Prevalence of Short Root Anomaly in a Group of Puerto Ricans.

OBJECTIVE: To estimate the prevalence of short root anomaly (SRA) in a group of Puerto Ricans at the Advanced Education Program in Orthodontics of the University of Puerto Rico. METHODS: A cross-sectional study was conducted with digital panoramic x-rays of 203 patients (112 females and 91 males; mean age: 17 years) in Puerto Rico. Utilizing the modified Lind's method, 406 maxillary right and left central incisors (1) were measured and evaluated for SRA. Root and crown length and R/C ratio were compared by sex and side. Linear regression was used to evaluate the associations between the R/C ratio and age, sex, and side (right/left). All the statistical analyses were evaluated using significance level of .05 (2). RESULTS: The prevalence of SRA was 0.49%. The average root and crown lengths for the maxillary right and left central incisors were 19.47 and 10.28 mm, respectively. Sex was associated with root and crown length, not with the R/C ratio. No differences were observed in the R/C ratio by the side. There were no significant associations between age, sex, and side and R/C ratio in the multivariate analysis. CONCLUSION: The prevalence of SRA in our population is lower than any reported in the literature. The R/C ratio in our Hispanic population was the highest compared with those of other ethnicities. Neither the sex nor the side of the incisor was associated with the R/C ratio. These findings are contrary to those of prior reports stating that males have higher R/C ratios than females.

Is Short Root Anomaly (SRA) a risk factor for increased external apical root resorption in orthodontic patients? A retrospective case control study using cone beam computerized tomography.

OBJECTIVES: To evaluate the amount of external apical root resorption (EARR) secondary to orthodontic treatment in patients with Short Root Anomaly (SRA) compared to patients with average root lengths using Cone Beam Computed Tomography (CBCT). SETTINGS AND SAMPLE POPULATION: Cone beam computed tomography scans of 23 SRA and 26 control patients were selected from 232 pretreatment scans from a single private practice. MATERIALS AND METHODS: Cone beam computed tomography scans before (T1) and after orthodontic treatment (T2) were evaluated for differences in the change in tooth and root length of the maxillary incisors between both groups. Gender, treatment duration and age were examined as covariates. RESULTS: The mean values for root and tooth length of the maxillary incisors decreased by a range of 0.6 to 1.3 mm after orthodontic treatment. There was no significant difference between the groups for the majority of the measurements although there was a trend for less EARR in the SRA group. The maxillary left central incisor had significantly less proportional and non-proportional loss in tooth length in the SRA group. Age, gender and treatment duration were not associated with change in the proportional and non-proportional lengths for both groups. CONCLUSION: Patients with SRA did not exhibit a significant difference in the proportional and non-proportional change of length after orthodontic treatment when compared to the controls for most measurements. Only tooth length for the maxillary left central incisor had significantly less reduction after orthodontic treatment for both the proportional and non-proportional measurements in the SRA group compared to the control group.

Deviations of Mesial Root Canals of Mandibular First Molar Teeth at the Apical Third: A Micro-computed Tomographic Study.

INTRODUCTION: The present study aimed to quantitatively analyze apical foramen deviations of mesial root canals of mandibular first molar teeth by means of micro-computed tomographic (micro-CT) imaging. METHODS: Micro-CT images of the mesial roots of 109 mandibular first molar teeth with independent mesiobuccal (MB) and mesiolingual (ML) root canals were analyzed. The deviations of the apical foramina of the MB, ML, and middle mesial root canals from the anatomic apex were measured. The vertical distance between the apical foramina of each mesial root canal in relation to each other was also calculated. RESULTS: The distances from the apical foramina of the MB, ML, and middle mesial root canals to the anatomic apex of the mesial root were up to 2.51 mm, 3.21 mm, and 5.67 mm, respectively. There was no significant difference between the deviations of MB and ML root canals from each other (P > .05). The middle mesial root canal showed the greatest deviation compared with the MB and ML canals (P < .05). CONCLUSIONS: The apical foramina of mesial root canals of mandibular first molar teeth showed greater variations from each other and anatomic apices than previously reported. Clinically, the use of electronic apex locators for the detection of minor apical foramen of each mesial root canal is of the utmost important.

Utilizing the GentleWave® System for Debridement of Undetected Apical Anatomy.

