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An endodontic failure caused by an unusual anatomical anomaly
JOURNAL OF ENDODONTICS [ VOL 3, NO 9, SEPTEMBER 1977
AN ENDODONTIC FAILURE CAUSED BY AN UNUSUAL ANATOMICAL ANOMALY
M. D. Peikoff, DM'D, MScD, and J. R. Trott, MDS, Winnipeq, Canada
Anatomical anomalies in the number, size, shape, direction, and distribution of root canals are an everyday occurrence to the endodontist. These anomalies can be responsible either directly or indirectly for endodontic failure. Failures in endodontic treatment can be due to many and various reasons, some more obvious than others. Excluding the more commonplace reasons for failure, Simon, Glick, and F r a n k 1 described a condition whereby a groove in the central fossa of maxillary central and lateral incisors extended through the cingulum area and continued apically for varying distances, in some cases to the apex. They drew attention to this type of anomaly particularly as a predictable failure in a joint endodontic-periodontic enterprise. This paper is a report of a case in which failure was due to a similar anomaly. W e have speculated on the cause of failure in this case because it was different in some aspects from those reported previously.
Report of Case The patient was a 28-year-old woman who came to our office in F e b r u a r y 1970 because of a recent swelling in the labial gingival sulcus corresponding to the maxillary left lateral incisor. The swelling had decreased in the past month and a draining sinus tract had developed on the labial gingiva in the affected area.
356
Clinically, the tooth was slightly discolored, but contained no caries or restorations. There was no history of trauma to any teeth in this region. The lingual surface of the crown demonstrated a rather deep groove extending over the cingulum and subgingivally from there. On probing, the gingival sutcus was intact and showed no pocket nor was there any localized inflammation. Radiographic examination showed that the tooth had a normal-appearing root and root canal. However, in the middle third of the root on the distal surface was a small spike-like accessory root coming off the main root at approximately a 45 ~ angle. It appeared as though the accessory root was composed of solid dentin with no root canal evident on the radiograph. A periapical radiolucent area about 5 to 6 m m was present around the apices of the two roots of this tooth (Fig 1A). Electric pulp tests and thermal tests indicated that the maxillary left lateral incisor had a necrotic pulp; the adjacent teeth all responded within normal limits. Examination of the soft tissue showed a red, edematous, soft swelling on the gingiva over the left lateral incisor with a draining sinus tract in the center. It was explained to the patient that nonsurgical endodontic therapy would be performed first, but that the possibility of surgical intervention would be
distinct if any difficulties were encountered in sealing the canal in the unusual accessory root. The patient returned for treatment, at which time the tooth was isolated and opened, and access was made. The main canal was explored with a no. 15 file with a curve in its apical 2 m m to determine if the second canal could be located. After considerable probing, the opening to the canal in the accessory root could not be found. The main canal was irrigated, dried, medicated with a cotton pellet with camphorated parachlorophenol ( C P C ) , and sealed with Cavit. A t the next visit, the canal in the accessory root could still not be located, so cleaning and shaping of the main canal were completed. It was noted at this time that an excessive amount of serous exudate was continuously leaking into the canal. Complete drying of the canal after instrumentation was not possible; the canal again was closed with CPC on a cotton pellet and Cavit. One more additional treatment was performed whereby the canal was recleaned, reirrigated, dried with paper points, and closed once again with CPC and Cavit. Persistent "weeping" was still present. On the basis of the clinical assumption that the canals could not be adequately cleaned, presumably due to the extra root or to a persistent infection, it was decided to fill the canals at that visit and to perform periapical surgery at a subse-
JOURNAL OF ENDODONTICS ] VOL 3, NO 9, SEPTEMBER 1977
quent visit. A n excess amount of sealer was used during the filling procedure in an attempt to seal any irregularities in the root canal system that had not been cleaned. This also accounted for some excess sealer in the periapical tissues; this was of no concern because of the contemplated surgery. It should also be noted that the canal in the accessory root was, in fact, patent because root canal cement was forced through it during the packing procedure (Fig 1B). It was decided to observe the case for a year in the event the healing might occur from nonsurgical treatment alone. In March 1971, the patient returned for examination at which time the radiograph showed a distinct decrease in the size of the periapical radiolucent area but healing was still incomplete (Fig 1C). Also, visual examination showed the presence of a small but persistent draining sinus tract on the labial gingiva. In June, an apical curettage with apicoectomy of the main root and apicoectomy and an apical amalgam seal of the accessory root were performed (Fig 1D). Postoperative healing appeared to be uncomplicated. In June 1972, the patient returned for reexamination. The radiolucent area around the main canal was completely healed but a radiolucent area was still present around the accessory root (Fig 1E). The small persistent draining sinus tract had recurred after surgery. A t this time, it was believed that everything possible that could be done for this patient had been done. Extraction was recommended and the referring dentist was informed of this decision. The patient was never seen by us again but, in 1976, the referring dentist brought us the tooth in a bottle of Formalin along with a radiograph that he had taken just before extraction (Fig. I F ) . Apparently the clinical
A
D
B
C
E
F
Fig l - - A , Two roots and periapical radiolucent area in maxillary lateral incisor before treatment. B, Excess sealer at apex o/main root and sealer passing into accessory root. C, Reduction in size o/periapical area but healing is incomplete. D, Appearance after apicoectomy and curettage of main root and resection o/accessory root and apical amalgam seal. E, Good resolution o/radiolucency around main root but area persists adjacent to apical amalgam seal after a year. F, Persistent radiolucent area adjacent to apical amalgam seal after/our years and before extraction.
