ENDODONTOLOGY Case Report

Endodontic re - treatment of a maxillary central incisor

with two roots
Thomas G * #
Charlie K.M. ** ## 
Joseph B. *** ## 
George Rajani M. **** ###  

ABSTRACT
This case report describes an endodontic retreatment of a maxillary central incisor with two roots. A 13 year old
female patient reported with labial swelling and pain associated with upper left maxillary central incisor. Radiographs
showed an under filled primary canal and a supernumerary root with periapical changes. Access was gained into
the additional root after removal of gutta-percha. Conventional cleaning and shaping of both the roots were performed
and obturation done with gutta-percha. This case emphasizes the need for complete knowledge of the internal and
external dental anatomy and the variations presented. Radiographs are vital in diagnosing such variations.
Key words: endodontic retreatment, central incisor, variations in dental anatomy

Introduction a single root and canal 1,13,15. The presence of

Root Canal treatment (RCT) has become the
standard of care in restoring compromised teeth
back to form and function. This protocol requires
the clinician to make a proper diagnosis and
treatment plan based on the knowledge of tooth
anatomy, root canal morphology, clinical situation,
materials and methods. One of the common causes
of failure of RCT is under filled or missed root canals.
A three dimensional seal of all the portals of exist
helps us in achieving very high success rates in RCT.
Radiographic interpretation often becomes the one
and only tool in the hands of the clinician to
understand the anatomical variations and
complexities associated with root canals. The advent
of microscopes and Cone Beam Computed
Tomography (CBCT) has revolutionized the way we
see dentistry forward.
Most of the available literature shows that
maxillary central incisors are always comprised of
*M.D.S., ** Assistant Professor, *** Professor, **** Assistant Professor, # Conservative Dentistry and Endodontics, Max Dent Dental Clinic, Mangalore, ## Dept. of
Conservative Dentistry and Endodontics, ### Dept of Public Health Dentistry,  Al-Azhar Dental College, Kerala,  A. J. Institute of Dental Sciences, Kuntikana,Mangalore
additional root is extremely rare. However,
variations are reported in the number of lateral
canals and position of apical foramen1,8,9,11,12. Few
studies have reported the presence of two roots and
canals 2-6
. The objective of the present study is to
present a clinical case of retreatment of a failed
central Incisor with two roots.
Case Report
A 13 year old female patient reported to my
clinic with pain and labial swelling associated with
the upper anterior region since two months. On
clinical examination the swelling was associated
with the upper left central incisor. Both the central
incisors were fractured due to trauma five years
back. Patient elicited a dental history of root canal
treatment else where, to both the central incisors
of one year duration. The teeth were subjected to
routine IOPA radiographs. (Fig 1) Radiograph
confirmed the previous RCT and under filled left

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ENDODONTOLOGY THOMAS G, CHARLIE K.M., JOSEPH B., GEORGE RAJANI M.

central incisor with a lateral radiolucency on the based on these observations and the patient was
distal surface of the root. An abnormal anatomical informed about the retreatment procedure.
anomaly was also noted along the middle third of
The access cavity was re entered using a endo
the root suggestive of a split or additional root. The
access bur. (Dentsply) Coronal guttapercha was heat
root appeared to be a little bulbous with a faint
softened and engaged with the help of H-files
crease line separating the abnormal anatomy. A faint
(Dentsply, Maileffer). Entire contents of the canal
trace of root canal was also noticeable with this
were removed and confirmed radiographically.
super numerary root and pathological changes
(Fig 2) Canal was irrigated with saline to flush the
associated with the apex. A diagnosis was made
GP and sealer remnants. The fact that the canal was

