MISSED LINGUAL CANAL IN ALL MANDIBULAR INCISORS AS A CAUSE OF ENDODONTIC FAILURE: A CASE REPORT

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1 Dhanapal et al Case Report MISSED LINGUAL CANAL IN ALL MANDIBULAR INCISORS AS A CAUSE OF ENDODONTIC FAILURE: A CASE REPORT Authors: Prasanth Dhanapal.T*, RobinTheruvil**, Ganesh C***, Anoj George****, Sheena Prasanth***** ABSTRACT The root canal anatomy of mandibular incisors can present a number of variations, including multiple canals. In the present case report, previous endodontic treatment had missed the lingually placed additional canals in all the four mandibular anteriors leading to endodontic failure. Locating the missed additional canal and its endodontic therapy resulted in healing of the periapical pathology. INTRODUCTION: Thorough knowledge of root canal anatomy and the possible variation is a must for successful endodontic therapy. Variation in root canal morphology in terms of presence of extracanal, separate portals of exists or foramina, isthmuses and ramifications in the apical delta are common. The mandibular incisors are teeth which have high variation in canal anatomy. It is generally presumed by treating dentist that the mandibular incisors have one canal. Mandibular incisors have been reported to have 2 canals. Missing of the additional canal leads to non instrumentation and obturation of the canal, thereby failure of endodontic therapy. The missed canal in mandibular incisor is often located lingually to the main canal. This case reports a case where all the mandibular incisor of the same patient had 2 canals with 2 ADDRESS FOR CORRESPONDENCE Dr Prasanth Dhanapal.T Sahyadri, NJRA-233, North Janatha Road, Palarivattom, Cochin Kerala. separate foramina (type IV configuration). The incidence of this configuration in mandibular incisor is very low. The occurrence of this canal variation in all the 4 mandibular incisors is reported in very few cases. The high light of this case report is that the additional lingual canal was missed during previous endodontic treatment. This lead to failure of endodontic therapy and development of large periradicular lesions and associated symptoms. The retreatment was carried out after locating the missed canal and the retreatment was successful as evidenced radiographically by healing of the lesions and total absence of symptoms for the patient. CASE REPORT: A 17 year male patient reported to the clinic with complaint of severe pain and swelling in the lower anterior teeth since a week. The patient revealed a history of trauma 6 years back upon which all his lower anterior teeth were endodontically treated. The patient also reported subjective symptoms of intermittent pain to hot and cold after the endodontic treatment. Pain intensified in the preceding 5 days with a noticeable swelling in *Professor, Department of Conservative Dentistry and Endodontics Annoor Dental College,Muvattupuzha, Kerala **Professor, Department of Conservative Dentistry and Endodontics St. Gregarious Dental College, Chelad, Kothamangalam,Kerala ***Professor and Head, Department of Conservative Dentistry and Endodontics Sri Sankara Dental College, Varkala, Trivandrum ****Professor, Department of Periodontics, Lenora Institute of Dental Science,Rajahmundry, A.P *****Dental Surgeon, Quality Dental Care, Cochin MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-3 September

