The radix entomolaris in mandibular first molars: an endodontic challenge

Aim To present cases of mandibular first molars with an additional distolingual root (radix entomolaris, RE) and to survey the literature on the incidence of this anatomical feature. Summary A major anatomical variant of the two-rooted mandibular first molar is a tooth with an additional distolingual and third root: the RE. The prevalence of these three-rooted mandibular first molars appears to be less than 3% in African populations, not to exceed 4.2% in Caucasians, to be less than 5% in Eurasian and Asian populations, and to be higher than 5% (even up to 40%) in populations with Mongolian traits. A total of 18 cases (12 root filled and six extracted mandibular first molars) with an RE were collected during the years 2000–2003 in patients of Caucasian origin. As far as the access was concerned, entering the root canal in the RE required a modification of the opening in a distolingual direction resulting in a trapezoidal opening cavity. None of the orifices was located midway between the mesial and distal root component. Based on the anatomy of the extracted samples and the bending of ISO 10 files after scouting of the root canal in the RE, three types of curvature were detected: (I) straight or no curvature (two cases); (II) coronal third curved and straight continuation to the apex (five cases); and (III) curvature in the coronal third and buccal curvature from the middle third or apical third of the root (11 cases). Key learning points • Clinicians should be aware of this unusual root morphology in mandibular first molars in Caucasian people. • Radiographs exposed at two different horizontal angles are needed to identify this additional root. • The access cavity must be modified in a distolingual direction in order to visualize and treat the RE, this results in a trapezoidal access cavity.