Introduction
Thorough knowledge of the root canal anatomy is very important for the success of endodontic therapy. 1 Anatomical complexities might interfere hindering the exploration, shaping, cleaning and disinfection of root canals. 2 Maxillary lateral incisors normally have a single root and single canal.3 However, morphological variations for these teeth include the presence of two 4, 5 three 6, 7 four 8 and even five canals 9 usually associated with the occurrence of traumatic stimuli during tooth development process 10. Other morphological variations such as dens invagination9, 11 radicular groove12 and fusion,13 germination 14 are also associated with the maxillary lateral incisors. There were cases of maxillary lateral incisors with two roots 5, 15, 16, 17, 18, 19 reported, but two rooted maxillary lateral incisor, one root with open apex and another normal root has not been reported in the literature.
Case Report
32 year old male patient reported to the department of conservative Dentistry & Endodontics, complaining of discoloured front tooth, on clinical examination # 22 was discoloured, the labial surface was intact, free of any surface defect and the palatal surface had a groove like defect extending from the cervical third of the crown &extending below the gingival margin. On probing the labial surface a groove was found starting in the Cemento Enamel junction extending subgingivally. The tooth was grade one mobile on percussion and did not respond to thermal tests. Intra Oral Periapical Radiograph (IOPA) (Figure 1) revealed two roots, one wide mesial root with open apex and thin distal root with periapical radiolucency involving both the roots. Based on the clinical examination and radiographic finding, diagnosis of pulpal necrosis with chronic apical periodontitis was established. Root canal treatment with the apexification was planned for the tooth.
Informed consent was taken from the patient and access opening was done using Endo Access bur no 1(Dentsply) under rubber dam isolation and magnification with loupes (3.5X) (Sanma Medineer Vision), working length determination done using Root ZX(JM Morita, Japan) apex locator & confirmed with the intraoral periapical radiograph. Cleaning and shaping was done using stainless steel K-files in circumferential and step-back technique till size 80 in mesial root and size 25 in distal root at working length while irrigating with 1.5% sodium hypochlorite throughout the procedure. Apical plug of MTA (proroot) was placed in the mesial root using MTA plugger(GDC, India) and hand plugger and moist cotton pellet was placed over it and coronal access sealed with cavit (3M ESPE). In the next visit back filling of mesial root was done using Calamus dual obturation system (Dentsply Sirona) and lateral canal was obturated with gutta-percha points and AHplus sealer (Dentsply De Trey Gmbh, Germany) in lateral condensation technique (Figure 2). Coronal access was sealed with light cure composite Z250 (3MESPE). The tooth was followed up for 1 year after the root canal treatment with IOPA radiograph. (Figure 3). The patient was asymptomatic & the post-operative IOPA radiograph was suggestive of periapical healing.
Discussion
The common developemental anamolies associated with maxillary lateral incisor are gemination, fusion, dens in dente and palatogingival groove. In gemination, there will be larger incompletely separated crown with single root & root canal. Fusion is union of two tooth germs resulting in a large crown with two root canals. Gemination & fusion are a common occurrence in deciduos than permanent dentition. Dens invaginatus presents itself as a radio-lucent sac surrounded by a radio-opaque enamel border in the radiograph. Since none of these findings were seen in our case & it presented in the radiograph with two distinct roots, broader mesial root and narrow thin distal root it was considered as a case of maxillary lateral incisor with one regular &extra accessory root. There were cases of maxillary lateral incisors with two roots5, 15, 16, 17, 18, 19 reported, but two rooted maxillary lateral incisor, one root with open apex and another normal root has never been reported in the literature. Since one mesial and one distal root was clearly seen in the IOPA radiograph, we didnot find the need for CBCT imaging. One of the challenges faced in the treatment of open apex is lack of apical stop, thus achieving a good apical seal is difficult. Apexification is formation of an apical calcified barrier consisting of osteocementum or other bone like tissue.20 Materials such as calcium hydroxide, Mineral Trioxide Aggregate (MTA) and Biodentine are used in the apexification procedure. Calcium hydroxide requires about 3 to 17 months,21 requiring multiple visits for material replacement and long term exposure may weaken the root structure. MTA has many advantages such as hard tissue formation, sealing ability and biocompatibility. Inspite of disadvantages such as long setting time, handling difficulty, expensive material22, MTA still remains the preferred material in the apexification of open apex cases. The shorter treatment time with MTA may translate into higher overall success rate because of better patient compliance.23
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