tratamiento endodóntico de dos molares mandibulares con taurodontismo

7/24/2019 Tratamiento Endodntico de Dos Molares Mandibulares Con Taurodontismo.

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ENDO (Lond Engl) 2008;2(3):199203

CASE REPORT

Pyramidal teeth are thought to be a minor form of taurodontism, which is a morpho-anatomical

change in the shape of a tooth, usually occurring in multirooted teeth as a result of failure of theinfolding of the epithelial root sheet of Hertwig. The characteristic features of these teeth are an

enlarged body and pulp chamber, as well as apical displacement of the pulpal floor. Endodontic

treatment of a taurodont tooth is challenging, because it requires special care in handling, and in the

identification of the number of root canals and morphology of the tooth. In this case report, the

endodontic treatment of a mandibular first and second molar with pyramidal root canal morphology

is presented.

Sebastian Brklein

Endodontic treatment of two pyramidal (taurodont)mandibular molars: a case report

dental malformation, endodontic treatment, root canal morphology, taurodontismKey words Sebastian BrkleiPrivate Practice, Zahnk

Bochum, Bergstrasse 2

D-44791 Bochum, Ger

Tel: +49 234 5839228

Email: sbuerklein@gmx

Introduction

The term taurodontism was introduced in 1913 by Sir

Arthur King1. He proposed that taurodont molars are

characterised by the distinct extension of the pulp

chamber below the level of the alveolar crest and the

cementoenamel junction (CEJ), and apical displace-

ment of the bi- or trifurcation of the roots. Addition-

ally, taurodontism refers to a tooth-form character-

ised by an external block configuration, which means

an elongated body that tends to enlarge at the ex-

pense of the root and give it a rectangular shape.Teeth with pulp chambers that are relatively small

and have constriction of the pulp chamber at approxi-

mately the level of the CEJ are called cynodonts2.

The aetiology of taurodontism is unclear, but is

attributed to the failure of invagination of the epi-

thelial root sheath sufficiently early to form the cyno-

dont. One hypothesis is that taurodontism might be

the result of a disrupted developmental haemostasis3.

An autosomal transmission of the trait has also been

observed4. Various manifestations of taurodontism

are described: this malformation can occur alone,

limited to one or more teeth or it can be associated

with various syndromes including Downs syndrome

or Klinefelters syndrome5,6. Taurodontism may be

unilateral or bilateral and affects permanent teeth

more frequently than primary teeth. It is commonly

observed among certain ethnic groups such as

natives of Alaska, Australia and Central America7.

Taurodontism may be classified as mild, moderate

and severe (hypo-, meso- and hypertaurodontism,

respectively)8 based on the degree of apical displace-

ment of the pulp chamber floor2. The prevalence oftaurodontism found by radiographic dental exami-

nation in patients has been shown as ranging from

5.69 to 8%10, up to 48% (18.8% of teeth affected)11,

or 60%12, whereas the prevalence of pyramidal molars

was 4.6% (1.6% of teeth) in specially selected ethnic

groups11. In western European subjects, the prevalence

is estimated to be about 10%13,14. Although tauro-

dontism does not involve molar teeth exclusively15 it is

found to be significantly more prevalent in second

maxillary molars16.


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ENDO (Lond Engl) 2008;2(3):199203

200 Brklein Treatment of two pyramidal (taurodont) mandibular molars

Generally, taurodontism and pyramidal teeth are

a rare dental anomaly, and endodontic treatment is

challenging because it requires special care in

handling and identifying the number of root canals17.

Case report

Diagnosis

A 43-year-old woman was referred to the authors

department for the treatment of the right first mandi-

bular molar. Dental history revealed that she had been

suffering from pain for 6 days prior to her visit to the

clinic and that the pain was spontaneous and

aggravated at night. This was disturbing her sleep and

meant she was taking analgesics. Tooth 46 had beenendodontically pretreated 1 week previously and an

intracanal dressing with Ledermix-paste (Riemser,

Greifswald, Germany) was placed. This medicament

consisted of corticosteroids and tetracycline. The cor-

ticosteroid component has a calming and anti-inflam-

matory effect, whereas the antimicrobial component

should prevent the proliferation of bacteria.