AIM AND BACKGROUND: Debriding and disinfecting complex anatomies within the root canal system pose a major challenge during root canal therapy. Even with current chemomechanical techniques, debris and bacterial remnants are commonly left behind, which are generally believed to increase the risk of endodontic failure. This case details the use of a new technique to debride complex apical anatomy in a maxillary molar. CASE REPORT: A 48-year-old female presented to the clinic with a chief complaint of increasing pain in her tooth. Clinical examination of the right first maxillary molar (#3) revealed moderate sensitivity to percussion and mild sensitivity to palpation. A pulpal diagnosis of symptomatic irreversible pulpitis and a periapi-cal diagnosis of symptomatic apical periodontitis were made. Mechanical instrumentation was performed using rotary file size #25/.04 for the mesiobuccal and distobuccal canals and size #25/.06 for the palatal canal to create a fluid path and enable obturation of the root canal system following the GentleWave® Procedure. The GentleWave Procedure was completed using Multisonic Ultracleaning™ for complete debridement and disinfection of the root canal system. The tooth was obturated using a warm vertical continuous wave obturation technique. Postoperative radiographs revealed complex anatomy within the apical third that was undetected both during pre-operative radiography and mechanical instrumentation. The palatal canal exhibited a complex apical delta with multiple points of exit, and the mesiobuccal canal revealed an undetected lateral canal within the apical third that had a separate and distinct egress. Conclusion and clinical significance: It is important for the clinician to debride and disinfect complex anatomy within the root canal system to reduce the risk of endodontic failure. This case report highlights the clinical significance of utilizing the GentleWave Procedure for detecting complex apical anatomy during endodontic therapy.

Endodontic Outcomes in Mandibular Second Premolars with Complex Apical Branching.

INTRODUCTION: Mandibular premolars that have rare and complex anatomies may have the highest failure rate in nonsurgical endodontic treatment. Awareness of rare and complex anatomies of mandibular second premolars would aid in better outcomes of the treatment. This study aimed to evaluate the success of nonsurgical root canal treatment of mandibular second premolar teeth with complex apical branching. METHODS: Twenty-six mandibular second premolar teeth with complex apical branching treated with multiple-visit nonsurgical root canal treatment or nonsurgical retreatment were retrospectively evaluated. RESULTS: For the clinical outcomes, 9 subjects had complete healing, 1 subject had functional healing, and no subject had no healing scores out of 10 root canal treatment subjects. Six subjects had complete healing, 8 subjects had functional healing, and 2 subjects had no healing scores out of 16 retreatment subjects. For the radiographic outcomes, 7 subjects had complete healing, 3 subjects had incomplete healing, and no subject had no healing scores out of 10 root canal treatment subjects. Six subjects had complete healing, 8 subjects had incomplete healing, and 2 subjects had no healing scores out of 16 retreatment subjects. The clinical outcome of root canal treatment subjects was significantly different than retreatment subjects (P < .05). Similarly, the radiographic outcome of root canal treatment subjects was also significantly different than retreatment cases (P < .05). CONCLUSIONS: The outcome of endodontic treatment of mandibular second premolars may be influenced by treatment type.

A Rare Case of Type III Dens Invaginatus in a Mandibular Second Premolar and Its Nonsurgical Endodontic Management by Using Cone-beam Computed Tomography: A Case Report.

Invaginated teeth present technical difficulties in clinical management because of their abnormal anatomic configuration. Endodontic clinical management of type III dens invaginatus can be greatly enhanced by newer techniques and materials such as cone-beam computed tomography (CBCT), mineral trioxide aggregate, and platelet-rich fibrin. This case report presents a 13-year-old male patient with type III dens invaginatus (DI) in left mandibular second premolar with history of recurrent swelling. Pulp testing revealed no response with the tooth. Dens invaginatus type III with an immature apex and periapical lesion was seen on radiograph. The case was diagnosed as Oehlers type III DI with pulp necrosis and chronic apical abscess. The treatment was planned and performed by using CBCT imaging. CBCT was performed to see the canal anatomy and to know the size of periapical lesion. Root canal treatment was completed in 2 visits. Calcium hydroxide dressing was placed in the first visit. In the second visit MTA was used for apexification in the main canal, and warm vertical compaction technique with gutta-percha was used in the invaginated canal. At the 2-year reevaluation, the patient was asymptomatic, and his tooth had remained functional since the treatment was completed. Radiographic assessment of the tooth showed significant osseous healing of the preoperative lesion. Three-dimensional imaging is a valuable tool for endodontic management of teeth with complex internal anatomy.

