http://dx.doi.org/10.5272/jimab.2014201.

490
Journal of IMAB
ISSN: 1312-773X (Online)
http://www.journal-imab-bg.org

Journal of IMAB - Annual Proceeding (Scientific Papers) 2014, vol. 20, issue 1

DIFFICULT CASES IN ENDODONTICS PROGNOSIS AND PROPHYLAXIS OF COMPLICATIONS

Janet Kirilova, Snezhanka Topalova-Pirinska.
Department of Conservative Dentistry, Faculty of Dental Medicine, Sofia, Bulgaria

ABSTRACT
Introduction: There are cases in the endodontic
treatment which are a real challenge. There are teeth with
taurodontism and radix entomolaris. Patients usually lose
their teeth because these anatomical features are less familiar.
Purpose: The aim of this study is to investigate several
cases with taurodontism and radix entomolaris.
Material and methods: Two cases with taurodontism
and one with radix entomolaris that are described in the
following article. Careful exploration of the grooves between
all orifices with magnification, use of ultrasonic irrigation;
and a modified filling technique are of particular use.
Results: Results are observed after several years. In
performing a root canal treatment on such teeth, one should
appreciate the complexity of the root canal system, canal
obliteration and configuration, and the potential for additional
root canal systems.
Conclusions: Knowledge of the phenomenon of
taurodontism and radix entomolaris will improve the medical
practice of the general dental practitioner.

second left premolar was found while examining the patient.

The patient reported pain and we observed symptoms of pain
on probing. The tooth to be treated has a deviation in the tooth
position (marginal rotation). The accompanying X-ray shows
that it is a rare case with hypotaurodontism of mandibular
second left premolar (Figure 1).
Fig.1. Mandibular second left premolar with
hypotaurodontism and communication with the dental pulp

Key words: Anatomical variation, taurodontism, radix

entomolaris, endodontic treatment
INTRODUCTION
The endodontic cases for treatment can be
conditionally divided into: simple, moderately difficult and
difficult. The group of difficult cases concerns the aberrations
of dental roots - taurodontism; C-shaped configuration of the
pulp chamber and the root canal system; radix entomolaris
of first mandibular molar; dens evaginatus and dens
ivaginatus.
The purpose of this article is to discuss some difficult
cases for treatment in the endodontic practice in order to
foresee and prevent complications. Such are rare cases of
taurodontism of lower premolars and radix entomolaris of the
first mandibular molar.
MATERIAL AND METHODS
Case with taurodontism of the mandibular second
left premolar
A patient (19 years old) is referred to us for
endodontic treatment after having been placed a necrotizing
agent and an unsuccessful attempt for extirpation of the pulp
tissue by a general dental practitioner.
A bleeding wide open pulp chamber of the mandibular

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The X-ray shows that the mandibular first left

premolar is also with taurodontism, but the dental pulp is not
affected.
Taurodontism is also described as an abnormality
associated with a common disease, but in this case such
disease is not found [13]. Nowadays, it is assumed that
taurodontism is an anatomical variation that occurs
sporadically in the human population [10].
The pulp tissue in the pulp chamber was removed
under anesthesia. When looked at under a microscope it was
found that a perforation of the distal pulp chamber tooth
was made, possibly in an attempt to locate the orifice of the
root canal. Two orifices, vestibular and lingual, were found
(Figure 2).

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Fig.2. C shaped pulp chamber of tooth 35. The little

white arrow indicates the location of the perforation.
Bleeding can be seen nearby due to the perforation. The big
white arrow indicates the vestibular orifice with a crescent
shape.

After obturation of the root canal system a treatment

of the perforation in the distal part of the pulp chamber was
performed using mineral trioxide aggregate (MTA). A lining
of glass ionomer cement was placed at the next visit and the
patient was referred to the treating general dental practitioner
to place the final filling (obturation).
The shape of the vestibular orifice, as shown in Figure
2, is a crescent, which is an evidence of either a wide large
vestibular root canal or possibly a second root canal.
On an X-ray used to establish the length of the root
canals two vestibular root canals located very close to each
other are well seen (Figure 3).
Fig.3. X-ray with gutta percha points in the root canals
of tooth 35. The second canal is indicated with a white arrow.

Case with taurodontism of the mandibular first

right premolar
Endodontic treatment of the mandibular first right
premolar was conducted on a 32-year old patient. The tooth
was with a destroyed clinical crown, periapical changes
(chronic granulomatous diffuse periodontitis PAI 2) and a
deviation in the tooth position (marginal rotation). The X-ray
showed that it was a rare case of tooth with
hypotaurodontism. Endodontic treatment was completed with
a filling with cold lateral condensation. The post endodontic
recovery was with a post (February 2005). Due to the tooth
rotation the control X-ray for filling is made with medial
displacement of about 30 degrees (Figure 5).
Fig.5. X-ray after filling of the mandibular first right
premolar with hypotaurodontism.

After treatment with rotary nickel titanium instruments

using the crown-down methodology and multiple irrigations,
the ultrasound activated (according to various literature
sources [4, 11, 14]) root canals were obturated with a
Thermafil obturator and a sealer (Figure 4).
Fig.4. X-ray after filling of the mandibular second left
premolar.
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We observed an intact periapical bone and excellent

healing results (Figure 6) after seven years, at a radiography
check-up of the same tooth 44 - mandibular first right
premolar with a normal centering,

When a rectangular or a trapezoidal pulp chamber is

identified on the X-ray, it is difficult to locate the orifices
connected to radix entomolaris. This is the tooth treated by
us and presented on a preoperative radiograph in Figure 8.

Fig.6. Mandibular first right premolar with

taurodontism 7 years later.

