Endodontic Management of a Mandibular Central Incisor With Vertucci Type V Configuration: A Case Report From Nepal

ABSTRACT

Mandibular central incisors may exhibit complex canal anatomy. A 21‐year‐old Nepalese female presented with pulpal necrosis and symptomatic apical periodontitis. A Vertucci Type V configuration was identified using conventional and angled periapical radiographs. Both canals were treated successfully, obturated, and restored with a lithium disilicate crown, without CBCT.

Key Clinical Message

• Mandibular central incisors may contain additional canals despite their usually simple anatomy.

• Angled periapical radiographs can improve visualization of canal bifurcations and should be considered when additional anatomy is suspected.

• Missed canals may allow persistent intracanal infection and increase the risk of post‐treatment apical periodontitis.

• CBCT provides three‐dimensional information when conventional radiography is inconclusive and should be used according to the clinical diagnostic task.

• Adjacent missing teeth should be considered during restorative planning in anterior endodontic cases.

1. Introduction

Mandibular central incisors are generally considered to have relatively simple root canal anatomy, most commonly presenting with a single root and a single canal (Vertucci Type I). Nevertheless, additional canals and other configurations are well documented, and their prevalence varies substantially among populations and according to the method used for anatomical assessment [1, 2, 3, 4]. A systematic review of mandibular incisors and canines involving more than 71,000 teeth from 26 countries found that anatomical deviations were particularly variable across geographical regions and emphasized that clinicians should not rely solely on the expected configuration of a tooth [2].

Available South Asian data demonstrate considerable variation. In an Indian CBCT study, approximately 30%–34% of mandibular central incisors had two canals, while Vertucci Type V accounted for 3.12% of mandibular incisors overall [3]. A more recent Nepalese CBCT study reported two canals in 27.6% of mandibular incisors overall and Type V in 2.9% [5]. In contrast, a Pakistani CBCT study of mandibular central incisors reported Type I in 71.09% and Type III in 28.91% [6]. These findings illustrate both the presence of additional canals in South Asian populations and the heterogeneity between studies.

Outside South Asia, prevalence also differs markedly. A systematic review of Chinese CBCT studies found second canals in 5.6% of mandibular central incisors [7], whereas an Italian CBCT study reported two canals in 45% of mandibular central incisors [4]. Such differences may reflect population characteristics, sample selection, imaging modality, and classification methods. Vertucci Type V is defined as a single canal that divides into two separate canals, usually in the middle or apical third, with separate apical foramina [1].

Failure to identify an additional canal can leave infected tissue or microorganisms within an untreated portion of the root canal system and may contribute to persistent or post‐treatment apical periodontitis [8, 9]. Radiographic interpretation is therefore an important component of diagnosis. Altered horizontal angulation can separate superimposed canal images and improve detection of additional canals on two‐dimensional radiographs [10]. CBCT can provide three‐dimensional information when conventional imaging is inconclusive or when complex anatomy is suspected; however, its use should be justified by the diagnostic task and balanced against radiation exposure [9, 11].

A Nepalese case report published in 2025 also described Vertucci Type V anatomy in a mandibular right central incisor; that case was confirmed with CBCT and followed for 6 months [12]. The present case differs in that the middle‐third bifurcation was identified using conventional/angled periapical radiography without CBCT, and the patient also had clinically confirmed bilateral absence of the mandibular lateral incisors requiring subsequent prosthetic consideration. We report the successful endodontic and restorative management of this uncommon anatomy.

2. Case History and Examination

A 21‐year‐old Nepalese female presented with a 15‐day history of throbbing pain in the right mandibular anterior region. The pain was moderate in intensity (Visual Analogue Scale 5–6/10), aggravated at night, and was not associated with swelling or discharge. Medical history was noncontributory.

Clinical examination revealed:

• Tenderness to percussion of tooth 41.

• Negative responses to cold testing and electric pulp testing.

• No swelling or sinus tract.

2.1. Radiographic Findings

Preoperative periapical radiography using an intraoral radiovisiography (RVG) sensor with the paralleling technique suggested a single root with a bifurcation at the middle third, consistent with a Vertucci Type V configuration (Figure 1). Angled periapical views were used to improve visualization of the canal separation. The bilateral absence of the mandibular lateral incisors was established clinically and is not clearly demonstrated in the available preoperative radiograph. CBCT was not performed because the conventional radiographic findings were considered sufficiently clear for diagnosis and treatment planning in this case.

FIGURE 1.