2 relation to the lower anterior region. Clinical examination revealed a swelling in the labial vestibule in relation to mandibular central incisor 31, 32 (Federation Dentaire International system). There was no draining sinus tract. The lower anterior teeth 31,32,41,42 were moderately discoloured and were tender on palpation. All mandibular anterior teeth showed grade II mobility with a periodontal probing depth of 6 mm in 31, 32 and 4 mm in 41, 42 with pus drainage through the gingival sulcus on digital manipulation. Thermal and electrical pulp testing was negative. Preoperative intraoral periapical radiograph (IOPA) was made of the lower anterior teeth, which showed periapical radiolucent areas in relation to 32, 31, and 41 with improperly obturated root canals in all the four mandibular anterior teeth. The radiograph showed a radiolucent line along the obturation material in all the 4 teeth suggestive of presence of additional canal. (Figure 1) and patient was conveyed the need for periapical surgical procedure if there is no relief of symptoms or if the lesion fails to heal by conventional retreatment. Following local anaesthesia retreatment was initiated under rubber dam isolation on #32, 31, 41 and 42. To locate the lingual orifices, the access cavity was extended in a lingual direction. The obturation materials in the four canals were removed using an H-file using a guttapercha solvent and the canals was irrigated with 3% sodium hypochlorite (Deor Pharma Products, India) and saline. The working length was estimated using an apex locator (Root ZX, JMorita, Japan) and confirmed radiographically. The canals were instrumented using conventional K Flexofile (Dentsply Maillefer, Ballaigues, Switzerland) upto #30 employing conventional step back technique. The lingual areas of the access were probed with DG 16 probe to trace the suspected lingually placed canal. Additional canals in the entire four mandibular incisors were located by using endodontic probe and the patency gained using No 10 K file. (Figure 2) Figure 1 : Pre Operative radiographs of 32,31,41,42 showing improperly obturated root canal with radiolucent line long the obturating material in all the canals, suggestive of additional canals. Note the periapical radiolucent lesions at the peripaical region involving all the anterior teeth Angulation radiographs were made, which revealed the presence of the additional canal which was missed during earlier endodontic treatment. Retreatment of the 4 anterior teeth was suggested Figure 2: Radiograph after removal of earlier obturating material from the canals. Additional canals located in 32 and 41 demonstrated by a endodontic file in place. Lingual canal in 31 is seen after instrumentation and packing the canal with calcium hydroxide. The canals were negotiated and instrumented to ISO MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-3 September

3 Dhanapal et al size 30 using K Flexofile and 3% sodium hypochlorite as the main irrigant. The canals were prepared using conventional step back technique. The canals were dried with absorbent points, and an intracanal dressing with Calcium hydroxide paste (Calexcel, Ammdent, India) was placed into the root canals using a lentulospiral. The access cavity was sealed temporarily with a cotton pellet and Zinc Oxide Eugenol (DPI, India) cement. The occlusion was relived and the patient was recalled after 2 weeks with instructions to report if there are any symptoms. On the second week recall, the patient reported relief of symptoms and reduction in the size of the vestibular swelling. The four anterior teeth exhibited grade II mobility but were not tender to palpation and touch. At the next appointment after 5 weeks, the patient reported total relief of symptoms and the swelling has disappeared. Lower anterior teeth exhibited grade I mobility. Evaluation IOPA was made, which showed calcium hydroxide in the canal space and reduction in the size of the periapical radiolucency. (Figure 3) calcium hydroxide. After final flushing with saline, the canals were dried and calcium hydroxide was repacked into the canal using absorbent point and the access cavity was sealed temporarily with a cotton pellet and Zinc Oxide Eugenol cement. At the next appointment, 9 weeks later, the teeth were totally asymptomatic. No tenderness to palpation and percussion were reported. IOPA made at this visit revealed resolution of the size of the periapical radiolucency and radiographic evidence of bone formation suggestive of healing. The process of instrumentation of the canal, flushing of the calcium hydroxide and repacking of calcium hydroxide was carried out again and the patient was recalled after 4 weeks. At 12 weeks recall, the patient remains asymptomatic. The calcium hydroxide was removed with ultrasonic instrumentation, and a final irrigation was performed with 2% chlorhexidine. The canals were dried with absorbent points and filled using cold lateral compaction of Gutta-percha Endomethasone N sealer (Septodont, France). (Figure 4) Figure 3 : 5 week evalaution radiograph after calcium hydroxde placement. Radiograph showing calcium hydroxide packed into canals. Regression of the peripaical radiolucency is observed in the apical region of 31,41 and 42 The interim dressing was removed, the canals were reinstrumented and irrigated with 3 % sodium hypochlorite and normal saline to flush out the Figure 4: Post obturation radiographs the periapical lesion has completely resolved and bone formation is visible in the interdental region of 32,31 and between 42,41 The access cavity was sealed with resin and post obturative radiograph were made. The post obturative angulation IOPA revealed obturation material in the buccal and lingual canals. The radiolucent lesions at the apical region have MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-3 September

