida

OCCUPATION : - Shopkeeper

CASE REPORT 1

Patient complains of pain in lower left back tooth region since 3-4 weeks

CHIEF COMPLAINT

Patient was asymptomatic 3-4 weeks back when he started experiencing pain in lower left back tooth region

Pain was dull, intermittent and aggravates on mastication and on taking hot and cold fluids and relieves on taking medication

HISTORY OF PRESENT ILLNESS

Undergone extraction in lower left back tooth region 2 years back

Not significant

PAST DENTAL HISTORY

PAST MEDICAL HISTORY

Facial Asymmetry – Not present

Lymph Nodes – Not Palpable

TMJ – Normal Movements No abnormality detected

EXTRAORAL EXAMINATION

On Inspection :• Deep caries w.r.t 36

Tender on Percussion w.r.t 36

Vitality Test-• Cold test – delayed response

Heat test- delayed response

EPT – delayed response

INTRAORAL EXAMINATION

Hard Tissue Examination -

PROVISIONAL DIAGNOSIS --

Symptomatic apical periodontitis w.r.t 36

DIFFERENTIAL DIAGNOSIS --

Symptomatic apical abscess w.r.t 36

Root canal treatment w.r.t 36

TREATMENT PLAN

PREOPERATIVE RADIOGRAPH

The tooth was anesthetised, caries were removed and pulp chamber was opened .

When the floor of the pulp chamber was reached ,three canal orifices were initially identified.

The conventional triangular access cavity was modified into more trapezoidal cavity in order to locate and open the orifice of the distlingually located RE.

On further exploration a second distal and more lingually located canal was found.

After scouting the root canals with a K file ISO 15 and flaring of the coronal thirds with a Gates Glidden burs, the canal length were measured with a radiograph.

The root canals were prepared by using Mtwo file system till size 20 .

During root canal preparation RC prep was used and root canal were irrigated with sodium hypochlorite solution (3%).

WORKING LENGTH DETERMINATION

The access cavity was temporized with cavit .

Patient was recalled after 1 week ,tooth was asymptomatic .

The root canals were irrigated again with normal saline and dried using paper points .

The master points were seated to test their suitability to the canals and radiograph taken .

MASTER CONE RADIOGRAPH

The root canals were obturated with 6% size 20 master gutta –percha cone and ZOE based sealer by single cone technique.

The coronal gutta percha cones were sheared off by a heated pluggers at individual canal orifices .

Post endodontic restoration was performed by amalgam restoration.

OBTURATION

OPD NO : 249375

NAME : Imran Saifi

AGE : 17 years

GENDER: Male

ADDRESS: Sikandarabad

OCCUPATION: Student

CASE REPORT 2

Patient complains of decay in lower right back tooth since 6-7 months

CHIEF COMPLAINT

Patient was asymptomatic having no pain or sensitivity. He was having the problem of food lodgement in the involved tooth

HISTORY OF PRESENT ILLNESS

Facial Asymmetry – Not present

Lymph Nodes – Not Palpable

TMJ – Normal Movements No abnormality detected

EXTRAORAL EXAMINATION

On Inspection :• Deep caries w.r.t. 46

Vitality Tests:• Cold test – delayed response

Heat test- delayed response

EPT – delayed response

INTRAORAL EXAMINATION

Asymptomatic apical periodontitis w.r.t 46

PROVISIONAL DIAGNOSIS

Asymptomatic apical abscess wrt 46

DIFFERENTIAL DIAGNOSIS

Root canal treatment w.r.t 46

TREATMENT PLAN

PREOPERATIVE

WORKING LENGTH DETERMINATION

MASTER CONE RADIOGRAPH

OBTURATION

Endodontic success in the presence of Radix entomolaris depends on its diagnosis, anatomy or morphology, canal configuration and clinical approach employed

An accurate diagnosis of Radix entomolaris can avoid complications like missed canal which is a common reason for endodontic Failure

Detection of Radix entomolaris can be based on clinical examination, radiographic and imaging techniques

It was reported that the radiographs were successful in over 90% of the cases while identifying additional roots but superimposition of the distal roots can be limiting factor

DISCUSSION

An angled radiograph (25-30°) can be more useful in this regard and it is said that a mesial angled radiograph is better than a distal angled radiograph for Radix entomolaris detection. (Saudi Endodontic Journal 2014;4(2):77-82)

Apart from a radiographical diagnosis, clinical inspection of the tooth crown and analysis of the cervical morphology of the roots by means of periodontal probing can facilitate identification of an additional root

Three-dimensional imaging techniques based on computed tomography (CT) and cone beam computed tomography (CBCT) are useful for visualizing or studying the true morphology of an Radix entomolaris in a noninvasive manner using less radiation

An initial relocation of the orifice to the lingual without excessive removal of dentin helps to achieve straight-line access and avoid perforations

Manual preflaring is recommended to prevent instrument separation

Initial root canal exploration with small files (size 10 or less), creation of a glide path along with the proper determination of the canal curvature and working length would reduce the procedural errors such as ledging and transportation

If the Radix entomolaris canal entrance is not clearly visible after removal of the pulp chamber roof, visual aids such as loupes, intra-oral camera or dental microscope can be useful

Endodontists must be aware of normal and abnormal root morphologies of tooth

Failure to identify and treat an Radix entomolaris can significantly affect the outcome of an endodontic treatment in mandibular molars displaying Radix entomolaris

Although angulated radiographs can play a key role in the identification and endodontic management of an Radix entomolaris, the knowledge about prevalence, diagnosis, morphology of an Radix entomolaris and clinical approach to treat it would be a very important prerequisite to achieve endodontic success in a mandibular molar with an Radix entomolaris

CONCLUSION

1. Nagaveni NB, Umashankara KV. Radix entomolaris and paramolaris in children: A review of the literature. Journal of Indian Society of Pedodontics and Preventive Dentistry; 2012 30(2): 94-102

2. Rambabu. T. Endodontic Management of Radix Entomolaris - Two Case Reports. Annals and Essences of Dentistry, 2010; 2(3):50-54

3. R. Vivekananda Pai, Rachit Jain, Ashwini S. Colaco. Detection and endodontic management of radix entomolaris: Report of case series. Saudi Endodontic Journal 2014;4(2):77-82

4. Filip L et al. A The Radix Entomolaris and Paramolaris: Clinical Approach in Endodontics. J Endod 2007;33:58–63

REFERENCES

THANK YOU


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