Preoperative periapical radiograph demonstrating bifurcation at the middle third of the root of the right mandibular central incisor, indicating Vertucci Type V canal configuration.

2.2. Differential Diagnosis and Investigations

The clinical diagnosis was pulpal necrosis with symptomatic apical periodontitis. Chronic irreversible pulpitis was excluded because both cold and electric pulp tests were negative.

Investigations included periapical radiography, cold testing, and electric pulp testing. CBCT was not obtained.

3. Treatment

Under inferior alveolar nerve block using 2% lignocaine with 1:100,000 adrenaline and rubber dam isolation, access cavity preparation was performed using a #2 round bur and Endo‐Z bur. The access was modified to an oval shape to accommodate both canal orifices. Both canals were negotiated with #8 K and #10 K hand files using a watch‐winding motion. Pulpal extirpation was completed and working lengths were established radiographically (Figure 2).

FIGURE 2.

Working length radiograph confirming the estimated working lengths in both canals.

Biomechanical preparation was performed using sequential hand and rotary instrumentation. Copious irrigation was performed with 5.25% sodium hypochlorite using manual agitation and 17% ethylenediaminetetraacetic acid (EDTA), followed by normal saline as the final flush. A master cone radiograph was obtained before obturation (Figure 3).

FIGURE 3.

Master cone radiograph verifying fit of gutta‐percha cones (#F1 and #40) in both canals.

Obturation was performed using standardized gutta‐percha cones and ADSEAL Plus sealer by lateral compaction. The access cavity was temporized with Type II glass ionomer cement, and a post‐obturation radiograph confirmed satisfactory apical and coronal seal (Figure 4).

FIGURE 4.

Post‐obturation radiograph demonstrating well‐condensed gutta‐percha fill in both canals with adequate apical and coronal seal.

3.1. Conclusion and Results (Outcome and Follow‐Up)

At the 1‐week review, the patient was asymptomatic. Crown preparation was subsequently performed, and a lithium disilicate (IPS e.max) crown, shade A2, was fabricated and cemented at the subsequent visit. The patient reported complete resolution of pain, satisfactory aesthetics, and satisfactory occlusal function.

The clinical treatment sequence and follow‐up are summarized in Table 1.

TABLE 1.

Clinical treatment timeline of the mandibular central incisor with Vertucci Type V canal configuration.

Timepoint	Date	Event	Findings/Action
Day 0	03‐02‐2026	Initial presentation	Throbbing pain for 15 days in the right lower anterior region. Tenderness on Percussion. Cold and EPT negative.
Day 0	03‐02‐2026	Radiographic diagnosis	IOPAR/RVG showed a single root with middle‐third bifurcation, consistent with Vertucci Type V. Diagnosis: pulpal necrosis with symptomatic apical periodontitis.
Visit 1 – Day 2	05‐02‐2026	Access and working length	Oval access cavity prepared. Canals negotiated with #8K/#10K files. Working‐length radiograph confirmed.
Visit 2 – Day 5	08‐02‐2026	Biomechanical preparation	Sequential instrumentation performed. Irrigation with 5.25% NaOCl, 17% EDTA, and saline. Master cone radiograph obtained.
Visit 3 – Day 7	10‐02‐2026	Obturation	Standardized GP cones and ADSEAL Plus sealer used for obturation. Access closed with Type II GIC. Post‐obturation radiograph obtained.
Visit 4 – Day 14	17‐02‐2026	Review	Patient asymptomatic. Crown preparation for lithium disilicate (IPS e.max, shade A2) completed. Impression taken.
Visit 5 – Day 21	24‐02‐2026	Final cementation	IPS e.max crown cemented. Patient reported satisfactory aesthetics and function.
Follow‐up – Day 49	24‐03‐2026	Outcome	Complete symptom resolution. Prosthetic rehabilitation was satisfactory.

Note: Follow‐up schedule: 1 week after obturation → 1 week later for crown cementation → 4 weeks after final crown cementation for outcome assessment.

4. Discussion

The present case illustrates the clinical importance of recognizing anatomical variations in mandibular central incisors. Although Type I anatomy is predominant, the prevalence of additional canals is sufficiently substantial that a single‐canal assumption can be unsafe. The 2022 systematic review by Dhuldhoya et al. showed that mandibular incisor anatomy varies across geographical regions, with the Indian subcontinent demonstrating a broad range of Type I prevalence and a meaningful proportion of Type II and Type III configurations [2].

