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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 32-35

Endodnontic management of a maxillary lateral incisor with two roots


1 Department of Conservative Dentistry and Endodontics, College of Medical Sciences, Bharatpur, Nepal
2 Department of Periodontology, Chongqing Medical University, Chongqing, China
3 Kalika Dental Clinic, Bharatpur, Nepal

Date of Submission18-Mar-2021
Date of Acceptance15-Jun-2021
Date of Web Publication30-Apr-2022

Correspondence Address:
Dr. Pujan Kranti Kayastha
College of Medical Sciences and Teaching Hospital, Bharatpur, Chitwan
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_11_21

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   Abstract 


Knowledge of dental anomalies and variations is a prerequisite for having a better prognosis after endodontic treatment. In this case report, a patient having birooted maxillary lateral incisor with periapical pathosis has been discussed. Due to lack of magnification and identification of two roots in intraoral periapical radiograph, cone-beam computed tomography was advised which help in diagnosis and location of the accessory canal of maxillary lateral incisor. With proper diagnosis and standard endodontic protocol, successful outcome of endodontic treatment can be achieved.

Keywords: Lateral incisor, maxillary, two roots


How to cite this article:
Kayastha PK, Shakya M, Poudel L. Endodnontic management of a maxillary lateral incisor with two roots. J Interdiscip Dentistry 2022;12:32-5

How to cite this URL:
Kayastha PK, Shakya M, Poudel L. Endodnontic management of a maxillary lateral incisor with two roots. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Jul 3];12:32-5. Available from: https://www.jidonline.com/text.asp?2022/12/1/32/344460




   Clinical Relevance to Interdisciplinary Dentistry Top


CBCT in diagnosis of tooth morphology and helps in treatment planning.


   Introduction Top


Knowledge of morphologies and variations in morphology of tooth structure for proper endodontic treatment. Although various form of developmental anomalies has been found in maxillary lateral incisor, such as-peg-shaped, dens invaginatus/dens in dente, palato-radicular grooves, and talon cusps with supernumerary root[1] but it is rare to find birooted maxillary lateral incisor. Studies have shown 100% presence of single root[2],[3] whereas one study found 1.05% case with 2 root in maxillary lateral incisor.[4] A proper radiographic method is required for the diagnosis of two root when roots are superimposed.

Cone-beam computed tomography (CBCT) provides undistorted three-dimensional information with high precision and sensitivity with a more detailed analysis of such tooth that improve the treatment planning.[5]

This paper presents a case of nonsurgical management of the maxillary lateral incisor with two roots.


   Case Report Top


History

A 15-year-old female patient visited the dental clinic with a chief complaint of swelling on the facial surface of the left maxillary lateral incisor region with no pain associated with that region. The patient had a history of pain a few months back and a history of trauma 3 years ago. The patient had no abnormal medical history, complicating illness.

Clinical examination

The extraoral examination revealed no abnormal findings. The intraoral examination shows swelling on the facial attached gingiva over the apex of the maxillary left lateral incisor [Figure 1].
Figure 1: Intraoral examination with swelling on buccal mucosa in relation to maxillary left lateral incisor

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No carious lesion, discoloration, or fracture present on the tooth. The patient experiences pain on percussion with no mobility of the tooth. Periodontal examination showed no abnormal pocket on the respective tooth. On radiographic examination, periapical radiolucency was detected in relation to the maxillary lateral incisor that revealed two roots [Figure 2].
Figure 2: Intraoral periapical X-ray with mesial shift shows 2 roots in relation to maxillary left lateral incisor

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For further confirmation, segmental CBCT was performed for the maxillary anterior which confirms two roots on the maxillary left lateral incisor [Figure 3].
Figure 3: Cone-beam computed tomography of left maxillary quadrant reveals two roots with two root canals located buccopalatal orientation. One and 2 also confirms periapical radiolucencies in the apical area of maxillary left lateral incisor

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Diagnosis

Primary endodontic lesion resulting in acute apical periodontitis

Treatment options

Root canal therapy was recommended.

