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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 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
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%).
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 .
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.
OPD NO : 249375
NAME : Imran Saifi
AGE : 17 years
GENDER: Male
ADDRESS: Sikandarabad
OCCUPATION: Student
CASE REPORT 2
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
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