Three Rooted Primary Mandibular Molar A Report of Three Cases

Case Report Three Rooted Primary Mandibular Molar A Report of Three Cases Authors: Vijay Bhaskar*, Purva Butala**, Manpreet Kaur*** ABSTRACT The dental literature contains a small number of reports of primary multirooted anomalies and even fewer reports on the clinical significance of these findings. Specifically, there are fewer reports of primary radicular anomalies than of permanent radicular anomalies. Knowledge of the size, morphology and variation of the roots and root canals of a primary tooth is useful in performing endodontic treatment. While performing endodontic therapy in primary teeth, the clinician should be aware of the possibility of an anomalous root. Here, we report three cases with three roots in relation with primary mandibular first and second molars which were indicated for endodontic treatment. Keywords : Dental anomalies, Three rooted primary mandibular molar, three rooted mandibular molar, primary mandibular molar INTRODUCTION Dental anomalies can be broadly considered as being morphologic and numeric. If anomalous is taken to mean an irregularity of the norm, then a dental anomaly is a feature of the dentition that can be expected to occur in the minority of a given [1] population. A smaller number of anomalies occur and are reported in the primary dentition than in the [2-4] permanent dentition. Specifically, there are fewer reports of primary radicular anomalies than of [ 3 ] permanent radicular anomalies. Primary mandibular second molars usually have 2 roots and 3 root canals, with the formation of accessory roots being uncommon. It is most frequently found in upper canines and lower molars. Tratman found that 3 rooted mandibular molars were rare in the primary dentition and common in the permanent dentition amongst the Mongolian division of Asian [2,3] population. The occurrence of an extra distal root in these molars is considered a racial characteristic ADDRESS FOR CORRESSPONDENCE: Dr. Vijay Bhaskar Professor & Head, Department of Pedodontics & Preventive Dentistry, Ahmedabad Dental College & Hospital. Email: Drvijaybhaskar@yahoo.com of certain Indian and Mongoloid populations. Winkler and Ahmad presented multirooted anomalies in the primary dentition of Native Americans. Jorgensen reported 7 cases of an additional root in primary mandibular second molars extracted from Danish patients. Ming Gene et al. concluded from their study that 5% of Taiwanese population had a three rooted mandibular primary first molar, 80% of them being [5] unilateral. Mann et al. & Badger have reported separate cases of children with 3 rooted primary mandibular second molars. Falk and Bowers have reported a case of bilateral three rooted mandibular [2, 6] primary first molars. Mayhall suggested that if a primary second molar has an accessory root, there is a high probability that the permanent first molar also will have one. Je Seon et al. supported this [7] finding. Dahlberg and Turner stated that the primary mandibular molars and the permanent mandibular first molars belong to the same molar field because of their similar time of development and crown morphology. Knowledge of the size, morphology and variation of the roots and root canals of a primary tooth is useful in performing [8, 9] endodontic treatment. The presence of a third root, whether primary or permanent, may alsohave a forensic value. *Prof and HOD, **P.G. Student, ***Reader Department of Pedodontics & Preventive Dentistry, Ahmedabad Dental College & Hospital, Ahmedabad BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 3 Issue-1 Jan. 2013 77

CASE REPORTS Case 1 A 4 year old male patient reported to Department of Pedodontics and Preventive Dentistry of chief complaint of severe pain in lower right back tooth since 2 days. Patient was relatively asymptomatic before 1 month. Then he started experiencing pain on taking cold water, with immediate spontaneous relief. Since last 2 days he felt spontaneous pain in 84 that was severe and lancinating in nature due to which the patient could not sleep. Patient was given analgesic medication by his parents which provided temporary pain relief. There were no systemic signs and symptoms. Clinical examination revealed caries on the distoocclusal surface of 84. Radiographic examination of tooth 84 revealed proximal caries involving the distal pulp horn (Fig.1.1). working lengths were estimated (Fig.1.3), Fig. 1.3 : Case 1 Working length radiograph pulp debridement was done and biomechanical preparation was completed at subsequent visits. The root canals were obturated with Metapex (Fig.1.4) Fig 1.1 : Case 1 Diagnostic radiograph A third root was detected between mesial and distal roots of 84. The diagnosis of acute irreversible pulpitis in relation with 84 was made and the treatment plan consisted of root canal treatment followed by stainless steel crown restoration. Root canal opening (Fig.1.2) Fig. 1.2 : Case 1 Intraoral image showing root canal orifices was performed under local anaesthesia and caries was excavated. Four root canals were located. The Fig. 1.4 : Case 1 Post obturation radiograph (calcium hydroxide and iodoform paste) followed by glass ionomer cement restoration. As the patient was asymptomatic for 1 week, stainless steel crown was fabricated for 84. Case 2 A 3½ year old male patient reported to Department of Pedodontics and Preventive Dentistry of chief complaint of dull pain in lower left back tooth since 1 week. Patient was relatively asymptomatic before 1 month. Then he started experiencing severe pain in 75 at night and spontaneous during day time with temporary relief on taking analgesic medication. Since last 1week, patient experiences dull and gnawing pain of continuous nature with occasional foul smell and taste in mouth. There were no systemic signs and symptoms. Clinical examination revealed deep occlusal caries in 75 involving pulp with draining sinus tract in buccal vestibule in the region of periapex of 75. Radiographic examination revealed perapical BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 3 Issue-1 Jan. 2013 78