Intraoral examination revealed that the coronal

access cavity was sealed with a temporary filling. At

tooth 47 a deep carious lesion was found on the

mesio-occlusal surface. Both teeth were subjected to

routine clinical tests and, although tooth 46 showed

the typical symptoms for an endodontically pre-

treated tooth with Ledermix-paste (the sensitivity test

was positive because of the remaining vital tissue, and

the percussion test was negative), a provisional diag-

nosis of symptomatic irreversible pulpitis was made

concerning tooth 47 (the sensitivity test was positive

and the percussion test was positive). The periodontal

probing depths showed no elevated levels.

Radiographic observations included an area ofrarefaction located between the roots of both teeth,

the carious lesion located at the mesial aspect of tooth

47, a kind of hypercementosis associated with the

root of tooth 46 and a tendency of root canal obliter-

ation (Fig 1). Moreover, the radiograph revealed an

abnormal pyramidal root anatomy for both teeth.

Endodontic treatment

Anaesthesia was achieved by means of inferior

alveolar nerve block with 1.8ml of 4% articaine

with 1:100.000 adrenaline. Access to the pulp

chamber of tooth 47 was gained under rubber dam

isolation. A huge pulp chamber was encountered

with one central root canal. The pulp tissue was

extirpated and the working length was determinedelectronically using the Root ZX device (Morita,

Tokyo, Japan). Chemo-mechanical preparation of

the root canal system was achieved by alternating

circumferential filing with manual stainless steel K-

and Hedstrm files at full working length. Copious

irrigation with 2% sodium hypochlorite (NaOCl)

was performed during the instrumentation process.

Finally, after instrumentation was completed, a

passive ultrasonic irrigation of the root canal was

performed with NaOCl to ensure optimal dissolu-

tion of remaining pulp tissue. Using an operatingmicroscope, no accessory apical canals were

detected and a wide-open apical foramen was

visible. A mechanical preparation up to ISO size 150

was necessary, because the first instrument that had

bound in the apical region was already a size 110.

At the same appointment, the pretreated tooth 46

was subjected to the same procedure after the

coronal access was enlarged and the overhanging

areas of the pulp chamber roof were removed. It

was detected that the clinician had nearly caused

perforation of the mesial (probably due to the ex-

ploration of the expected mesial canals during the

previous appointment) but the absence of further

root canals was proved using the operating micro-

scope. The apical region was extremely calcified and

a wide foramen could not be detected. Root canal

instrumentation up to size 110 was thoroughly per-

formed using circumferential filing with stainless

steel K-files alternating with Hedstrm files, and

repeated irrigation with NaOCl was performed after

electronic determination of the working length. Theroot canals of both teeth were dried and dressed

with an aqueous solution of calcium hydroxide

(Ca(OH)2). Finally, the access cavities were sealed

with zinc oxide-eugenol cement.

The patient was recalled after 2 weeks. The

intracanal dressing was removed with stainless steel

hand instruments, and passive ultrasonic irrigation

was performed to optimise the removal of the intra-

canal dressing. After thorough irrigation with

NaOCl and EDTA for smear layer removal, the


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ENDO (Lond Engl) 2008;2(3):199203

Brklein Treatment of two pyramidal (taurodont) mandibular molars

canals were dried using paper points. Gutta-percha

master cones were then fitted at working lengths

with a slight tug-back. Obturation was performed

using cold lateral condensation with a size 25

spreader and size 20 collateral points using AH Plus

(Dentsply, Konstanz, Germany) as a sealer. After

removing the surplus filling material and thorough

cleaning of the access cavities, 37% phosphoric

acid was syringed into both access cavities, left for

15s, rinsed off and a bonding agent was applied.

Finally, both access cavities were sealed with a resin

composite restoration. The post-operative radio-

graph shows homogeneous root canal fillings with

an adequate length (Fig 2).

Post endodontic treatment

The patient was reviewed 3 months later and was

free of symptoms. A new crown for tooth 46 was

made. The 1-year follow-up radiograph revealed that

healing had occurred (Fig 3). The radiograph that

was subsequently made showed that all molars were

characterised by the same root morphology (Fig 4).

Discussion

Taurodontism can occur in various forms, but depend-

ing on the severity of this malformation, a distinction in

meso-, hypo-, hypertaurodontism or pyramidal teeth

Fig 1 Pretreatment radiograph of teeth46 and 47.

Fig 2 Post-treatment radiographshowing obturation of teeth 46 and 47.

Fig 3 1-year follow-up radiographshowing that healing has occurred.

Fig 4 Radiographshowing multipletaurodont teeth. Nthat all molars dispthis anomaly.


