Case Presentation

RADIX ENTOMOLARIS

BY Mansi Punjabi
MDS 2nd Yr (2013-16)
MODERATOR-Dr. Ruchika Dewan

Contents

Introduction
Prevalence of RE
Etiology
Morphology of RE
Case report
Discussion
Conclusion
References

INTRODUCTION
Molars are frequently affected by caries at an early
age and require successful endodontic treatment
Mandibular molars can have an additional root located
lingually (the Radix Entomolaris) or buccally (the Radix
Paramolaris)
Failure to diagnose and treat the extra roots in molars
may lead to the endodontic treatment failure

 Radix entomolaris (RE) is one of the anatomical variant

found in a permanent Mandibular molar
First described by carabelli in 1844 and described by
various terms, such as extra third root or
distolingual root or extra distolingual root
It can be found in the first, second and third mandibular
Molars, occurring the least frequently in the second
molar

 Radix entomolaris (RE) Characterized by the presence

of an additional or extra third root, which is typically
found disto-lingually

 Radix paramolaris (RP) is known as the mesiobuccal

root (Carlsen et al, 1991) and was first described by Bolk in
1915
Radix paramolaris is seen buccally to the mesial root and may
found separate or fused with the mesial root

Prevalence of Radix Entomolaris

The prevalence of Radix entomolaris is reported to differ
significantly with races and ranges from 0-33.1%
African population -- 3% (Int Endod J 1998;31:112-6)
Eurasian and Indian populations -- 5% (Br Dent J
1938;64:264-74)

Mongoloid traits such as Eskimo, Chinese, and American

Indians -- 530% (Br Dent J 1985;159:298-9 and Community Dent
Oral Epidemiol 1981;9:191-2)

Because of its high prevalence in these populations, the RE is

considered to be a normal morphological variant (Eumorphic
root morphology)

Caucasians -- 3.44.2% (Braz Dent J 1992;3:113-7 and J Dent Res

1973;52;181) considered to be unusual or dysmorphic root

morphology

Prevalence of Radix Paramolaris

The prevalence of Radix paramolaris as observed by

Visser (1948) was found to be
0% for the first mandibular molar
0.5% for the second molar
2% for the third molar

ETIOLOGY
The etiology behind the formation of the Radix entomolaris
is still unknown
In dysmorphic supernumerary roots -- its formation could
be related to external factors during odontogenesis, or to
penetrance of an atavistic or polygenetic system (atavism
is the reappearance of a trait after several generations of
absence)
In eumorphic roots -- racial genetic factors influence the
more profound expression of a particular gene that results
in the more pronounced phenotypic manifestation

Morphology of the Radix Entomolaris

De Moore et al. (Int Endod J 2004;37:789-99) classified RE based on
the curvature of the root or root canal in bucco-lingual
orientation

In 1991, Carlson and Alexandersen (Scand J Dent Res

1990;98:363-73) classified four types of RE (A, B, C, and AC)
based on the location of the cervical portion of the root

Recently in 2010 Song et al. (J Endod 2010;36:653- 7) have

suggested a new classification based on morphologic
characteristics assessed from cross-sectional computed
tomography technique

Carlsen and Alexandersen (Scand J Dent Res 1991;99:189-95)

classified Radix paramolaris (RP) into two types

CASE REPORT 1
OPD NO : - 248343
NAME

: - Dinesh

AGE

: - 29 years

GENDER : - Male
ADDRESS : - Greater Noida
OCCUPATION : - Shopkeeper

CHIEF COMPLAINT

Patient complains of pain in lower left back tooth region

since 3-4 weeks

HISTORY OF PRESENT ILLNESS

Patient was asymptomatic 3-4 weeks back when he started

experiencing pain in lower left back tooth region
Pain was dull, intermittent and aggravates on mastication
and on taking hot and cold fluids and relieves on taking
medication

PAST DENTAL HISTORY

Undergone extraction in lower left back tooth region
2 years back
PAST MEDICAL HISTORY

Not significant

EXTRAORAL EXAMINATION
Facial Asymmetry Not present
Lymph Nodes Not Palpable
TMJ Normal Movements
No abnormality detected

INTRAORAL EXAMINATION
Hard Tissue Examination On Inspection :
Deep caries w.r.t 36
Tender on Percussion w.r.t 36
Vitality Test Cold test delayed response
Heat test- delayed response
EPT delayed response

PROVISIONAL DIAGNOSIS -Symptomatic apical periodontitis w.r.t 36

DIFFERENTIAL DIAGNOSIS -Symptomatic apical abscess w.r.t 36

TREATMENT PLAN

Root canal treatment w.r.t 36

PREOPERATIVE RADIOGRAPH

The tooth was anesthetised, caries were removed and pulp

chamber was opened .
When the floor of the pulp chamber was reached ,three canal
orifices were initially identified.
The conventional triangular access cavity was modified into
more trapezoidal cavity in order to locate and open the
orifice of the distlingually located RE.
On further exploration a second distal and more lingually
located canal was found.