Figure-1.Preoperative radiograph
Figure-3. Working length radiograph

Figure-4. Mastercone radiograph

Figure-2. Post gutta-percha removal

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ENDODONTOLOGY
under filled made the GP removal easy. A size 08
K-file was pre curved at the apical third and engaged
laterally on the middle third of primary root canal.
Based on tactile feedback a breach was detected
and the file was pushed into the additional root.
Care was taken so as to not lose the path of insertion.
File was not removed until it was significantly
pushed in. A size 45 H-file was inserted into the
main root canal. Working length was determined
at 18 mm for the additional root. (Fig 3) The tortuous
path of the K-file confirmed the presence of an
additional root and canal lateral to the main root.
Bio Mechanical Preparation (BMP) was done using
Glyde (Dentsply) as a chelating agent and irrigation
was alternated using Sodium Hypochlorite (NaOCl
3%) and normal saline. Chlorhexidine (Dentachlor
2%) was used as a final rinse. Calcium hydroxide
paste (RC cal) was used as an intracanal medicament
and the cavity was closed with Zinc Oxide Eugenol
(ZnOE) temporary cement. Antibiotics and
analgesics were prescribed to manage the pain and
swelling.
Patient was recalled after ten days for further
follow up. Patient was totally asymptomatic on the
second visit. Canal was re entered and BMP was
completed. The primary root apex was enlarged to
size 50 K-file and the supernumerary root to size
20 step back. Master cone radiograph was taken to
confirm the length and size. (Fig 4) Canals were
coated with AH plus sealer (Dentsply) and a size
20 master cone coated with sealer was inserted into
the super numerary root. Lateral condensation was
done using a size 20 spreader and accessory cones
added. Obturation of the primary root was also
carried out similarly. A radiograph was exposed
soon after, which revealed that the primary cone
inserted into the additional canal was split into two
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ENDODONTIC RE - TREATMENT OF A MAXILLARY CENTRAL INCISOR WITH TWO ROOTS
probably by the spreader due to a difficult path of
insertion. (Fig 5) An option of re entry was
considered at this time, but was decided against
because of the concerns of re entry. Orifice was
sealed again with ZnOE temporary cement. Patient
was recalled after two weeks and the access cavity
Figure-5. Post obturation radiograph
was sealed with Glass Ionomer (Fuji II) cement.
Follow up radiograph was taken after one month
and the fractured teeth were restored using
composite resin.
Discussion
When RCT is considered for incisors the
clinician must be aware of conditions such as fusion,
gemination, dens in dente, dens evaginatus,
palatogingival groove etc15. The challenge therefore
lies in the proper diagnosis of these conditions and
treating these anomalies. Normally any teeth with
such anomalies will present with a defective crown
surface either labially or lingually. In this case the
clinical crown was morphologically normal. During
normal root development, the Hertwig’s root sheath
is horizontally bent at the cementoenamel junction
causing the cervical opening of the tooth germ to
ENDODONTOLOGY
narrow14. In this case some unusual factor caused
the development and fusion of a horizontal flap of
the root sheath resulting in the formation of the
additional root. In order to identify these defects it
is often necessary to expose multiple radiographs
at different angulations. The advent of digital
radiography and CT scans has minimized the errors
in clinical diagnosis.
Inadequate knowledge about all possible root
canal anatomical configurations can lead to
untreated root canal spaces, which in turn acts as
nidus for bacterial contamination and failure of
treatment 13
. In this case, the clinical error of an
under filled primary canal and the missed root canal
was a sure shot recipe for failure. The importance
of careful pre operative evaluation with different
diagnostic resources, using standard and modern
materials and methods and adopting well judged
techniques is paramount in ensuring 100% success
in endodontics. Needless to say, the error while
obturating the additional root could have been
avoided by the use of thermoplasticized gutta-
percha technique. The advantages of using heated
gutta-percha in sealing lateral and additional canals
are well documented. In developing countries, the
scales of economics often stand in the way of
delivering the best standard of care for the patients.
Conclusion
As clinicians, we need to use our best wisdom
in diagnosis, planning and treatment delivery.
Radiographic interpretation is a vital tool in ensuring
successful endodontic treatment. Re treatment in
endodontics is a challenge especially with the kind
of drug resistant bacterial strains isolated from the
root canal of a failed tooth. Adequate techniques
and proper use of irrigants and intracanal
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THOMAS G, CHARLIE K.M., JOSEPH B., GEORGE RAJANI M.
medicaments helps to eliminate these bacteria and
coupled with a hermetic seal of all the portals of
exit ensures maximum satisfaction for the patient
and the clinician.
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