|Year : 2019 | Volume
| Issue : 3 | Page : 231-234
Root canal treatment of maxillary first molar with Vertucci Type V diagnosed by cone beam computed tomography
Abdulaziz Alsaeed1, Ahmed Jamleh2
1 Department of Dentistry, King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
2 Restorative and Prosthetic Dental Sciences, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Centre, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
|Date of Web Publication||16-Aug-2019|
Dr. Ahmed Jamleh
College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh 11426
Source of Support: None, Conflict of Interest: None
Cone beam computed tomography (CBCT) imaging can be used as a reliable aid to identify root canal system configurations and guide their treatment. The aim of this case report is to describe the root canal treatment of maxillary first molar with an unusual morphology diagnosed by CBCT. The tooth had a canal that started with a single canal orifice and ended with two apical foramina.
Keywords: Maxillary first molar, single root, Vertucci Type V
|How to cite this article:|
Alsaeed A, Jamleh A. Root canal treatment of maxillary first molar with Vertucci Type V diagnosed by cone beam computed tomography. Saudi Endod J 2019;9:231-4
|How to cite this URL:|
Alsaeed A, Jamleh A. Root canal treatment of maxillary first molar with Vertucci Type V diagnosed by cone beam computed tomography. Saudi Endod J [serial online] 2019 [cited 2020 Apr 1];9:231-4. Available from: http://www.saudiendodj.com/text.asp?2019/9/3/231/264643
| Introduction|| |
The main purpose of the endodontic treatment is to effectively shape and disinfect the root canal system. High treatment success rate can be achieved by having enough knowledge about the root canal configuration. Canal variations such as extra canals, apical ramifications, apical deltas, or lateral canals are commonly encountered and their incidence and significance have been well documented., Due to the complex dental anatomy that is not always detected radiographically, it is common for some canal parts to be overlooked during canal shaping. Moreover, this incomplete treatment might cause failure of the root canal treatment.
Cone beam computed tomography (CBCT) imaging is an invaluable tool which shows the root canal system in three dimensions with superior sensitivity relative to two-dimensional radiographic modalities.,
The literature describes various root canal morphologies in maxillary first molars. The most common configuration is the presence of three roots and four root canals. However, the presence of additional roots, canals in fused roots, C-shaped canal, and single root and a single canal have been reported [Table 1].,,,,,,,,,,,,,,,,,,, This case report discusses the diagnosis and treatment of an unusual root canal configuration of maxillary first molar, showing single root with single canal divides deeply into two canals and two foramina with the aid of CBCT.
|Table 1: Case reports of maxillary first molar with unusual canal morphology|
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| Case Report|| |
This case report complies with the Helsinki Declaration, and the patient provided informed consent. A 25-year-old Saudi female patient was referred to our department in the dental center at King Abdulaziz Medical City, National Guard Hospital, Riyadh, Saudi Arabia. The patient had a chief complaint of pus exudate coming from the upper right side for a long period of time. The history revealed that the patient had a restoration for more than 5 years. Clinical examinations revealed the presence of orthodontic band on tooth #16 and a discharging sinus tract between teeth #16 and #15. The sinus tract was traced with gutta-percha size 30 which was directed at the apical area of #16 [Figure 1]a. Tooth #16 was not tender to percussion; not responsive to thermal pulp testing; and not mobile with normal probing depths. A diagnosis of pulpal necrosis with chronic apical abscess of the right maxillary first molar was established, and root canal treatment followed by crown placement was planned.
|Figure 1: Preoperative radiograph of the right maxillary molars with sinus tract tracing (a) and different CBCT slice images show that the canal starts as one and branches at the apical 3 mm ending with two foramina. The black arrow points at the two canal spaces (b-f). Access cavity (g). Postobturation radiographs with straight and mesial angle views (h and i). The white arrow points at the two exits|
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Preoperative radiograph revealed the presence of one root in tooth #16 with large canal in the middle and apical radiolucency. CBCT (Planmeca Promax, Planmeca, Finland) was taken to assess the unusual tooth morphology. The three-dimensional CBCT imaging was made with 0.2 mm-thick slices. The images revealed that the tooth had a large single canal divided at 2.5 mm away from the apex into two canals which were located buccally and palatally [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f.
