jorr_4_19R7
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Case Report
Endodontic management of badly broken down tooth with
radix entomolaris using the canal projection technique
Huma Iftekhar
Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College and Hospital, AMU, Aligarh, Uttar Pradesh, India
Abstract
The management of teeth with minimal coronal structure can be a challenging task when root canal
treatment is required as a part of oral rehabilitation. Coronal leakage, isolation complexities, and risk of
interappointment coronal‑radicular fracture may be major contributors to endodontic failure. It is a great
challenge to an endodontist to maintain root canal patency while isolating grossly destructed tooth with
open pulp chamber, without blocking the root canals with restorative material. Pre‑endodontic build‑up
of the coronal tooth structure following caries removal and identification of all the canal orifices while
maintaining the canal patency can facilitate the endodontic process by providing a strong core and coronal
seal. Hence, a restoration before endodontic treatment is mandatory during management of these teeth.
This can be achieved successfully by the canal projection technique, wherein a tapered plastic sleeve is
used to maintain the canal patency, projecting the canal from pulp chamber to cavosurface margin. Taking
into consideration the limited worldwide availability and cost of original projectors, the aim of the present
case is to highlight a simple yet effective method of placement of a pre‑endodontic restoration using the
canal projection technique by custom made plastic sleeves. This case report demonstrates the use of an
innovative technique for canal projection, as an efficient method for managing complex cases.
Keywords: Broken down teeth, endodontic canal projection, isolation, pre‑endodontic build‑up, radix
entomolaris
Address for correspondence: Dr. Huma Iftekhar, Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College and Hospital, AMU, Aligarh,
Uttar Pradesh, India.
E‑mail: huma.iftekhar@yahoo.com
Submission: 16‑01‑2019; Accepted: ???
INTRODUCTION
Advancement in endodontic techniques has resulted in
retention of those teeth which were earlier considered
unrestorable. [1] It is universally accepted that the
preservation of a natural tooth is always superior to tooth
loss and replacement.[2] The presence of minimal coronal
structure can risk damage to the crown during rubber dam
clamp placement compromising isolation thereby leading
to coronal leakage.[3] Placing pre‑endodontic restoration
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DOI:
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to achieve a strong coronal seal without compromising
the canals patency is desirable when treating such cases.
This can be achieved by the canal projection technique
as suggested originally by Gerald N Glickmann and
Roberta Pileggi, also known as “Projector Endodontic
Instrument Guidance System” (PEIGS)[4] which provides
pre‑endodontic reconstruction of debilitated coronal and
radicular tooth structure while preserving individualized
access to canals. The technique helps to project the
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How to cite this article: Iftekhar H. Endodontic management of badly broken
down tooth with radix entomolaris using the canal projection technique. J Oral
Res Rev 2019;11:XX-XX.
© 2019 Journal of Oral Research and Review | Published by Wolters Kluwer - Medknow
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Iftekhar: Management of badly mutilated teeth using canal projection with uniquely designed projectors
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canal orifice from the floor of the pulp chamber to the
cavosurface, enhancing visualization and access to the
canals. Isolation is facilitated further by ease of clamp
retention rending many structurally debilitated teeth
endodontically treatable.[5,6]
A major anatomical variant of the two‑rooted mandibular
first molar is a tooth with an additional distolingual third
root, the radix entomolaris (RE).[7]
This case report describes the management of a case of
mandibular first molar with distolingual root (RE) restored
using canal projection technique with custom made plastic
projectors before endodontic treatment.
There are very few cases of canal projection reported in
literature, since the original projector (PEIGS) is costly and
not easily available.[5,8,9] In our case, we have utilized plastic
disposable delivery tips of Metapex (Premixed root canal
filling material, Calcium hydroxide Iodoform formulation,
METABIOMED) which is readily available almost in every
clinical setting.
extra root. An angled radiograph of the tooth was taken
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which revealed the presence of at least three distinct
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roots, but a confirmatory diagnosis was still needed to
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rule out the possibility of any missed root or canals. After
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taking informed consent from the patient, SCT scan was AQ4
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done with SCT scanner (Somatom Balance, Siemens,
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Erlangen, Germany). All the protective measures were
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taken to protect the patient from radiation. Slices of
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the mandibular first molar were obtained at different
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level coronal third, middle third, and apical third, which
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confirmed three distinct roots with four separate canals
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and four separate orifices [Figure 3a‑c]. A diagnosis of RE
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with pulpal necrosis and chronic periradicular periodontitis
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was made. Root canal treatment was planned using canal
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projection technique. The projectors were made using
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plastic delivery needles of Metapex (Premixed root canal
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filling material, calcium hydroxide iodoform formulation,
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METABIOMED). The cut conical projectors were slid
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onto endodontic files [Figure 4].