radiolucency with ill-defined non corticated borders in relation with 75 (Fig.2.1). Fig. 3.1 : Case 3 Diagnostic radiograph Fig. 2.1 : Case 2 Diagnostic radiograph The third root could not be detected at this time.the diagnosis of chronic periapical abscess in relation with 75 was made and the treatment plan consisted of root canal treatment followed by stainless steel crown restoration. Caries was excavated completely and root canal opening was performed with straight line access.an extra root was detected in relation w i t h 7 5 o n t a k i n g t h e wo rking l e n g t h radiograph.(fig.2.1) An extra root was detected in relation with 75. The diagnosis of chronic irreversible pulpitis in relation with 75 was made and the treatment plan consisted of root canal treatment followed by stainless steel crown restoration. Root canal opening was performed under local anaesthesia and caries was excavated. The working lengths were estimated (Fig.3.2), Fig. 3.2 : Case 3 Working length radiograph Fig. 2.2 : Case 2 Working length radiograph Case 3 A 5 year old female patient reported to Department of Pedodontics and Preventive Dentistry of chief complaint of dull pain in lower left back tooth since 1 week. Patient was relatively asymptomatic before 1 month. Then she started experiencing severe pain in 75 at night and spontaneous during day time with temporary relief on taking analgesic medication. Since last 1week, patient experiences dull and gnawing pain of continuous nature in 75. There were no systemic signs and symptoms. Clinical examination revealed deepocclusalcaries in 75 involving pulp.radiographic examination revealed large radiolucency involving the pulp in 75 (Fig. 3.1). pulp debridement was done and biomechanical preparation was completed at subsequent visits. The root canals were obturated with Metapex (calcium hydroxide and iodoform paste) (Fig.3.3) followed by glass ionomer cement restoration. Patient is under follow up. Fig. 3.3. : Case 3 Post obturation radiograph DISCUSSION This article reports three cases with three rooted primary mandibular molars. This developmental BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 3 Issue-1 Jan. 2013 79