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ENDO (Lond Engl) 2008;2(3):199203

202 Brklein Treatment of two pyramidal (taurodont) mandibular molars

has been suggested. The position of the pulpal floor in

relation to the CEJ is the deciding factor8. The

prevalence of taurodont teeth varies within different

populations, and the aetiology is not clear. Root mor-

phology is primarily determined genetically, but may

also be environmentally modified18

. The failure ofsufficiently early invagination of the epithelial root

sheath to form the cynodont, a disrupted develop-

mental haemostasis3 and an autosomal transmission of

the trait are aetiological factors of taurodont teeth that

have been observed4. Teeth most frequently affected

are molars, although premolars and incisors have also

been diagnosed as taurodonts in a radiographic study19.

The incidence of taurodontism is variable,

depending on the different series and groups studied.

In general, molars and premolars in both the primary

and permanent dentitions are affected15,20. Theoccurrence of taurodontism associated with develop-

mental disorders such as amelogenesis and dentino-

genesis imperfecta21, or hypodontia22,23 has been

documented. In patients with syndromes such as

Downs syndrome24, Klinefelters syndrome20,25,

ectodermal dysplasia syndrome26, Mohr-syndrome27,

tricho-dento-osseous syndrome28 or in patients with

cleft lip and palate29, taurodont teeth are more pre-

valent than in healthy subjects.

In this particular case, the patient had no sys-

temic disturbances, malformations or syndromes

and, therefore, both teeth were considered to be

non-syndromic taurodont teeth. Both teeth were

classified as pyramidal teeth. An inheritable aeti-

ology could not be found, as the families of the

patients were not available for examination.

Endodontic treatment in taurodont teeth has

been described as complex and difficult, because

these teeth show wide variations in the size and

shape of the pulp chamber with varying degrees of

obliteration and canal configuration31. This morph-ology could complicate the location of the canal

orifices, which consequently causes difficulties in

subsequent instrumentation and obturation32.

The exploration of the canal configuration was

done using an operating microscope because of the

width of the pulp chamber. Some authors propose the

use of micro-computerised tomography (micro-CT) to

examine the morphology of difficult teeth. With this

technique, three-dimensional information about the

examined object is available for the planning of

endodontic and surgical treatment. Some details may

become visible that were not detectable using con-

ventional examination methods33,34,35.

The radiation exposure depends on the CT and

is much higher than with conventional intraoral

radiographs36,37

. The indication for the diagnosticmethod should be evaluated carefully, and the

ALARA-principle (as low as reasonably achievable)

considered for the use of radiation.

Mechanical debridement and shaping of the root

canals was achieved with circumferential filing using

stainless steel hand K-files alternating with stainless

steel hand Hedstrm-files, because the pulp chamber

was huge. Preparing oval or large straight root canals

by this technique leads to satisfying results and is

superior to rotary instrumentation alone38,39. An even

preparation of all canal walls during the root canalinstrumentation is possible using this circumferential

filing technique. The root canal of tooth 47 was ob-

turated by lateral condensation, as a wide apical fora-

men was present. This technique allows a good api-

cal control by trial fitting the master cone, and the

risk of overextension of gutta-percha or sealer is

minimised. However, thermoplastic techniques are

not well controlled and can lead to apical extrusion

into the periapical tissue40,41. This could cause post-

operative complaints as well lead to a failure of the

root canal treatment, or in the worst case, to an

irreversible nerve injury if material is extruded into

the nerve canal. Alternatively, an apical plug with

mineral trioxide aggregate or apexification proce-

dures using repeated Ca(OH)2 dressings would have

been possible, but the chosen therapy was easy to

handle and safe.

Summary

Taurodontism including all its varieties (meso-, hypo-,hypertaurodontism and pyramidal teeth)8 is a rare

dental malformation, in which root canal treatment

is still a challenge because of multiple and complex

forms of canal configurations. In each case,

radiographic examination is essential before

initiating root canal treatment, so as to become

aware of the particular root canal configuration. An

operating microscope may be helpful for the

exploration of further and accessory canals or a wide

apical foramen. Chemo-mechanical preparation


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ENDO (Lond Engl) 2008;2(3):199203

Brklein Treatment of two pyramidal (taurodont) mandibular molars

with copious irrigation and circumferential filing is

necessary for successful endodontic treatment

including the obturation technique, which allows

good apical control, because wide foramina are

among the characteristics of taurodont teeth.

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