An unusual case of maxillary first molar with seven canals and the successful surgical recovery of a separated instrument.

This case report highlights the intricate anatomy of root canals and the challenges they pose for clinicians. A 26-year-old female patient presented to the department with a chief complaint of pain in her left upper back tooth region. After thorough clinical and radiographical examinations, the diagnosis of pulpal necrosis with symptomatic apical periodontitis in the maxillary left first molar was confirmed. An intraoperative cone-beam computed tomography was performed. The axial imaging unveiled that there were, two distal (DB1 and DB2) canals, two palatal (P1 and P2) canals, and three mesiobuccal (MB1, MB2, and MB3) canals. The appearance of a convoluted root canal configuration serves to highlight the inherent complexity that clinicians may encounter during endodontic procedures. However, when this complexity is further compounded by the incident of separation of root canal instruments, the challenges faced by clinicians become significantly more demanding. It exemplifies the increased difficulty posed by the combination of tortuous root canal morphology and the additional complication of instrument separation, highlighting the importance of careful management and precise techniques in such scenarios and the significance of modern adjuncts, into the diagnostic process and magnification in the surgical and endodontic therapy.

Comparison of the sealing ability amongst orthograde apical plugs of mineral trioxide aggregate plus, mineral trioxide aggregate repair HP, and Biodentine after root resection: a bacterial leakage study.

This study aimed to analyse the effect of root-end resection on the sealing ability of orthograde apical plugs of three root-end filling materials (MTA Repair HP, Biodentine, MTA Plus) using the bacterial leakage method and compare it with the retrograde root-end filling technique. Eighty-four extracted mandibular premolar teeth with single root and single straight canals were selected and randomly divided into two main experimental groups (n = 36) depending on the apical plug placement technique and a control: Group I: orthograde technique, followed by root-end resection; Group II: retrograde root-end filling technique; one control Group III (n = 12): obturation with gutta-percha, followed by root-end resection. Experimental groups were further subdivided into three subgroups A, B, and C (n = 12) depending on the three different root-end filling materials used. An apical plug of 3 mm thickness was obtained in both the experimental groups. The apical sealing ability was evaluated with the dual-chamber bacterial leakage method. Statistical analysis was performed using the Kaplan-Meier survival analysis test. By the end of 30 days, the occurrence of turbidity indicating bacterial leakage was 75% in MTA Repair HP, 83.3% in Biodentine, and 91.7% in MTA Plus samples. This trend of turbidity was similar in both orthograde and retrograde technique. The control group showed turbidity in all the samples (100%). More MTA Repair HP samples (25%) survived the 30 days observation period with no bacterial leakage compared to Biodentine (16.7%) and MTA Plus (8.3%). The sealing ability of already set root-end filling materials placed through the orthograde technique did not deteriorate after root-end resection. Also among three root-end filling materials, MTA Repair HP presented the lowest bacterial microleakage followed by Biodentine and MTA Plus, respectively.

Assessment of minimally invasive file systems on resistance to fracture using traditional and contracted access cavity designs in the maxillary first and second molars.

Objective: The objective of the study was to evaluate the effect of access cavity design on fracture resistance of the extracted maxillary first and second molars prepared with three minimally invasive files. Materials and Methods: One hundred and twelve extracted human maxillary molars were selected for the study and divided randomly into three groups according to different minimally invasive files used (self-adjusting files [SAF], XP-endo Shaper [XP], and 4 V-Taper 2H [VT]) and one control group (CG). All experimental groups were subdivided into two subgroups, i.e., conservative access cavity (CAC) and traditional access cavity (TAC). All the canals in different experimental groups were enlarged up to apical size 30. The data were analyzed using the analysis of variance and Post hoc Tukey tests (P < 0.05). Results: The highest mean fracture resistance of teeth with CAC was of the CG (1399.957), followed by teeth with CAC instrumented by SAF (1378.314) and XP-endo Shaper (1202.929). The least value was of the V-Taper file system (937.157). Furthermore, the highest mean fracture resistance value of teeth with TAC was of the CG (1143.171), followed by teeth with TAC instrumented by SAF (1150.607) and then XP-endo Shaper (998.150). The least value was of the V Taper file system (757.050). Conclusion: Conservative endodontic access (CAC) in the maxillary molars had shown significantly increased fracture resistance over TAC. SAF showed the maximum fracture resistance, while V-Taper files showed the least fracture resistance among the experimental groups compared.