Characterization of short root anomaly in a Mexican cohort--hereditary idiopathic root malformation.

OBJECTIVE: The purpose of this study was to systematically characterize individuals with short root anomaly (SRA) without any history of orthodontic treatment. The long-term objective of the study was to improve diagnosis and treatment planning and determine risk factors for developing SRA. SETTING AND SAMPLE POPULATION: Twenty-seven patients including two families and 16 unrelated individuals from (9-48 years) reported to orthodontic and/or dental practitioners within the USA. MATERIALS AND METHODS: Digital panoramic and periapical films were analyzed to document pattern and frequency of SRA-affected teeth. Crown-to-root (CR) ratios of the affected teeth were used to characterize the extent of malformation. Pedigree analysis by inspection was completed for one family to determine pattern of inheritance. RESULTS: Twenty-six of the twenty-seven individuals were of Latino descent, and one was of Filipino descent. Hard tissues including enamel, dentin, pulp chambers and canals, and surrounding soft tissues were normal. We found that 25 of 27 individuals had localized SRA and two Latino individuals had generalized SRA. Teeth were affected bilaterally with maxillary central incisors (~63%) and mandibular second premolars most commonly involved (~33%). Affected teeth had a distinct, similar radiographic appearance; in the generalized cases, there was a more severe affection with larger (~twice) CR ratios. Ninety-four percent of affected individuals did not show a significant difference in the CR ratios at different ages. Pedigree analysis suggests an autosomal dominant inheritance pattern in one family. CONCLUSION: This is the first report to show that SRA occurs more frequently in Latino individuals and has a predilection for anterior teeth. The occurrence of SRA in two families further confirms a hereditary component and supports a distinct nosology and nomenclature, hereditary idiopathic root malformation (HIRM) and warrants further investigation.

Wntless regulates dentin apposition and root elongation in the mandibular molar.

Wnt signaling plays an essential role in the dental epithelium and mesenchyme during tooth morphogenesis. However, it remains unclear if Wnt ligands, produced from dental mesenchyme, are necessary for odontoblast differentiation and dentin formation. Here, we show that odontoblast-specific disruption of Wntless (Wls), a chaperon protein that regulates Wnt sorting and secretion, leads to severe defects in dentin formation and root elongation. Dentin thickness decreased remarkably and pulp chambers enlarged in the mandibular molars of OC-Cre;Wls(CO/CO) mice. Although the initial odontoblast differentiation was normal in the mutant crown, odontoblasts became cuboidal and dentin thickness was reduced. In immunohistochemistry, Wnt10a, ß-catenin, type I collagen, and dentin sialoprotein were significantly down-regulated in the odontoblasts of mutant crown. In addition, roots were short and root canals were widened. Cell proliferation was reduced in the developing root apex of mutant molars. Furthermore, Wnt10a and Axin2 expression was remarkably decreased in the odontoblasts of mutant roots. Deletion of the Wls gene in odontoblasts appears to reduce canonical Wnt activity, leading to inhibition of odontoblast maturation and root elongation.

In vitro analysis of extracted dens invaginatus using various radiographic imaging techniques.

AIM: Dens Invaginatus (DI) is a rare malformation of the teeth, showing a broad spectrum of morphologic variations. The aim of this study was to perform in vitro radiographic analyses of three extracted dens invaginatus (DI) teeth with complex root anatomy using plain radiographs, CBCT, MRI and micro CT techniques. MATERIALS AND METHODS: Study design: Three maxillary lateral incisors (A, B and C) from two patients were extracted due to poor prognosis and were radiographically analysed. Initially, conventional two dimensional digital radiographs were taken. Subsequently CBCT, micro CT and MRI analyses were performed. RESULTS: According to the Schulze and Brand system of classification, teeth A, B and C were classified as A2, B3 and B2 respectively. To detect the relationship between the invagination to the oral cavity and pulp chamber, conventional two dimensional radiographs were of no help. CBCT and MRI images were found to be complementary to each other but provided lesser structural detail than micro CT images. CONCLUSION: Reporting on these three DI teeth, normal conventional radiographs did not provide detailed structural information about the malformation due to geometric distortion and lack of information. Even though Oehlers classification system is the most widely used, classification by Schulze and Brand is more applicable in rare and deviant teeth.

