Endo treatment for taurodontium

[Anonymous]

CASE REPORT 2

A 53 year old male was referred to our department for the management of the right upper first molar. History revealed that the man was suffering from pain for the past six days before his visit to the hospital and the pain was spontaneous and aggravated at night which disturbed his sleep. His medical history was not contributory. On intra oral examination, a deep carious lesion was found on the disto-occlusal surface of the right upper first molar. The tooth was subjected to routine clinical tests and a provisional diagnosis of acute irreversible pulpitis was made. Radiographic examination revealed an abnormal root anatomy as in the previous instance – case report 1 [Figure – 6]. The radiographs of the other quadrants of upper and lower first molars could not be compared as these teeth were extracted earlier.

Endodontic management

Access was gained to the pulp chamber after local anaesthesia under rubber dam isolation and enlarged to involve the entire pulp chamber [Figure – 7]. In this case too, a huge pulp chamber was encountered, which bifurcated into two divisions at the apical one-third of the root. Pulp was extirpated using of 2.5% sodium hypochlorite and IT­ files. Bio-mechanical preparation of the pulp chamber was achieved by circumferential filing with ISO K-files till the apical divisions. The apical divisions were almost near the apex, to about 3mm and they were separately cleaned and shaped using Pro-Taper files after initial preparation with hand files till ISO size 30 size. Sodium hypochlorite irrigation was restricted for initial pulp removal after which, ultrasonic irrigation was done with saline to make sure, that no pulp tissue was left behind. In this case, obturation was completed with then no plasticized gutta-percha (then nafil) technique as the apical for aminahad distinct apical stops [Figure – 8].

Discussion

Taurodontism refers to a condition in which the pulp chamber is widened apico-occlusally and thus, the farcations are positioned more apically than nonnal[1]. The incidence of taurodontism is variable, depending on the different series and groups studied. It is lower than 1 in modem man. Several reports have been published in which taurodontism appears as a part of various syndromes. Ackerman and associates believed that tooth root morphology is primarily determined genetically but that it may be environmentally modified. In both the patients discussed above, systemic disturbances or malformations could not be identified and hence considered to be of non syndromec taurodontism. An inheritable aetiology could not be elicited as the families of the patients were not available for examination.

The teeth most frequently affected are the molars, although it can be occasionally seen in premolar and incisors and are mostly diagnosed by radiographic study. Endodontic treatment in taurodont teeth has been described as complex and difficult. Durr et al suggested that the morphology could hamper the location of the orifices, thus creating difficulty in instrumentation and obturation. The number of root canals varied in each case. Since the pulpal chamber was huge in both the cases, mechanical debridement and shaping was achieved with circumferential filing using “K” files of standard ISO size and taper. Sodium hypochlorite irrigation was limited to the initial use as the apical foramina were wide open and as a precautionary measure to avoid a hypochlorite accident. In the first case custom made gutta-percha (roll-cone technique) was used, as the main pulp chamber was huge and large wide apical foramina were present. This technique allows good apical control and adapts well to the canal configuration. Thermo plasticized gutta-percha was used in the second case as distinct apical stops were present and not like the previous case where the use of it could have caused an apical extrusion.

The remaining dentin thickness of these roots is less, leading to chances of root fracture, which is very high in such cases. Hence it was decided to reinforce the root canal walls, by using light curing composite resin. Intra radicular rehabilitation with light cured composite resin using clear light transmitting post was therefore used. Layered adhesion technique was used as it allows incremental composite build up inside the root canal. Aco responding size fibre reinforced resin post was used in the post space left by the light transmitting post and a monoblock effect was created which has the advantage of good stress distribution.

The patients were reviewed after three months and were found to be asymptomatic. They were referred to the Department of Prosthodontia, for further management.

Summary

Though taurodontism is of rare occurrence, the clinician should be aware of the complex canal system for its successful endodontic management.