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ENDO (Lond Engl) 2008;2(3):199203
CASE REPORT
Pyramidal teeth are thought to be a minor form of taurodontism, which is a morpho-anatomical
change in the shape of a tooth, usually occurring in multirooted teeth as a result of failure of theinfolding of the epithelial root sheet of Hertwig. The characteristic features of these teeth are an
enlarged body and pulp chamber, as well as apical displacement of the pulpal floor. Endodontic
treatment of a taurodont tooth is challenging, because it requires special care in handling, and in the
identification of the number of root canals and morphology of the tooth. In this case report, the
endodontic treatment of a mandibular first and second molar with pyramidal root canal morphology
is presented.
Sebastian Brklein
Endodontic treatment of two pyramidal (taurodont)mandibular molars: a case report
dental malformation, endodontic treatment, root canal morphology, taurodontismKey words Sebastian BrkleiPrivate Practice, Zahnk
Bochum, Bergstrasse 2
D-44791 Bochum, Ger
Tel: +49 234 5839228
Email: sbuerklein@gmx
Introduction
The term taurodontism was introduced in 1913 by Sir
Arthur King1. He proposed that taurodont molars are
characterised by the distinct extension of the pulp
chamber below the level of the alveolar crest and the
cementoenamel junction (CEJ), and apical displace-
ment of the bi- or trifurcation of the roots. Addition-
ally, taurodontism refers to a tooth-form character-
ised by an external block configuration, which means
an elongated body that tends to enlarge at the ex-
pense of the root and give it a rectangular shape.Teeth with pulp chambers that are relatively small
and have constriction of the pulp chamber at approxi-
mately the level of the CEJ are called cynodonts2.
The aetiology of taurodontism is unclear, but is
attributed to the failure of invagination of the epi-
thelial root sheath sufficiently early to form the cyno-
dont. One hypothesis is that taurodontism might be
the result of a disrupted developmental haemostasis3.
An autosomal transmission of the trait has also been
observed4. Various manifestations of taurodontism
are described: this malformation can occur alone,
limited to one or more teeth or it can be associated
with various syndromes including Downs syndrome
or Klinefelters syndrome5,6. Taurodontism may be
unilateral or bilateral and affects permanent teeth
more frequently than primary teeth. It is commonly
observed among certain ethnic groups such as
natives of Alaska, Australia and Central America7.
Taurodontism may be classified as mild, moderate
and severe (hypo-, meso- and hypertaurodontism,
respectively)8 based on the degree of apical displace-
ment of the pulp chamber floor2. The prevalence oftaurodontism found by radiographic dental exami-
nation in patients has been shown as ranging from
5.69 to 8%10, up to 48% (18.8% of teeth affected)11,
or 60%12, whereas the prevalence of pyramidal molars
was 4.6% (1.6% of teeth) in specially selected ethnic
groups11. In western European subjects, the prevalence
is estimated to be about 10%13,14. Although tauro-
dontism does not involve molar teeth exclusively15 it is
found to be significantly more prevalent in second
maxillary molars16.
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ENDO (Lond Engl) 2008;2(3):199203
200 Brklein Treatment of two pyramidal (taurodont) mandibular molars
Generally, taurodontism and pyramidal teeth are
a rare dental anomaly, and endodontic treatment is
challenging because it requires special care in
handling and identifying the number of root canals17.
Case report
Diagnosis
A 43-year-old woman was referred to the authors
department for the treatment of the right first mandi-
bular molar. Dental history revealed that she had been
suffering from pain for 6 days prior to her visit to the
clinic and that the pain was spontaneous and
aggravated at night. This was disturbing her sleep and
meant she was taking analgesics. Tooth 46 had beenendodontically pretreated 1 week previously and an
intracanal dressing with Ledermix-paste (Riemser,
Greifswald, Germany) was placed. This medicament
consisted of corticosteroids and tetracycline. The cor-
ticosteroid component has a calming and anti-inflam-
matory effect, whereas the antimicrobial component
should prevent the proliferation of bacteria.
Intraoral examination revealed that the coronal
access cavity was sealed with a temporary filling. At
tooth 47 a deep carious lesion was found on the
mesio-occlusal surface. Both teeth were subjected to
routine clinical tests and, although tooth 46 showed
the typical symptoms for an endodontically pre-
treated tooth with Ledermix-paste (the sensitivity test
was positive because of the remaining vital tissue, and
the percussion test was negative), a provisional diag-
nosis of symptomatic irreversible pulpitis was made
concerning tooth 47 (the sensitivity test was positive
and the percussion test was positive). The periodontal
probing depths showed no elevated levels.
