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Two rooted mandibular canine with severe dilacerations

Article · April 2012

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Case Report
Two rooted mandibular canine with severe dilacerations

Rudra Kaul, Postgraduate student, Riyaz Farooq, Professor and Head, Aamir
Rashid Purra, Ravinder Kumar Bhagat. Postgraduate student, Shafayat Ullah
Khateeb, Department of Conservative dentistry & Endodontics, Govt. Dental
College, Srinagar, India. Email: suhaillatoo@yahoo.com

International Journal of Clinical Cases and Investigations 2012. Volume 4

(Issue 1), 75:79, 1st April, 2012

Key Words: Two rooted mandibular canine, internal anatomy, dilaceration, instrument
separation

Abstract
The mandibular canine is usually considered a single-rooted tooth with a single root
canal. However, two canals and more rarely two roots with dilaceration may also occur.
An atypical morphology of a two rooted canine showing severe dilaceration is a
challenge for any clinician to clean, shape and obturate. This paper reports the case of a
patient with left mandibular canine with two roots and two root canals with severe
dilaceration in lingual root. After coronal opening, the cervical third was prepared with a
SX file of the ProTaper® system. Root canal preparation of buccal canal was completed
with the series of ProTaper® instruments and in lingual canal, ISO Dentsply Mallifer
files® were used. While negotiating lingual canal, 10# Dentsply Mallifer K file®
separated in the canal curvature which was later on successfully retrieved. The buccal
root canal was filled with Protaper gutta-percha Cone® and in lingual canal Gutta-flow
(Reiko)® was used. The final radiographs showed two well-obturated canals ending. The
6-month post treatment follow-up showed apparent clinical and radiographic success.
Clinicians should always consider the presence of anatomical variations in the teeth
during endodontic treatments. Despite the low prevalence, variations may occur in the
number of roots and root canals with severe dilacerations of mandibular canines, as
demonstrated in this case report.

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Introduction
Knowledge of root canal anatomy is mandatory for the success of endodontic
treatment. In most cases, the mandibular canines present only one root1-5. The
occurrence of two roots and even more two root canals is rare, ranging from 1%4 to
5%5. Despite the low prevalence, clinicians should consider the possible variations in
the number and shape of roots and root canals of mandibular canines. This paper
reports the case of left mandibular canine with two roots and two root canals with
severe dilaceration in lingual root with two roots and two root canals.

Case Report:
A 16 year old Kashmiri female reported to the department of conservative dentistry
and endodontics, Government Dental college with spontaneous throbbing pain in
mandibular left anterior region. The tooth was tender on vertical percussion and pulp
vitality tests proved that the tooth was non-vital. Radiographic examination showed
two roots with severe dilaceration in lingual canal and periapical radiolucency.
(Figure1A)

Based on vitality test results, a multivisit rootcanal therapy was planned and consent
was obtained. After local anesthesia, rubber dam was placed and a access cavity was
prepared under optical loops (6x magnification Heine) using #1014 round diamond
bur (KG Sorensen, São Paulo, SP, Brazil) and an Endo Z tapered safe-end bur
(Dentsply/Maillefer, Ballaigues, Switzerland) (Figure 1B). The cervical and middle
thirds were prepared SX file of the ProTaper® system (Dentsply/Maillefer). Root
canal length was determined radiographically (Figure 2A) and confirmed with an
electronic apex locator (Root ZX; J Morita Co, Kyoto, Japan). Chemomechanical
preparation of buccal canal was completed with the series of ProTaper® instruments
and in lingual canal, ISO Dentsply Mallifer files® were used. While negotiating lingual
canal, 10# Dentsply Mallifer K file® separated in the canal curvature which was later
on successfully retrieved(Figure 2B). The buccal root canal was filled with Protaper
gutta-percha Cone® and gutta flow (Reiko)® in lingual canal (Figure 3). The final
radiographs showed two well-obturated canals ending at the electronically located
apexes. The 6-month post treatment follow-up showed apparent clinical and
radiographic success.

Discussion:
Diagnosis and identification of the number and morphology of roots and root canals
are key factors for endodontic treatment. The initial radiograph is extremely
important because it allows for the identification or suspicion of root and root canal
anatomical variations. Bifurcations in the cervical and middle thirds may be observed
radiographically when the x-ray incidence angle does not cause superimposition of
images. In mandibular canines, bifurcation at these sites has been shown to occur in
43.1% of the situations6. In the present case, identification of the second root was
evident, especially due to dilaceration of lingual root. However, it does not always
occur. Identification of the second root is even more difficult in the presence of tooth
crowding. Therefore, the radiographic image should be carefully analyzed in order to

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interpret and identify details that may suggest the presence of bifurcations or
trifurcations, such as sudden root canal discontinuity7.

Endodontists should always search for two canals in mandibular canines during
endodontic treatment, even in single-rooted teeth. Green2 observed two canals in a
single root in 13 out of 100 mandibular canines examined. This is consistent with the
findings of Hess8, who observed two canals in 15% of the cases. Vertucci9 reported
the presence of two canals in 18% of the mandibular canines. Mandibular canines
with two separated canals also demonstrated in a recent case report10.

However, the presence of two roots in mandibular canines is rarely observed11,12.

Quellet5 described the occurrence of two roots and two canals in mandibular canines
in only 5% of all analyzed teeth. Laurichesse et al.4 described the second root of
mandibular canines in only 1% of cases. A previous study that investigated the
internal anatomy, direction and number of roots and size of 830 extracted human
mandibular canines found only 1.7% of the teeth with two roots and separate two
canals13. D´Arcangelo et al.14 reported two cases of endodontic treatment of
mandibular canines with two roots. A case report of two roots in mandibular canine
was also presented by Heling et al.15, yet the tooth exhibited three root canals.

To the best of our knowledge,the occurrence of mandibular canines with two roots
and two separate canals and with sever dilacerations in one of the roots, as
described in the present case, has not yet been published .

Conclusion
Even though the most common anatomy of mandibular canines comprises a single
root and a single root canal, clinicians should consider the possible variations and
always search for the second root canal in teeth with one or two roots. The
radiograph in various angulations should be taken to analyze such dilacerations in all
planes.

Moreover, diagnosing root dilaceration before endodontic treatment is an important

objective in gaining control as endodontic instruments to curves in root canals. A
frequent error in endodontic procedure is the failure to maintain root canal
curvature, resulting in ledging, apical cavitation (transport and zipping), perforation,
and instrument breakage as seen in the case presented.To the best of our
knowledge,the occurrence of mandibular canines with two roots and two separate
canals and with sever dilacerations in one of the roots, as described in the present
case, has not yet been published .

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 Figure 1

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