Treatment

The patient was asked to gargle with betadine mouth wash and access opening was performed using round bur and taper fissure bur was used for refining wall. Three percent NaOCL was used to flush out all the debris from the coronal portion. The main canal was negotiated with no. 10 ISO stainless steel file K-file. An accessory canal was negotiated, with the help of CBCT, by extending access opening palatally. Working length was taken radiographically which reveals 19 mm for palatal and 19.5 mm for the buccal canal [Figure 4].
Figure 4: Working length determination of buccal and palatal root of maxillary left lateral incisor

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Root canal instrumentation was performed using K-files 2% taper with step-back techniques. Apical preparation was done till no. 35 k-file and coronal preparation was done till no. 50 k-file in step-back fashion. Copious irrigation with 3%sodium hypochlorite and normal saline was done while increasing the file size as well as recapitulation was performed simultaneously. After final instrumentation with no 50 k-file, recapitulation was done with the master apical file. Irrigation was performed with 3%NaOCL about 9 ml volume followed by normal saline of equal volume to flush out NaOCL crystals. Two percent CHX about 3 ml was later used followed by with normal saline using 28 gauge irrigating needle. Canals were dried and calcium hydroxide powder mixed with normal saline was used as intracanal medicaments and closed dressing given using Cavit. The patient was recalled after 2 weeks.

In the second visit, swelling on the buccal mucosa subsided. Cavit was removed and sodium hypochlorite irrigation was used to flush out Ca (OH)2 dressing from both canals. Master cone was selected and preobturation radiograph was taken that confirms the final master cone. Canals were thoroughly irrigated using 3% NaOCL 9 ml followed by NS of equal volume. Canals were dried with no. 40 paper points. Zinc oxide eugenol sealer was mixed and carried with lentulo spiral to the canals. Selected master cones were placed in both the canals and accessory gutta-percha were added one by one in each canal and obturated using the cold lateral compaction technique. Excess GP were cut using a heated spoon excavator and then condensed using a plugger. The coronal seal was performed using GIC cement and final restoration was done with A2 shade composite restoration after taking postobturation radiograph [Figure 5].
Figure 5: Postobturation intraoral periapical radiograph of maxillary left lateral incisor

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   Discussion Top


The presence of two roots in the maxillary lateral incisor is a rare case. The etiology of two roots in a lateral incisor is unknown. Various options have been postulated. This variation in the normal anatomy of the maxillary lateral incisor is thought to be due to its location of high embryological risk.[6] During the developmental stage, upper jaw forms by fusion of the paired medial nasal processes (MNP) and maxillary processes (MP)[7] during the fourth and 6th week of the human embryonic development period and the premaxilla, medial portion of the upper lip, and primary palate are formed by the fusion of MNP.[8] It is still questionable about the exact origin of maxillary lateral incisor relative to MNP/MP fusion area and the location of premaxillary/maxillary suture. The presence of this MNP/MP fusion area may be medial to the lateral incisor or at the medial or middle one-third of the lateral incisor. Various root canal morphology of maxillary lateral incisors may be due to the position of premaxillary/maxillary suture between lateral incisor and canine or at the middle third of the canine.[9]

Variations in the normal development of Hertzwig's epithelial root sheath (HERS) results in certain developmental conditions such as fusion, gemination, dens in dente, palatogingival groove, or distolingual groove that mimics or result in two roots or multiple canals in the maxillary lateral incisor.[10] It was presumed that a radicular-shaped accessory formation was developed due to the traumatic injury of the HERS at the time of root formation.[11] Gemination results when the tooth germ divides during the development of the tooth resulting in the formation of a double crown with a single root. Gemination mainly affects maxillary incisors and canines and more prevalent in primary teeth compared to the permanent tooth with incidence range from 0.1% to 1%.[12] Gemination can often be confused with fusion. Fusion results in a bifid crown with two root canals in one root. After fusion, the number of teeth in the dental arch is less which is not found in gemination. In this case, number of teeth in the dental arch is not altered. Clinical pictures show the normal shape and size of the crown when compared with the contralateral side. This was also verified with a pretreatment radiograph. This helps to rule out the diagnosis of fusion and gemination.

Few reports have been documented with maxillary lateral incisor with dens in dente and dens invaginatus with two roots.[13],[14] In this case, the pretreatment radiograph showed no evidence of enamel or dentin invagination that help to rule out the diagnosis of dens in dente or dens invaginatus.

Most of the case report documented for birooted maxillary lateral incisor show palatogingival groove or distolingual groove.[5],[15],[16],[17],[18],[19] In the present case, the clinical evaluations as well as pretreatment radiological evaluations and CBCT ruled out the presence of any grooves or invaginations in enamel or dentin. Thus, the current case is a rare case of birooted maxillary lateral incisor without any developmental defects.