Fracture resistance of post and core in immediate and delayed post space in trauma simulated teeth.

INTRODUCTION: This research aims to assess and analyze the fracture resistance of GC Everstick post with separate composite core buildup and Edelweiss prefabricated resin composite post and core single unit into immediate and delayed post space prepared teeth. METHODS: A total of 120 extracted human mandibular premolars have been subjected to a standardized protocol of mechanical trauma to simulate tooth fracture. Teeth samples were randomly divided into four groups (n = 30) on the basis of time taken for the preparation of post space (approximately following root canal obturation and 24 h after root canal obturation) for the single unit Edelweiss post and core system and GC post with separate core buildup. Compressive load has been utilized to do the analysis necessary to establish the fracture resistance using a universal testing machine. The fracture force calculated was in Newtons (N), and a stereomicroscope was utilized for investigating the common causes of failure. RESULTS: In an immediate post space prepared tooth, the GC post exhibited a mean failure load of 970.584 N. In contrast, the Edelweiss post, and core system showed a significantly higher mean failure load of 1250.349 N. In delayed post space prepared tooth, the GC Everstick post exhibited a mean failure load of 950.287 N. In contrast, the Edelweiss post, and core system showed a significantly higher mean failure load of 1229.348 N. CONCLUSION: This study aims to assess and analyze the fracture resistance of the GC Everstick post with separate composite core buildup and the Edelweiss prefabricated resin composite post and core single unit in immediate and delayed post space prepared teeth. The study results showed that the failure modes in both groups were non-catastrophic in nature. These findings suggest that the Edelweiss post and core system may be a more suitable option for restoring teeth that have been subjected to traumatic conditions. The study provides valuable information for dental professionals in their decision-making process for post and core restoration techniques in teeth that have been subjected to trauma.

Comparison of Dentinal Tubular Penetration of Intracanal Heated and Preheated Sodium Hypochlorite Through Different Agitation Techniques.

INTRODUCTION: The efficacy of sodium hypochlorite (NaOCl) as an intracanal irrigant is widely debated in endodontic therapy. This study aimed to analyze and compare the penetration abilities of different modes of NaOCl application and assess the impact of various agitation strategies on promoting root canal cleanliness. MATERIALS AND METHODS: This study included 168 single-rooted mandibular premolars that were randomly divided into 8 groups. The 2 modes of application of 5% NaOCl evaluated were intracanal heating and preheating, and the agitation strategies included ultrasonic, sonic, and manual dynamic agitations. The samples were sectioned and observed at a magnification of 1000 × under a scanning electron microscope. RESULTS: The analysis of variance test showed a statistically significant difference among the various groups of agitation (P < .05). The post hoc Tukey test confirmed that preheated NaOCl with ultrasonic agitation, intracanal-heated NaOCl with sonic agitation, and manual dynamic agitation had significantly higher debris scores of 1, 4, and 5, respectively, in the apical third of the canal. CONCLUSION: The results indicated that the combination of intracanal-heated NaOCl and ultrasonic agitation is an effective method for reducing debris in the root canal system. These findings highlight the importance of considering both the mode of application and the agitation strategies when optimizing the use of NaOCl as an intracanal irrigant in endodontic therapy.

Radicular dentinal microcracks during biomechanical root canal preparation using four minimally invasive endodontic files.

