maxillary second molar using an endoscope as magnication device T. Weinstein, G. Rosano, M. Del Fabbro & S. Taschieri Department of Health Technologies, IRCCS Istituto Ortopedico Galeazzi, Universita` degli Studi di Milano, Milano, Italy Abstract Weinstein T, Rosano G, Del Fabbro M, Taschieri S. Endodontic treatment of a geminated maxillary second molar using an endoscope as magnication device. International Endodontic Journal, 43, 443450, 2010. Aim To describe endodontic treatment for a rare case of gemination. Summary A case of complex endodontic treatment in a geminated tooth is presented. With the assistance of microinstruments and magnication devices, a geminated maxillary second molar was successfully treated. In such a case, ultrasonic tips and the use of an endoscope were essential to detect the peculiar anatomy of the tooth involved. Key learning points Knowledge of anomalies concerning fused teeth is essential. Using an endoscope as a magnication device is useful during the inspection of pulp chambers. Ultrasonic tips are safe and useful to detect canal orices. Keywords: endodontic treatment, endoscope, fusion, gemination, maxillary sec- ond molar, ultrasonic tips. Received 10 February 2010; accepted 12 February 2010 Introduction Gemination is a rare morpho-anatomic anomaly that develops when the bud of a single tooth attempts to divide (White & Pharoah 2000). Such a developmental anomaly is often confused with fusion. In fact, gemination and fusion are anomalies with similar clinical presentation and unclear aetiology (Tsesis et al. 2003). Fusion might be dened as a condition in which two separate tooth buds have a joined crown that resembles a bid crown, whilst gemination as an attempt by the tooth bud to divide. Union or division might be total or partial and might concern the dentine and/or the doi:10.1111/j.1365-2591.2010.01714.x Correspondence: Dr Massimo Del Fabbro, Department of Health Technologies, Istituto Ortopedico Galeazzi, Universita` degli Studi di Milano, Via R. Galeazzi, 4, 20161 Milano, Italy (Tel.: +39 02 50319950; fax: +39 02 50319960; e-mail: massimo.delfabbro@unimi.it). 2010 International Endodontic Journal International Endodontic Journal, 43, 443450, 2010 443 enamel or even the pulp (Tannenbaum & Alling 1963, Grover & Lorton 1985). To distinguish between fusion and gemination, it has been suggested that the teeth in the arch be counted with the anomalous crown counted as one. A full complement of teeth indicates gemination, whilst one tooth less than normal indicates fusion (Milazzo & Alexander 1982, Camm & Wood 1989). This rule cannot be applied if a normal tooth fuses with a supernumerary tooth (Croll et al. 1981, Peyrano & Zmener 1995, Kayalibay et al. 1996). In such a case, differentiating fusion from gemination might be clinically difcult if not impossible. The prevalence of these anomalies is <1%, occurring, predominantly in incisors and canines, in normal dentition or between a normal tooth and a supernumerary (Levitas 1965). There are four types of fusion anomalies (Tadahiro 1981): (i) concrescent teeth: two teeth fused by coalescence of their cementum; (ii) fused teeth: teeth joined by dentine in their developmental stage, resulting in the union of two (or more) adjacent teeth; (iii) geminated teeth: fusion of a tooth with a supernumerary one and (iv) dens in dente: malformation of a tooth probably resulting from an infolding of the dental papilla during dental development. The aetiology of such dental anomalies is unclear; possibilities include genetic predisposition, racial differences, trauma and environmental factors such as thalidomide embryopathy, foetal alcohol exposure or hypervitaminosis A of the pregnant mother (Cetinbas et al. 2007). The purpose of this article is to describe a successful root canal treatment in a maxillary second molar with gemination anomalies. Case report A 28-year-old white female patient with a non-contributory medical history presented for an endodontic consultation. Clinical examination revealed a temporary restoration in tooth 27, provided by a private practitioner, and revealed an anomalous second molar that could have been a fusion of the