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Endodontic management of mandibular anterior teeth with two root canals

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Saudi Endodontic Journal

Volume 9
Issue 2
May-August 2019
Pages ***-***

Endodontic management of mandibular second premolar with Type IX canal configuration using cone-beam
computed tomography, Al-Shawwa SS, Al-Khairallah Y, Alenazy MS, Al-Dayel O.
Saudi Endod J 2019;9:144-7.

Volume 9 / Issue 2 / May-August 2019

 Case Report

Endodontic management of mandibular anterior teeth with

two root canals
Mohammed S. Alenazy, Shatha Sulaiman Alrushoud1, Abdulrahman Almasoud2, Omar Al‑Dayel3
Ministry of Health, King Khalid Hospital, Alkharj, 1Prince Abdulrahman Advanced Dental Institute, 2Prince Sultan Military
Medical City, 3Consultant in Restorative Dentistry, Prince Abdulrahman Advanced Dental Institute, Riyadh, Saudi Arabia

Abstract Teeth with single root canals are considered to be the simplest for endodontic treatment. In the literature,
the internal and external root canal anatomy of mandibular incisors and canines could present with a
number of variations including extra canals. This case report illustrates the detection and successful
nonsurgical endodontic retreatment of root canal systems in all mandibular incisors and canines in one
patient.

Keywords: Canal configuration, mandibular canine, mandibular incisor, two root canals

Address for correspondence: Dr. Mohammed S. Alenazy, Ministry of Health, King Khalid Hospital, P.O. Box 21437, Riyadh 11475, Saudi Arabia.
E‑mail: alenazy.endodontics@gmail.com

INTRODUCTION canines, each with two canals of varied configurations in

The main core of endodontic treatment is achieved by
reaching an adequate chemomechanical debridement
and filling the entire canal space in three‑dimensional
manner. [1] Failure to locate all root canals may lead
to several complications such as posttreatment
disease.[2] Therefore, a sound knowledge of root canal
morphology is essential for the successful outcome of
root canal therapy. Several studies had been conducted
on the root canal internal anatomy mandibular anterior
teeth. The incidence of two canals on mandibular
incisors was 12%–41.4%, [3‑7] while in mandibular
canines, two canals range from 4.1% to 24%.[8‑11] The
two canals may merge into one at the apical third or in
rare cases split into two.
The purpose of this case report describes the clinical
endodontic management of all mandibular incisors and
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one patient.
CASE REPORT
A 34‑year‑old Saudi female with no history of any systemic
diseases was referred to the Department of Endodontics
of Prince Abdulrahman Advanced Dental Institute for
endodontic treatment of her mandibular incisors and
canines (#33–43). The patient was prepared for prosthetic
rehabilitation and his dentist needs to evaluate the
endodontic treatment of his mandibular anterior teeth. The
patient had no symptoms, and the root canal treatment was
done long time ago. The percussion and palpation testes
were applied for all teeth and the response was negative,
and mobility was normal. All radiographic images with
different angulations had been evaluated and showed
inadequate root canal filling and periapical radiolucency
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DOI: How to cite this article: Alenazy MS, Alrushoud SS, Almasoud A, Al-Dayel O.
10.4103/sej.sej_51_18 Endodontic management of mandibular anterior teeth with two root canals.
Saudi Endod J 2019;9:140-3.