4 substantially reduced and there were evidence of trabecular formation suggestive of and clinically correlated as periapical healing. The patient was recalled after 3 months for evaluation. The 3 month post treatment recall evaluation revealed asymptomatic mandibular anterior teeth with no swelling, tenderness to palpation and percussion. The post treatment IOPA revealed radiographic regression of the lesion and evidence of bone formation including the interdental region. The patient was recalled after 6 months and evaluated radiographically. The evaluation radiograph showed evidence of healing and bone formation. (Figure 5) Figure 5 : A 6 month follow up radiograph d e m o n s t ra t i n g h e a l i n g o f t h e l e s i o n radiographically and bone trabeculae formation in the periapical region DISCUSSION: Proper chemicomechanical preparation of the root canal system and its obturation in three dimensions is a must for successful endodontic therapy. Incomplete cleansing of the root canals can lead to failure by percolation. Bacteria and their by products can remain in the canal space favouring growth and development of periradicular lesions. Non identification of additional and lateral canal can be a cause of failure. Periradicular lesions of endodontic origin are caused by extension of bacterial infection from the pulpal space into the periradicular region. The elimination of bacteria from the root canal system is of great importance for periapical healing following [1,2] endodontic treatment. Periradicular lesions would not heal if the infectious material from the pulp space is not totally removed. Chemomechanical preparation of the canal by employing irrigants along with usage of intracanal medicaments to disinfect the root canal system is widely accepted. The medicaments also create a conducive environment for healing of the periradicular lesion. Variation in root canal anatomy can occur in any teeth. The incidence of variation in root canal [3,4] anatomy can be based on race and population. Mandibular anterior teeth with 2 canals have been reported in literature. The 2 canals can either be two canals joining in the apical area to emerge at single foramina or can be two separate canals with 2 different apical foramina. Two distinct canals originating in the pulp chamber, continuing as separate canals and finally exiting the root as two separate foramina has been categorised by Frank J [5] Vertucci as Type IV canal configuration. Rankine, [6] Wilson and Henry reported a 5% incidence of type IV canal configuration in mandibular anteriors. [7] Benjamin and Dowson studied 364 specimens radiographically and reported 1.3% incidence of type IV canal configuration in mandibular anterior teeth. In a larger sample study of 1085 specimens by [8] Miyashita et al reported 3.1% of the sample had separate canals and foramina. The incidence of such canal configuration in mandibular anterior ranges [9] from 1 % to 6.25 % in various reports. Occurrence of type IV configuration in all 4 mandibular anterior [10,11] teeth is reported only in few case reports. Most common cause of non identification and treatment of the lingually placed second canal is the anatomical lingual tilt of the crown of the mandibular incisors. The shape and location of the standard access for mandibular incisor at the MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-3 September

