|Year : 2014 | Volume
| Issue : 2 | Page : 87-90
A maxillary first molar with six root canals
Ranjith Karaththodiyil, Jojo Kottoor, Joy Mathew, Saira George, Jain Mathew
Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, Kochi, Kerala, India
|Date of Web Publication||19-May-2014|
Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala - 686691
Source of Support: None, Conflict of Interest: None
The purpose of this article is to describe a clinical case of a maxillary first molar with three roots and six root canals.The clinical detection of the six canals was made using a dental operating microscope and conﬁrmed using multiple angled radiographs.This report serves to remind clinicians that such anatomical variations should be taken into account during endodontic treatment of the maxillary molars.
Keywords: Maxillary first molar, root canal nomenclature, root canal anatomy, tooth morphology, six root canals
|How to cite this article:|
Karaththodiyil R, Kottoor J, Mathew J, George S, Mathew J. A maxillary first molar with six root canals. Saudi Endod J 2014;4:87-90
| Introduction|| |
The goal of root canal treatment is to clean the root canal system as thoroughly as possible and to fill it in all its dimensions.  It is of the utmost importance that the clinician be familiar with root canal anatomy in order to satisfactorily eliminate all pulp tissue during treatment. Several anatomical variations existing in the root canal system may contribute to failure of root canal therapy. To achieve clinical success, the correct location, cleaning and shaping, and obturation of all canals are mandatory. 
The root canal anatomy of maxillary first molars has been described as 3 roots with 3 canals and the commonest variation is the presence of a second mesiobuccal canal.  Numerous case reports are documented with a wide variation in both root and root canal anatomy. The variations in root form include single root, fused buccal roots, three buccal roots, and two palatal roots. , Patterns of root canal configuration are diverse ranging from one, two, five, six, C ' -shapedand sevenroot canal systems. , Recently, Kottoor et al.,  reported the endodontic management of a maxillary first molar with eight root canal systems.The present case report describes the endodontic management of a maxillary first molar with six root canal systems.
| Case report|| |
A 26-year-old male patient reported to the postgraduate clinic of the Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kochi, India, with a chief complaint of pain in upper right posterior teeth. On examination, a deep carious lesion was observed in the maxillary right second premolar and first molar (tooth #15 and #16). The teeth were tender to percussion and mobility was within physiological limits. Pulp sensibllity testing of the involved teeth with heated gutta-percha (DentsplyMaillefer, Ballaigues, Switzerland) and Dry Ice (R C Ice; Prime Dental Products Pvt. Ltd, Mumbai, India) caused an intense lingering pain, whereas electronic pulp stimulation (Parkel Electronics Division, Farmingdale, NY) caused a premature response. Preoperative radiographic evaluation showed deep carious lesion in #15 and #16 approaching the pulp space [Figure 1]a]. A diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis was made and a conventional root canal treatment for #15 and #16 was planned for the patient.
The tooth was anesthetized with 2% lignocaine containing 1:200000 epinephrine. After caries excavation, proximal surface of tooth #16 is restored with posterior composite resin for optimum rubber dam placement and isolation. An endodontic access cavity was established under rubber dam isolation and four canals were located, the mesiobuccal (MB), the distobuccal (DB), mesiopalatal (MP), and distopalatal (DP). For further exploration using a dental operating microscope (DOM), a future early visit was planned for the patient. An intra-canal dressing with calcium hydroxide paste (Calcicur; VOCO, Cuxhaven, Germany) was placed into the root canals using a Lentulo Spiral (DentsplyMaillefer). The access cavity was sealed temporarily with a cotton pellet and Cavit (3M ESPE AG, Seefeld, Germany).
