Home Print this page Email this page Users Online: 727
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 3  |  Page : 153-156

Cone-beam computed tomography of bilateral radiculous maxillary first premolars


1 Department of Endodontics, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia; Dental Department, Ministry of Health, Kuwait
2 Preventive Department, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia; Dental Department, Ministry of Health, Kuwait
3 Department of Restorative Dental Sciences, Division of Endodontics, King Saud University, College of Dentistry, Riyadh, Saudi Arabia

Date of Web Publication29-Aug-2016

Correspondence Address:
Mohammad Ahmad Alenezi
Department of Endodontics, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia; Dental Department, Ministry of Health, Kuwait

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.189352

Rights and Permissions
  Abstract 


A deep knowledge of the internal and external anatomy of various human teeth is a backbone for a successful outcome of endodontic therapy. Usually, maxillary first premolar tooth has two roots, buccal and palatal. Three-rooted maxillary first premolar is scarce. The clinician has to expect any variation in root canal system and use the best diagnostic tools to manage the cases. The aim of this case report was to illustrate bilateral three-rooted maxillary first premolars and to describe the endodontic implication in preoperative assessment and during operative procedures.

Keywords: Cone-beam computed tomography, maxillary first premolar, root canal morphology, three roots


How to cite this article:
Alenezi MA, Tarish MA, Al-Nazhan S. Cone-beam computed tomography of bilateral radiculous maxillary first premolars. Saudi Endod J 2016;6:153-6

How to cite this URL:
Alenezi MA, Tarish MA, Al-Nazhan S. Cone-beam computed tomography of bilateral radiculous maxillary first premolars. Saudi Endod J [serial online] 2016 [cited 2019 Dec 12];6:153-6. Available from: http://www.saudiendodj.com/text.asp?2016/6/3/153/189352




  Introduction Top


The major purpose of root canal therapy is to carry out adequate biomechanical preparation, fill, and seal the entire root canal system. Failure to do that may lead to posttreatment complications and diseases.[1],[2] Therefore, the dental practitioners should have a sound knowledge of internal and external teeth morphology and their frequent variations to improve the predictability of root canal therapy.[3]

The maxillary first premolar teeth morphology has been studied by different methods.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] These teeth may reveal a considerable variation in their roots number, ranging from one to three. The percentage three-rooted maxillary first premolar has been reported to range from 0.4% to 4%.[4],[13],[14],[15],[16]

Bellizzi and Hartwell [17] and Carlsen [18] classified the external anatomical features of three-rooted maxillary premolars into three classes and categories [Table 1]. In addition, three-rooted maxillary molars teeth also named as radiculuos premolars, small molars, mini-molars, and miniature three-canalled maxillary molars.[19],[20],[21]
Table 1: Classification of the external anatomical features of three-rooted maxillary premolars

Click here to view



  Case Report Top


An 18-year-old Saudi male with no history of any systemic diseases presented for periodontal treatment at Riyadh Colleges Dental Hospital. Radiographic evaluation by cone-beam computed tomography (CBCT) revealed that the maxillary right (#14) and left (#24) first premolar have three separated roots, two in the buccal side (mesiobuccal and distobuccal) and one in the palatal side [Figure 1].
Figure 1: The axial plane of cone beam computed tomography of the maxilla. White arrows denote tooth 14 and 24 with three roots

Click here to view



  Discussion and Clinical Implications Top


Endodontic success of teeth having more canals than normally expected requires a careful diagnosis and correct clinical and radiographic inspection before beginning treatment.[22] Maxillary first premolars of Saudi Arabia population have been evaluated by different methods,[9],[12],[23] and the reported percentage of three-rooted teeth was 1.2%.[9]

Sabala et al.[24] reported that 60% of root canal aberrations are bilateral, and the most rare ones are 90% bilateral, which is the same in this case.

The clinical examination of three-rooted maxillary premolars usually shows a relatively large sized crown, particularly in the mesiodistal diameter, resembling a small molar.[21] Moreover, the presence other crown anomalies such as germination might as well indicate root canal morphology.[25]

Periodontal pocket and/or gingival recession may help in identifying the external root anatomy, such as root bifurcation. However, in three-rooted premolar teeth, the furcation is commonly located between the apical and middle third of the root length,[26] which is difficult to detection.[27]

The conventional radiographic appearance of three-rooted maxillary premolars can be identified on straight preoperative radiographs, in which the mesiodistal width of the mid-root image is equal or greater than the mesiodistal width of the coronal image.[19] Tracing the periodontal ligament space of each individual root is essential. Although the radiographic interpretation would become more difficult when the three roots lie close to each other or are fused, altering the horizontal angle can facilitate their detection.[2],[21],[28]

Recent advances in diagnostic radiographic techniques have provided promise in the detection and interpretation of root canal anatomy.[29],[30],[31],[32] CBCT can provide three-dimensional imaging with a low radiation dose and reasonably high resolution, producing images resembling that of modified canal staining and clearing techniques in identifying root canal anatomy.[30],[31] However, CBCT should be only considered when the conventional periapical radiographs fail to provide adequate information and details of the structures to be identified,[33] as CBCT views can also show some misleading findings.[34]