An idiosyncratic post-traumatic tetrad: compound odontome, dentigerous cyst, impaction, and double-dilaceration.

OBJECTIVE: This report describes the case of a 13-year-old patient who experienced traumatic intrusion of the primary maxillary right central incisor and subsequently suffered an atypical tetrad, comprising of an unerupted compound odontoma associated with a dentigerous cyst, and an impacted, doubly dilacerated permanent maxillary right central incisor; however, the high interconnectivity of the occurrence of four pathologies together is unusual has not previously been reported. SUMMARY: The pathologies were detected 7 years after trauma; surgical removal of odontome along with the dentigerous cyst was performed, followed by orthodontic extrusion of the impacted double-dilacerated permanent central incisor. The 18-month follow-up shows no pathology, no gingival recession, and normal probing depth.

Concrescence: assessment of case by periapical radiography, cone beam computed tomography and micro-computed tomography.

The aim of this article was to describe imaging aspects of concrescence analyzed by three imaging modalities. A second molar joined together with a third molar was imaged using digital periapical radiography, cone beam computed tomography (CBCT) and micro-computed tomography (Micro-CT). On periapical radiograph, the mesial root of the third molar is superimposed on the distal root of the second molar. On CBCT images, a large cementum union between bulbous roots was detected, confirming the diagnosis of concrescence. On micro-CT images, the cementum union appeared limited to the apical third of the roots. In conclusion, both computed tomography modalities allowed for the diagnosis of concrescence. However, only micro-CT provided the real extension of the cementum union.

Giant canine with dentine anomalies in oculo-facio-cardio-dental syndrome.

Radiculomegaly affecting incisors, canines or premolars is a rare radiological finding (Maden et al., 2010) but is pathognomomic of a rare x-linked dominant syndrome called oculo-facio-cardio-dental syndrome (OFCDS). As this syndrome includes cardiac malformations and can lead to blindness due to congenital glaucoma, oral and maxillofacial surgeons should be aware of the somatic anomalies potentially associated with radiculomegaly. We report a typical case of OFCDS and provide the first description of the microscopic dental anomalies associated with this syndrome.

Apicificação com plug apical de MTA em dente traumatizado / Apexification with MTA apical plug in traumatized tooth

O tratamento de dentes jovens traumatizados requer atenção especial devido à presença de ápice aberto e paredes dentinárias finas, inviabilizando um tratamento endodôntico convencional. Para tanto, é necessária a realização de um procedimento para induzir a formação de uma barreira mineralizada com o auxílio de materiais biocompatíveis, como o hidróxido de cálcio e o agregado trióxido mineral (MTA). O objetivo deste trabalho é relatar um caso clínico no qual se optou por realizar a apicificação com hidróxido de cálcio, durante dez meses, e após confirmação da existência de uma barreira, realizou-se a obturação com plug apical de MTA e guta percha. A apicificação é uma técnica que apresenta alto índice de sucesso, sendo assim consagrada para o processo de rizogênese incompleta.

The treatment of traumatized young teeth requires special attention due to the presence of open apex and thin dentine walls, preventing conventional endodontic treatment. Therefore, it is necessary perform a procedure to induce formation of mineralized barrier with the aid of a biocompatible materials such as calcium hydroxide and mineral trioxide aggregate (MTA). The aim of this study is report a case wich it was decided to perform apexification with calcium hydroxide for ten months, and after confirmation of the existence a barrier, held filling with apical plug of MTA and gutta percha. The apexification is a technique of high success rate, so devoted to the process of incomplete root formation.

Apicotomy: surgical management of maxillary dilacerated or ankylosed canines.

This clinical article reports a technique, apicotomy, for managing dilacerated or ankylosed canines. The records of 3 patients successfully treated with apicotomy are presented. Orthodontists observe clinically significant incidences of impacted maxillary canines in their daily practices. Several procedures have been described to bring an ankylosed, impacted tooth into occlusion. Luxation is the most widely used solution, but there are risks involved with that approach, and the success rate is low. Surgical repositioning has also been used, but morbidity is high, and the aggressiveness of the procedure might also contraindicate it. Ankylosis might be related to the anatomic position of the canine's root apex and its adjacent anatomic structures. Apicotomy is a guided fracture of a canine root apex, followed by its orthodontic traction. It is a conservative surgical alternative for treating impacted canines with dilacerations or apical root ankylosis.

