Revolutionary Paradigm for the Future Vision of Endodontics and Restorative Dentistry ‘NDODONTIC RETREATMENT OF MAXILLARY FIRST MOLAR WITH ADDITIONAL OF MB 2 ROOT CANAL, ACASE REPORT Hernika Harperiana’, Juanita AGunawan’, Anastasia EPrahasti? Departement of Conservative Dentistry, Faculty of Dentistry, Trisakti University ' Resident in Departemet Conservative Dentistry and Endodontics Trisakti University > Lecturer in Departemet Conservative Dentistry and Endodontics Trisakti University Background : The main objective of the root canal treatment is to clean the entire pulp ind to obture it with a solid filling material. For a complete healing of periradicular tissues, all of the root canals must be located and treated. Missing root canals like second mesiobuccal canal and infected spaces like under obturation is one of the reasons of endodontic failure. To eliminate such problems, clinicians need to know thoroughly the morphology of the external and internal anatomy of teeth and atypical root canal configuration and its variation, Maxillary first molar usually exhibits a second mesiobuccal canal. This canal provides a great challenge for clinicians to recognized. Failure to locate this extra canal may result in endodontic failure, Objective : The aim of this case report is to demonstrate a succeed retreatment of maxillary first molar in which an extra canal in mesiobuceal root was located using visual, tactile and magnifying devices. Case Management : A 23-years-old female patient came with a chief complaint on the maxillary first molar. Patient felt uncomfortable in chewing. The tooth was tender to percussion but the palpation and mobility was normal. radiographic examination showed that the tooth has been treated endodontically but the obturation showed uncompleted and there was a miscanal in mesiobuccal. Conclusion : A complete cleaning and obturation the entire pulp on maxillary first molar showed a successful treatment outcome. Keywords : root canal retreatment, second mesiobuccal canal, endodontics failure. INTRODUCTION seal it in 3 dimension,’so that any possibility ‘The general purpose of the endodontic of @ secondary infection occurrence due to treatment is to maintain teeth duration as the mouth cavity or periradicular tissue long as possible in the oral cavity.’The leakage into the root canal system can be ‘major goals of root canal treatment are to @voided.' clean and shape the root canal system and PROCEEDING INTERNATIONAL SCIENTIFIC MEETING (TINIIV) | 237 {& IKORGI NATIONAL CONGRESS XI Surabaya, November 3°~ 5, 2017Theme Revolutionary Paradigm forthe Future Vision of Endodontics and Restorative Dentistry Although initial root canal therapy has been shown to be a predictable procedure with a high degree of success, failures can occur after treatment, Recent publications reported fail 16% for initial root canal treatment.’The ire rates of 14% causes of the endodontic failures can be variations in the anatomy of the teeth, the presence of additional root canals, lateral canals, depend on technical, biological and iatrogenic factors which contribute to accomplishment of treatment.’ Studies have shown that unprepared areas of the root canal system may harbor bacteria and necrotic tissue that may result in root canal treatment failure.Thus the primary goal of root canal treatment should be to eliminate completely or reduce the microbial population with in the root canal system and to prevent re-infection by providing tight seal.’Knowing and understanding the relation between these factors may help in increasing the chances, of preventing the possible endodontic treatment failures." Endodontic failures must be evaluated so a decision can be made among nonsurgical retreatment, surgical retreatment, or extraction, The goals of nonsurgical retreatment are to remove materials from the root canal space and if present, address deficiencies or repair defects that are pathologic or iatrogenic in origin.Additionally, retreatment procedures confirm mechanical failures, previously Importantly, disassembly and corrective nonsurgical missed canals. procedures allow clinicians to shape canals and three dimensionally clean and pack root canal systems.* The success of endodontic treatment also requires adequate knowledge of the intemal anatomy of the teeth and possible variations in relation to those teeth. Inadequate access can lead to canals being left untreated and may lead to the failure of the treatment.‘ The most common cause of treatment failures in permanent maxillary first molars have been attributed to failure in detecting additional canals especially in the mesiobuccal root.® Missed canals hold tissue, and at times bacteria and related irritants that inevitably contribute jcal symptoms and lesions of to cli endodontic ori A thorough knowledge of the anatomy of root canal systems is required to achieve successful root canal treatment. Extra roots or root canals if not detected are a major reason for failure.’The maxillary first ‘molar has some of the highest failure rates in endodontic treatment. The failure often is due to the presence of a second canal in the mesiobuccal root that the operator fails to explore, prepare and obturate three dimensionally.’ Maxillary first molar largest in volume and has a complicated details in root and root canal configuration, and possibly the most treated teeth endodontically.” CASE REPORT A.23 year old female was referred to department of conservative dentistry 238 || PROCEEDING INTERNATIONAL SCIENTIFIC MEETING (TINLIV) {& KORGI NATIONAL CONGRESS XI Surabaya, November 3%~ 58, 2017Theme Revolutionary Paradigm for the Future Vison of Endodontics and Restorative Dentistry Trisakti_ University with the chief complaint of pain on her upper left molar. Clinical examination revealed a large resin composite restoration on area of tooth #26 (Fig.1a). The tooth had no tenderness on palpation, percussion was positive, and mobility was normal, No fistulae and edema was observed. Radiographic examination revealed a large ing to the pulp chamber, the occlusal the tooth had pre treated, but the inadequte and there was a miscanal on mesial. Also it found