Furthermore, CBCT reconstructed scans are invaluable for assessing teeth with unusual anatomy, such as teeth with an unusual number of roots, dilacerated teeth, and dens in dente. The exact location and anatomy of the root canal system can be assessed, allowing successful management of the clinical cases.[29],[35] In general, two and three-dimensional radiographic images are valuable tools in providing useful information regarding the root and root canal anatomy; however, they should be correlated with the clinical picture to achieve proper morphological assessment.[2],[34]

Access cavity preparation is a critical step during which accessory roots or root canals are detected. Complete removal of the roof of the pulp chamber and all interferences to the root canal orifices should then give an indication of the internal morphology features of the root.[2] Better precision and enhanced visibility of the internal root anatomy can be achieved by utilizing some form of assisted vision, such as magnification and coaxial illumination.[2],[36]

In three-rooted maxillary premolar teeth, the access cavity should be wide buccally, in a mesiodistal direction, forming a “T” shape or triangular configuration,[19],[21],[37] resembling that of maxillary molar teeth, but smaller in size. The buccal canal orifices are located at the same horizontal line, and can often be clearly identified when the two canals open into the pulp chamber separately. The two orifice openings are shifted mesially and distally, respectively, relative to the palatal orifice.

The pulp chamber volume of the three-rooted maxillary premolars variant is variable and a distance of <1 mm between the most cervical region of the pulp chamber roof and the canal bifurcation can exist.[38] This requires great caution by using suitably sized access burs to prevent accidental perforation of the pulp chamber furcation.


  Conclusion Top


The occurrence of three-rooted maxillary premolar teeth with variable morphological features reflects their extreme anatomical variability. Therefore, sufficient awareness for their identification and management is necessary to prevent any undesirable consequences, if they are missed during root canal therapy. Advanced diagnostic tools such as CBCT and magnifying equipment can be applied to improve the clinical root canal therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics 2005;10:3-29.  Back to cited text no. 1
    
2.
Cantatore G, Berutti E, Castellucci A. Missed anatomy: Frequency and clinical impact. Endod Topics 2006;15:3-31.  Back to cited text no. 2
    
3.
Friedman S. Prognosis of initial endodontic therapy. Endod Topics 2002;2:59-88.  Back to cited text no. 3
    
4.
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99.  Back to cited text no. 4
[PUBMED]    
5.
Bellizzi R, Hartwell G. Radiographic evaluation of root canal anatomy ofin vivo endodontically treated maxillary premolars. J Endod 1985;11:37-9.  Back to cited text no. 5
[PUBMED]    
6.
Walker RT. Root form and canal anatomy of maxillary first premolars in a southern Chinese population. Endod Dent Traumatol 1987;3:130-4.  Back to cited text no. 6
[PUBMED]    
7.
Pécora JD, Saquy PC, Sousa Neto MD, Woelfel JB. Root form and canal anatomy of maxillary first premolars. Braz Dent J 1991;2:87-94.  Back to cited text no. 7
    
8.
Zaatar EI, al-Kandari AM, Alhomaidah S, al-Yasin IM. Frequency of endodontic treatment in Kuwait: Radiographic evaluation of 846 endodontically treated teeth. J Endod 1997;23:453-6.  Back to cited text no. 8
    
9.
Atieh MA. Root and canal morphology of maxillary first premolars in a Saudi population. J Contemp Dent Pract 2008;9:46-53.  Back to cited text no. 9
    
10.
Awawdeh L, Abdullah H, Al-Qudah A. Root form and canal morphology of Jordanian maxillary first premolars. J Endod 2008;34:956-61.  Back to cited text no. 10
    
11.
Tian YY, Guo B, Zhang R, Yu X, Wang H, Hu T, et al. Root and canal morphology of maxillary first premolars in a Chinese subpopulation evaluated using cone-beam computed tomography. Int Endod J 2012;45:996-1003.  Back to cited text no. 11
    
12.
Elkady AM, Allouba K. Cone beam computed tomographic analysis of root and canal morphology of maxillary premolars in Saudi subpopulation. Egypt Dent J 2013;59:3419-29.  Back to cited text no. 12
    
13.
Abella F, Teixidó LM, Patel S, Sosa F, Duran-Sindreu F, Roig M. Cone-beam computed tomography analysis of the root canal morphology of maxillary first and second premolars in a Spanish population. J Endod 2015;41:1241-7.  Back to cited text no. 13
    
14.
Chaparro AJ, Segura JJ, Guerrero E, Jiménez-Rubio A, Murillo C, Feito JJ. Number of roots and canals in maxillary first premolars: Study of an Andalusian population. Endod Dent Traumatol 1999;15:65-7.  Back to cited text no. 14
    
15.
Özcan E, Çolak H, Hamidi MM. Root and canal morphology of maxillary first premolars in a Turkish population. J Dent Sci 2012;7:390-4.  Back to cited text no. 15
    
