|Year : 2013 | Volume
| Issue : 1 | Page : 33-35
Interdisciplinary management of a two-rooted mandibular first premolar with furcation involvement: A 2-year follow-up
Amber Ather1, M Jothi Varghese2, M Vidya Saraswathi1, Vasudev Ballal1, Shashirashmi Acharya1
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
2 Department of Periodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||25-Oct-2013|
M Jothi Varghese
Department of Periodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Consistent knowledge of developmental anomalies along with careful clinical and radiographic interpretation is essential pre-requisites for successful management. This case describes a 2-year follow-up of a case with carious mandibular right first premolar with two roots, three root canals and a deep periodontal probing depth along with an early Grade II furcation involvement. The tooth was endodontically treated followed by periodontal surgery, to eliminate the pocket and promote bone fill in the osseous and furcation defect. Hydroxyapatite graft composited with bioactive glass was utilized for enhancing bone formation.
Clinical Relevance to Interdisciplinary Dentistry
- Detailed knowledge of root anomalies in mandibular premolars is a pre-requisite for successful management of combined endo-perio lesions.
- Periodontal regenerative procedure using hydroxyapatite graft can be performed to enhance bone formation.
- Use of radiographs and advanced diagnostic aids are recommended for clinical evaluation of tooth anomalies.
Keywords: Furcation, hydroxyapatite bone graft, mandibular first premolar, root anomalies
|How to cite this article:|
Ather A, Varghese M J, Saraswathi M V, Ballal V, Acharya S. Interdisciplinary management of a two-rooted mandibular first premolar with furcation involvement: A 2-year follow-up. J Interdiscip Dentistry 2013;3:33-5
|How to cite this URL:|
Ather A, Varghese M J, Saraswathi M V, Ballal V, Acharya S. Interdisciplinary management of a two-rooted mandibular first premolar with furcation involvement: A 2-year follow-up. J Interdiscip Dentistry [serial online] 2013 [cited 2020 Jan 26];3:33-5. Available from: http://www.jidonline.com/text.asp?2013/3/1/33/120526
| Introduction|| |
The proximity between pulpal and periodontal zone has been explored and studied extensively. Review of literature , has focused its attention on all possible etiological factors varying from pathways of spread of infection to anatomical aberrations. Mandibular premolars owing to its varied morphological oddities pose a challenge in its treatment. Sylvester in documented literature reveals that lower first premolars can have either a single root or double roots and if so, most common occurrence is to have a buccal and lingual orientation of roots. A mesio-distal root configuration is a rare finding. 
Cumulative data on mandibular first premolar reported that the number of roots could vary from one to four. The incidence being 97% with a single root, 1.8% with two roots, 0.2% with three roots and <0.1% with four roots. ,,,, Although the incidence of a single root canal is most evident in mandibular first premolar, Zillich and Dowson reported that a second or a third canal exists in 23% of cases. 
To the best of our knowledge, furcation involvement in mandibular first premolar with two roots is an unusual finding. This report highlights a carious right mandibular first premolar with two roots (mesial and distal), three root canals (mesiobuccal, distobuccal and distolingual) and an early Grade II furcation involvement. The tooth was successfully managed by conventional endodontic treatment and regenerative periodontal surgical intervention.
| Case Report|| |
A 52-year-old healthy female patient presented with a complaint of decay in the lower right back tooth for the past 6 months. On clinical examination, a carious lesion affecting tooth #44 was seen, which tested percussion sensitive. A detailed periodontal examination of tooth #44 revealed a pocket probing depth of 10 mm along its lingual aspect with Grade 2 mobility.
The tooth (#44) was subjected to vitality test with an electronic pulp tester (Parkell Electronic Division, New York, USA) which confirmed a non-vital pulp. An intraoral periapical radiograph (IOPA) of 44 revealed a deep carious lesion, with a mesial and distal root. In addition, it revealed an advanced bony defect extending up to middle-third of distal aspect of the distal root along with mild bone loss in the furcation area. The above findings suggest a possible diagnosis of concurrent endodontic and periodontal disease with communication [Figure 1]a.