signs, including the persistent draining sinus tract, had remained much the same during the four years since our last examination. Grossly, the tooth appeared like any other lateral incisor with the exception that on the distal portion of the root, starting from the cingulum on the lingual aspect, was the beginning of formation of another root ( F i g 2). The accessory root was separated from the main root by a deep groove starting on the cingulum and proceeding two thirds of the way down the lingual surface. A t that
point, it then crossed over the distal surface and ended on the labial surface in about the middle third of the root 4 to 5 m m apical to the cementoenamel junction. The small apical amalgam could be seen at the end of the distal root (Fig 3). Discussion This case illustrates a number of interesting clinical, anatomical, and pathological points. The initial treatment plan recognized the existence of an accessory root and, during the early phases of
857
JOURNAL OF ENDODONTICS [ VOL 3, NO 9, SEPTEMBER 1977
Fig 2---Lingual view o/maxillary le[t lateral incisor showing de/ect running [rom cingulum to two thirds o] way to apex. Notice apical amalgam seal at apex o[ accessory root.
treatment, the persistent weeping was attributed to the impossibility of finding the canal in the accessory root and filling it adequately. Therefore, as a result of the moisture, the main canal was unintentionally overfilled. Also, cement appeared to pass most of the way up the canal in the accessory root. In spite of a less than desirable root canal filling, considerable resolution of the periapical radiolucent area did occur before we resorted to surgery. However, because of the persistent draining sinus tract, and the residual radiolucent area around the accessory root a year after the completion of nonsurgical treatment, it was presumed that the failure at this stage was associated with an inadequate debridement and sealing of the canal in the accessory root. A t the time o f
358
Fig 3--Distal view of maxillary le/t lateral incisor showing de/ect running [rom lingual to buccal aspect.
Fig 4--Decalci/ied cross section o] root showing through-and-through nature o/de/ect (H&E, orig mag x25).
surgery, the groove from the lingual root surface to the buccal surface was seen as the furcation separating the two roots. A year after surgery, the labial sinus tract was still present as was a radiolucent area around the area where the accessory root had been removed. At the time extraction was recommended, it appeared that there were three possibilities for the f a i l u r e - first, a persistent infection around the accessory root stump; second, a vertical root fracture; and third, a periodontal pocket associated with the anomaly as described by Simon, Glick, and Frank. 1 None of these possibilities appeared to be treatable. Decalcified cross sections were taken of the root at all levels. Histologically, there had been a complete failure of formation of the root to fuse along the line of the defect that appeared harmless, clinically. Therefore, there was a soft tissue connec-
tion between the pulp and the periodontal tissues for the entire length of the defect. Histologic specimens showed acellular cementum entering the area of the groove and proceeding to varying distances toward the pulp chamber (Fig 4). In some sections, the cementum was within 40/z to 50/~ of the pulp chamber while, in others, it barely entered into the defect. There is no doubt histologically that there has been a complete absence of first enamel-dentin and then cementumdentin along the length of the defect. While Simon, Glick, and Frank 1 correctly drew attention to this type of radicular anomaly and its periodontal-endodontic diagnostic and treatment problems, they did not show any histologie evidence for their cases that failed. Thus it is possible that there may be a gamut of defects ranging from a groove running from the cingulum apically along the root for varying distances to a complete lack of closure of the calcified tissues al-
JOURNAL OF ENDODONTICS I VOL 3, NO 9, SEPTEMBER 1977
lowing for a direct soft tissue connection between the pulp and the periodontium. The main diagnostic problem in the case presented was the complete lack of any coronal or gingival pathosis that would lead one to suspect the enormity of the defect that was actually present. Thus one must speculate on the cause or causes of failure. There is probably little doubt that the pulp became infected via the lingual-gingivalcervical area. Although at no time was there an apparent clinical break in the form of a pocket at this area, there was probably an ingress of either toxins or bacteria sufficient to cause complete pulpal necrosis and the formation, at a later stage, of a purulent exudate. The exudate tracked labially from the area of the linguolabial groove through to the labial tissues and formed a draining sinus tract.