Radiographic observations included an area ofrarefaction located between the roots of both teeth,
the carious lesion located at the mesial aspect of tooth
47, a kind of hypercementosis associated with the
root of tooth 46 and a tendency of root canal obliter-
ation (Fig 1). Moreover, the radiograph revealed an
abnormal pyramidal root anatomy for both teeth.
Endodontic treatment
Anaesthesia was achieved by means of inferior
alveolar nerve block with 1.8ml of 4% articaine
with 1:100.000 adrenaline. Access to the pulp
chamber of tooth 47 was gained under rubber dam
isolation. A huge pulp chamber was encountered
with one central root canal. The pulp tissue was
extirpated and the working length was determinedelectronically using the Root ZX device (Morita,
Tokyo, Japan). Chemo-mechanical preparation of
the root canal system was achieved by alternating
circumferential filing with manual stainless steel K-
and Hedstrm files at full working length. Copious
irrigation with 2% sodium hypochlorite (NaOCl)
was performed during the instrumentation process.
Finally, after instrumentation was completed, a
passive ultrasonic irrigation of the root canal was
performed with NaOCl to ensure optimal dissolu-
tion of remaining pulp tissue. Using an operatingmicroscope, no accessory apical canals were
detected and a wide-open apical foramen was
visible. A mechanical preparation up to ISO size 150
was necessary, because the first instrument that had
bound in the apical region was already a size 110.
At the same appointment, the pretreated tooth 46
was subjected to the same procedure after the
coronal access was enlarged and the overhanging
areas of the pulp chamber roof were removed. It
was detected that the clinician had nearly caused
perforation of the mesial (probably due to the ex-
ploration of the expected mesial canals during the
previous appointment) but the absence of further
root canals was proved using the operating micro-
scope. The apical region was extremely calcified and
a wide foramen could not be detected. Root canal
instrumentation up to size 110 was thoroughly per-
formed using circumferential filing with stainless
steel K-files alternating with Hedstrm files, and
repeated irrigation with NaOCl was performed after
electronic determination of the working length. Theroot canals of both teeth were dried and dressed
with an aqueous solution of calcium hydroxide
(Ca(OH)2). Finally, the access cavities were sealed
with zinc oxide-eugenol cement.
The patient was recalled after 2 weeks. The
intracanal dressing was removed with stainless steel
hand instruments, and passive ultrasonic irrigation
was performed to optimise the removal of the intra-
canal dressing. After thorough irrigation with
NaOCl and EDTA for smear layer removal, the
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ENDO (Lond Engl) 2008;2(3):199203
Brklein Treatment of two pyramidal (taurodont) mandibular molars
canals were dried using paper points. Gutta-percha
master cones were then fitted at working lengths
with a slight tug-back. Obturation was performed
using cold lateral condensation with a size 25
spreader and size 20 collateral points using AH Plus
(Dentsply, Konstanz, Germany) as a sealer. After
removing the surplus filling material and thorough
cleaning of the access cavities, 37% phosphoric
acid was syringed into both access cavities, left for
15s, rinsed off and a bonding agent was applied.
Finally, both access cavities were sealed with a resin
composite restoration. The post-operative radio-
graph shows homogeneous root canal fillings with
an adequate length (Fig 2).
Post endodontic treatment
The patient was reviewed 3 months later and was
free of symptoms. A new crown for tooth 46 was
made. The 1-year follow-up radiograph revealed that
healing had occurred (Fig 3). The radiograph that
was subsequently made showed that all molars were
characterised by the same root morphology (Fig 4).
Discussion
Taurodontism can occur in various forms, but depend-
ing on the severity of this malformation, a distinction in
meso-, hypo-, hypertaurodontism or pyramidal teeth
Fig 1 Pretreatment radiograph of teeth46 and 47.
Fig 2 Post-treatment radiographshowing obturation of teeth 46 and 47.
Fig 3 1-year follow-up radiographshowing that healing has occurred.
Fig 4 Radiographshowing multipletaurodont teeth. Nthat all molars dispthis anomaly.
