Endodontic management of a mandibular second molar with radix entomolaris: a case report
A 27-year-old male patient was referred to the Department of Conservative Dentistry and Endodontics with the complaint of spontaneous pain in the lower left posterior tooth for 3 days. The patient reported a history of intermittent pain for the past one month. On clinical examination, there was a carious mandibular left second molar (tooth #37). The tooth was tender to percussion and palpation did not reveal any tenderness. There was no mobility, and periodontal probing was within the physiological limits. A heat test resulted in intense lingering pain. The involved tooth showed a premature response to electronic pulp stimulation. The preoperative radiograph showed disto-occlusal radiolucency with pulpal involvement and periodontal space widening relative to the mesial and distal roots with an additional distolingual root (). Based on these findings, the tooth was diagnosed with dental caries with symptomatic irreversible pulpitis and apical periodontitis. Endodontic management was planned for the involved tooth.\nAn inferior alveolar nerve block was performed with 1.8 mL of 2% lidocaine containing 1 : 200,000 epinephrine (LOX 2%, Neon Laboratories Ltd., Mumbai, India) followed by buccal infiltration (1.8 mL) of the same anesthetic solution. The endodontic access cavity was prepared under rubber dam isolation. The conventional triangular outline form of the access cavity was modified into a trapezoidal form to place the distolingually located RE under the surgical operating microscope. A clinical examination was carried out with a DG16 endodontic explorer (Hu-Friedy, Chicago, IL, USA), and the surgical microscope (Seiler 600 series) revealed two mesial and two distal canal orifices. Coronal enlargements of the canals were performed with the nickel-titanium Protaper series orifice shaper (Dentsply Maillefer, Ballaigues, Switzerland) (). The canal length was determined with an electronic apex locator (Root ZX, Morita, Tokyo, Japan) and later confirmed using a radiograph ().\nTo confirm RE, CBCT imaging of the tooth (Kodak 9500, tube voltage: 90 kV, current: 10 mA, Carestream health Inc., Rochester, NY, USA) was performed after obtaining informed consent from the patient. The transverse, axial, and sagittal CBCT sections of the involved tooth were taken. The CBCT scan slices confirmed the presence of RE (). During the next visit, the patient was asymptomatic, and cleaning and shaping was done with Protaper nickel-titanium rotary instruments (Dentsply Maillefer) in a crown-down manner until F2. Irrigation was performed with 2.5% sodium hypochlorite solution, 17% EDTA, and 2% chlorhexidine digluconate solution as the final irrigant. Obturation was done with Protaper gutta-percha cones (Dentsply DeTrey Gmbh, Konstanz, Germany) and AH Plus resin sealer (Dentsply DeTrey Gmbh, ). The access cavity was then restored with posterior composite resin, and the patient was advised to undergo full coverage restoration of the tooth.