On the second visit, the access cavity was re-entered under local anesthesia. Floor of pulp chamber was further observed under DOM (Seiler Revelation Microscope, St. Louis, MO) and two additional orifices, palate-mesiobuccal (P-MB) and palate-distobuccal (P-DB)  were located [Figure 1]b]. Coronal enlargement was performed with a nickel-titanium (Ni-Ti) ProTaper (PT) series orifice shaper (DentsplyMaillefer, Ballaigues, Switzerland) to improve the straight-line access to all the root canal orifices. The working length was determined with the help of an apex locator (Rayapex, DentsplyMaillefer, Ballaigues, Switzerland) and later confirmed using a radiograph [Figure 1]c]. Multiple working length radio-graphs were taken at different angulations for further understanding of root canal morphology. Cleaning and shaping were performed using PT Ni-Ti rotary instruments with a crown-down technique.Irrigation was performed using normal saline, 2.5% sodium hypochlorite solution, and 17% EDTA; 2% chlorhexidine di-gluconate was used as the final irrigant. The canals were dried with absorbent points, and obturation was performed using cold lateral compaction of gutta-percha and AH Plus resin sealer (MailleferDentsply, Konstanz, Germany). The tooth was then restored with Miracle Mix (GC Corp, Tokyo, Japan) [Figure 1]d]. However, all the six root canals could not be visualized separately after obturation because of the two-dimensional nature of radiographs. Subsequently, endodontic management of tooth #15 was completed.The patient was advised a full-coverage porcelain crown and was asymptomatic during the follow-up period of 12 months [Figure 2].
|Figure 1: (a) Preoperative radiograph, (b) An access opening shows six root canal orifi ces named according to the nomenclature proposed by Kottoor et al., (c) Working length radiograph demonstrating Vertucci Type II canal confi guration in the 3 roots, (d) Post-operative radiograph|
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| Discussion|| |
Several studies have investigated the anatomy of root canal systems and the anatomical variations found in the different types of teeth. These have provided information that might improve the outcome of endodontic treatment. Out of the various laboratory ex vivo studies in the dental literature only two have reported the presence of six or more root canals in maxillary first molar and with an incidence of 0.31-0.72%. , Conversely, several case reports have documented the existence of six or more root canals in maxillary first molar after 2002. A probable reason for this may be an increase in the use of supplementary aids such as DOM, in identifying and locating root canals. In the present case, the additional P-MB and P-DB canals were located while examining the pulpal floor under a DOM. DOM assists all types of endodontic procedures in producing higher-quality dentistry. Seeing better also means decreasing operating time. Use of magnification was also shown to increase the percentage of located and treated extra canals in maxillary molars. ,,, Hence, working under magnification is useful, and clinicians should give strong consideration to adopting the concept.
Numerous terminologies have been employed in the dental literature to describe the roots and root canal systems of maxillary molars. This multiplicity in naming of roots and canals makes the reader susceptible to misinterpretation. Consequently, Kottoor et al.,  and Valerian Albuquerque et al.,  proposed a new anatomically based nomenclature for the root canals providing a clear picture of any existing root and canal aberrancies in maxillary and mandibular molars, respectively. In the present case, root canal orifices were named as per this nomenclature.
The reported case presented with each root having two canals that fused to form a single canal before exit into a single apical foramen (Vertucci Type II canal configuration). After determining the working length of individual canals, the canals were individually explored with K-files. However, subsequent to the placement of the file in the first canal, the file in the second canal did not reach the full working length. Hence, it was concluded that the two canals joined at the apical third of the MB, DB, and Palatal roots. This, apical third fusion was managed by instrumentation of both the root canals independently to their full working length and obturated using cold lateral compaction of gutta-percha.
Previous case reports have used cone-beam computed tomography as an adjunctive aid for detection and management of variable root canal morphology. , The major advantages of CBCT scanning over the conventional CT scans are X-ray beam limitation, rapid scan time, and effective dose reduction; X-ray beam limitation is achieved by reducing the size of the irradiated area by collimation of the primary X-ray beam to the area of interest. , In the present case, radiographs and clinical examination clearly depicted the rare anatomic variation. Additionally, it is essential that the radiation dose is kept As Low as Reasonably Achievable (ALARA) when exposing patients to ionizing radiation.  Hence, advanced imaging techniques were not used in the present case, as endodontic management was possible with traditional radiographic techniques.
| Conclusions|| |
The anatomy of teeth is not always normal and a great number of variations could occur in formation, number of roots, and their shape. Most dentists are used to treating normal root canal configurations and therefore deviations from the norm could lead to failure in root canal therapy. These findings although are rare, an endodontic practitioner must be equipped to successfully manage root canal aberrations.
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[Figure 1], [Figure 2]