With such an extensive pulpal-periodontal connection extending as it did two thirds of the way along the lingual surface and across onto the labial surface, total removal of the necrotic debris was impossible and no permanent seal could be obtained for resolution of the inflammatory response that occurs in most situations. It is virtually impossible to ascertain from the radiograph the extent of such a defect in its entirety and, even if this were possible, there is no sure method of forecasting whether it is a total defect from the pulp to the periodontal tissues, as it was in this instance. There is no known effective way of treating such a defect.
root was treated endodonticaUy; both nonsurgical and surgical treatments failed. The tooth was extracted, decalcified, and sectioned. Histologic examination showed an anatomical defect in the groove between the roots that allowed for communication of the pulp and periodontal tissues, thus accounting for the failure. Drs. Peikoff and Trott are on the facul'ty of dentistry, departments of rehabilitative dental science and oral biology, University of Manitoba. Requests for reprints should be directed to Dr. M. D. Peikoff, Faculty of Dentistry, Department of Rehabilitative Dental Sciences, University of Manitoba, Winnipeg, Canada, R3E 0W3. Reference
Summary A case report is presented whereby a maxillary lateral incisor with a radiographicaUy demonstrable accessory
1. Simon, J.H., Glick, D.H., and Frank, A.L. Predictable endodontic and periodontic failures as a result of radicular anomalies. Oral Surg 37:823 June 1971.
359
AN ENDODONTIC FAILURE CAUSED BY AN UNUSUAL ANATOMICAL ANOMALY
M. D. Peikoff, DM'D, MScD, and J. R. Trott, MDS, Winnipeq, Canada
Anatomical anomalies in the number, size, shape, direction, and distribution of root canals are an everyday occurrence to the endodontist. These anomalies can be responsible either directly or indirectly for endodontic failure. Failures in endodontic treatment can be due to many and various reasons, some more obvious than others. Excluding the more commonplace reasons for failure, Simon, Glick, and F r a n k 1 described a condition whereby a groove in the central fossa of maxillary central and lateral incisors extended through the cingulum area and continued apically for varying distances, in some cases to the apex. They drew attention to this type of anomaly particularly as a predictable failure in a joint endodontic-periodontic enterprise. This paper is a report of a case in which failure was due to a similar anomaly. W e have speculated on the cause of failure in this case because it was different in some aspects from those reported previously.
Report of Case The patient was a 28-year-old woman who came to our office in F e b r u a r y 1970 because of a recent swelling in the labial gingival sulcus corresponding to the maxillary left lateral incisor. The swelling had decreased in the past month and a draining sinus tract had developed on the labial gingiva in the affected area.
