Nonsurgical Endodontic Management Case Study

Nonsurgical Endodontic Management Case StudyIntroductionThe main(prenominal) aim of any endodontic treatment is to thoroughly debride and disinfect the radical transmission channel system followed by the contouring of groundwork provide walls and apical tip, for the propose of sealing the etymon cigaretteal wholly with a condensed, inert alter material. Failure to ac companionship the figurehead of an superfluous base groove during an endodontic treatment is amongst the major ca theatrical roles of an endodontic treatment failure. Other ca characters include contradictory epithelial duct instrumentation, incomplete obturation and untreated major canals.An important key to victory of any root canal treatment is proper understanding of the body-build of root canal system this can be achieved by knowledge of the sound structure of the root and root canal systems of teeth and diagnostic image techniques are required for successful root canal treatment, especially in inframaxillary bicuspid teeth (England et al. 1991). In-depth knowledge ab come forth the occurrence of maverick external and internal root canal morphologies contributes to the success of root canal treatment.It has been indicated by slowey that due to the variations in the root canal word form of mandibular premolars, they rush a high flare up and failure yard and are hence the most difficult teeth to treat. Both the mandibular head start and second premolars most often have a angiotensin-converting enzyme root and a single canal, however, anomalies of the root and root canal systems as well as multiple canals have been reported in the literature (Baisden et al. 1992, Robinson et al. 2002).4Zillich and Dowson have, in a definitive anatomical study, unveiled the occurrence of trine canals in mandibular second premolars to be 0.4%.5The mandibular first premolars arrangement a large variation in the occurrence of number of root canals and apical foramina. Data from anatomi cal studies report that three rooted mandibular first premolars are rare, about 0.2%.6This event report presents a case of a successful nonsurgical endodontic management of a mandibular first premolar with three screen root utilize strobile Beam Computed Tomography (CBCT).Case ReportA twenty four-spot year old female longanimous of Indian origin, with the chief illness of intermittent pain along with food lodgement in the disdain left back region of jaw since 3 months, was referred to the Post calibrate Department of Conservative Dentistry and Endodontics. Patient also complained of bleeding from gums time brushing since eight months. Medical and dental history was non-contributory.On clinical inquiry, patients oral hygiene was found to be moderate. Deep occlusal carious lesion was seen with wish to tooth 34 and 35 and both the teeth were found to be tenderize on percussion, with no associated periodontal pockets. Neither the affected nor the contra sidelong face of the crown of the mandibular first premolar sighted any unusual cast in terms of number of cusps and dimensions. A lingering response was seen on heat testing and electric chassis testing. No evidence of bulge or sinus tract was seen.Intra oral periapical shadowgraphic evaluation of the knotted tooth revealed normal mandibular first premolar root anatomy. There was outfit of the periodontal ligament space with periapical radiolucency around the root of tooth 34.A diagnosing of irreversible pulpitis was made ground on clinical and radiographic evidences.After the plaque of local anesthesia (2% Lidocaine with180,000 adrenaline), access was gained to the pulp chamber under closing off and conventional access opening was d single to locate the canal. Tactile examination of the walls of the major canals was done with a small precurved pathfinder bear down, while pickle the canal, which was proceeded slowly down each wall of the major canal, probing for a catch. A slight catch m ay indicate the orifice of an additional canal, especially in case of the buccal and lingual walls, because these are not generally visible on the radiograph. . On thorough inspection of the pulp chamber down, three separate root canal orifices were detected (one mesiobuccal, one mesiolingual, and one distal). With the help of a pathfinder file, access cavity was temporarily sealed with Cavit, and to confirm the root morphology, the patient was referred to an oral and maxillofacial radiologist for a cone-beam computed tomography. CBCT of the mandible was performed using the CS 3D imaging, after sticking an informed consent of the patient. A three-dimensional image of the mandible was obtained. The involved tooth was focused, and the morphology was obtained in transverse, axial, and sagittal sections with a thickness of 0.48 mm, along with three-dimensional suppose images.The axial image obtained from CBCT confirmed the presence of three roots in mandibular first pre molar 34. T he roots were found to be mesiobuccal, mesiolingual and distal .After re-isolating the tooth, coronal flaring of all the three canals was carried out using Gates Glidden drills and working length was determined using an apex locator, which was later confirmed by a radiograph. The canals were cleaned and shaped up to ISO 35 masterapical file under copious irrigation with 2.5% sodium hypochlorite and 17% EDTA. The root canals were dried with sterilized paper points, followed by temporary sealing of the access cavity with Cavit (3M ESPE AG, Seefeld, Germany). The patient was re-scheduled a week after for follow up. The tooth was found to be completely asymptomatic after a week, and the roots canals were obturated by cold lateral compaction of gutta-percha using AH26 sealer (Kemdent Associated Dental Products Ltd, Wiltshire, UK). A postoperative radiograph was taken (Figure 3B), and the access cavity was permanently restored using universal amalgam restorative material.DiscussionDiagn osis and management of extra roots and root canals in mandibular premolars is one of the major challenges in endodontics. 8-18 Therefore, the clinician must have an appropriate knowledge about the normal root canal anatomy and the most common variations associated. Inability to find, debride and obturate a root canal has been reported to be a major reason for failures in endodontic treatment. 19Based on race, lone(prenominal) one study by Trope et al. has showed an increase prevalence of two or more canals in mandibular first premolar in African American patients as compared to Caucasian American patients .20 The failure rate in mandibular first premolar was shown to be 11.45% according to the Washington study. 21This might be due to the extreme variations in the root canal morphology of the mandibular premolar teeth and consequently poses an endodontic challenge to the clinician. Considering the high prevalence of aberrations in these teeth, an endodontist must wary the presence of one or more missed canals, when a patient returns with persistent post-operative pain or sensitivity to hot and cold. Judicious use of high-end diagnostic aids should also be considered in such cases. Radiographs obtain two-dimensional images of three dimensional objects, resulting in superimposition of the images. Therefore, they are of limited use in complex root canal anatomy cases.Interpretation based on a two-dimensional radiograph may circumspect the clinician of the presence of aberrant root canal anatomy but cannot completely show the morphological structure of the root canals and their interrelations .22 Based on the results of previous studies carried out by Kottoor et al., and La et al. wherein spiral CT was used for the confirmatory diagnosis of morphological aberrations in the root canal anatomy, CBCT of the involved tooth was planned in the present case .23-25The 3D CBCT images in this study revealed three roots (mesiobuccal, mesiolingual and distal ), with three d istinct canals, each canal having a separate apical orifice as compared to the two dimensional radiograph which showed only one root, just like the anatomy of a typical single-rooted mandibular first premolar, that led to a false diagnosis and treatment plan. This is in all probability why the mandibular first premolar is known as an secret to the endodontist. However, the high cost and inaccessibility to the patient as well as the extra radiations as compared to the standard radiographic methods makes its routine use limited.We can therefore conclude that a thorough knowledge of the root canal anatomy and its variations, careful interpretation of the radiographs, close clinical examination of the floor of the chamber and proper techniques of access opening along with adequate blowup are essential for successful treatment outcome.ConclusionThe mandibular premolar teeth can present with extremely complex root and root canal system morphology, and if not considered during treatment can lead to difficulties when playacting root canal treatment. The use of 3D CBCT is a valuable mechanism in studying the variations that may occur in root canal anatomy.