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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 86-90

A Novel Case Report of Impacted Mandibular Canine with Bifid Roots


Department of Orthodontics, KM Shah Dental College, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Submission08-Jun-2020
Date of Decision12-Jun-2020
Date of Acceptance13-Jun-2020
Date of Web Publication06-Aug-2020

Correspondence Address:
Dr. Pallavi Raina
Department of Orthodontics, 1st Floor, KM Shah Dental College, Sumandeep Vidyapeeth, Vadodara - 390 020, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIHS.JIHS_18_20

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  Abstract 


Mandibular canine impaction is less frequently encountered in orthodontic practice compared to maxillary canine impaction and poses a challenge to orthodontic treatment. A very rare incidental finding of an impacted mandibular canine having bifid roots is reported in this article. The case report highlights the key points to be kept in mind to diagnose the presence of bifid roots and canals. It also discusses how the finding of an impacted mandibular canine with bifid roots can influence orthodontic treatment planning. Since the diagnosis and the evaluation of the number of roots and canals are key to the success of root canal treatment, endodontic implications have been highlighted as well.

Keywords: Bifid canine, canine impaction, endodontic challenges, intraoral periapical, orthodontic management of impacted canine


How to cite this article:
Raina P, Goje SK. A Novel Case Report of Impacted Mandibular Canine with Bifid Roots. J Integr Health Sci 2020;8:86-90

How to cite this URL:
Raina P, Goje SK. A Novel Case Report of Impacted Mandibular Canine with Bifid Roots. J Integr Health Sci [serial online] 2020 [cited 2021 Apr 12];8:86-90. Available from: https://www.jihs.in/text.asp?2020/8/2/86/291506




  Introduction Top


Canine is the cornerstone of the human dentition. Both the canines together resist forces exerted upon the teeth in the lateral direction during the functional movements of the mandible. It provides functional efficiency, structural balance, and esthetic harmony, which form the pillars of Jackson's triad.

Impacted canines are a commonly occurring phenomenon whose presence in human dentition is not new. Šikanjić et al. reported a case of an adult male from the archeological setting (3rd–4th century) Roman period Croatia, having maxillary and mandibular impacted canines.[1] Mandibular canine normally has one root and one canal.[2] Yet, a small percentage of canines have more than one root, which is a rare occurrence. The first case report of a mandibular canine with bifid roots was published in 1886 by Vawter.[3]

Various factors influence treatment planning in the management of impacted teeth. A bifid canine can be one such factor. At the same time, variable internal anatomy such as two canals can complicate endodontic treatment, leading to its failure if the presence of a second canal goes undiagnosed.

No article in the literature has reported an “impacted mandibular canine with bifid roots.” Articles were found on “impacted mandibular canines with single root” and “erupted mandibular canines with bifid roots.” The incidence rates of mandibular impacted canines found in the literature are 1.29% by Yavuz et al., 0.37% by Jain and Debbarma, and 1.36% by Sanu et al. in the participants from the Turkish, Indian, and Nigerian population, respectively.[4],[5],[6] A systematic review published by Dalessandri et al. in 2017 concluded that the incidence of impacted mandibular canine ranged from 0.92% to 5.1%.[7]

Jain et al. found that crowding, wide mandibular teeth, and Class II division 2 malocclusion increased the likelihood of mandibular canine impaction.[8],[9] Dalessandri et al. found that odontomes (20%) and lateral incisor anomalies (16%) caused mandibular canine impactions.[7] Al-Abdallah et al. found retained deciduous canines to be responsible for angular impaction of the mandibular canine.[10]

A longitudinal study conducted by Sajnani and King observed that the most preferred modality of treatment for impacted mandibular canines was surgical extraction (approximately 80%).[11] Where orthodontic traction was applied, the average time required for the eruption was 12 months. Frequently reported postoperative sequel was swelling around the soft tissues, and the most common complication was a lack of movement of the tooth after traction. Similar results were obtained by Aras et al. and Dalessandri et al., where 70% and 89% of the participants, respectively, underwent extraction of the impacted mandibular canine.[7],[12]

This case report is unique in that it presents a case with an impacted mandibular canine with bifid roots. In orthodontics, diagnosis and treatment planning are the keys to a successfully finished case. This report highlights the importance of looking out for the presence of and the method of diagnosing bifid roots from routine pretreatment radiographs as it has a bearing on the decision taken for the management of an impacted tooth.


