Endodontic management of a four rooted retained primary maxillary second molar
An 18-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with the complaint of pain in the left upper posterior region of the mouth since 1 week. Intraoral clinical examination of the patient revealed the presence of retained primary second molar in first and second quadrant of the oral cavity and absence of maxillary second premolars; however, there was no retained primary tooth in the mandibular arch. Remaining teeth except third molars were present in the oral cavity in their usual anatomic position. The left side primary second molar was deeply carious. The primary tooth had similar cusp-fossa relationship alike adjacent permanent teeth and infraocclusion was not clearly visible. Patient had Angle's Class I molar relationship. Furthermore, there was the absence of any obvious crowding or spacing in the permanent dentition. Radiographic examination of the left primary second molar showed the presence of deep caries involving pulp space. Furthermore, the presence of extra root in the primary left second molar and congenital absence of the second premolar tooth bud was noted, also occlusal height of primary tooth was at similar level as compared to adjacent permanent teeth in intraoral periapical radiograph []. Patient was recommended following treatment options: (1) Extraction of primary tooth followed by space closure using either crown and bridge placement or implant placement. (2) Extraction of primary tooth followed by orthodontic space closure. (3) Root canal treatment for the same tooth alike permanent tooth and follow-up. Also, in third treatment option patient was informed about the possibility of root resorption or ankylosis leading to tooth loss, which again had to be treated with implant or prosthodontic crown or bridge or orthodontic treatment. Patient insisted on saving the tooth rather than immediate extraction; hence, root canal treatment was planned. After, obtaining patient's consent root canal treatment was initiated under local anesthesia and strict rubber dam isolation. Adequate access preparation revealed four root canal orifices. Working length was measured using electronic apex locator (Root ZX™, Morrita, Tokyo, Japan) and radiographic technique using Ingle's method. Working length radiograph confirmed the presence of four separate roots and canals []. Biomechanical preparation was done using NiTi rotary endodontic instruments (Protaper™, Dentsply, New Delhi, India) in a crown down manner. 17% ethylenediaminetetraacetic acid (EDTA) and urea peroxide paste (Glyde™, Dentsply, New Delhi, India) was used as canal lubricant along with 3% sodium hypochlorite as irrigating solution. Apical canal size was prepared until size F3 for all the canals. After complete instrumentation, all canals were flushed with 17% EDTA solution to remove the smear layer followed by final flush with 5% sodium hypochlorite solution. Later on canals were completely dried using absorbent paper points (Dentsply, New Delhi, India) and all the root canals were obturated using resin based sealer (AH Plus™, New Delhi, India) and Gutta-percha points (Protaper Gutta Percha™, Dentsply, New Delhi, India) [] and the access was restored with dental composite (Ceramax Mono™, Dentsply, New Delhi, India). Post-treatment radiograph showed adequate obturation [] and the patient was asymptomatic.