5 Dhanapal et al cingulam area of the crown also obstructs the visualization of the lingually placed second canal. During diagnosis radiographic evaluation employing angulation radiographs can be useful to identify the lingual canal in mandibular anterior [12] teeth. Extending the access to the incisal edge to access the lingual canal and even labial access for [13] straight line access in mandibular incisor has been suggested. During access opening the lingual aspect of the chamber should be slightly widened to remove the lingual shelf of the chamber to access and visualize the lingual canal. In instrumentation the canal orifices should be manually explored with probe of files to get an idea of the canal configuration. Failure to locate and thoroughly chemicomechanically cleanse and obturate the additional canal can cause failure of endodontic treatment. When only the directly accessible canal is treated and sealed necrotic pulp tissue in the additional missed canal would harbour bacteria. Bacteria and bacterial by products from this additional canal would leach out through the foramen or multiple portals of exit into the periodontium leading to formation of periradicular lesions. Calcium hydroxide [Ca(OH)2] has been used in [14] endodontics for almost a century. Its use as an intracanal medication has been associated with [15] periradicular healing. The antibacterial efficiency of calcium hydroxide as an intracanal interappointment medicament has been [16,17,18,19] documented by many studies. The effectiveness of Ca(OH)2 as intracanal antibacterial dressing is mainly attributed to its high ph and its destructive effect on bacterial cell walls and protein [20] structures. Calcium hydroxide when used as an intracanal medication in teeth with large and chronic periapical lesions creates a favourable environment for healing and encourages osseous repair. CONCLUSION: Variation in root canal anatomy can occur in any teeth. Through knowledge of the root canal complexities and the possible variation of each tooth and its canal systems are essential for successful endodontic therapy. Meticulous attention to detail during diagnosis, access and instrumentation would contribute for location and treatment of additional canals. Endodontic therapy can fail if additional canals are missed and left untreated. REFERENCES : 1) Byström A, Sundqvist G: Bacteriologic evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy: Scand J Dent Res 1981;89: ) Tronstad L, Barnett F, Riso K, Slots J. Extraradicular endodontic infections: Endod Dent Traumatol 1987;3: ) Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30: ) Trope M, Elfenbein L, Tronstad L. Mandibular premolars with more than one root canal in different race groups. J Endod 1986;12: ) Vertucci FJ. Root canal anatomy of the mandibular anterior teeth. J Am Dent Assoc 1974; 89(2): ) Rankine-Willson RW, Henry P. The bifurcated root canals in lower anterior teeth. J Am Dent Assoc 1965; 70: ) Benjamin KA, Dowson J. Incidence of two root canals in human mandibular incisor teeth. Oral Surg Oral Med Oral Pathol 1974; 38(1): ) Miyashita M, Kasahara E, Yasuda E, Yamamoto A, Sekizawa T. Root canal system of the mandibular incisor. J Endod 1997; 23(8): ) Boruah LC, Bhuyan AC. Morphologic characteristics of root canal of mandibular incisors in North-East Indian population: An in vitro study. J Conserv Dent Oct: 14 (4) : MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-3 September

6 10) Vibha Hegde, Sharad R. Kokate, Yogesh R. Sahu. An unusual presentation of all the 4 mandibular incisors having 2 root canals in a single patient A Case report. Endodontology: ) Tikku AM, Kalaskar RR, Damle SG. An unusual presentation of all the mandibular anterior teeth with two root canals A case report. J Indian Soc Pedod Prev Dent 2005;23: ) Ingle JI, Simon JH, Machtou P, Bogaerts P.Outcome of endodontic treatment and retreatment. In: Ingle JI, Bakland LK. th Endodontics, 5 ed. Philadelphia: Lea & Febiger; p ) Raghu Srinivasan, Ramya Raghu. Labial access for lower anterior teeth A rational approach. Archives of Oral Sciences & Research; 2011; 1(3): ) Siqueira JF Jr, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361 9) 15) Sjogren U, Figdor D, Spangberg L, Sundqvist G. The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int Endod J 1991;24: ) Bystrom A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol 1985;1: ) BystromA, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endod J 1985;18:35 403,4 18) Orstavik D, Kerekes K, Molven O. Effects of extensive apical reaming and calcium hydroxide dressing on bacterial infection during treatment of apical periodontitis: a pilot study. Int Endod J 1991;24: ) Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of e n d o d o n t i c t r e a t m e n t. J E n d o d 1990;16: ) Hauman CH, Love RM. Biocompatibility of dental materials used in contemporary endodontic therapy: a review. Part 1. Intracanal drugs and substances. Int Endod J 2003;36: Source of Support : Conflict of Interest : Date of Submission : Review Completed : NIL NOT DECLARED MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-3 September

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