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A 22‑year‑old male reported to the Department of
Conservative Dentistry and Endodontics Dr. Z. A. Dental
College and hospital AMU Aligarh, India, complaining
of a dull, mild pain in the left mandibular posterior
region for 2 months. Intraoral examination revealed the
presence of a grossly decayed mandibular left first molar
with three walls missing [Figure 1]. Pulp sensibility testing
elicited a negative response. The preoperative radiograph
[Figure 2] revealed deep occlusal caries involving the pulp
and widening of the periodontal ligament space with the
apical contour of roots indicating some possibility of the
After securing adequate anesthesia and application of
rubber dam with a clamp with apically inclined beaks,
caries was excavated. Access cavity preparation was
performed, and four root canal orifices were identified
(mesiobuccal, mesiolingual, distobuccal, and distolingual)
[Figure 5]. The canals were enlarged to a size 30 k file
using the standardized method of cleaning and shaping.
A stainless steel automatrix band was placed followed
by the application of phosphoric acid gel to etch the
exposed dentine and enamel. Rinsing and drying were
accomplished after 20 s. The Projectors were placed on
four endodontic files and slid up toward the file handles
so that 5–8 mm of each file tip protruded beyond the tip
of the projector. Different sizes of files were used to aid
in the identification of the projected orifices. Size 25 k
Figure 1: Preoperative photograph showing severely broken down
mandibular left molar
Figure 2: Preoperative radiograph showing deep occlusal caries and
periradicular periodontitis
CASE REPORT
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Iftekhar: Management of badly mutilated teeth using canal projection with uniquely designed projectors
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file was used for the mesiobuccal canal, size 25 for the
distobuccal, size 30 for the mesiolingual, and size 20 for the
distolingual. Each file with a Projector was then inserted
into its respective orifice. A dentine bonding agent was
then applied and light cured. The build‑up was placed in
increments using a nanohybrid composite (Filtek Z350 XT,
3M ESPE) and light‑cured [Figure 6]. Following curing, the
files were removed, leaving the projectors in place. A size
50 Hedstrom hand file was engaged in projectors and
projectors removed from the core. A high‑speed diamond
bur was used to level the occlusal surface providing ideal
endodontic reference points. Thus, a pre‑endodontic
build‑up with individualized access to each canal was
achieved successfully [Figure 7].
VDW GmbH, Munchen, Ger many). Canals were
instrumented with protaper rotary files and were medicated
with calcium hydroxide preparation (Metapex, BIOMED)
and temporarily sealed with Cavit (3M ESPE). At the
subsequent visit, obturation was performed with protaper
gutta‑percha and sealer (Endoflas, Colombia) [Figure 9],
and canals were sealed with glass ionomer cement. The
pre‑endodontic build‑up itself was used as a core, and
full crown preparation was performed followed by crown
cementation at a subsequent appointment. Follow‑up
radiographs at subsequent appointments revealed
completely asymptomatic tooth [Figure 10].
The original hand file was introduced into each projected
orifice, and a working length radiograph was taken [Figure 8]
and confirmed with an electronic apex locator (Raypex 5,
Frequently endodontist encounter severely compromised
teeth which requires pre‑endodontic build‑up of lost
coronal structures to ensure a strong core, good coronal
seal, placement of rubber dam clamp and to act as reservoir
for irrigating solutions.[10] Pre‑endodontic build‑up can be
a
DISCUSSION
b
c
Figure 3: Slices of molar at (a) coronal, (b) middle, and (c) apical third
revealing four separate canals and four separate orifices
Figure 5: Access opening completed under rubber dam, four orifices
detected
Journal of Oral Research and Review | Volume 11 | Issue 1 | January-June 2019
Figure 4: Projectors prepared with delivery tips of metapex and cut
projectors slided onto K files
Figure 6: Composite built‑up around projectors to occlusal surface
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Iftekhar: Management of badly mutilated teeth using canal projection with uniquely designed projectors
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Figure 7: Orifices projected to occlusal surface
Figure 8: Working length radiograph
Figure 9: Postobturation radiograph
Figure 10: Follow‑up radiograph
achieved by a variety of materials as amalgam, composites,
or glass ionomer cements. It can also be facilitated by
the application of copper bands, orthodontic bands, or
temporary crown.[11] Surgical exposure of subgingival
tooth structure to aid clamp placement, usage of serrated
clamps, clamps with gingivally oriented prongs are helpful
during the isolation of severely destructed tooth. The
usage of orthodontic bands, pin‑retained amalgam, and
adhesive restorations are also advocated.[12] However, these
restorative methods are time‑consuming; they can impede
endodontic access and may require replacement when they
are weakened by endodontic access procedures.
outcomes. These alternative techniques of canal projection
offered all the benefits of conventional PEIGS, without
any extra learning curve and they were economical, easily
available yet equally effective.