Aim: The aim of the study was to compare the dentinal microcrack formation on human mandibular molars using 4 different minimally invasive file systems at 3, 6 and 9 mm from apex using a stereomicroscope. Method: 125 mesial roots of mandibular molars were randomly divided into 5 groups and instrumented (n=25). Group 1: Control Group (CG), Group 2: Self Adjusting File (SAF), Group 3: XP-Endoshaper (XP), Group 4: TRUShape (TS), Group 5: V Taper 2H (VT). After instrumentation was completed, the roots were sectioned at 3 mm, 6 mm, and 9 mm from apex using a slow-speed circular saw. Digital images were captured using a 24× stereomicroscope by using a digital camera. Two operators independently checked each specimen for the presence of dentinal defects. Statistical comparison between the file systems was done using Chi-square (p<0.05). Result: There was no statistically significant difference in the frequency of microcracks between the groups of file systems (X2=4.509, p>0.05). VT file system exhibited higher microcracks (25%) but was not statistically significantly higher than XP (12%), TRUShape (12%), and SAF (4%) endodontic file systems. Conclusion: Within the limitations of this study, it can be concluded that all the file systems used in our research are minimally invasive files and produced few dentinal microcracks. VT files produced maximum while SAF produced the least number of micro-cracks.

Light emitting diode assessment of dentinal microcracks after root canal preparation with 4 different heat-treated file systems.

BACKGROUND: The purpose of this research was to evaluate the dentinal microcracks formation after root canal preparation with Hyflex® EDM ([electrical discharge machining], Coltene; Altstätten, Switzerland), Neolix Neoniti A1 EDM (Neolix; Beijing, China), Wave One Gold (Dentsply Sirona; York, PA, USA) and Edge File® X1 (EdgeEndo; Albuquerque, NM, USA) under illumination and magnification. METHODS: One hundred fifty mandibular molars with 2 different mesial canals extracted for periodontal reasons were included in the study. The samples were decoronated at 15 mm from the apex using a carborundum disc under copious water cooling. Access opening was done using a round bur. Sectioning of the distal root was done. Patency of mesial canals were checked using a 10 K file. The samples were randomly divided into 5 groups using simple randomization technique: group 1 (uninstrumented group); group 2 (Hyflex® EDM [HEDM] [Coltene]); group 3 (Neolix Neoniti A1 [NA1] [Neolix]); group 4 (Wave One Gold [WOG] [Dentsply Sirona]); and group 5 (Edge File® X1 [EFX] [EdgeEndo]). Biomechanical preparation in all groups was done following the manufacturer's instructions. Sectioning was done at 3 mm, 6 mm, and 9 mm from the apex using a 0.13 mm circular saw under copious water cooling. Sections were observed at 16× magnification under the dental operating microscope and illumination using a light emitting diode (LED) curing light. The χ2 test was used to determine the statistically significant differences at P<0.05. Intergroup comparison was done by the post-hoc Tukey test. RESULTS: Total of 1800 images were analyzed. The highest number of cracks was seen in Neoniti A1 group (43.33%) while the least number of cracks were seen with Wave One Gold group (13.33%). There was statistically difference between reciprocating groups and the rotary group. CONCLUSIONS: Within the limitations of this study, it can be concluded that all the heat-treated file systems produced dentinal microcracks. Rotary group (NA1 and HEDM) produced significantly more cracks than reciprocation group (WOG and EFX).

Radix entomolaris and radix paramolaris in mandibular molars: a case series and literature review.

The success of root canal treatment depends on complete debridement of pulp tissue from the root canals. Therefore, a thorough knowledge of unusual anatomical findings is of utmost importance. Although the majority of mandibular molars present with 2 roots (mesial and distal) and 3 or 4 root canals, the number of roots and root canals in individual molars may vary. An extra root is called a radix entomolaris if it is located distolingually and a radix paramolaris if located mesiobuccally. This article presents a series of 5 cases of radix entomolaris and radix paramolaris in mandibular first, second, and third molars and reviews the literature on these morphologic variations.

Comparative Evaluation of Accuracy of Ipex, Root Zx Mini, and Epex Pro Apex Locators in Teeth with Artificially Created Root Perforations in Presence of Various Intracanal Irrigants.