aperiapical lession on. the apical of the mesial root canal (Fig.1b). The clinical and radiographic examination led to a diagnosis of simptomatic apical periodontotitis of previously treated teeth and requiring root canal retreatment. uusly endodontically obturation revealed Figure 1. a) preoperative on occlusal view. b) initial radiograph. c) access opening. d) radiograph conformation of working length. e) preparation result of second mesiobuccal £) radiograph confirmation of master cone gutta percha. g) obturation result. h) obturation result in different angle with object buccal rule technique. i) final restoration with resin composite. PROCEEDING INTERNATIONAL SCIENTIFIC MEETING (TIN Iv) | 239 {& IKORGI NATIONAL CONGRESS XI Surabaya, November 3°~ 5", 2017Revolutionary Paradigm for the Future Vision of Endodontics and Restorative Dentistry Previously composite restoration was removed. Access cavity resin was prepared with a round diamond bur followed by isolation with rubber dam. The old gutta percha was removed with solvent (xylol) and hedstrom file #15. All canals were negotiated with k-file #10 and #15 and a second mesiobuccal canal was found. After negotiated all canals and then the working length was determined using Propex Pixie apex locator (Dentsply, Malillefer) and confirmed with radiograph (Fig.1d). After establishing glide path with Proglider (Denstply, Maillefer), all canals were shaped with Protaper Next (Denstply, Maillefer) file X1 and X2, respectively. In between instrumentation, copious irrigation was done with 5.25% NaOCl! (Chloraxid, Cerkamed) and saline, and recapitulated with k-file #10. Final irrigation was done with 5 mL NaOCl 5,25%, 5 mLEDTA 17%, and 5 mL Chlorhexidine 17% and activated with Eddy (VDW, Germany), respectively, for 20 hydroxide (Ultracal XS, UltraDent) was used as an intracanal medicament. sonic second. Calcium Second visit was seven days later, patient was clinically evaluated and the tooth revealed asymptomatic, Rubber dam was placed and followed by removal of calcium hydroxide with NaOCI 5,25% and activated by sonic eddy (VDW, Germany). Trial master cone gutta percha was done with gutta percha Protaper Next X2 and confirmed with radiograph (Fig. Lf) and followed by final irrigation with 5 mL NaOCl 5,25%, 5 mL EDTA 17%, and 5 mL Chlorhexidine 17% and activated with Eddy (VDW, Germany), respectively, for 20 second. Obturation was performed with gutta-percha Protaper Next sonic X2 (Denstply, Maillefer) and root canal sealer (Saelapex, SybronEndo) using warm vertical compaction technique (Fig.1g and 1h). The tooth was then restored with resin composite (Fig. li), DISCUSSION The main objective of endodontic treatment is thorough mechanical and chemical debridement of necrotic tissue and its complete obturation with an inert filling material. The major cause of endodontic failure when treating the first maxillary molar is failure to debride the entire root canal system, which usually occurs because the clini jan was unable to detect additional root canals.* The permanent first maxillary molar and permanent second maxillary molar are the teeth that present the greatest complexity and variation in the root canal system and this is reflected in them having the highest rates of endodontic failure and being a constant challenge for the clinician."Extra roots or root canals if not detected are a major reason for failure.” The maxillary first molar has some of the highest failure rates in endodontic treatment.A high percentage of treatment failures is due to the impossibility of detecting the presence and location of the secondary mesiobuccal canal (MB2), located in the mesiobuccal root of the 240 | PROCEEDING INTERNATIONAL SCIENTIFIC MEETING (TINIIV) & IKORGI NATIONAL CONGRESS XI Surabaya, November 3%Theme Revolutionary Paradigm for the Future Vision of Endodontics and Restorative Dentistry and has a complicated details in root and root canal configuration, and possibly the most treated teeth endodontically,” first maxillary molar, which prevents the correct implementation of biomechanical instrumentation, irrigation and obturation."First molar largest in volume ‘Table 1. Incidence of two canals in the mesiobuccal root in laboratory and clinical studies ‘No.of canals nd apices [No ofstlits ied No. oftet (cana studies) 1 eal > Deans Mesibucel rot fala yy ams 389% (1259) 6.181996) Mesiouceal rot (Cuca acho, B 10 453% (2393) 547852887) Table 2. Result of investigation of second mesiobuccal canals.® Figure 2. Occlusal view of maxillary first molar with MBI and MB2. D = distance between MB1 and MB2.* Morphologic variation in the anatomy of the root canal system should always be considered at the beginning of a treatment, Each case, independent of the type of tooth, should be examined clinically investigating and successfully detecting all root canal orifices CONCLUSION ‘The success of endodontic treatment and radiologically in a thorough manner to detect possible anatomic anomalies. Endodontic treatment should be initiated with proper preparation to allow access to the cavity, which can ease the process of PROCEEDING INTERNATIONAL SCIENTIFIC MEETING (TINIIV) also requires adequate knowledge of the internal anatomy of the teeth and possible those teeth. variations in relation to Inadequate access can lead to canals being 241 & IKORGI NATIONAL CONGRESS XI Surabaya, November 3°—5", 2017Revolutionary Paradigm for the Future Vision of Endodontics and Restorative Dentistry left untreated and may lead to the failure of the treatments ‘The most common cause of treatment failures in permanent maxillary first molars have been attributed to failure in detecting additional canals especially in the mesiobuceal root.* Missed canals hold tissue, and at times bacteria and related irritants that inevitably contribute to clinical symptoms and lesions of endodontic “Remnants of pulp tissue can be a reservoir for the growth of microorganisms, which may affect and compromise treatment outcomes.® A thorough knowledge of the anatomy of root canal systems is required to achieve successful root canal treatment, REFERENCES 1. 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