maxillary left second molar with a supernumerary tooth on its palatal aspect. The patient reported the tooth had been treated previously for an extensive carious lesion and reported spontaneous vague clinical symptoms. Intraoral examination revealed an irregular morphology of the maxillary left second molar with enlargement at the buccal aspect, suggestive of a possible union of a paramolar with the buccal portion of the crown of tooth 27 (Fig. 1). The soft tissues were inamed at the buccal gingival margin of the geminated tooth where periodontal probing depth revealed a 4-mm buccal pocket; moreover, the patient complained of difculties in maintaining oral hygiene. Radiographic examination revealed that an access cavity in tooth 27 had already been performed (Fig. 2). After isolating the tooth with a rubber dam, a sensibility test with cold stimuli was performed. The response was painful. A local anaesthetic was administered by periapical inltration with 4% articaine chlorhydrate and adrenaline 1 : 100 000 (Alfacaina N; Weimer Pharma, Rastat, Germany). The access cavity was rened, and four canals (two of which were mesiobuccal) were detected with the aid of magnication loupes. The canals were then shaped with ProTaper rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland), S1 and S2 being used at the working length and F1, F2 and F3 being used with a 0.5-mm step back technique. The root canal system was irrigated after each instrumentation with 2.5% sodium hypochlorite (Giovanni Ogna & gli S.p.A., Muggio` , Milano, Italy), and apical patency was maintained throughout the whole procedure. After the instrumentation phase, nal C A S E R E P O R T International Endodontic Journal, 43, 443450, 2010 2010 International Endodontic Journal 444 irrigation was completed with 17% EDTA (ethylenediaminetetraacetic acid; Giovanni Ogna & gli S.p.A.) for 2 min to remove the smear layer. The root canals were dried with sterile paper points. Working lengths were determined using an apex locator (Root Zx; J. Morita USA, Irvine, CA, USA), and specic radiographs were taken to conrm such lengths. Finally, an intermediate restorative material cement made of zinc oxideeugenol with polymethyl methacrylate (IRM; LD Caulk, Milford, DE, USA) was used as a temporary restoration. One week later, the patient returned to complete the therapy but reported pain exacerbated by both cold and hot stimuli. The presence of accessory canals was suspected in the geminated portion of the tooth. Therefore, it was decided to extend the access cavity outline to its distobuccal (DB) aspect into the geminated portion of the tooth using an endoscope as a magnication device (Fiegert-Endotech
; Ga nsa cker 42,
Figure 1 The tooth after the rst treatment performed by a private practitioner. Figure 2 Preoperative radiographic examination. C A S E R E P O R T 2010 International Endodontic Journal International Endodontic Journal, 43, 443450, 2010 445 Tuttlingen, Germany) and dedicated zirconium nitride-coated ultrasonic endodontic tips (Dentsply Maillefer Instruments). Thus, two separate pulp chambers and a fth canal in the gemination [geminated buccal (GB)] were detected (Fig. 3). Five canal orices were found: one leading to the supernumerary tooth and four leading to the maxillary second molar. The GB canal was found to communicate with the DB canal and treated in the same way as the others, and the lling of all ve canals was performed with the Thermal (Dentsply Maillefer) technique (Figs 46). A postoperative radiograph was taken (Fig. 7). Both the access cavity and the buccal aspect of the tooth were restored permanently (Fig. 8) with composite resin material (Enamel Plus; Micerium spa, Avegno, Genova, Italy). The periodontal pocket was also treated and the tooth shape modied buccally to enhance ease of cleaning (Fig. 9). At 6-month follow-up, the tooth had no clinical signs and symptoms and, radiograph- ically, no periradicular sclerosis or bone rarefaction was visible (rstavik 1996, Chugal et al. 2001). Figure 3 Endoscopic vision of the pulp chamber showing: mesiobuccal (MB1), mesiobuccal (MB2), distobuccal (DB), palatal (P) and geminated buccal (GB). Figure 4 Radiographic