condition is not uncommon in permanent dentition and may involve any tooth. Teeth that are normally single rooted, particularly the mandibular bicuspids and cuspids, often have two roots. Both maxillary and mandibular molars, particularly third molars, also may exhibit one or more supernumerary roots. [10] The mechanism for normal development of multiple roots is well known. From the cervical loop of the dental organ, the inner and outer enamel epithelia proliferate as a double layer of cells known as Hertwig'sepithelial root sheath. The outer and inner enamel epithelia bend at the future cementoenamel junction, creating the epithelial diaphragm. The rim of this sheathen closes the primary apical foramen. In multirooted teeth, an unknown factor stimulates continued morpho differentiation. By differential growth, tongue like extensions of the horizontal diaphragm develop, grow toward each other, and fuse. For each new [11] secondary apical foramen, a root will develop. Three rooted lower molars result either from a bifurcated mesial root or an accessory distolingual root. The nature of this additional root is also variable, ranging from a short conical extension to full length, with pulp extending into the root. This additional root can occur unilaterally or bilaterally with a predilection for unilateral distribution in [12] males and bilateral in females. The dental literature contains a wealth of articles on dental anomalies. The rarity of reports of anomalous root patterns in primary teeth may be more apparent than real. This is because there is only a limited time between formation and resorption when radiography may reveal their presence, and in many cases where primary teeth are extracted, root resorption has already removed the evidence. Conventional radiographs have limitations of showing a three dimensional object in two d i m e n s i o n w h i c h g ive s a n i m a g e w i t h superimpositions. It is possible to overcome this limitation by taking at least two radiographs from [13] two different, usually horizontal directions. While performing endodontic therapy in primary teeth, the clinician should be aware of the possibility of an anomalous root. During exodontic procedures, the clinician should make sure that the crown of the premolar is not trapped in the interradicular area of the primary tooth as this could cause accidental removal of the developing permanent tooth. The clinician also should inspect extracted ano-malous primary teeth to ensurethat all roots have been retrieved. Since it is not known whether these abnormal root configurations affect the normal exfoliation of the primary teeth, it is unclear whether these anomalous teeth present orthodontic problems. Pulpal morphology of deciduous molar teeth need to be studied for [14] effective management of endodontic treatment. Studies have discussed the endodontic and periodontal implications of extra distal roots of permanent mandibular first molars. The same caution should be applied to the treatment of primary mandibular molars with accessory roots. Accurate clinical knowledge of the general morphology of such a tooth being considered for endodontic treatment and/or extraction is essential. CONCLUSION Dental anomalies like supernumerary roots are often incidental findings. These multirooted teeth are assumed to be rare because of thelack of documentation in the literature. However, their occurrence necessitates efforts by the clinicians to take routine radiographs to rule out their presence. Clinicians who encounter them should make an effort to document them as well as to make necessary modifications in the treatment protocols. REFERENCES 1. Nigel M. King, S. Tongkoom, H. M. Wong. Morphological and numerical characteristics of the Southern Chinese dentitions. Part III: Anomalies in the primary dentition. The Open Anthropology Journal 2010; 3: 25 36. 2. Jeng Fen Liu, Pei Wei Dai, San Yue Chen, Heng Li Huang, Jui Ting Hsu, Wil Lie Chen, Ming Gene Tu. Prevalence of 3 rooted primary mandibular second molars among Chinese patients. Pediatric Dentistry 2010; 32: 123 6. 3. Michael Paul Winkler, Rubina Ahmad. BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 3 Issue-1 Jan. 2013 80

Multirooted anomalies in the primary dentition of Native Americans. Journal of American Dental Association 1997; 128: 1009 11. 4. C. Kavanagh, V. R. O'Sullivan. A four rooted primary upper second molar. International Journal of Pediatric Dentistry 1998; 8: 279 82. 5. Ming Gene Tu, Jeng Fen Liu, Pei Wei Dai, San Yue Chen, Jui Ting Hsu, Heng Li Huang. Prevalence of three rooted primary mandibular molars in Taiwan. Journal of the Formosan Medical Association 2010; 109(1): 69 74. 6. W. V. Falk, D. F. Bowers. Bilateral three rooted mandibular first primary molars: report of case. ASDC J Dent Chill 1983; 50(2): 136 7. 7. Je Seon Song, Seong Oh Kim, Byung Jai Choi, Hyung Jun Choi, Heung Kyu Son, Jae Ho Lee. Incidence and relationship of an additional root in the mandibular first permanent molar and primary molars. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology 2009; 107(1): e56 e60. 8. Fouad S. Salama, Ronald W. Anderson, Carole McKnight Hanes, James T. Barenie, David R. Myers. Anatomy of primary incisor and molar root canals. Pediatric Dentistry 1992; 14(2): 117 8. 9. Meena kumara, Sandhya Kapoor Punia, Vikas Punia. Diagnosis and treatment of mandibular first molar with three mesial root canals A case report. Annals and Essence of Dentistry 2011; 3(1): 70 2. 10. R. Rajendran, S. Sivapathasundharam. Textbook of Oral Pathology. 6th Edition. Reed Elsevier India Private Limited; 2009. 11. Norman W. Ott, Randall N. Ball. Birooted primary canines: report of three cases. American Academy of Pediatric Dentistry 1996; 18(4): 328 30. 12. Antonio Bonaccorso, Teresa Roberta Tripi. Root canal treatment of a three rooted mandibular first molar: a case report. Endo (Lond Engl) 2008; 2(3): 211 7. 13. Krishna Prasad Parvathaneni, Bharani Devi Parvathaneni, Mahesh Moltani. Endodontic miscellany: A mandibular second bicuspid with three root canals. Annals and Essence of Dentistry 2011; 3(2): 44 6. 14. S. Sarkar, A. P. Rao. Number of root canals, their shape, configuration, accessory root canals in radicular pulp morphology A preliminary study. J Indian Soc Pedo Prev Dent 2002; 20(3): 93 7. Source of Support : Conflict of Interest : Date of Submission : Review Completed : NIL NOT DECLARED 09-11-2012 24-12-2012 BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY Vol. 3 Issue-1 Jan. 2013 81