140 © 2019 Saudi Endodontic Journal | Published by Wolters Kluwer ‑ Medknow

 Alenazy, et al.: Mandibular anterior teeth with two root canals and their management
at teeth #33–43 [Figure 1]. Based on the clinical and
radiographic examinations, the diagnosed teeth were
previously treated with asymptomatic apical periodontitis.
A plan of nonsurgical root canal retreatment was decided
accordingly.
All coronal restorations were removed. Then, the local
anesthesia with 2% lidocaine and 1:100,000 epinephrine
was established and the rubber dam was placed. A careful
examination of the pulp chambers  under dental operating
microscope  (Möller‑Wedel International Microscopes,
Germany) revealed two separated labial and lingual orifices
in #33–43 teeth. The root canal filling was removed
with chloroform and ProTaper retreatment rotary
files  (DENTSPLY Maillefer, Ballaigues, Switzerland),
access cavity was closed, then rubber dam was removed,
and a multiplanar reconstruction cone‑beam computed
Figure 1: Preoperative radiographs of teeth (#33–43) with inadequate
root canal treatment and periapical radiolucency
b
c
Figure 3: Axial view of cone‑beam computed tomography (coronal [a],
middle [b], and apical [c]) showing the mandibular anterior teeth with
two canals in each tooth
Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019 141
tomography (CBCT) was taken to confirm the numbers and
canal configuration of the mandibular incisors and canines’
teeth (#33–43). The images of CBCT were obtained with
Planmeca ProMax 3D Max CBCT (Planmeca OY, Helsinki,
Finland) and showed the general configuration of the
mandibular incisors and canines as follow: teeth #33, 32,
42, and 43 were Type III (1‑2‑1), tooth #41 Type IV (2‑2),
and tooth # 31 Type V  (1‑2) according to Vertucci’s
classification [Figures 2 and 3].[11] Rubber dam was placed,
and the outline of access cavity was adjusted to establish
straight‑line access for all canals. The working length was
re‑established with Root ZX II (J. Morita, Tokyo, Japan)
and confirmed radiographically.
The instrumentation was done with ProTaper universal
files (DENTSPLY Maillefer, Ballaigues, Switzerland) to size
F2 using copious irrigation with 5.25% sodium hypochlorite.
Then, the canals were dried with sterile paper points and filled
with gutta‑percha and Endosequence BC sealer (Root Sealer
Material, Brasseler, USA) in a lateral compaction manner.
Finally, the access cavity was closed with Cavit (Dent‑a‑Cav,
Barmstedt, Germany) and resin‑modified glass ionomer
filling (ChemFil, DENTSPLY DeTrey, Germany) [Figure 4].
The patient was referred back to the department of
prosthodontics to fabricate for final restorations.
The follow‑up posttreatment radiographs after 12 months
showed a complete reduction of the periapical radiolucency
Figure 2: Sagittal view of cone‑beam computed tomography showing
variety of canal configurations
Figure 4: Postoperative radiographs with obturation material
 Alenazy, et al.: Mandibular anterior teeth with two root canals and their management
Figure 5: Follow‑up radiographs after 12 months with final restorations
showing the healing of periapical radiolucency
for all treated teeth [Figure 5] with no clinical signs and
symptoms.
DISCUSSION
An adequate root canal therapy requires sufficient
biomechanical instrumentation and obturating the entire
canal space in three‑dimensional perspectives. The main
reason of endodontic treatment failure is missed canals due to
ignorance or neglect of the internal anatomy of the teeth.[1,2]
This case report described nonsurgical root canal retreatments
of mandibular anterior teeth each with two canals which
were missed during the previous treatment. Therefore, every
effort should be made by the clinician to diagnose and treat
such teeth through using appropriate available armamentaria.
Some investigators recommend exposing several angulated
periapical radiographs for detecting teeth the morphological
variation.[12,13] Root sectioning, staining, and clearing
techniques have been used. The use of CBCT images is very
useful technology in detecting the dental morphological
variation.[14] It was used in the current case to identify the
potential suspected accessory canals of the treated teeth.
The proper preparation and design of teeth access cavity
is the utmost importance to visualize and detect the whole
pulp‑chamber floors. Therefore, the access cavities of
the affected teeth were modified under dental operating
microscope. In this case, the outline was extended more
lingually to manage the lingual missed canals. In addition, a
detailed examination of the pulp‑chamber floors under the
proper magnification and illumination increased the possibility
of detecting and treating the entire pulp and canal system.[15,16]
The occurrence of two canals in mandibular incisor has
been reported in a Saudi subpopulation by Al‑Fouzan et al.[17]
They found that 70% of the samples had one canal, while
the reaming had two. The two canal configurations were
of Type III, which is similar most of the teeth of this case.
Endodontic treatments of mandibular canine have been
described in Saudi population as case reports.[18‑20] This
142 Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019
report showed the occurrence of two canals in both canines
of the same patient in different configuration forms.
The new bioceramic endodontic materials are totally not
sensitive to both moisture and blood contaminations
