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Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 191-195

Endodontic management of a maxillaryfirst molar with three palatal canals - A case report

Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication26-Aug-2015

Correspondence Address:
Osama Adeel Khan Sherwani
Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, Aligarh-202 002, Uttar Pradesh
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Source of Support: Nil., Conflict of Interest: None

DOI: 10.4103/1658-5984.163624

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This case report presents a successful endodontic management of left maxillaryfirst molar with three palatal canals. This rare root canal morphology was diagnosed using dental operating microscope (DOM) and confirmed with cone beam computed tomography (CBCT). Axial CBCT images confirmed that the palatal canals merged with each other in the apical third and exited through one apical foramen. This report highlights the importance of magnification (DOM) and advanced imaging techniques (CBCT) in better understanding of complex Root canal anatomy.

Keywords: Cone beam computed tomography, dental operating microscope, maxillary first molar, three palatal canals

How to cite this article:
Sherwani OA, Kumar A, Tewari RK, Mishra SK, Ali S. Endodontic management of a maxillaryfirst molar with three palatal canals - A case report. Saudi Endod J 2015;5:191-5

How to cite this URL:
Sherwani OA, Kumar A, Tewari RK, Mishra SK, Ali S. Endodontic management of a maxillaryfirst molar with three palatal canals - A case report. Saudi Endod J [serial online] 2015 [cited 2022 Jan 17];5:191-5. Available from: https://www.saudiendodj.com/text.asp?2015/5/3/191/163624

  Introduction Top

Thorough cleaning and shaping of the root canal system requires an adequate knowledge of the root canal anatomy and frequent variations associated with it. Post treatment endodontic disease is often a result of incomplete cleaning, shaping, and obturation of the entire root canal system.[1] This can occur if one or more canals are missed particularly in teeth which exhibit considerable anatomic variations and abnormalities with respect to the number of roots and root canals.[2]

The root canal morphology of maxillary molars has been extensively studied. Among the three roots; the mesiobuccal (MB) root, especially its mesiopalatal (MP) canal has been thoroughly investigated.[3],[4] The incidence of second MB canal (MB2) or MP canal has been reported to be between 18 and 96.1%.[4],[5] The distobuccal (DB) and palatal roots with more than one canal have also been reported though the incidence is far low. The incidence of two canals in DB roots has been reported to be 1.9 and 4.30% in two independent studies, respectively.[5],[6]

Palatal root with one root canal is a more common occurrence having an incidence of almost 99%.[7] The incidence of palatal roots with two canals has been shown to be between 2.0 and 5.1%.[8] More than two canals in palatal roots have been reported by Wong and Maggiore et al., in their respective case reports.[9],[10] Both the case reports described a trifurcation of the palatal canals in the apical thirds, exiting through three separate apical foramina. This case report in contrast, describes endodontic therapy of a maxillaryfirst molar with three palatal canals merging in the apical third and exiting through one single apical foramen.

  Case Report Top

A 14-year-old male patient with noncontributory medical history reported to our department with a complaint of pain in upper left back region of jaw since last night. History revealed that one of the teeth was decayed and intermittent pain was felt for the past 3–4 months. The pain atfirst was minimal, but gradually increased in intensity, frequency, and duration to the present level prompting the patient to seek dental advice. The pain used to intensify by thermal and physical stimuli. Extraoral examination was normal. Intraoral examination revealed deep occlusal caries in the left maxillaryfirst molar (# 26). Tooth was slightly tender on percussion. Electric pulp testing (Parkel Electronics Division, Farmingdale, NY) revealed a delayed response, while thermal tests (heated gutta-percha and dry ice) increased the intensity of pain.

Preoperative periapical radiograph [Figure 1]a revealed a three-rooted maxillaryfirst molar with deep occlusal caries extending to the pulp chamber. The radiograph did not reveal unusual morphology associated with any of the three roots. A diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis was made and nonsurgical endodontic therapy was suggested to the patient.
Figure 1: (a) Preoperative radiograph of tooth 26. (b) Access opening showing three palatal, two MB, and one DB root canal orifices. (c) WL radiograph of palatal root. (d) WL radiograph of two buccal roots suggestive of two canals in each root. (e) Axial CBCT images at cervical, middle, and apical third. (f) Post-obturation radiograph. MB = Mesiobuccal, DB = distobuccal, WL = working length, CBCT = cone beam computed tomography

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After taking consent from the patient, the tooth was anesthetized with 1.8 ml of 2% lignocaine containing 1:200,000 adrenaline (Xylocaine, AstraZeneca PharmaIndia Ltd, Bangalore, India) and rubber dam was applied. An endodontic access was established using Endo Access bur and Endo Z bur (Dentsply Tulsa, Tulsa, OK). Careful exploration with DG 16 endodontic explorer (Hu-Friedy, Chicago, IL) under dental operating microscope (DOM; Seiler IQ, St Louis, MO) revealed six canal orifices in close approximation with each other. The coronal two-thirds of the canals were shaped with rotary nickel-titanium ProTaper Universal instruments (DentsplyMaillefer, Ballaigues, Switzerland). Coronal flaring of the DB canal gave an impression of two very closely linked canals in the DB root [Figure 1]b. Working length (WL) was established with Electronic Apex Locator (Raypex 5 VDW, Germany) and verified with multiple periapical radiographs [Figure 1]c and [Figure 1]d. The WL radiograph of the palatal root revealed three canals exiting through single apical foramen [Figure 1]c and that of the MB and DB roots revealed two canals in each root exiting through one foramen, respectively [Figure 1]d. However, the radiographs were inconclusive in revealing the exact morphology of the DB and palatal roots. Hence, it was decided to perform a cone beam computed tomography (CBCT) of the involved tooth and the tooth was sealed with temporary cement (Intermediate Restorative Material (IRM) cement, Dentsply, DeTrey GmbH, Konstanz, Germany).