working length of distobuccal (DB) and palatal (P). C A S E R E P O R T International Endodontic Journal, 43, 443450, 2010 2010 International Endodontic Journal 446 Discussion Maxillary second molar anatomy is well known: it has three roots (rarely fused) showing three separate canals in 88% of cases; in the remaining 12% of cases, a fourth canal can be encountered in the mesiobuccal root (Vertucci 1984). Peikoff et al. (1996) analysed 520 root lled maxillary second molars and found six variants of this tooth: (i) three separate roots and three separate canals (in 56.9% of cases); (ii) three separate roots and four canals, two of which in the mesiobuccal root (in 22.7% of cases); (iii) three roots and canals, whose mesiobuccal and DB canals combine to form a common buccal with a separate palatal canal (in 9% of cases); (iv) two separate roots with a single canal in each (in 6.9% of cases); (v) one main root and canal (in 3.1% of cases) and (vi) four separate roots and four separate canals including two palatal (in 1.4% of cases). There are only a few case reports on maxillary second molars with more than four canals (Ozcan et al. 2009). Thus, a maxillary second molar in gemination with ve canals represents a rare anatomical variation. Figure 6 The four wall cavity access after endodontic treatment showing the ve canals. Figure 5 Radiographic working length of mesiobuccal (MB1), mesiobuccal (MB2) and geminated buccal (GB). C A S E R E P O R T 2010 International Endodontic Journal International Endodontic Journal, 43, 443450, 2010 447 From a clinical point of view, much confusion has always been generated on the difculty of deciding whether a tooth is geminated or fused, mainly because of their similarities. Indeed, Brook & Winter (1970) proposed that these anomalies be referred to using the neutral term double teeth. However, even if a differentiation between gemination and fusion might not be clinically important for the treatment, the authors believe that a geminated maxillary second molar has been described in the present case because of the apical connection between the GB root canal, located in a secondary anomalous pulp chamber, and the DB canal and of the full-arch complement of teeth (Fig. 7). Figure 8 Access restored permanently with composite resin material: occlusal view. Figure 7 Post-treatment radiograph. C A S E R E P O R T International Endodontic Journal, 43, 443450, 2010 2010 International Endodontic Journal 448 To evaluate such conuence, a gutta-percha cone was inserted into the cleaned and shaped DB canal, whilst a size 08 K-le was inserted into the GB canal: a defect was apparent in the gutta-percha. With the help of a gutta-percha cone and a small instrument, the conuence of the DB and GB canals in a common foramen was detected. Such a nding allowed dentine to be retained in the GB canal with less risk of causing stripping. To negotiate all ve canals, the treatment was performed using an endoscope as a magnication device and dedicated ultrasonic endodontic tips. Working with loupes and/or with a surgical microscope as well as with an endoscope has become a widely accepted practice in conventional and surgical endodontics. An endoscope allows rapid and easy adjustment of viewing angle without the need for dental mirrors (Von Arx et al. 2003). In addition, it is far more versatile than a microscope: focusing and zooming using just one nger is faster and more comfortable with an endoscope than with a microscope (Taschieri et al. 2008). In this case, ultrasonic tips as well as the endoscope were useful for the exploration of the access cavity in the most conservative way and for the detection of the GB unexpected canal in the geminated portion of tooth 27. In particular, one of the most important advantages of ultrasonic tips is that they do not rotate, thus enhancing safety and control, whilst maintaining a high cutting efciency. This is especially important when the pulp chamber anatomy is unclear, and a risk of perforation exists (Plotino et al. 2007). Conclusions In the present case, root canal treatment was complicated by an abnormal pulp chamber anatomy. In modern endodontics, endoscopic devices as