To overcome these challenges, the canal projection
technique was developed by Gerald N Glickmann and
Robert Pileggi also known as PEIGS which used plastic
sleeves for pre‑endodontic rehabilitation of a badly
mutilated teeth. However, due to its limited availability and
high cost, alternatives such as greater taper gutta‑percha[5]
and hypodermic needles[8,9] were tried with effective
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However, gutta‑percha is flexible, and there may be a
possibility that it may get mechanically retained to the resin
material thus creating difficulties during removal after the
composite core build‑up. Similar is the case with sleeves
of hypodermic needles as there are chances of sticking of
composite onto it and the parallel needles do not perfectly
adapt to the conical roots. The present case focuses on the
use of plastic delivery tips of metapex which has some
inherent taper when cut, and it does not adhere composite
onto it as well as it can be easily removed post core build up.
Since in the above case apical contour of roots some
possibility of extra roots thorough inspection of
preoperative radiographs coupled with spiral computed
tomography examination was done which provided us
Journal of Oral Research and Review | Volume 11 | Issue 1 | January-June 2019
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Iftekhar: Management of badly mutilated teeth using canal projection with uniquely designed projectors
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three‑dimensional observation of roots to avoid the
possibility of missed root or canal and possibility of
endodontic failure.
The present case demonstrates the use of an innovative
technique of canal projection offering similar benefits of
conventional PEIGS, using plastic disposable delivery tips
as an efficient method for managing teeth with minimum
coronal tooth structure to maintain canal patency and for
successful rehabilitation of grossly mutilated teeth.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given
his consent for his images and other clinical information
to be reported in the journal. The patient understands that
name and initials will not be published and due efforts
will be made to conceal identity, but anonymity cannot be
guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1.
Johns BA, Brown LJ, Nash KD, Warren M. The endodontic workforce.
J Endod 2006;32:838‑46.
2. Lazarus JP. Provisionally restoring a necrotic tooth while maintaining
root canal access. J Am Dent Assoc 2004;135:458‑9.
3. Jeffrey IW, Woolford MJ. An investigation of possible iatrogenic damage
caused by metal rubber dam clamps. Int Endod J 1989;22:85‑91.
4. Glickman GM, Pettiette MT. Preparation for treatment. In: Cohen S,
Hargreaves KM, Keiser K, editors. Pathways of the Pulp. 9th ed. St.
Louis, MO, USA: Mosby; 2006. p. 120‑32.
5. Tanikonda R. Canal projection using gutta‑percha points: A novel
technique for pre‑endodontic buildup of grossly destructed tooth.
J Conserv Dent 2016;19:194‑7.
6. Weathers AK. Endodontics from access to success, part 1. Access, the
important first step. Dent Today 2004;23:78‑80, 82, 84‑5.
7. Calberson FL, De Moor RJ, Deroose CA. The radix entomolaris and
paramolaris: Clinical approach in endodontics. J Endod 2007;33:58‑63.
8. Velmurugan N, Bhargavi N, Lakshmi N, Kandaswamy D. Restoration
of a vertical tooth fracture and a badly mutilated tooth using canal
projection. Indian J Dent Res 2007;18:87‑9.
9. Mangat P, Tomer AK, Bhardwaj G, Singh A, Muni S, Sneha.
Pre‑endodontic rehabilitation of badly mutilated teeth with canal
projection technique. Int J Appl Dent Sci 2016;2:65‑7.
10. Scott GL, Walton RE, Torabinejad M. Principles and Practice of
Endodontics. 3rd ed. Philadelphia, PA, USA: W.B. Saunders; ???. p. 118‑29.
11. Ingle JI, Walton RE, Malamed SF. Preparation for endodontic
treatment. In: Ingle JL, Bakland LK, editors. Endodontics. 5th ed.
Hamilton, Ontario, Canada: B. C. Decker; 2002. p. 357‑404.
12. Carrotte P. Endodontics: Part 7. Preparing the root canal. Br Dent J
2004;197:603‑13.
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