Non-surgical endodontic treatment for dens invaginatus type III using cone beam computed tomography and dental operating microscope: a case report.

Dens invaginatus is a morphological abnormality of the tooth in which the coronal tooth enamel and dentin fold inwards towards the pulp cavity. Dens invaginatus type III (Oehlers: 1957) is characterized by infolding of the enamel and dentin as far as the root apex. This report describes a case of surgical and non-surgical endodontic therapy for a maxillary lateral incisor with type III dens invaginatus, necrotic pulp, and an associated large periradicular lesion. The patient was a 16-year-old man. Periapical radiographs suggested the presence of an untreated area of invagination. Cone beam computed tomography (CBCT) was then used for three-dimensional observation of the morphological details of this area. The CBCT scans revealed invagination and its relationship with the pulp chamber. A dental operating microscope was used to access two primary root canals and the area of invagination. The root canals were then localized, negotiated, enlarged, and filled with calcium hydroxide. Two months later, the canal and invagination were obturated with core-based gutta-percha (FlexPoint Neo: FP core-carrier technique) and restored. Cone beam computed tomography and microscopic techniques allow even complicated cases of dens invaginatus to be diagnosed and treated using non-surgical root canal management.

Mandibular first premolar with four canals.

A case of endodontic treatment of a mandibular first premolar exhibiting a total of four distinct root canals and four apical foramina is described. This occurrence in mandibular first premolar has rarely been reported in the endodontic literature. Endodontic treatment that considers the anatomic variation of root canal morphology is important to ensure a favorable healing outcome, and its identification could be enhanced by careful examination using a dental operating microscope. Obturation of root canals using a warm vertical compaction technique with a highly-radiopaque root canal sealer, such as AH Plus, after careful ultrasonic activated irrigation with ethylenediaminetetraacetic acid might allow the flow of sealer into the narrowed but unprepared part of the canal. This offers valuable adjuncts for the successful negotiation of calcified main canals, thereby facilitating optimum chemo-mechanical debridement of the root canal system.

Open apex type III dens invaginatus: a rare case report of an endodontic retreatment with an anatomical redesign.

Dens invaginatus is a critical condition for endodontic treatment. It frequently presents a complex internal anatomy and might be associated with incomplete root and apical development. This article presents one of the few reported cases of endodontic retreatment of Type III dens invaginatus. First, the internal anatomy was modified using burs under an operating microscope. Next, conventional chemical and mechanical preparation with hand files and 2.5% sodium hypochlorite was performed. Finally, an intracanal dressing with calcium hydroxide was used for nine months, at which point the anatomical features in the root canal system could be accessed. Adequate periradicular healing was observed and regression of the lesion was noted at the two-year follow-up. This case reinforces the idea that knowledge about the biologic aspects of endodontics, combined with adherence to technical standards, is helpful in resolving complex cases.

Successful management of pulpo-periodontal lesion in maxillary lateral incisor with palatogingival groove using CBCT scan.

Palatogingival groove is a rare developmental anomaly involving the lingual surface of the maxillary incisor and resulting in severe endodontic and periodontal lesions. This case report describes a multidisciplinary approach for the combined management of the endodontic and periodontal problems for successful rehabilitation of the involved tooth. Cone-beam computed tomography (CBCT) helped in correct diagnosis of the lesion and hence enabled effective treatment.

Sellado del sistema de conductos en ápices de gran calibre apical: a propósito de dos casos / Root canal filling in large diameter ápex: two cases reports

El tratamiento de dientes con ápice de gran calibre y periodontitis apical crónica debe afrontarse clínicamente como un desafío. El sellado tridimensional y hermético del sistema de conductos, junto a una correcta limpieza y desinfección del mismo, en dientes con ausencia de un adecuado stop apical son objetivos fundamentales para conseguir el éxito a lar plazo en el tratamiento de estos dientes. En este artículo se presentan dos casos clínicos con ápices de gran calibre y periodontitis apical crónica, que fueron afrontados de distinta manera obteniéndose los mismos resultados a largo plazo (AU)

Root canal treatment n teeth with large diameter apex and apical periodontitis must be confronted clinically as a challenge. Three dimensional and hermetic filling as a cleaning and disinfection of the root canal system in teeth with absence of the apical constriction are essential aims to achieve the long-term success of treatment. In this article there are exposed two clinical case with large diameter apex and apical periodontitis with different clinical management and the same long-term outcome results (AU)