Accurate diagnosis of any dental anomalies or anatomical variations is utmost for complete debridement of root canal that ultimately favors prognosis of the treatment. Intraoral periapical radiograph provides information of any dental variations. Radiographic examination following Clark's rule in such cases is strongly recommended. However, limited information is gained from conventional dental radiograph due to superimposition and geometric distortion of anatomical structures.[20] Computed tomography provides three-dimensional images, reproducing the structures more precisely and allowing a more accurate diagnosis. CBCT is widely used in dentistry to overcome the limitations of conventional two-dimensional imaging techniques by resulting in a better understanding of root canal configuration. CBCT is also helpful for the identification of anatomical features and variations of the root canal system. In such cases, CBCT also guides for the canal localization as well as identify the tomography of the root. High-resolution three-dimensional CBCT is beneficial when two root canals are superimposed on each.[5]

In the present case since both canals of both roots were negotiated, orthograde root canal treatment was performed. Periapical radiolucency was healed after Ca (OH) 2 dressing for 2 weeks. Both the canals were well-instrumented, irrigated, and obturated till working length. With the advancement of magnification in the endodontic field, possibilities of locating the extra canals, roots, and accessory canals have increased over time. Complete debridement of the root canal followed by hermetic seal of the root canals favor complete healing of the periapical radiolucency.


   Conclusion Top


The present case demonstrates rare condition in the maxillary lateral incisor focusing on the importance of a three-dimensional radiograph for diagnosis as well as a treatment procedure. The proper diagnostic tool provides proper diagnosis and treatment reduces mental efforts and time of the practitioner.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Giner-Lluesma T, Micó-Muñoz P, Prada I, Micó-Martínez P, Collado-Castellanos N, Manzano-Saiz A, et al. Role of cone-beam computed tomography (CBCT) in diagnosis and treatment planning of two-rooted maxillary lateral incisor with palatogingival groove. Case report. J Clin Exp Dent 2020;12:e704-7.  Back to cited text no. 5
    
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Wei X, Senders C, Owiti GO, Liu X, Wei ZN, Dillard-Telm L, et al. The origin and development of the upper lateral incisor and premaxilla in normal and cleft lip/palate monkeys induced with cyclophosphamide. Cleft Palate Craniofac J 2000;37:571-83.  Back to cited text no. 8
    
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Hatton JF, Ferrillo PJ Jr. Successful treatment of a two-canaled maxillary lateral incisor. J Endod 1989;15:216-8.  Back to cited text no. 10
    
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Romano N, Souza-Flamini LE, Mendonça IL, Silva RG, Cruz-Filho AM. Geminated maxillary lateral incisor with two root canals. Case Rep Dent 2016;2016:3759021.  Back to cited text no. 12
    
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Greenfeld RS, Cambruzzi JV. Complexities of endodontic treatment of maxillary lateral incisors with anomalous root formation. Oral Surg Oral Med Oral Pathol 1986;62:82-8.  Back to cited text no. 13
    
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Çalışkan MK, Asgary S, Tekin U, Güneri P. Amputation of an extra-root with an endodontic lesion in an invaginated vital maxillary lateral incisor: A rare case with seven-year follow-up. Iran Endod J 2016;11:138-41.  Back to cited text no. 14
    
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Rajput A, Talwar S, Chaudhary S, Khetarpal A. Successful management of pulpo-periodontal lesion in maxillary lateral incisor with palatogingival groove using CBCT scan. Indian J Dent Res 2012;23:415-8.  Back to cited text no. 16
[PUBMED]  [Full text]  
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Lee MH, Ha JH, Jin MU, Kim YK, Kim SK. Endodontic treatment of maxillary lateral incisors with anatomical variations. Restor Dent Endod 2013;38:253-7.  Back to cited text no. 17
    
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Alizadeh Tabari Z, Homayouni H, Pourseyediyan T, Arvin A, Eiland D, Moradi Majd N. Treatment of a developmental groove and supernumerary root using guided tissue regeneration technique. Case Rep Dent 2016;2016:2738569.  Back to cited text no. 18
    
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Hasan A, Ali Khan J. Combined endodontic and surgical management of twin rooted maxillary lateral incisor with a palatogingival groove. Iran Endod J 2018;13:413-9.  Back to cited text no. 19
    
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Huumonen S, Kvist T, Gröndahl K, Molander A. Diagnostic value of computed tomography in re-treatment of root fillings in maxillary molars. Int Endod J 2006;39:827-33.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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