  Case Report Top


An 18-year-old female patient presented to the department of orthodontics, with a chief complaint of crowded upper and lower anterior teeth. Evaluation of soft tissue revealed normal vertical and transverse proportions, mildly convex profile with straight divergence, slightly protrusive upper lip, and a nonconsonant smile arc [Figure 1].
Figure 1: (a) Frontal smiling face view. (b) Profile face view

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Intraorally, she had Class I molar relationship bilaterally and Class I canine relationship on the left. The upper left lateral incisor was proclined, while the upper canines were rotated. The lower right canine was clinically absent, and there was a bulge felt in the lower labial mucosa between the central and lateral incisor. She had an overjet of 6 mm from the most proclined tooth and an overbite of 4 mm [Figure 2]. Appropriate consent was obtained from the patient for revealing her images and information in the Journal.
Figure 2: (a) Frontal intraoral. (b) Right lateral intraoral. (c) Left lateral intraoral

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Evaluation of radiographs

Orthopantomography (OPG) – Vertically impacted canine was visible on the OPG. The crown of the canine was superimposed onto the root of the lateral incisor. The root of the impacted canine was not clearly visible here [Figure 3].
Figure 3: Orthopantomography: the impacted canine is positioned over the root of the lateral incisor

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Intraoral periapical (IOPA) – The crown of the impacted canine was overlapping the root of the lateral incisor. The root of the canine looked well developed. It was observed on careful examination that a small radiolucent branching of the main root canal was present in the middle third of the root, suggesting the presence of two canals. On the distal aspect of the root of the canine, two periodontal ligament spaces were seen running parallel and very close to each other, indicating the presence of a bifid canine [Figure 4].
Figure 4: Intraoral periapical: careful examination of the canine reveals branching of the pulp canal indicating two root canals (vertical arrow). On the distal aspect of the root of the canine, two periodontal ligament spaces are seen parallel to each other and situated very close together, suggesting the presence of bifid roots (horizontal arrow)

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Lateral cephalogram – Cephalometric values showed a skeletal Class III jaw relationship. The dentition was well compensated; maxillary incisors were proclined, whereas the mandibular incisors were retroclined. The values of occlusal plane angle, mandibular plane angle, Y-axis, and Jarabak ratio suggested a normodivergent growth pattern. The Steiner and McNamara analysis revealed retrognathic maxilla and retrognathic mandible with respect to cranial base. Impacted canine was seen buccal to the lower anteriors close to the buccal cortical plate of the symphysis [Figure 5] and [Table 1].
Figure 5: Lateral cephalogram: the impacted canine is buccally positioned and very close to the buccal cortical plate

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Table 1: Cephalometric values

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Treatment objectives

  1. To correct upper and lower anterior crowding
  2. To achieve ideal overjet and overbite
  3. To achieve a lateral excursive functional occlusion on the right
  4. To improve esthetics
  5. To obtain a straight profile.


Treatment alternatives

Extract only the impacted canine

Extraction of a single anterior tooth in the lower arch can be done in Class III camouflage treatment where the anterior teeth are in edge-to-edge relation, especially when there is mandibular anterior Bolton ratio excess. The patient had crowding in the upper arch; thus, extraction of impacted canine alone would not suffice.

Surgical exposure and orthodontic traction to the impacted canine

To accommodate the impacted canine into the mandibular arch, extraction of the adjacent first premolar (44) would be required. Since the canine was bifid, it is a questionable eruption and the prolonged treatment time led to the rejection of this treatment plan.

Extraction of the impacted canine and the first premolar in the first quadrant

Extraction of the impacted canine would provide enough space for alignment of other teeth in the mandibular arch in a shorter span of time. The lower right first premolar would be converted to canine. Extraction of 14 would give sufficient space in the upper arch for decrowding and moving the maxillary right canine into Class I relation with the lower premolar (converted to canine) to achieve lateral excursive functional occlusion on the right side. It was decided to go ahead with this treatment plan.