well as ultrasonic tips are important aids for examination of morphological aspects of both the pulp chamber and root canals from almost any perspective, whilst preserving as much tooth tissue as possible. Disclaimer Whilst this article has been subjected to Editorial review, the opinions expressed, unless specically indicated, are those of the author. The views expressed do not necessarily Figure 9 Buccal view of the tooth restored to recreate an appropriate and physiological dental anatomy. C A S E R E P O R T 2010 International Endodontic Journal International Endodontic Journal, 43, 443450, 2010 449 represent best practice, or the views of the IEJ Editorial Board, or of its afliated Specialist Societies. References Brook AH, Winter GB (1970) Double teeth. A retrospective study of germinated and fused teeth in children. British Dental Journal 129, 12330. Camm JH, Wood AJ (1989) Gemination, fusion, and supernumerary teeth in the primary dentition: report of a case. Journal of Dentistry for Children 56, 601. Cetinbas T, Halil S, Akcam M, Sari S, Cetiner S (2007) Hemisection of a fused tooth. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 104, e1204. Chugal NM, Clive JM, Spa ngberg LSW (2001) A prognostic model for the assessment of the outcome of endodontic treatment: effect of biologic and diagnostic variables. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 91, 34252. Croll TP, Rains NJ, Chen E (1981) Fusion and gemination in one dental arch: report of a case. Journal of Dentistry for Children 48, 2979. Grover PS, Lorton L (1985) Gemination and twinning in the permanent dentition. Oral Surgery, Oral Medicine, Oral Pathology 59, 3138. Kayalibay H, Uzamis M, Akalin A (1996) The treatment of a fusion between the maxillary central incisor and supernumerary tooth: report of a case. The Journal of Clinical Pediatric Dentistry 20, 23740. Levitas TC (1965) Gemination, fusion, twinning, and concrescence. Journal of Dentistry for Children 32, 93100. Milazzo A, Alexander SA (1982) Fusion, gemination, oligondontia, and taurodontism. Journal of Periodontology 6, 1946. rstavik D (1996) Time-course and risk analysis of the development and healing of chronic apical periodontitis in man. International Endodontic Journal 29, 1505. Ozcan E, Aktan AM, Ar H (2009) A case report: unusual anatomy of maxillary second molar with 3 mesiobuccal canals. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 107, 436. Peikoff MD, Christie WH, Fogel HM (1996) The maxillary second molar: variations in the number of roots and canals. International Endodontic Journal 29, 3659. Peyrano A, Zmener O (1995) Endodontic management of mandibular lateral incisor fused with supernumereary tooth. Endodontics & Dental Traumatology 11, 1968. Plotino G, Pameijer C, Mariagrande N, Somma F (2007) Ultrasonics in endodontics: a review of the literature. Journal of Endodontics 33, 8195. Tadahiro O (1981) Human Tooth and Dental Arch Development. Tokyo, Osada, Japan: Ishiyaku Publishers, pp. 17181. Tannenbaum KA, Alling EE (1963) Anomalous tooth development: case reports of gemination and twinning. Oral Surgery, Oral Medicine, Oral Pathology 16, 8837. Taschieri S, Del Fabbro M, Testori T, Weinstein R (2008) Microscope versus endoscope in root-end management: a randomized controlled study. International Journal of Oral and Maxillofacial Surgery 37, 10226. Tsesis I, Steinbock N, Rosenberg E, Kaufman AY (2003) Endodontic treatment of developmental anomalies in posterior teeth: treatment of geminated/fused teethreport of two cases. International Endodontic Journal 36, 3729. Vertucci FJ (1984) Root canal anatomy of the human permanent teeth. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 58, 58999. Von Arx T, Montagne D, Zwinggi C, Lussi A (2003) Diagnostic accuracy of endoscopy in periradicular surgery a comparison with scanning electron microscopy. International Endodontic Journal 10, 6919. White SC, Pharoah MJ (2000) Oral Radiology: Principles and Interpretation, 4th edn. Louis, MO, USA: CV Mosby. C A S E R E P O R T International Endodontic Journal, 43, 443450, 2010 2010 International Endodontic Journal 450
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