The available South Asian evidence supports this concern. Verma et al. found two canals in 30%–33.5% of mandibular central incisors in an Indian subpopulation and identified Type V in 3.12% of mandibular incisors overall [3]. In Nepal, Kayastha et al. reported two canals in 27.6% of mandibular incisors and Type V in 2.9% [5]. The Pakistani study by Rehman et al. reported Type I in 71.09% and Type III in 28.91% of mandibular central incisors [6]. Together, these findings indicate that additional canal systems are clinically relevant in South Asian mandibular incisors, even though the exact prevalence varies between populations and studies.

Comparison with other geographical populations demonstrates that prevalence is not uniform. A systematic review of Chinese CBCT studies reported second canals in 5.6% of mandibular central incisors [7], whereas Valenti‐Obino et al. reported two canals in 45% of mandibular central incisors in an Italian population [4]. These differences should be interpreted cautiously because imaging methods, study design, population composition, and definitions of canal configurations differ. The clinical implication is that population‐based prevalence can inform expectations but should not replace individual radiographic and clinical assessment.

A missed canal can compromise disinfection because microorganisms and necrotic tissue may remain in the untreated canal space. A recent systematic review and meta‐analysis found a strong association between missed canals detected by CBCT and post‐treatment apical periodontitis, with a substantially higher prevalence of apical periodontitis in root‐filled teeth with missed canals [8]. This reinforces the importance of identifying all canal orifices and following the canal system to its apical termination.

Radiographic angulation is a useful, accessible method when an additional canal is suspected. He et al. reported that altered horizontal angulation, particularly with a file in the canal, improved detection of multiple canals in mandibular anterior teeth and premolars [10]. In the present case, the middle‐third bifurcation could be recognized from conventional and angled periapical radiographs, allowing both canals to be negotiated without additional three‐dimensional imaging. This approach is particularly useful where CBCT is unavailable or where the clinical and radiographic information already provides sufficient confidence for treatment.

CBCT nevertheless has an important role when conventional radiographs are inconclusive or when complex morphology requires three‐dimensional characterization. A systematic review and meta‐analysis reported high overall diagnostic accuracy of CBCT for detecting second canals, although performance varied with tooth type, prevalence, and the spectrum of anatomy [9]. The 2025 American Association of Endodontists/American Academy of Oral and Maxillofacial Radiology (AAE/AAOMR) position statement emphasizes task‐specific use of limited‐FOV CBCT and recognizes that three‐dimensional imaging can provide information not consistently available from two‐dimensional radiographs [11]. Thus, the decision not to obtain CBCT in the present case should not be interpreted as a general recommendation against CBCT; rather, it reflects the diagnostic sufficiency of the available periapical radiographs in this individual case.

The present case also has relevance to the recent Nepalese literature. Neupane et al. reported a mandibular right central incisor with Vertucci Type V anatomy in a 20‐year‐old male; CBCT confirmed the bifurcation and the tooth was followed for 6 months with satisfactory periapical healing [12]. In contrast, the present case involved a 21‐year‐old female, the bifurcation was diagnosed using periapical radiography without CBCT, and the patient had absence of mandibular lateral incisors. The prosthetic rehabilitation with a lithium disilicate crown therefore formed an additional component of management.

The bilateral absence of mandibular lateral incisors also influenced restorative planning. A lithium disilicate crown was selected for its combination of strength and optical properties, and the patient reported satisfactory aesthetics and function after cementation.

The principal limitations are the short clinical follow‐up and absence of long‐term radiographic assessment of periapical healing. In addition, CBCT was not performed, so the three‐dimensional anatomy was inferred from conventional and angled radiographs and clinical canal negotiation. Future documentation should include longer‐term clinical and radiographic follow‐up where available.

5. Conclusion

This case demonstrates successful endodontic management of a mandibular central incisor with a Vertucci Type V canal configuration. The case emphasizes that mandibular incisors should not be assumed to have a single canal and that careful interpretation of conventional and angled periapical radiographs can reveal clinically important bifurcations. CBCT should be considered when conventional imaging does not provide adequate diagnostic information or when three‐dimensional assessment is expected to influence treatment planning.

Author Contributions

Bijita Phuyal: conceptualization, case management, manuscript writing. Neebi Shrestha: supervision, manuscript review, and editing. All authors have read and approved the final manuscript.

Funding

The authors have nothing to report.

Ethics Statement

This case report did not require formal ethical approval as it describes standard clinical care. Patient written informed consent was obtained for radiographic images and publication of case details. Patient anonymity has been preserved throughout the manuscript in accordance with institutional and journal requirements.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.