Presence of radix entomolaris and paramolaris in primary teeth in children of Garhwa district: A report on two cases

Introduction

The morphology of primary teeth in comparison to permanent is different in its enamel, dentin thickness, more accentuated pulp horns which lead to early spread of infection to the pulp once caries starts. Pediatric endodontics is the method to remove infection from the coronal and radicular pulp followed by chemico-mechanical cleaning and obturating with suitable material. Generally mandibular molars (primary or permanent dentition) have two roots that is mesial and distal with three canals and sometimes four canals also which is very rare. Two canals in the mesial root being mesiobuccal and mesiolingual canals and one canal in distal root.3

Sometimes two canals are also present in distal canal which often creates a rare chance of presence of extra root also termed as “Radix entomolaris” or “Paramolaris”.4 The prevalence of dental anomalies is less in the deciduous dentition than in permanent dentition. The occurrence of an extra distal root in these mandibular molars is considered as a racial characteristic of certain native Indian and Mongoloid populations.

This extra root should also be endodontically treated and obuturated with suitable obturating material to prevent premature extraction.

Case Report

Case 1

A 5 years old male patient came in the Department of pedodontics and preventive dentistry in Vananchal Dental College and Hospital Garhwa with a chief complain of pain and swelling in lower right back tooth region since 4 to 5 days. Access opening was done followed by working length determination with No.10K file and RVG was taken. On Radiographic evaluation this extra root was detected (Figure 1). Chemico-mechanical preparation was done and then patient was recalled after 2 days.

After two days also the pain and swelling did not subsided so the tooth was planned for extraction. The primary molar was extracted.

Figure 1

Case 2

A 10 years old male patient came in the department with a chief complain of pain, swelling and mobility in lower right back tooth region, medication was given and patient was recalled after 3 days for extraction as on the radiographic evaluation roots were resorbed more than half and interradicular radiolucency was also present. After extraction, it was observed that the mandibular primary molar had three roots Figure 2.

Figure 2

Discussion

The success of pediatric endodontics is determined by thorough clinical examination, diagnosis, adequate chemo-mechanical preparation, and three-dimensional obturation with suitable obturating material.5

The first stage of endodontic triad, i.e., correct diagno­sis is one of the most important steps towards the success of the endodontic procedure. One of the main reasons for the failure of root canal treatment is incomplete remov­al of pulpal tissue and microbes from all the pulp canals. Hence, proper radiographic diagnosis playa a very important role in the successful treatment of endodontic therapy to rule out any extra canals.6

So, radiographs must be taken at different angulations to decrease the chances of “missed canals”. The prevalence rate of Radix ento­molaris is less than 5% in the Indian population and such cases are not seen commonly during dental treatment. The exact etiology of radix entomolaris is still idiopatheic but according to some authors it may be due to disturbance during odontogenesis or may be due to the high degree of genetic penetrance.7

To avoid the failure of endodontic therapy, minimum two different angulated diagnostic radiographs must be taken with the careful clinical examination. If radix entomolaris is diagnosed in the radiograph before commencing the endodontic treatment, the access cavity design should be modified trap­ezoidal so that the additional canal orifice can be easily accessed.8, 9

Through knowledge of the law of symmetry, various methods like visualization of the dentinal map and bleeding points in the canal orifice using magnification, ultrasonic tips, staining the pulp chamber floor with 1% methylene blue dye, performing champagne bubble test, and cone beam computed tomography imaging will help identify the missed canal.

According to De Moor et al.10, 11 the morphology of radix entomolaris canals in the majority of cases, were curved. Hence, after initial root canal exploration with small files (size 10 or less) together with radiographic working length and curvature determination, the creation of straight-line access and preparation of glide path has to be emphasized to avoid procedural errors.

Conclusion

The presence of extra root and its complex anatomical morphology creates a challenge for endodontic therapy. Prognosis of endodontic therapy is determined by the identification of radix entomolaris and para molaris. At 30⁰ mesial and distal angu­lations preoperative radiographs and their proper interpretation are mandatory to prevent any misdiagnosis of RE. So accurate radiographic diagnosis, thorough knowledge about the variation in root canal morphology, prevalence and canal configuration of radix entomolaris are the major factors for the success of endodontic treatment.

Source of Funding

None.

Conflict of Interest

None.