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ENDO (Lond Engl) 2008;2(3):199203
202 Brklein Treatment of two pyramidal (taurodont) mandibular molars
has been suggested. The position of the pulpal floor in
relation to the CEJ is the deciding factor8. The
prevalence of taurodont teeth varies within different
populations, and the aetiology is not clear. Root mor-
phology is primarily determined genetically, but may
also be environmentally modified18
. The failure ofsufficiently early invagination of the epithelial root
sheath to form the cynodont, a disrupted develop-
mental haemostasis3 and an autosomal transmission of
the trait are aetiological factors of taurodont teeth that
have been observed4. Teeth most frequently affected
are molars, although premolars and incisors have also
been diagnosed as taurodonts in a radiographic study19.
The incidence of taurodontism is variable,
depending on the different series and groups studied.
In general, molars and premolars in both the primary
and permanent dentitions are affected15,20. Theoccurrence of taurodontism associated with develop-
mental disorders such as amelogenesis and dentino-
genesis imperfecta21, or hypodontia22,23 has been
documented. In patients with syndromes such as
Downs syndrome24, Klinefelters syndrome20,25,
ectodermal dysplasia syndrome26, Mohr-syndrome27,
tricho-dento-osseous syndrome28 or in patients with
cleft lip and palate29, taurodont teeth are more pre-
valent than in healthy subjects.
In this particular case, the patient had no sys-
temic disturbances, malformations or syndromes
and, therefore, both teeth were considered to be
non-syndromic taurodont teeth. Both teeth were
classified as pyramidal teeth. An inheritable aeti-
ology could not be found, as the families of the
patients were not available for examination.
Endodontic treatment in taurodont teeth has
been described as complex and difficult, because
these teeth show wide variations in the size and
shape of the pulp chamber with varying degrees of
obliteration and canal configuration31. This morph-ology could complicate the location of the canal
orifices, which consequently causes difficulties in
subsequent instrumentation and obturation32.
The exploration of the canal configuration was
done using an operating microscope because of the
width of the pulp chamber. Some authors propose the
use of micro-computerised tomography (micro-CT) to
examine the morphology of difficult teeth. With this
technique, three-dimensional information about the
examined object is available for the planning of
endodontic and surgical treatment. Some details may
become visible that were not detectable using con-
ventional examination methods33,34,35.
The radiation exposure depends on the CT and
is much higher than with conventional intraoral
radiographs36,37
. The indication for the diagnosticmethod should be evaluated carefully, and the
ALARA-principle (as low as reasonably achievable)
considered for the use of radiation.
Mechanical debridement and shaping of the root
canals was achieved with circumferential filing using
stainless steel hand K-files alternating with stainless
steel hand Hedstrm-files, because the pulp chamber
was huge. Preparing oval or large straight root canals
by this technique leads to satisfying results and is
superior to rotary instrumentation alone38,39. An even
preparation of all canal walls during the root canalinstrumentation is possible using this circumferential
filing technique. The root canal of tooth 47 was ob-
turated by lateral condensation, as a wide apical fora-
men was present. This technique allows a good api-
cal control by trial fitting the master cone, and the
risk of overextension of gutta-percha or sealer is
minimised. However, thermoplastic techniques are
not well controlled and can lead to apical extrusion
into the periapical tissue40,41. This could cause post-
operative complaints as well lead to a failure of the
root canal treatment, or in the worst case, to an
irreversible nerve injury if material is extruded into
the nerve canal. Alternatively, an apical plug with
mineral trioxide aggregate or apexification proce-
dures using repeated Ca(OH)2 dressings would have
been possible, but the chosen therapy was easy to
handle and safe.
Summary
Taurodontism including all its varieties (meso-, hypo-,hypertaurodontism and pyramidal teeth)8 is a rare
dental malformation, in which root canal treatment
is still a challenge because of multiple and complex
forms of canal configurations. In each case,
radiographic examination is essential before
initiating root canal treatment, so as to become
aware of the particular root canal configuration. An
operating microscope may be helpful for the
exploration of further and accessory canals or a wide
apical foramen. Chemo-mechanical preparation
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ENDO (Lond Engl) 2008;2(3):199203
Brklein Treatment of two pyramidal (taurodont) mandibular molars
with copious irrigation and circumferential filing is
necessary for successful endodontic treatment
including the obturation technique, which allows
good apical control, because wide foramina are
among the characteristics of taurodont teeth.
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