16.
Gupta S, Sinha DJ, Gowhar O, Tyagi SP, Singh NN, Gupta S. Root and canal morphology of maxillary first premolar teeth in North Indian population using clearing technique: Anin vitro study. J Conserv Dent 2015;18:232-6.  Back to cited text no. 16
[PUBMED]  Medknow Journal  
17.
Bellizzi R, Hartwell G. Evaluating the maxillary premolar with three canals for endodontic therapy. J Endod 1981;7:521-7.  Back to cited text no. 17
    
18.
Carlsen O. Dental Morphology. 1st ed. Copenhagen, Denmark: Munksgaard; 1987.  Back to cited text no. 18
    
19.
Sieraski SM, Taylor GN, Kohn RA. Identification and endodontic management of three-canalled maxillary premolars. J Endod 1989;15:29-32.  Back to cited text no. 19
[PUBMED]    
20.
Mattuella LG, Mazzoccato G, Vier FV, Só MV. Root canals and apical foramina of the buccal root of maxillary first premolars with longitudinal sulcus. Braz Dent J 2005;16:23-9.  Back to cited text no. 20
    
21.
Barros DB, Guerreiro Tanomaru JM, Tanomaru-Filho M. Root canal treatment of three-rooted maxillary second premolars: Report of four cases. Aust Endod J 2009;35:73-7.  Back to cited text no. 21
    
22.
Ferreira CM, de Moraes IG, Bernardineli N. Three-rooted maxillary second premolar. J Endod 2000;26:105-6.  Back to cited text no. 22
    
23.
Al-Nazhan S, Al-Daafas A, Al-Maflehi N. Radiographic investigation ofin vivo endodontically treated maxillary premolars in a Saudi Arabian sub-population. Saudi Endod J 2012;2:1-5.  Back to cited text no. 23
  Medknow Journal  
24.
Sabala CL, Benenati FW, Neas BR. Bilateral root or root canal aberrations in a dental school patient population. J Endod 1994;20:38-42.  Back to cited text no. 24
    
25.
Nahmias Y, Rampado ME. Root-canal treatment of a trifid crown premolar. Int Endod J 2002;35:390-4.  Back to cited text no. 25
    
26.
Alves N. Morphometric and morphological study of the dental roots of the upper first premolars. Int J Odontostomatol 2010;4:111-5.  Back to cited text no. 26
    
27.
Blanchard SB, Almasri A, Gray JL. Periodontal-endodontic lesion of a three-rooted maxillary premolar: Report of a case. J Periodontol 2010;81:783-8.  Back to cited text no. 27
    
28.
Martínez-Lozano MA, Forner-Navarro L, Sánchez-Cortés JL. Analysis of radiologic factors in determining premolar root canal systems. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:719-22.  Back to cited text no. 28
    
29.
Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG. Endodontic applications of cone-beam volumetric tomography. J Endod 2007;33:1121-32.  Back to cited text no. 29
    
30.
Sachdeva GS, Ballal S, Gopikrishna V, Kandaswamy D. Endodontic management of a mandibular second premolar with four roots and four root canals with the aid of spiral computed tomography: A case report. J Endod 2008;34:104-7.  Back to cited text no. 30
    
31.
Tu MG, Huang HL, Hsue SS, Hsu JT, Chen SY, Jou MJ, et al. Detection of permanent three-rooted mandibular first molars by cone-beam computed tomography imaging in Taiwanese individuals. J Endod 2009;35:503-7.  Back to cited text no. 31
    
32.
Neelakantan P, Subbarao C, Subbarao CV. Comparative evaluation of modified canal staining and clearing technique, cone-beam computed tomography, peripheral quantitative computed tomography, spiral computed tomography, and plain and contrast medium-enhanced digital radiography in studying root canal morphology. J Endod 2010;36:1547-51.  Back to cited text no. 32
    
33.
Patel S. New dimensions in endodontic imaging: Part 2. Cone beam computed tomography. Int Endod J 2009;42:463-75.  Back to cited text no. 33
    
34.
Krithikadatta J, Kottoor J, Karumaran CS, Rajan G. Mandibular first molar having an unusual mesial root canal morphology with contradictory cone-beam computed tomography findings: A case report. J Endod 2010;36:1712-6.  Back to cited text no. 34
    
35.
Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J 2007;40:818-30.  Back to cited text no. 35
    
36.
Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod 2002;28:324-7.  Back to cited text no. 36
    
37.
Nallapati S. Three-canal maxillary premolar teeth: A common clinical reality. Endod Pract 2003;6:22-8.  Back to cited text no. 37
    
38.
Vier-Pelisser FV, Dummer PM, Bryant S, Marca C, Só MV, Figueiredo JA. The anatomy of the root canal system of three-rooted maxillary premolars analysed using high-resolution computed tomography. Int Endod J 2010;43:1122-31.  Back to cited text no. 38
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion and C...
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1310    
    Printed21    
    Emailed0    
    PDF Downloaded192    
    Comments [Add]    

Recommend this journal