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Authors : Dr. Karthikeyan Radhakrishnan, Dr. Shanmugasundaram Karthikeyani, Dr.Bharathan Rajendran .
 

INTRODUCTION

Primary molars are mostly multi‑rooted with the primary maxillary molars usually having three roots and primary mandibular molars are having two roots1. The incidence of root morphological variation especially single rooted primary molar in the primary dentition is not very distinctively documented2. The physiology of root formation and tooth eruption is a complex process. The root formation is initiated by derivatives of enamel organ. Failure in invagination of these derivatives may result in dysmorphological roots3. A great number of variations occur in the formation and the number and shape of the roots. Routine intraoral radiographs with different angulations help in detecting the presence of extra roots4. Single tapering root forms are seen most frequently in second and third permanent molars but may be found in any molar tooth1. These anomalies become clinically significant when pulpal therapy is indicated in such teeth due to Dental caries and dental trauma, to maintain the integrity of oral tissues.

In addition, endodontic procedures for the treatment of deciduous teeth are indicated if the canals are accessible and if there is evidence of essential normal supporting bone5. This case report presents a rare case of endodontic management of single rooted decidous mandibular first molar.
 

CASE PRESENTATION

A 5-year-old girl reported with pain and swelling in lower right back tooth region for the past five days. Pain was spontaneous and aggravated at night. The associated extra oral swelling was of size 2X3 cm and was involving the tooth 84. Intraoral examination revealed all erupted primary teeth. Dental caries were found in 54, 64, 74, 75 and 85.

The patient had Frankel behavior with positive rating. No relevant medical history was given. Radiographic examination of the tooth showed deep caries extending to the pulp in 84, with a complex root anatomy (Figure 1). From the clinical and radiographic findings, diagnosis of symptomatic irreversible pulpitis with alveolar abscess was made for the tooth 84, and a pulpectomy was scheduled.
 
Figure 1 Preoperative radiograph showing single root and single canal in 84


The inferior alveolar nerve block was given with 2% lignocaine containing 1:80000 adrenaline (Lignox 2%; Indoco Remedies Ltd., Mumbai, India). The tooth was isolated with a rubber dam, and following caries removal the access cavity was prepared in 84. All pulp tissue was removed. Canal exploration with a No.10 file and instrumentation was performed using a K-files. Normal saline irrigation was done through-out the instrumentation.The canals were dried with absorbent paperpoints (DENTSPLY Tulsa dental specialties, Tulsa, USA) and obturated with Endoflas using compaction technique.

The access was sealed with Glass ionomer Cement (GC Corporation, Tokyo, Japan) and a post-operative periapical radiograph was taken after obturation (Figure 2). After 1 week, stainless steel crown (3M ESPE Unitek, USA) was done and a periapical radiograph was taken.The patient was advised to seek a periodic review every 3 months. GIC restoration was done in 54, 64, 75 and 85. Radiograph of lower left back tooth region shows taurodontism in 74(Figure 3). Patient was not willing for treatment in 74 as it was asymptomatic.
 
Figure 2 Radiograph showing single canal in 84 obturated
with Endoflas, restoration done in 85
Figure 3 Radiograph showing Taurodontism in 74.
 

DISCUSSION

The role of genetics is documented and accepted to have an influence on tooth agenesis as genes directly influence the proteins and their signaling molecules which are essential for tooth development. A defect in any of these genes could lead to multiple problems like agenesis, delayed eruption and shape or size malformation6. Also, environmental factors such as chemotherapy, radiation therapy and trauma may affect the morphology of the developing roots. Literature regarding etiology of single rooted molars reveals failure in invagination of Hertwig’s epithelial root sheath (HERS) resulting in dysmorphological roots7.

Perkins et al stated that in humans, genes msx-1 and pax-9 has been shown to be associated with selective tooth agenesis, however, gene expression and signalling molecules for occurrence of single rooted molars have to be studied8-9.

Females are seen to be more frequently affected than males with respect to root dysmorphology. The cause for this female predilection is unknown10. Sabala et al stated that occurrence of single rooted deciduous molar is more likely to be bilateral11. But in the present case it is unilateral and with taurodontism on the otherside.

Several factors should be taken into consideration before endodontically treating single rooted primary molars. First, excessive tooth removal and perforation are the common iatrogenic access opening errors. These errors occur during the search for the extra canals in teeth with unusual root morphology12.

Next, an ideal root canal filing material which possess the necessary properties of being antibacterial, resorbable at the same rate of the root and harmless to periapical tissues and the developing tooth bud should be used. In addition, it must be easily fill the canals, adhere to the walls, not shrink, must readily resorb if passed away beyond the apex, be easily removed if necessary, be radiopaque and should not causes discoloration of the tooth13-15. In the present case, Endoflas, a mixture of calcium hydroxide, zinc oxide eugenol and iodoform was used. Ramar et al, compared the efficacy of three obturating materials- calcium hydroxide with iodoform (Metapex), zinc oxide eugenol with iodoform (RC FILL), zinc oxide eugenol and calcium hydroxide with iodoform (ENDOFLAS) in which they observed Endoflas gave an overall success rate of 95.1% which fulfills most of the required properties of an ideal root canal filling material for a primary teeth16.
 

Conclusion

In endodontic therapy, the success of the procedure depends on the knowledge of anatomic characteristics and their possible variation. This together with good radiographs made from different angles and careful evaluation of the internal anatomy goes a long way in achieving our goal.
 

REFERENCES

  1. Dubrul EL. Sicher’s Oral Anatomy. St. Louis: CV Mosby Co.; 1980. p. 256‑6.
  2. Ackerman JL, Ackerman AL, Ackerman AB. Taurodont, pyramidal and fused molar roots associated with other anomalies in a kindred. Am J Phys Anthropol 1973;38:681‑94.
  3. Neville BW, Damm DD, Allen CM, Bouquot JE. Abnormalities of teeth In: Oral and Maxillofacial Pathology. 2nd ed. Philadelphia, PA: Saunders; 2004. P. 49-89.
  4. J. Ghoddusi, N. Naghavi,M. Zarei, and E. Rohani, “Mandibular first molar with four distal canals,” Journal of Endodontics, vol. 33, no. 12, pp. 1481–1483, 2007.
  5. St McDonald RE, Avery DR, Dean JA (2004) Dentistry for the child and adolescent, 8th ed, Mosby Louis, 388-412.
  6. Dubrul EL. Sicher’s Oral Anatomy. St. Louis: CV Mosby Co.; 1980. p. 256‑6.
  7. Minicucci EM, Lopes LF, Crocci AJ. Dental abnormalities in children after chemotherapy treatment for acute lymphoid leukemia. Leuk Res 2003;27:45-50.
  8. Mostowska A, Kobielak A, Biedziak B, et al. Novel mutation in the paired box sequence of PAX9 gene in a sporadic form of oligodontia. Eur J Oral Sci 2003;111:272–6.
  9. Steele-Perkins G, Butz KG, Lyons GE, et al. Essential role for NFI- C/CTF transcription-replication factor in tooth root development. Mol Cell Biol 2003;23:1075–84.
  10. Winter GB, Brook AH. Tooth abnormalities. In: A companion to dental studies,Volume 3. Clinical dentistry. Oxford: Blackwell Scientific Publications, 1989:55–104.

More Refrences are avilable on request

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