and hence are not technique sensitive.[21‑23] With their
antimicrobial and the high sealability properties, endodontic
premixed bioceramic materials could contribute a critical
role in endodontic treatment success.[24] In addition,
number of investigators noted that bioceramic sealers have
a high potential for promoting bone regeneration in case
of unintentionally extruded sealer materials apically.[22,25]
The process of healing appears subsequently in periapical
lesions in case of adequate biomechanical preparation
and filling of the entire root canal space.[26] Several studies
revealed that healing takes place within 12 months, while
others found that this reaction may take several years.[27]
However, in certain cases, periapical lesions could heal
with scar tissue.[28] Although the outcome of nonsurgical
retreatment success is lower than the treatment,[29] in the
present case, a complete healing of periapical lesions was
observed within the 1st year.
CONCLUSION
The clinician should always pay enough attention to all
endodontic treated cases. Utilization of operation, dental
microscope, CBCT, and additionally selected appropriate
obturation materials will assure a successful outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Vertucci FJ. Root canal morphology and its relationship to endodontic
procedures. Endod Topics 2005;10:3‑29.
2. Cantatore G, Berutti E, Castellucci A. Missed anatomy: Frequency and
clinical impact. Endod Topics 2006;15:31‑3.
3. Al‑Qudah AA, Awawdeh LA. Root canal morphology of mandibular
incisors in a Jordanian population. Int Endod J 2006;39:873‑7.
4. Boruah LC, Bhuyan AC. Morphologic characteristics of root canal of
 Alenazy, et al.: Mandibular anterior teeth with two root canals and their management
mandibular incisors in North‑East Indian population: An in vitro study.
J Conserv Dent 2011;14:346‑50.
5. de Oliveira  SH, de Moraes  LC, Faig‑Leite  H, Camargo  SE,
Camargo  CH. In vitro incidence of root canal bifurcation
in mandibular incisors by radiovisiography. J  Appl Oral Sci
2009;17:234‑9.
6. Miyashita M, Kasahara E, Yasuda E, Yamamoto A, Sekizawa T. Root
canal system of the mandibular incisor. J Endod 1997;23:479‑84.
7. Benjamin  KA, Dowson  J. Incidence of two root canals in human
mandibular incisor teeth. Oral Surg Oral Med Oral Pathol
1974;38:122‑6.
8. Calişkan MK, Pehlivan Y, Sepetçioğlu F, Türkün M, Tuncer SS. Root
canal morphology of human permanent teeth in a Turkish population.
J Endod 1995;21:200‑4.
9. 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;30:391‑8.
10. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic
investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol
1972;33:101‑10.
11. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral
Surg Oral Med Oral Pathol 1984;58:589‑99.
12. Slowey RR. Radiographic aids in the detection of extra root canals.
Oral Surg Oral Med Oral Pathol 1974;37:762‑72.
13. Fava LR, Dummer PM. Periapical radiographic techniques during
endodontic diagnosis and treatment. Int Endod J 1997;30:250‑61.
14. Patel S. New dimensions in endodontic imaging: Part 2. Cone beam
computed tomography. Int Endod J 2009;42:463‑75.
15. Patel S, Patel P. Endodontic management of maxillary second
molar with two palatal roots: A report of two cases. Case Rep Dent
2012;2012:590406.
16. Görduysus MO, Görduysus M, Friedman S. Operating microscope
improves negotiation of second mesiobuccal canals in maxillary molars.
J Endod 2001;27:683‑6.
Saudi Endodontic Journal | Volume 9 | Issue 2 | May-August 2019 143
View publication stats
17. Al‑Fouzan K, Al‑Manee A, Jan J, Al‑Rejaie M. Incidence of two canals
in extracted mandibular incisors teeth of Saudi Arabian samples. Saudi
Endod J 2012;2:65‑9.
18. Rahmatulla M, Wyne A. Bifid roots in a mandibular canine: Report of
an unusual case. Saudi Dent J 1993;5:77‑8.
19. Balto HA, Alwakeel M. Mandibular canine with two root canals – Case
report. Egypt Dent J 2007;53:2535‑8.
20. Alenazi  MA, Al‑Hawwas  AY. Permanent mandibular canine with
two roots and two root canals: Two case reports. Saudi Endod J
2016;6:98‑100.
21. Zhang H, Shen Y, Ruse ND, Haapasalo M. Antibacterial activity of
endodontic sealers by modified direct contact test against enterococcus
faecalis. J Endod 2009;35:1051‑5.
22. Zhang  W, Li  Z, Peng  B. Ex vivo cytotoxicity of a new calcium
silicate‑based canal filling material. Int Endod J 2010;43:769‑74.
23. Nekoofar  MH, Stone  DF, Dummer  PM. The effect of blood
contamination on the compressive strength and surface microstructure
of mineral trioxide aggregate. Int Endod J 2010;43:782‑91.
24. Debelian G, Trope M. The use of premixed bioceramic materials in
endodontics. G Ital Endod 2016;30:70‑80.
25. Bryan  TE, Khechen  K, Brackett  MG, Messer  RL, El‑Awady  A,
Primus CM, et al. In vitro osteogenic potential of an experimental
calcium silicate‑based root canal sealer. J Endod 2010;36:1163‑9.
26. Orstavik  D. Time‑course and risk analyses of the development
and healing of chronic apical periodontitis in man. Int Endod J
1996;29:150‑5.
27. Sjogren  U, Hagglund  B, Sundqvist  G, Wing  K. Factors affecting
the long‑ter m results of endodontic treatment. J Endod
1990;16:498‑504.
28. Grung B, Molven O, Halse A. Periapical surgery in a norwegian county
hospital: Follow‑up findings of 477 teeth. J Endod 1990;16:411‑7.
29. Ng  YL, Mann  V, Gulabivala  K. Outcome of secondary root canal
treatment: A  systematic review of the literature. Int Endod J
2008;41:1026‑46.