After scouting the root canals with a K file ISO 15 and

flaring of the coronal thirds with a Gates Glidden burs, the
canal length were measured with a radiograph.
The root canals were prepared by using Mtwo file system till
size 20 .
During root canal preparation RC prep was used and root
canal were irrigated with sodium hypochlorite solution
(3%).

WORKING LENGTH DETERMINATION

The access cavity was temporized with cavit .

Patient was recalled after 1 week ,tooth was
asymptomatic .
The root canals were irrigated again with normal saline
and dried using paper points .
The master points were seated to test their suitability to
the canals and radiograph taken .

MASTER CONE RADIOGRAPH

The root canals were obturated with 6% size 20 master

gutta percha cone and ZOE based sealer by single
cone technique.
The coronal gutta percha cones were sheared off by a
heated pluggers at individual canal orifices .
Post endodontic restoration was performed by amalgam
restoration.

OBTURATION

CASE REPORT 2

OPD NO : 249375
NAME

: Imran Saifi

AGE

: 17 years

GENDER: Male
ADDRESS: Sikandarabad
OCCUPATION: Student

CHIEF COMPLAINT

Patient complains of decay in lower right back tooth

since 6-7 months

HISTORY OF PRESENT ILLNESS

Patient was asymptomatic having no pain or

sensitivity. He was having the problem of food
lodgement in the involved tooth

EXTRAORAL EXAMINATION
Facial Asymmetry Not present
Lymph Nodes Not Palpable
TMJ Normal Movements
No abnormality detected

INTRAORAL EXAMINATION
On Inspection :
Deep caries w.r.t. 46

Vitality Tests:
Cold test delayed response
Heat test- delayed response
EPT delayed response

PROVISIONAL DIAGNOSIS

Asymptomatic apical periodontitis w.r.t 46

DIFFERENTIAL DIAGNOSIS

Asymptomatic apical abscess wrt 46

TREATMENT PLAN

Root canal treatment w.r.t 46

PREOPERATIVE

WORKING LENGTH DETERMINATION

MASTER CONE RADIOGRAPH

OBTURATION

DISCUSSION
Endodontic success in the presence of Radix entomolaris
depends on its diagnosis, anatomy or morphology, canal
configuration and clinical approach employed
An accurate diagnosis of Radix entomolaris can avoid
complications like missed canal which is a common reason
for endodontic Failure
Detection of Radix entomolaris can be based on clinical
examination, radiographic and imaging techniques
It was reported that the radiographs were successful in
over 90% of the cases while identifying additional roots
but superimposition of the distal roots can be limiting
factor

 An angled radiograph (25-30) can be more useful in this

regard and it is said that a mesial angled radiograph is
better than a distal angled radiograph for Radix
entomolaris detection. (Saudi Endodontic Journal 2014;4(2):77-82)
Apart from a radiographical diagnosis, clinical inspection of
the tooth crown and analysis of the cervical morphology of
the roots by means of periodontal probing can facilitate
identification of an additional root
Three-dimensional imaging techniques based on computed
tomography (CT) and cone beam computed tomography
(CBCT) are useful for visualizing or studying the true
morphology of an Radix entomolaris in a noninvasive
manner using less radiation

 An initial relocation of the orifice to the lingual without

excessive removal of dentin helps to achieve straight-line
access and avoid perforations
Manual preflaring is recommended to prevent instrument
separation
Initial root canal exploration with small files (size 10 or
less), creation of a glide path along with the proper
determination of the canal curvature and working length
would reduce the procedural errors such as ledging and
transportation
If the Radix entomolaris canal entrance is not clearly
visible after removal of the pulp chamber roof, visual aids
such as loupes, intra-oral camera or dental microscope
can be useful

CONCLUSION
Endodontists must be aware of normal and abnormal root
morphologies of tooth
Failure to identify and treat an Radix entomolaris can
significantly affect the outcome of an endodontic treatment
in mandibular molars displaying Radix entomolaris
Although angulated radiographs can play a key role in the
identification and endodontic management of an Radix
entomolaris, the knowledge about prevalence, diagnosis,
morphology of an Radix entomolaris and clinical approach
to treat it would be a very important prerequisite to achieve
endodontic success in a mandibular molar with an Radix
entomolaris

REFERENCES
1. Nagaveni NB, Umashankara KV. Radix entomolaris and
paramolaris in children: A review of the literature. Journal of
Indian Society of Pedodontics and Preventive Dentistry; 2012
30(2): 94-102
2. Rambabu. T. Endodontic Management of Radix Entomolaris Two Case Reports. Annals and Essences of Dentistry, 2010;
2(3):50-54
3. R. Vivekananda Pai, Rachit Jain, Ashwini S. Colaco. Detection
and endodontic management of radix entomolaris: Report of
case series. Saudi Endodontic Journal 2014;4(2):77-82
4. Filip L et al. A The Radix Entomolaris and Paramolaris:
Clinical Approach in Endodontics. J Endod 2007;33:5863

THANK YOU