356
Clinically, the tooth was slightly discolored, but contained no caries or restorations. There was no history of trauma to any teeth in this region. The lingual surface of the crown demonstrated a rather deep groove extending over the cingulum and subgingivally from there. On probing, the gingival sutcus was intact and showed no pocket nor was there any localized inflammation. Radiographic examination showed that the tooth had a normal-appearing root and root canal. However, in the middle third of the root on the distal surface was a small spike-like accessory root coming off the main root at approximately a 45 ~ angle. It appeared as though the accessory root was composed of solid dentin with no root canal evident on the radiograph. A periapical radiolucent area about 5 to 6 m m was present around the apices of the two roots of this tooth (Fig 1A). Electric pulp tests and thermal tests indicated that the maxillary left lateral incisor had a necrotic pulp; the adjacent teeth all responded within normal limits. Examination of the soft tissue showed a red, edematous, soft swelling on the gingiva over the left lateral incisor with a draining sinus tract in the center. It was explained to the patient that nonsurgical endodontic therapy would be performed first, but that the possibility of surgical intervention would be
distinct if any difficulties were encountered in sealing the canal in the unusual accessory root. The patient returned for treatment, at which time the tooth was isolated and opened, and access was made. The main canal was explored with a no. 15 file with a curve in its apical 2 m m to determine if the second canal could be located. After considerable probing, the opening to the canal in the accessory root could not be found. The main canal was irrigated, dried, medicated with a cotton pellet with camphorated parachlorophenol ( C P C ) , and sealed with Cavit. A t the next visit, the canal in the accessory root could still not be located, so cleaning and shaping of the main canal were completed. It was noted at this time that an excessive amount of serous exudate was continuously leaking into the canal. Complete drying of the canal after instrumentation was not possible; the canal again was closed with CPC on a cotton pellet and Cavit. One more additional treatment was performed whereby the canal was recleaned, reirrigated, dried with paper points, and closed once again with CPC and Cavit. Persistent "weeping" was still present. On the basis of the clinical assumption that the canals could not be adequately cleaned, presumably due to the extra root or to a persistent infection, it was decided to fill the canals at that visit and to perform periapical surgery at a subse-
JOURNAL OF ENDODONTICS ] VOL 3, NO 9, SEPTEMBER 1977
quent visit. A n excess amount of sealer was used during the filling procedure in an attempt to seal any irregularities in the root canal system that had not been cleaned. This also accounted for some excess sealer in the periapical tissues; this was of no concern because of the contemplated surgery. It should also be noted that the canal in the accessory root was, in fact, patent because root canal cement was forced through it during the packing procedure (Fig 1B). It was decided to observe the case for a year in the event the healing might occur from nonsurgical treatment alone. In March 1971, the patient returned for examination at which time the radiograph showed a distinct decrease in the size of the periapical radiolucent area but healing was still incomplete (Fig 1C). Also, visual examination showed the presence of a small but persistent draining sinus tract on the labial gingiva. In June, an apical curettage with apicoectomy of the main root and apicoectomy and an apical amalgam seal of the accessory root were performed (Fig 1D). Postoperative healing appeared to be uncomplicated. In June 1972, the patient returned for reexamination. The radiolucent area around the main canal was completely healed but a radiolucent area was still present around the accessory root (Fig 1E). The small persistent draining sinus tract had recurred after surgery. A t this time, it was believed that everything possible that could be done for this patient had been done. Extraction was recommended and the referring dentist was informed of this decision. The patient was never seen by us again but, in 1976, the referring dentist brought us the tooth in a bottle of Formalin along with a radiograph that he had taken just before extraction (Fig. I F ) . Apparently the clinical
A
D
B
C
E
F
Fig l - - A , Two roots and periapical radiolucent area in maxillary lateral incisor before treatment. B, Excess sealer at apex o/main root and sealer passing into accessory root. C, Reduction in size o/periapical area but healing is incomplete. D, Appearance after apicoectomy and curettage of main root and resection o/accessory root and apical amalgam seal. E, Good resolution o/radiolucency around main root but area persists adjacent to apical amalgam seal after a year. F, Persistent radiolucent area adjacent to apical amalgam seal after/our years and before extraction.
signs, including the persistent draining sinus tract, had remained much the same during the four years since our last examination. Grossly, the tooth appeared like any other lateral incisor with the exception that on the distal portion of the root, starting from the cingulum on the lingual aspect, was the beginning of formation of another root ( F i g 2). The accessory root was separated from the main root by a deep groove starting on the cingulum and proceeding two thirds of the way down the lingual surface. A t that
point, it then crossed over the distal surface and ended on the labial surface in about the middle third of the root 4 to 5 m m apical to the cementoenamel junction. The small apical amalgam could be seen at the end of the distal root (Fig 3). Discussion This case illustrates a number of interesting clinical, anatomical, and pathological points. The initial treatment plan recognized the existence of an accessory root and, during the early phases of
857
JOURNAL OF ENDODONTICS [ VOL 3, NO 9, SEPTEMBER 1977
Fig 2---Lingual view o/maxillary le[t lateral incisor showing de/ect running [rom cingulum to two thirds o] way to apex. Notice apical amalgam seal at apex o[ accessory root.