Objective: The study aimed to compare and evaluate the accuracy of iPex, Root ZX mini, and Epex Pro Electronic apex locators (EALs) in diagnosing root perforations in both dry and in different wet conditions: 5% sodium hypochlorite (NaOCl), 2% chlorhexidine (CHX), and 17% Ethylenediaminetetraacetic acid (EDTA). Methods: Thirty extracted, human single rooted mandibular premolars were artificially perforated with a diameter of 1.5 mm in middle third of root. Actual canal lengths (ALs) in millimetre (mm) were evaluated for all teeth up to perforation location, and alginate mould were used to embed the teeth. After this, the electronic measurements were calculated by all EALs up to perforation site using a 20 K-file in both dry and wet canal conditions. Up to the perforation sites, the ALs were subtracted from the electronic length. Statistical analyses were done using One-way ANOVA with post hoc tukey's test for pairwise comparison and the level of significance was set at 0.05. Results: All three EAL's detected canal perforations which were clinically acceptable. There was significant difference for dry and wet conditions. Most accurate measurement were seen in dry canals for all three EALs. Root ZX mini in dry condition showed most accurate reading and there was a significant difference when compared with other groups. No significance difference was observed in iPex and Epex Pro Apex locator, and between NaOCl and CHX, CHX and EDTA. Conclusion: Perforations were determined within a clinical acceptable range of 0.03-0.05 mm by all three EALs. Root ZX mini in dry canals gave most accurate measurement. The presence of irrigating solution influenced the accuracy of all the apex locators.

Dentinal Adaptation of Warm Thermoplastic Obturating Material and Cold Thermoplastic Obturating Material: An In vitro Study.

INTRODUCTION: The objective of endodontic obturation is to provide a complete seal along the length of the root canal system, thereby ensuring the healing and sustained health of the periradicular tissue. Root canal obturation involves the three-dimensional filling of the entire root canal system and is a critical step in endodontic therapy. Gutta-percha has universally been accepted as the gold standard for root canal filling materials. However, it lacks bonding to the internal tooth structure resulting in the absence of complete seal. AIM: The aim of the present study is to compare the dentinal adaptation of warm thermoplastic obturating material and cold thermoplastic obturating materials. MATERIALS AND METHODS: Thirty single-rooted, anterior noncarious human teeth extracted for periodontal or orthodontic reasons were used for the study. The samples were stored in distilled water until obturation. The specimens were then randomly divided into three groups of ten specimens each: Control group - Cold lateral condensation with AH Plus, Group I - Endosure with AH Plus®, and Group II - GuttaFlow® 2 with master cone. The obturation for each group was done following manufacturer's instructions. Under On-demand software, the area of voids at the level of 3 mm, 5 mm, and 8 mm from the apex was observed for all the samples. The obtained results were submitted for statistical analysis. RESULTS: The result in the present study showed that Endosure provides a better consistent seal as compared to cold lateral condensation, or GuttaFlow 2 techniques. CONCLUSION: Mean void value was maximum for GuttaFlow 2 group, followed by cold lateral condensation, Endosure. Though there was a difference in the mean void values, it was not statistically significant except between Endosure and GuttaFlow 2. The result in the present study showed that Endosure provides a better seal as compared to cold lateral compaction, GuttaFlow 2 or Endosure technique.

Cysteamine improves the bactericidal efficacy of intra-canal medicaments against Enterococcus faecalis.

AIM: The aim of this study was to compare the antimicrobial efficacy of cysteamine, calcium hydroxide[Ca(OH)2], triple antibiotic paste (TAP), chlorhexidine (CHX) and their combinations against Enterococcus faecalis (E. Faecalis). METHODS: The E. Faecalis eradication capacity of cysteamine, Calcium hydroxide (Ca[OH]2), TAP, CHX, and their combinations was tested on E. Faecalis by Kirby Brauer disc diffusion method. RESULTS: Cysteamine in combination with TAP was able to completely eradicate E. Faecalis within 24 hours. Ca(OH)2 was unable to show its effect on E. Faecalis in the given time. CONCLUSION: Cysteamine increased the E. Faecalis eradicating capacity of TAP and also showed positive results when used in combination with Ca(OH)2, which if used alone was unable to show any action in 24 hours.

Cutaneous dental sinus of submental region: an eight years follow-up.

