Nouman Noor, Manzoor Ahmed, Nusrat Jabeen, Sadaf Humayoun.
Endodontic treatment of premolar with unusual anatomy and hypercementosis — case report.
Pak Oral Dental J Jan ;35(3):519-23.

The purpose of this article was to report the successful nonsurgical endodontic management of mandibular first premolar with unusual anatomy and hypercementosis that was not reported elsewhere before and the challenges that were faced while determining the apical stop and preparation of apical part of the canal. A 25-year old Saudi male patient reported to referral hospital, with chief complaint of continuous pain in lower right quadrant for 2-3 days. His medical history was non-contributing. Clinical examination revealed a carious lesion on the mandibular right first premolar. The pain was of acute in nature but was not tender on percussion . Interestingly unique pattern of the canal system was found on periapical radiographs which resembled configuration of Vertucci type V and hypercementosis at the apex of the tooth. In this case while performing the endodontic treatment two very important challenges were faced. The first one was to determine the working length as the apices of tooth were hindered by hypercementosis and other one was to prepare the apical part of canal adequately without file separation that was obstructed by hypercementosis. Determination of working length was challenged as there was no definitive apex found on the digital radiographs and also variable readings were found with the apex locator, therefore the image was magnified and contrast with different color scheme with the help of digital imaging software (Vatech) in order to determine the radiographic apical preparation stop. Following the working length determination, the root canals were prepared with a crown down technique and the great resistance were noticed in apical part of canal due to hypercementosis, therefore the apical preparation was finished at proptaper finishing file (F 1) and obturated with lateral condensation. This case describes a mandibular premolar with an unusual anatomy and pathology. Coronally the single canal is divided into two canals in mid-root that terminate into separate apical foramens, but presence of excessive cementum at apex of root hindered the apex on radiographs, thus apical termination point of endodontic instrumentation was difficult to evaluate and also the apical part of canal was hard to prepare, owing to hypercementation.

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