Endo treatment for taurodontium

[Anonymous]

Taurodontism has been recognized as a clinical entity for almost a century. It is a dental anomaly characterised by enlargement of the pulp chamber, which may approximate of the root apex, with the body of the tooth enlarged at the expense of the roots and apically displaced furcation areas . The bifurcation or bifurcation may be only a few millimeters above the apices of the roots. It was first described by Gorjanovic – Kramberger (1908) in a 70,000 year old pre-neanderthal fossil, discovered in Kaprina, Croatia. This term taurodontism was however first stated by Sir Arthur Keith in 1913. The origin of this term is from Greek “tauros” which means “Bull” and “odontos” which means “Tooth”. Witkop  defined tamodontism as follows, “taurodont teeth have pulp chambers in which the bifurcation or bifurcation is displaced apically, so that the chamber has a greater apico-occlusal height than in normal teeth and lacks a constriction at the level of the cemento-enameljunction”.

Recent literature contains reports of tamodontism as an isolated oddity a family trait with high frequency in Eskimos . Taurodontism was initially thought to be absent in modern populations, at least in the extreme forms. However there are an increasing number of reports of taurodontism in present-day man in permanent dentition, deciduous dentition or both concurrently . It seems taurodontism is a great deal more prevalent than it was previously thought Scow and Lai  found that 38.4% of 66 patients with hypodontia had atleast one mandibular first permanent molar that showed taurodontism compared with only 7.5% of a control group without hypodontia Shifman and Bucher reported that in one case, eight teeth were tamodonts,of which four were molar teeth. They stated that the majority of the affected teeth occurred singly and the mandibular second molar was the tooth most frequently involved. Sert and Byrili reported one patient with six taurodont molar teeth. It is more common in molars; although it occurs occasionally in premolars and incisors. A study by Axel Ruprecht in 1987 in the Saudi Arabian population found an incidence of 11.3%.

The unusual nature of this condition is best visualized on the radiograph. No involved teeth were frequently found to be rectangular in shape, rather than tapering towards the roots. Taurodontism, although not common, is an important finding that may influence the treatment of those teeth, particularly their endodontic management

        

[drsushant]

Abstract
Taurodontism is a morpho-anatomical change in the shape of the tooth in which the body of the tooth is enlarged and the roots are reduced in size. Although taurodontism is a dental rarity, this unusual radicular form should merit circumspect considerations in planning and treatment. Endodontic management in taurodont teeth has been described as complex and difficult. The present paper describes the successful completion of endodontic treatment in three taurodontic teeth with appropriate use of instruments and techniques and also emphasizes the need for post endodontic rehabilitation.

Introduction

Taurodontism has been recognized as a clinical entity for almost a century. It is a dental anomaly characterised by enlargement of the pulp chamber, which may approximate of the root apex, with the body of the tooth enlarged at the expense of the roots and apically displaced furcation areas. The bifurcation or bifurcation may be only a few millimeters above the apices of the roots. It was first described by Gorjanovic – Kramberger (1908) in a 70,000 year old pre-neanderthal fossil, discovered in Kaprina, Croatia. This term taurodontism was however first stated by Sir Arthur Keith in 1913. The origin of this term is from Greek “tauros” which means “Bull” and “odontos” which means “Tooth”. Witkop defined tamodontism as follows, “taurodont teeth have pulp chambers in which the bifurcation or bifurcation is displaced apically, so that the chamber has a greater apico-occlusal height than in normal teeth and lacks a constriction at the level of the cemento-enameljunction”.

Recent literature contains reports of tamodontism as an isolated oddity a family trait with high frequency in Eskimos. Taurodontism was initially thought to be absent in modern populations, at least in the extreme forms. However there are an increasing number of reports of taurodontism in present-day man in permanent dentition, deciduous dentition or both concurrently. It seems taurodontism is a great deal more prevalent than it was previously thought Scow and Lai found that 38.4% of 66 patients with hypodontia had atleast one mandibular first permanent molar that showed taurodontism compared with only 7.5% of a control group without hypodontia Shifman and Bucher reported that in one case, eight teeth were tamodonts,of which four were molar teeth. They stated that the majority of the affected teeth occurred singly and the mandibular second molar was the tooth most frequently involved. Sert and Byrili reported one patient with six taurodont molar teeth. It is more common in molars; although it occurs occasionally in premolars and incisors. A study by Axel Ruprecht in 1987 in the Saudi Arabian population found an incidence of 11.3%.

The unusual nature of this condition is best visualized on the radiograph. No involved teeth were frequently found to be rectangular in shape, rather than tapering towards the roots. Taurodontism, although not common, is an important finding that may influence the treatment of those teeth, particularly their endodontic management This paper highlights the importance of different aspects in the endodontic management of taurodontic teeth and in their final post endodonticre habilitation.

Aetiology and pathogenesis

Theories regarding the aetiology of taurodontism have been many. It has been suggested that the anomaly represents a primitive pattern, a mutation, a specialized or retrograde character, an atavistic feature, an X-linked trait, familial or an autosomal dominant trait

Taurodontism appears most frequently as an isolated anomaly, but it has also been found to occur as apart of several well known syndromes due to alterations of sex chromosomes, such as Khnefelter’s syndrome­, Trisomy 21 or Down’s syndrome and certain diseases like hypophosphatasia.