A 22-year-old female patient had a history of a 7-month recurrent pus discharge from her chin. She had been previously treated by physicians, dermatologist, and surgeons. The sinus kept re-occurring and she was referred to dental hospital for opinion. The patient had cutaneous opening of size 5 mm × 6 mm with purulent discharge in submental region. Patient had undergone three surgical excisions and multiple antibiotic regimens. Patient had a history of trauma due to fall six years back. A 30 number standard gutta-percha was used to trace the sinus tract and dental origin was confirmed radiographically. The tract led to in-between the root canal apices of both mandibular incisors. Treatment included non-surgical endodontic treatment with both mandibular central incisors and antibiotic coverage following bacterial culture of discharge. The pus culture showed Streptococcus anginosus which was found to be sensitive to penicillin. Patient was kept on 1-week course of oral amoxicillin-clavulanate along with root canal therapy. The cutaneous sinus healed following root canal treatment and antibiotic coverage. On an 8-year follow-up skin of sub-mental region appeared normal and peri-apical healing with both mandibular central incisors was evident radiographically. Cutaneous lesions on face may be of dental origin. A cross referral between dentists, physicians, surgeons, and dermatologists should be considered in such cases.

Association of midline discrepancy with tempromandibular joint disorder. A systematic review.

AIM: The aim is to evaluate the association between midline discrepancies and tempromandibular disorders (TMDs). METHODS: Literature search was performed by using various search engines to include human studies in English. TMDs include a wide variety of signs and symptoms such as pain in and around TMJ, jaw muscles, clicking and locking of jaws, pain during mandibular movement and restricted mandibular movements. The etiology is multifactorial, including one or several of the following factors like severe malocclusions (increased overjet, retroclination of incisors, cross bite, CR CO discrepancies etc), stress and psychological factors, structural abnormalities as possible etiology. There are controversies concerning the association between different traits of malocclusion and TMDs. The aim of the present study was to find out any association between signs and symptoms of TMDs with midline discrepancies, which represent an important trait of malocclusion. RESULT: Of the seven studies evaluated in this systematic review for investigating the association between midline discrepancy and TMD, six had moderate grade (B) of evidence. Four studies of moderate grade evidence (B) showed a significant association between the presence of midline shift and TMDs, and the remaining studies (two) had non-significant association. Only one study had a strong grade of evidence (A) and interestingly it denies the presence of midline shift to be a causative factor for TMDs. So, it can be concluded that the results are inconclusive regarding the association of midline discrepancies with TMDs. Nonetheless, this requires concrete evidence which necessitates further long term research into this aspect.

Management of intrinsic discoloration using walking bleach technique in maxillary central incisors.

INTRODUCTION: Non-vital bleaching is a non-invasive technique to treat the intrinsic discoloration of teeth of several etiologies. Hydrogen peroxide and sodium perborate are commonly used bleaching agents. AIM: The aim of this case report is to demonstrate the non-vital bleaching technique in maxillary anterior teeth. METHOD: Maxillary central incisors were isolated with rubber dam and root canal treatment was performed. Barrier space preparation was done using a heated instrument. Glass ionomer cement was used a barrier material. Mixture of hydrogen peroxide and sodium perborate was placed in the canal and sealed with intermediate restorative material. After 1 week, the procedure was repeated to achieve the desired results. CONCLUSION: Non-vital bleaching is a minimally invasive procedure to restore the esthetics of a discolored non-vital tooth. However, care should be taken to prevent any post-operative complications.

Internal tunneling resorption associated with invasive cervical resorption.

Treating pathological defects that are caused by resorption in teeth can be challenging. The task is complicated further if the resorption extends beyond the restrains of the root. The aim of this report is to describe a case of extensive internal tunneling resorption (ITR) associated with invasive cervical resorption (ICR) in a maxillary right lateral incisor and its nonsurgical treatment. A 22-year-old male was referred to the department of endodontics with a chief complaint of discolored maxillary right lateral incisor or tooth 12 and a history of trauma. An extensive ITR associated with ICR accompanied by apical periodontitis was detected on a preoperative radiograph which was confirmed on a cone-beam computed tomography (CBCT) scan in a maxillary lateral incisor. After chemomechanical debridement and withdrawal of a separated file in the canal, calcium hydroxide was placed as an intracanal medicament for 2 weeks. Biodentine (BD) was used to obturate the defect as well as entire root canal system and to restore ICR. On a 5-year follow-up, the tooth was functional, and periapical healing was evident. Based on results of this case, successful repair of ITR associated with ICR with BD may lead to resolution of apical periodontitis. Trauma to teeth may lead to resorption which may be internal, external, and or a combination of both which may be asymptomatic in some patients. Preoperative assessment using CBCT imaging achieves visualization of location and extents of resorptive defects. Bioactive materials like BD may lead to favorable results in treating such extensive defects.