treatment, the persistent weeping was attributed to the impossibility of finding the canal in the accessory root and filling it adequately. Therefore, as a result of the moisture, the main canal was unintentionally overfilled. Also, cement appeared to pass most of the way up the canal in the accessory root. In spite of a less than desirable root canal filling, considerable resolution of the periapical radiolucent area did occur before we resorted to surgery. However, because of the persistent draining sinus tract, and the residual radiolucent area around the accessory root a year after the completion of nonsurgical treatment, it was presumed that the failure at this stage was associated with an inadequate debridement and sealing of the canal in the accessory root. A t the time o f
358
Fig 3--Distal view of maxillary le/t lateral incisor showing de/ect running [rom lingual to buccal aspect.
Fig 4--Decalci/ied cross section o] root showing through-and-through nature o/de/ect (H&E, orig mag x25).
surgery, the groove from the lingual root surface to the buccal surface was seen as the furcation separating the two roots. A year after surgery, the labial sinus tract was still present as was a radiolucent area around the area where the accessory root had been removed. At the time extraction was recommended, it appeared that there were three possibilities for the f a i l u r e - first, a persistent infection around the accessory root stump; second, a vertical root fracture; and third, a periodontal pocket associated with the anomaly as described by Simon, Glick, and Frank. 1 None of these possibilities appeared to be treatable. Decalcified cross sections were taken of the root at all levels. Histologically, there had been a complete failure of formation of the root to fuse along the line of the defect that appeared harmless, clinically. Therefore, there was a soft tissue connec-
tion between the pulp and the periodontal tissues for the entire length of the defect. Histologic specimens showed acellular cementum entering the area of the groove and proceeding to varying distances toward the pulp chamber (Fig 4). In some sections, the cementum was within 40/z to 50/~ of the pulp chamber while, in others, it barely entered into the defect. There is no doubt histologically that there has been a complete absence of first enamel-dentin and then cementumdentin along the length of the defect. While Simon, Glick, and Frank 1 correctly drew attention to this type of radicular anomaly and its periodontal-endodontic diagnostic and treatment problems, they did not show any histologie evidence for their cases that failed. Thus it is possible that there may be a gamut of defects ranging from a groove running from the cingulum apically along the root for varying distances to a complete lack of closure of the calcified tissues al-
JOURNAL OF ENDODONTICS I VOL 3, NO 9, SEPTEMBER 1977
lowing for a direct soft tissue connection between the pulp and the periodontium. The main diagnostic problem in the case presented was the complete lack of any coronal or gingival pathosis that would lead one to suspect the enormity of the defect that was actually present. Thus one must speculate on the cause or causes of failure. There is probably little doubt that the pulp became infected via the lingual-gingivalcervical area. Although at no time was there an apparent clinical break in the form of a pocket at this area, there was probably an ingress of either toxins or bacteria sufficient to cause complete pulpal necrosis and the formation, at a later stage, of a purulent exudate. The exudate tracked labially from the area of the linguolabial groove through to the labial tissues and formed a draining sinus tract.
With such an extensive pulpal-periodontal connection extending as it did two thirds of the way along the lingual surface and across onto the labial surface, total removal of the necrotic debris was impossible and no permanent seal could be obtained for resolution of the inflammatory response that occurs in most situations. It is virtually impossible to ascertain from the radiograph the extent of such a defect in its entirety and, even if this were possible, there is no sure method of forecasting whether it is a total defect from the pulp to the periodontal tissues, as it was in this instance. There is no known effective way of treating such a defect.
root was treated endodonticaUy; both nonsurgical and surgical treatments failed. The tooth was extracted, decalcified, and sectioned. Histologic examination showed an anatomical defect in the groove between the roots that allowed for communication of the pulp and periodontal tissues, thus accounting for the failure. Drs. Peikoff and Trott are on the facul'ty of dentistry, departments of rehabilitative dental science and oral biology, University of Manitoba. Requests for reprints should be directed to Dr. M. D. Peikoff, Faculty of Dentistry, Department of Rehabilitative Dental Sciences, University of Manitoba, Winnipeg, Canada, R3E 0W3. Reference
Summary A case report is presented whereby a maxillary lateral incisor with a radiographicaUy demonstrable accessory
1. Simon, J.H., Glick, D.H., and Frank, A.L. Predictable endodontic and periodontic failures as a result of radicular anomalies. Oral Surg 37:823 June 1971.
359