The other less common entities, where taurodontic trait was observed and reported were Tricho-dento-osseous syndrome, Oto-dental syndrome, X­chromosome aneuploidy syndrome, XXX ­chromosome syndrome, XYY syndrome, Hereditary ectodermal dysplasia, Tricho-onchyo­dental syndrome orofacial digital It syndrome or Mohr syndrome, Amelo-onchyo-hypohidrotic syndrome, Hypohidrotic ectodermal dysplasia linked to the X-chromosome and a trait associated with systemic disturbances such as microcephalic dwarfism and certain dental anomalies such as agenesis or fusions, amelogenesis imperfecta and in dermatologic diseases.

Theories concerning the pathogenesis of taurodontic root formation are also varied: an unusual developmental pattern, a delay in the calcification of pulpal chamber, an odontoblastic deficiency, an alteration in Hertwig’s epithelial root sheath.

Classification

In 1928 Shaw classified sub-types of this condition as hypotaurodontism, mesotaurodontism and hypertaurodontism based on the relative displacement of the floor of the pulp chamber. This subjective, arbitrary classification led normal teeth to be misdiagnosed as taurodontism. In 1977, Feichfnger and Rossiwall stated that the distance from the bifurcation or bifurcation of the root to the cemento-enamel junction should be greater than the occluso-cervical distance for a taurodontic tooth. In 1978 Shifman and Chanannel proposed the following criteria for determining the presence or absence of tamodontism. Taurodontism is present, if the distance (a) from the lowest point (A) at the occlusal end ofthe pulp chamber to the highest point at the apical end of the chamber (B), divided by the distance (b) from the occlusal end of the pulp chamber to the apex (C) is 0.2mm or greater i.e. [A/b=0.2mm] and if the distance from the highest point of the pulp chamber floor to cemento-enamel junction is more than 2.5 mm. Though there are many classification systems to determine the severity of tamodontism, the one above proposed by Shifman and Chanannel is the widely used system till now.

        

[drsushant]

CASE REPORT

A 11 year old boy was referred for opinion and management of the first molars of maxillary arch. The patient complained of recurrent pain over the bilateral maxillary first molars for a period of 2 months. His medical history was not contributory. Radiographic examination revealed caries involving the pulp and also an abnormality in tooth anatomy was observed and hence the radiograph was repeated in two different angulations.

The findings were:

Unusually long pulp chamber which had no constriction at the cemento-enamel junction.
No distinct roots were found but large canal openings, ending at the apex were observed.

From these radiographic findings, the tooth was diagnosed to be a taurodont. The teeth were subjected to routine clinical tests and a diagnosis of acute irreversible pulpitis was made.

Endodontic Management of right upper first molar

The tooth was anaesthetized, the access opening was done under rubber dam isolation and the pulp tissues were extirpated using ‘H’ files of size 80. The pulp was voluminous and to ensure complete removal, 2.5% sodium hypochlorite was initially used as an irrigant to soften the pulp. Once the pulp was extirpated, further irrigation was done with normal saline and 0.2% chlorhexidine. The pulp chamber was huge and the floor of the chamber could not be visualised, which on further exploration revealed two divisions in the buccal and one in the palatal side with wide apical foramina [Figure – 1]. The huge pulp chamber walls were planed circumferentially using ‘K’ files of standard ISO taper. Sterile saline was used as the final irrigant and ultrasonic irrigation was done. A calcium hydroxide was dressing was placed, which was removed after a week and the canals were prepared for obturation. Custom made gutta-percha was prepared using glass slab and stainless steel spatula (Roll cone technique). Gutta-percha cone was trial fitted and the obturation done. The remaining canal was obturated using cold lateral completion technique [Figure – 2].

Endodontic Management of left upper first molar

The tooth was anaesthetised, the access opening was done under rubber dam isolation and the pulp tissues were extirpated using ‘H’ files of size 80. The walls were circumferentially planed using ‘K’ files, sterile saline and chlorhexidine irrigation was done. Ultrasonic irrigation was finally performed with saline. Intra canal medicament of calcium hydroxide was placed, as in right upper first molar and the patient was recalled after a week. The calcium hydroxide dressing was removed and the canal was dried. Obturation using the custom roll cone technique was performed, like in the previous instance [Figure – 3]. The patient was recalled after a week for review.

Post endodontic management

The patient after the completion of endodontic management was asymptomatic and comfortable during review. It was decided to use resin post to rehabilitate the root dentine, as the teeth were badly damaged. Gutta­percha was removed using heat and mechanical methods upto the middle third of the length of the root canal. Smear layer removal was done with sodium hypochlorite and EDTA solution. 37% phosphoric acid (Etchant) was syringed into the pulpal chamber and left for 15 seconds, rinsed off and bonding agent was applied and cured with two light transmitting posts inside the canal. Composite resin root rehabilitation was done using layered adhesion technique. Composite resin (3M – flowable) was injected into the canal and a clear light transmitting post (Dentatus, Transluminex) was placed in the centre of the canal and cured using conventional halogen (Heraeus – Kulzer) curing lamp for 120 seconds [Figure – 4]. The clear post was retrieved using artery forceps [Figure – 5] and a corresponding fibre reinforced composite post was bonded into the post space with dual cure resin luting cement (Rely – k) and cured for 40 seconds. The excess post was sheared off using a high speed handpiece and core build up was done with posterior composite resin (3M).

        

[drsushant]

figures..

        

[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.

        

[Anonymous]

 Figures..

        

[Author]

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