Endodontic management of maxillary third molar with MB2 (Vertucci type IV) canal configuration diagnosed with Cone Beam Computed Tomography - a case report.

The endodontic treatment of maxillary third molar often poses a challenge even to an experienced endodontist because of their most posterior location in the dental arch, aberrant occlusal anatomy, abnormal root canal configuration and eruption patterns. Owing to these anatomical limitations, their extraction remains the treatment of choice for many clinicians. As we know, retaining every functional component of the dental arch is of prime importance in contemporary dental practice. This clinical case report aims to discuss the endodontic treatment of maxillary third molar with MB2 root canal separated throughout the length and exit at two separate apical foramina (Vertucci type IV) diagnosed with Cone Beam Computed Tomography (CBCT)..

Comparison of different irrigation and agitation methods for the removal of two types of calcium hydroxide medicaments from the root canal wall: an in-vitro study.

BACKGROUND AND AIM: Comparison of different irrigation and agitation methods for the removal of two types of calcium hydroxide medicaments from the root canal walls. METHODS: Fifty extracted single rooted teeth were selected for this study. After decoronation, the root canals of these teeth were prepared to the size F3 (30 no.) using rotary ProTaper file system. These samples were randomly divided into four groups. Group 1 (n=20) were filled completely with water based calcium hydroxide (CH), Group 2 (n=20) were filled with oil based CH using lentulo spiral, Group 3 (n=5) - the positive control group received the CH as intracanal medication, but no subsequent removal, Group 4 (n=5) - the negative control did not receive CH placement. Further on, Group 1 and Group 2 were divided into four sub-groups (n=5). In sub-group A we performed conventional syringe irrigation with side-vented needle sub-group B) manual dynamic agitation, sub-group C sonic agitation using endoactivator, sub-group D passive ultrasonic irrigation (PUI). Roots were split longitudinally into mesial and distal halves. Digital images of the root canal walls were acquired by a Dental Operating Microscope (DOM) and assessed by using a scoring criteria at different thirds (coronal, middle and apical) of the root canal as follows: score 1, score 2, score 3, and score 4. Data were analyzed applying one-way analysis of variance (ANOVA) and Tukey's multiple comparison tests at a 95% confidence interval (P < 0.05). RESULTS: Statistically significant differences were not found between the experimental groups and the negative group in any one third of the root canal (P>0.05). However, a difference did exist between the experimental groups and the positive control group (P<0.05). None of the experimental groups totally removed CH substances from root canal walls. CONCLUSION: Among all experimental groups, removal of CH was best achieved by sonic agitation using endoactivator followed by passive ultrasonic irrigation (PUI), manual dynamic agitation and conventional syringe irrigation with side-vented needle.

A Conservative Approach to the Management of a Dental Trauma for Immediate Natural Esthetics.

INTRODUCTION: The fracture of front teeth is one of the routine presentations of traumatic injuries. The treatment of a fractured tooth involving the pulp includes root canal therapy and post placement followed by core build-up or by the extraction of the fractured tooth if it is not restorable. CASE PRESENTATION: We report a case of an adult male who had traumatized both his maxillary central incisors following a blow experienced during domestic violence. He had lost a fractured fragment of the right central incisor, while the left incisor had complicated fractures with fragments retained attached to the soft tissue. Following radiovisiography (RVG), both incisors were conservatively treated in a single visit by reattachment and post and core techniques. CONCLUSIONS: The treatment reported for reattachment of the tooth fractures and post and core techniques are reasonably easy while providing immediate and lasting results in patients' regaining of social confidence and functionality.