Fig. 8. X-ray of the mandibular first molar with radix

entomolaris.

Case with radix entomolaris of the first mandibular

molar
Another root aberration affecting the mandibular first
molar is the radix entomolaris. It occurs infrequently and is
difficult for endodontic treatment.
The sixth lingual tubercle in the crown of the first
mandibular tooth is considered a sign of such root aberration
(Figure 7).
Fig.7. Crown of the mandibular first molar with radix
entomolaris.

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The case is difficult because it is difficult for the

endodontic clinician to locate the orifice of the radix
entomolaris and because of the fact that there is a narrow root
canal with a large curvature. A therapy was carried out with
the help of nickel titanium instruments using crown-down
methodology and multiple irrigations, and the root canals
were obturated with a Thermafil obturator and a sealer
(Figure 9).
Fig.9. X-ray of the root canal filling of the mandibular
first molar with radix entomolaris.

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RESULTS AND DISCUSSION

According to G. Tomov (2010) in Bulgaria the
frequency of taurodontism ranges from 2.9% in 15-35-year
old individuals to 37.5% in individuals with hypodontia
[13].
Sometimes locating, cleaning and filling root canals
of teeth with taurodontism create major problems.
Individual approach, precise planning and implementation
of health activities are essential for the endodontic result [2,
7, 8 and 11].
It is necessary to work under anesthesia rather than
with devitalizing agents, as heavy bleeding may occur.
Moreover, it is risky to make perforation when detecting
root canals [14]. It is recommended to use passive ultrasonic
irrigation with hypochlorite for irrigation (no irrigation with
syringes), because the endodontic volume contains greater
amount of infected channel contents and extrusion of debris
or irrigant is possible. A combination of lateral and vertical
condensation [1] is required for the successful filling of the
root canal system.
The rare root aberration radix entomolaris is
associated with certain ethnic groups. In the African
population the frequency of entomolaris is 3% while in

REFERENCES:
1. Jafarzadeh H, Azarpazhooh A,
Mayhall JT. Taurodontism: a review of
the condition and endodontic treatment
challenges. Inter Endod J. 2008 May;
41(5):375-88. [PubMed] [CrossRef]
2. Jayashankara CM, Shivanna AK,
Sridhara K, Kumar PS. Taurodontism:
A dental rarity. J Oral Maxillofac
Pathol. 2013 Sep:17(3):478-82.
[PubMed] [CrossRef]
3. Carlsen O, Alexandersen V. Radix entomolaris: Identification and
morphology. Scand J Dent Res. 1990
Oct;98(5):363-73. [PubMed]
4. Davini F, Cunha RS, Fontana
CE, Silveira CFM, Buena CES. Radix
entomolaris - a case report. RSBO.
2012 Jul-Sep;9(3):340-4.
5. Gupta S, Raisingani D, Yadav R.
The Radix Entomolaris and

Europeans the frequency is less than 5% (3.4% to 4.2%).

In the Mongoloid race the frequency is more than 5% and
may reach more than 30% (Chinese, Eskimos and American
Indians). Radix Entomolaris is considered normal
morphology among these populations due to the identified
high frequency [3, 4, 5]. For Europeans, it is unusual
morphology.
Ethnicity is a predisposing factor for anatomical
abnormalities such as the number of tooth roots. The
Mongoloid population shows significantly more often first
mandibular molar with three roots with a 3:1 ratio when
compared to Caucasians and Afro-Americans. This is the
reason this variation to be discussed as genetically
determined characteristic [6, 9, 13, 14].
Its size can range from short conical to very narrow
root canal with large curvature. Generally, the radix
entomolaris has a smaller size than the distal and
mesiovestibular root. In most cases these root canals are
very narrow and with a large curvature [13, 14].
It is important to recognize and diagnose teeth with
taurodontism and radix entomolaris for the successful
treatment of such cases. This gives a good estimate of the
treated teeth and may prevent complications.

paramolaris: a case report. J Int Oral

Health. 2011; 3(1):43 -9.
6. Kuzmanova Y. Rare morphological endodontic variation in the permanent molars in the Bulgarian population. Dental medicine (Sofia). 2014;
96(1):30-41. [in Bulgarian]
7. Mena CA. Taurodontism. Oral
Surg Oral Med Oral Pathol. 1971
Nov;32(5):812-23. [PubMed]
8. Navak G, Shetty S, Agarwal P.
Endodontic management of a mandibular first molar with radix entomolaris.
Conservative Endodontics. 2011; (12):
34 -7.
9. Saini T, Wilson CA. Taurodont
molars: review of literature and radiological features. Saudi dent J. 1990;
2(2):68-70.
10. Sathyanarayana R, Carounanidy

U. Taurodontism - review and an endodontic case report. Endodontology.

2001; 13(1):8-10.
11. Sert S, Bayirli G. Taurodontism
in six molars: a case report. J Endod.
2004 Aug; 30(8):601-2. [PubMed]
12. Shaw JCM. Taurodont teeth in
South African races. J Anat. 1928;
62:476-498.
13. Tomov G, Vladimirov St.
Taurodontism. Epidemiological, Genetic and Clinical Aspects. Dental
medicine (Sofia). 2010; 92(1) 57-61.
[in Bulgarian]
14. Tsesis I, Shifman A, Kaufman
AY. Taurodontism: An endodontic
challenge. Report of a case. J Endod.
2003 May; 29 (5): 353-5. [PubMed]
[CrossRef]

Address for correspondence:

Dr Janet Kirilova, PhD
Department of conservative Dentistry, Faculty of Dental Medicine
1, St. George Sofiiski Str., 1431 Sofia, Bulgaria
E-mail: janetkirilova@gmail.com,
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