Extraction phase

Atraumatic extraction of 14 was done. After ascertaining the position of the impacted right mandibular canine from IOPA, OPG, lateral cephalogram, and the clinical bulge, surgical extraction of 43 was performed. Mucoperiosteum was reflected in the right labial mucosa region. Bone overlying the canine was removed from the buccal aspect to expose it. On extraction, it was confirmed that the impacted mandibular canine had bifid roots, one buccal and one lingual. There was no contact between the impacted canine and the root of the lateral incisor [Figure 6]. Seven days postoperatively, the extraction and the surgical site had healed, and orthodontic treatment was begun starting with the retraction of the upper right canine for decrowding.
Figure 6: Impacted mandibular bifid canine with buccal and lingual roots

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  Discussion Top


The incidence of bifid roots in a mandibular canine is rare as reflected in the literature. Vertucci classified the root canal configurations present within the roots of human permanent teeth into eight types. The mandibular canine is considered to have a high prevalence of Vertucci's Type I configuration where a single canal extends from the pulp chamber to the apex.[13] A systematic review published by Plascencia et al. in 2017 reported that the two root variations had a strong preference (87.5%) for female sex, with an age range of 17–60 years.[14] According to Stojanac et al., the roots of two-rooted mandibular canines are often positioned buccally and lingually.[15] The methods they suggested to identify them are:

  1. Sudden loss in continuity of the root canal lumen may indicate branching of the canal
  2. Presence of a radiolucent groove in the lateral part of the root
  3. Loss in continuity of the periodontal ligament.


The diagnosis of bifid roots occurred during root canal procedures in all the articles that have reported it. This is obvious since endodontists pay keen attention to the number of roots and canals as it directly determines the success of root canal treatment. Most diagnosed it on the IOPA before starting treatment, but some found it during the procedure itself when a lack of clear access to the radicular canal made the clinician take subsequent X-rays with gutta-percha points for diagnosing the internal anatomy of the tooth.[16] Versiani et al. reported that the apical foramen tends to be eccentrically located in all two-rooted mandibular canines, and thus, the possibility of over instrumentation is high. They, thus, suggested the use of an electronic apex locator to determine the apical constriction.[17]

Incidentally, there is a gap in orthodontic literature with respect to the presence of bifid roots in a mandibular canine. It seems rather strange that no orthodontist ever treated a case where the mandibular canine had bifid roots. Orthodontists are trained to look at the position and inclination of the teeth rather than the number of roots. It is worth remembering that the number of roots also determines the anchor value of a tooth. For instance, in a first premolar extraction case, the second premolar and the first molar together have a greater root surface area due to the presence of large, multiple roots compared to the single-rooted teeth in the anterior segment, and thus, the former is used as anchors to retract the latter. If the canines are bifid, it would increase the overall root surface area of the anterior segment, and more amount of posterior anchor loss may be expected to occur. Thus, the diagnosis of such a variation is of paramount importance.

Orthodontic cases often present with canine impactions. Azaz et al. identified insufficient space in the arch to be the most common reason for causing interference in the eruption of teeth.[18] The above case is in affirmation with the same. The decision to either extract the canine or orthodontically align it after surgical exposure is a crucial one. Many factors dictate the above. According to Cruz, extraction of impacted teeth is indicated in situations where the prognosis of orthodontic traction followed by alignment of the impacted tooth is poor. 19 He cited examples of poor prognosis situations such as deep impaction, well developed canine roots, dilacerations, unfavourable position of the canine, very little space in the arch and where orthodontic treatment may harm other teeth.[19] Since the impacted right mandibular canine was a well-developed bifid tooth with less space in the arch for its alignment, the decision for extraction was taken.

The authors recommend that active search should also be made for the presence of bifid roots in an impacted canine before the decision to give orthodontic traction is taken. In the above case, routine orthodontic records such as lateral cephalogram, OPG, and IOPA were taken. These revealed the labiolingual position, mesiodistal position, and the anatomy of the impacted right mandibular canine, respectively. Evaluation of the IOPA with a keen eye tracing the root canal lumen and the continuity of the periodontal ligament is a key to establishing the diagnosis of a bifid tooth. In addition, a second IOPA from another angle may also be taken for confirmation. In this case, extraction of 14 and impacted 43 was the most practical choice. According to authors such as Manne et al. and Mirabella et al., extraction of the impacted tooth followed by the replacement by an implant or by the first premolar can avoid risks associated to orthodontic movement, such as difficulty in obtaining good periodontium and the possibility of root resorption of adjacent teeth.[20],[21]


  Conclusion Top


Early diagnosis of bifid roots of a canine favorably influences the success rate of both orthodontic and endodontic treatment. Be it treatment planning of impacted teeth or strategies to negotiate the root canals, individualized patient approach can be carried out with greater efficiency. Knowledge of the possibility of bifid roots and two canals in a mandibular canine should be the driving force for the clinician to actively search for any sign of the same from routine radiographs. An accurate diagnosis will facilitate better decision-making and translate into better treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her 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 Top