The patient was explained about the need for a CBCT scan and his consent was taken. Thus, a CBCT scan (Next Generation i-CAT, Imaging Sciences International, Hatfield, PA, USA) of the left maxilla was performed under tube voltage of 65 KV and tube current of 8 mA. Images were reconstructed at 90 microns thickness increments. Axial CBCT images of tooth 26 at cervical third revealed six orifices; two towards MB root, one elliptical orifice towards DB root, and three orifices towards palatal root [Figure 1]e. Axial images at middle third revealed that the three orifices in the palatal root started to merge with each other [Figure 1]e. Axial images at apical third revealed a three foramina one in each root [Figure 1]e. Thus six root canals were confirmed; two in MB root, one in DB root, and three in palatal root. The three canals in the palatal roots seemed to follow type 1 (3-1) of Gulabivala and coworkers' classification of canal configurations.[11] CBCT images provided valuable information in revealing that there was a single elliptical canal, not two in DB root and the three palatal canals merged to exit through one apical foramen.

At the second appointment, patient was asymptomatic. Rubber dam was applied and temporary restoration was removed. Further cleaning and shaping of the canals was performed with the rotary Ni-Ti ProTaper Universal instruments (DentsplyMaillefer, Ballaigues, Switzerland) in a crown down manner. Irrigation was performed with 6% sodium hypochlorite and 17% ethylenediaminetetreacetic acid (EDTA). The canals were dried with absorbent points (DentsplyMaillefer, Ballaigues, Switzerland). Obturation was performed with gutta-percha (DentsplyMaillefer, Ballaigues, Switzerland) and AH Plus resin sealer (DentsplyDeTrey, Konstanz, Germany) using single cone technique and the tooth was permanently restored [Figure 1]f. The patient was asymptomatic at 1month follow-up examination.

  Discussion Top

This case report highlights the importance of magnification (DOM) and advanced imaging modalities (CBCT) in successful exploration of abnormal root canal morphology. Maxillary molars with three roots and three to four canals is a common occurrence.[12],[13] However, extreme variations in the canal morphology of maxillaryfirst molars have been reported ranging from one single canal and one root to as many as eight root canals.[14],[15] Palatal roots with two or more canals is a rare phenomenon. BarattoFilho et al., reported the frequency of finding extra canal in the palatal root was only 2.05% (ex vivo results), 0.62% (clinical results), and 4.55% (CBCT results).[16] Case reports describing two or more canals in palatal roots of three rooted maxillaryfirst molars are summarized in [Table 1].
Table 1: Case reports of three rooted maxillary first molars with two or more palatal canals

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During endodontic therapy, intraoral periapical radiographs serve as important diagnostic tool in assessing number, pattern, and curvature of roots as well as root canals. However, radiographs represent a two-dimensional image of a three-dimensional object, and thus offer only limited information.[35] Advanced imaging techniques such as CBCT can greatly enhance detection and mapping of root canal configurations with the potential to increase the efficacy of root canal therapy.[36] The role of CBCT in endodontics for effective evaluation of root canal morphology is well established. Matherne et al., in an in vitro study compared CBCT with digital radiography in identification of root canal systems. He concluded that CBCT images always resulted in the identification of greater number of root canal systems than digital images.[37]

In the present case, CBCT was extremely helpful in assessing the canal morphology, especially of DB and palatal roots. Initially, the WL radiograph gave an impression of two canals in the DB root; however, CBCT images concluded that the canal was single although wide buccolingually. The CBCT images also confirmed that the three palatal canals merged into one single canal in the apical third and exited through one apical foramen.

The role of magnification in root canal therapy should not be overlooked. Magnification increases the probability of identifying and locating all possible root canal orifices. Buhrley et al., in an in vivo study concluded that the frequency of identifying MB2 canal in maxillaryfirst molars was 71.1% with DOM, 62.5% with magnifying dental loupes, and only 17.2% with naked eye.[4] Another study reported that DOM enhanced the probability of locating and negotiating third canal in the mesial roots of mandibular molars.[38] In the present case, all canals were located and instrumented under DOM.

  Conclusion Top

This case report highlights the fact that variations in root canal morphology are inevitable. Clinicians must always look for additional canals under adequate magnification and correlate their clinical diagnosis with radiographs and advanced imaging techniques like CBCT where deemed necessary.

  References Top

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  [Figure 1]

  [Table 1]


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