|Figure 1 : (a) Pre-operative radiographic view of mandibular first premolar depicting two roots, deep carious lesion and a bony defect involving the furcation. (b) Radiographic view of working length determination depicting three separate root canals (c) Radiographic view demonstrating obturated root canals (d) Surgical view demonstrating two roots (mesial and distal) with furcation-involvement (mirror-view image) (e) Post-operative recall radiograph after 2 years, demonstrating satisfactory healing|
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Prior to commencement of therapy, an oral informed consent was taken and treatment plan was explained. A full mouth oral prophylaxis followed by root canal treatment was performed under rubber dam isolation. On entry into the pulp chamber, one main canal orifice was found, which split into three different canal orifices at the mid-root level. Gates Glidden drills (Mani Inc., Tochigi, Japan) were used with a brushing motion, in a crown down fashion, to enlarge the main orifice to the level of the trifurcation to obtain a straight line access to all the three canals. Canal patency was checked with #10 Senseus ProFinder™ files (Dentsply-Maillefer, Ballaigues, Switzerland). Working length was determined with an apex locator (Root ZX, J. Morita Inc., Irvine, CA, USA) and was confirmed by radiographs at different horizontal angulations [Figure 1]b. The canals were dried and calcium hydroxide (Calasept, Nordiska AB, Angelholm, Sweden) was used as the intracanal dressing. The tooth was then temporized and patient was recalled after 2 weeks. At the following visit, the tooth was completely asymptomatic and was obturated using cold, laterally condensed Gutta-percha (Dentsply-Maillefer, Ballaigues, Switzerland) and resin sealer (AH plus, Dentsply De Trey, Konstanz, Germany). Post-endodontic restoration was given in the form of composite resin nayyar core followed by an extra-coronal full metal crown with ceramic facing [Figure 1]c.
The initial periodontal therapy provided a reduction in the inflammatory components. The mobility of the tooth had reduced to Grade 1, but a deep probing pocket depth of 7 mm was still evident, which suggested that the need for surgical intervention. A full thickness flap was reflected along the lingual aspect of tooth #44. After debridement, a well-defined bony defect was seen along with two roots (mesial and distal), along with a bifurcation at the middle third of the root. On detailed probing, an early Grade II furcation involvement was noticed [Figure 1]d. In order to promote bone regeneration in the defects, hydroxyapatite graft material composited with bioactive glass ceramic (Grabio Glascera, Dorthom™, Medi Dents Pvt., Ltd., Chennai, India) was placed into the deep bony defect along the distal aspect of distal root and in the furcation area. The flap was stabilized using 3-0 sutures and covered with non-eugenol periodontal dressing (Coe Pak; GC America Inc., ALSIP, IL-60803, USA). Following week after surgery, an uneventful healing was observed. Patient was recalled at a later date for the construction of extra-coronal full metal crown. After the metal crown was cemented, patient was instructed to use interdental aids so as to maintain plaque control in the interproximal area between #44 and #45.
Patient was placed on a maintenance recall schedule and the results over two years were observed to be satisfactory.
| Discussion|| |
Treatment of teeth with anatomical anomalies often places the clinician in a perplexed situation. Prior to commencing endodontic therapy, the clinician should have adequate knowledge regarding the variants in tooth anomaly. Cleghorn et al.  recommended that two or more radiographs are mandatory for critical judgment of any extra root or root canal. Other advanced diagnostic devices such as surgical microscopes, illumination loupes, fiber-optic transillumination, etc., can also be utilized as an adjunct in enhanced search of root canal system.  For furthermore detailed information regarding the tooth and surrounding tissues, a cone beam computed tomography can be utilized.  Three-dimensional geometric accuracy is its major benefit compared with the conventional radiographs. Therefore, it does not get affected by superimposition of overlying anatomy as seen in conventional methods. 
In the present case, an IOPA radiograph revealed a two dimensional view of a mesial and distal root along with extensive bone loss affecting the furcation. Due to financial constraints from patient, further sophisticated diagnostic measures could not be used. The radiographic presence of two separate roots suggested the tooth to be distinctive from the normal root anatomy of mandibular premolar. It is imperative that a clinician should be able to identify such anomalies and treat it accurately so as to avoid acute exacerbations or failure of endodontic treatment.
A regenerative periodontal flap surgical procedure was performed to eliminate the deep periodontal pocket, access the bone defect and the furcation involvement. The osteoconductive bioactive ceramic composite graft has shown to have a positive effect on bone formation. The bioactivity of this glass ceramic was as a result of apatite formation on its surface in the bone matrix.  In the present case, hydroxyapatite crystals composited with bioactive glass also showed adequate bone regeneration along the root surface.
The radiograph taken at 2 years recall visit, showed acceptable bone fill [Figure 1]e and clinically satisfactory results.
| Conclusion|| |
This particular case highlights the successful management of a two rooted mandibular first premolar complicated with a Grade II furcation involvement. The mandibular premolars are known candidates for multiple morphological complexities and can create pathfinder routes from the pulp to periodontium. Though such cases are documented in the literature, variations in complexities do exist. Critical assessments using clinical and radiographic skills, along with regenerative management of the furcation defect has attributed to the satisfactory management of the tooth.
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