1.
Šikanjić P, Premužić Z, Meštrović S. Hide and seek: Impacted maxillary and mandibular canines from the Roman period Croatia. Int J Paleopathol 2019;24:89-93.  Back to cited text no. 1
    
2.
Pécora JD, Neto S, Saquy PC. Internal anatomy, direction and number of roots and size of human mandibular canines. Braz Dent J 1993;4:53-7.  Back to cited text no. 2
    
3.
Vawter GA. Dental anomalies. Dent Cosmos 1886;28:64.  Back to cited text no. 3
    
4.
Yavuz MS, Aras MH, Büyükkurt MC, Tozoglu S. Impacted mandibular canines. J Contemp Dent Pract 2007;8:78-85.  Back to cited text no. 4
    
5.
Jain S, Debbarma S. Patterns and prevalence of canine anomalies in orthodontic patients. Med Pharm Rep 2019;92:72-8.  Back to cited text no. 5
    
6.
Sanu OO, Adeyemi TA, Isiekwe MC. Incidence of impacted mandibular canine and associated pathologies in an orthodontic patient population in Lagos, Nigeria. Nig Q J Hosp Med 2012;22:291-5.  Back to cited text no. 6
    
7.
Dalessandri D, Parrini S, Rubiano R, Gallone D, Migliorati M. Impacted and transmigrant mandibular canines incidence, aetiology, and treatment: A systematic review. Eur J Orthod 2017;39:161-9.  Back to cited text no. 7
    
8.
Jain S, Shetty KS, Prakash AT, Agrawal M, Jain S. Permanent mandibular canine (s) impaction: Expansion of our understanding. Aust Orthod J 2014;30:39-44.  Back to cited text no. 8
    
9.
Jain S, Agrawal M, Jain S, Jain S. Evaluation of the mandibular arch in patients with impacted permanent lower canines. Aust Orthod J 2015;31:37-41.  Back to cited text no. 9
    
10.
Al-Abdallah M, AlHadidi A, Hammad M, Dar-Odeh N. What factors affect the severity of permanent tooth impaction? BMC Oral Health 2018;18:184.  Back to cited text no. 10
    
11.
Sajnani AK, King NM. Success rates of different management techniques for impacted mandibular canines and associated complications in children and adolescents. J Investig Clin Dent 2015;6:228-33.  Back to cited text no. 11
    
12.
Aras MH, Halicioğlu K, Yavuz MS, Çağlaroğlu M. Evaluation of surgical-orthodontic treatments on impacted mandibular canines. Med Oral Patol Oral Cir Bucal 2011;16:e925-8.  Back to cited text no. 12
    
13.
Vertucci FJ. Root canal anatomy of the mandibular anterior teeth. J Am Dent Assoc 1974;89:369-71.  Back to cited text no. 13
    
14.
Plascencia H, Cruz Á, Gascón G, Ramírez B, Díaz M. Mandibular canines with two roots and two root canals: Case report and literature review. Case Rep Dent 2017;2017:8459840.  Back to cited text no. 14
    
15.
Stojanac I, Premović M, Drobac M, Ramić B, Petrović L. Clinical features and endodontic treatment of two-rooted mandibular canines: Report of four cases. Srp Arh Celok Lek 2014;142:592-6.  Back to cited text no. 15
    
16.
Andrei OC, Mărgărit R, Dăguci L. Treatment of a mandibular canine abutment with two canals. Rom J Morphol Embryol 2010;51:565-8.  Back to cited text no. 16
    
17.
Versiani MA, Pécora JD, Sousa-Neto MD. The anatomy of two-rooted mandibular canines determined using micro-computed tomography. Int Endod J 2011;44:682-7.  Back to cited text no. 17
    
18.
Azaz B, Steiman Z, Koyoumdjisky-Kaye E, Lewin-Epstein J. The sequelae of surgical exposure of unerupted teeth. J Oral Surg 1980;38:121-7.  Back to cited text no. 18
    
19.
Cruz RM. Orthodontic traction of impacted canines: Concepts and clinical application. Dental Press J Orthod 2019;24:74-87.  Back to cited text no. 19
    
20.
Manne R, Gandikota C, Juvvadi SR, Rama HR, Anche S. Impacted canines: Etiology, diagnosis, and orthodontic management. J Pharm Bioallied Sci 2012;4:S234-8.  Back to cited text no. 20
    
21.
Mirabella D, Giunta G, Lombardo L. Substitution of impacted canines by maxillary first premolars: A valid alternative to traditional orthodontic treatment. Am J Orthod Dentofacial Orthop 2013;143:125-33.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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