After giving anesthesia of 2% lidocaine with 1:100,000 epinephrine, a rubber dam was placed and access cavity was prepared. Under dental operating microscope at ×8.5 (OPMI Pico, Carl Zeiss Surgical, Oberkochen, Germany), the presence of a single-wide canal orifice was found in the center of the pulpal floor [Figure 1]g. In this visit, initial cleaning with size 15 K file along with 5.25% sodium hypochlorite irrigation was performed. The canal was dried with paper points and medicated with nonsetting calcium hydroxide (UltraCal XS, Ultradent, St Louis, MO).
The second visit was scheduled after 4 weeks. The working length was determined using electronic apex locator and confirmed by digital radiograph. The canal space was shaped with size 15–25 K files which were prebent and placed alternatively against the buccal and palatal walls to negotiate the canal till the buccal and palatal canal foramina. The canal was then shaped with profile rotary system (Dentsply Maillefer, Ballaigues, Switzerland) in a crown-down fashion until size 40 taper 6% reached the working length. During canal shaping, EDTA gel (Glyde File Prep. Dentsply Maillefer, Ballaigues, Switzerland) was used as lubricant, and the root canal was disinfected with 5.25% sodium hypochlorite solution. Canal obturation was performed with two gutta-percha cones size 40 taper 6% placed to reach close to the two canal foramina and AH26 sealer (Dentsply Maillefer, Ballaigues, Switzerland) using hybrid technique (cold lateral/warm vertical compaction) [Figure 1]h and [Figure 1]i. Hybrid technique was proposed by Tagger, wherein thermomechanical compaction following lateral condensation of the apical part of the master cone with addition of accessory cones. Pulp chamber was cleaned with alcohol-moistened cotton pellet. Moreover, the tooth was subsequently built up and finally restored with porcelain fused to metal crown.
One-year follow-up showed that the patient was asymptomatic and comfortable. Clinical examination revealed normal response to percussion and palpation. Radiographic [Figure 2]a and [Figure 2]b and CBCT [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f, [Figure 2]g examination showed significant osseous healing around the root.
|Figure 2: One-year follow-up radiographic (a and b) and cone beam computed tomography images of right maxillary molars (c-g). The black arrow points at the two canal spaces located at the apical third which were filled|
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| Discussion|| |
The American Association of Endodontists and American Academy of Oral and Maxillofacial Radiology and the European Society of Endodontology Position Statement recommended intraoral radiograph as the imaging modality of choice. Furthermore, they stated that CBCT should be considered as an adjunct in certain situations such as investigation of teeth with complex anatomy or inconclusive interpretation of two-dimensional radiographs., CBCT has emerged as an invaluable tool in the field of endodontics due to its accuracy, reliability, and three-dimensional imaging capabilities. In this case, we took CBCT to further investigate the root canal morphology. The CBCT confirmed the presence of a single root with single canal, as shown in the periapical radiograph, which was divided at deep level and ended with two apical foramina. The use of dental operating microscope offers an excellent magnification and illumination of the operating field that substantially improves the visualization of canal system, quality of treatment, the ease of documentation and enhances ergonomics., Kim and Baek stated that the use of dental operating microscope is important to visualize the deep bifurcation and the two separate canals. In this experiment, this device facilitated detection of the canal bifurcation at deep level. Moreover, since the CBCT showed deep canal bifurcation into buccal and palatal canals, the endodontic files were bent and placed against the buccal and palatal walls, respectively, to negotiate the canals until the two foramina. Collectively, these techniques and tools were used to facilitate shaping the canal system.
Extensive research has been done to investigate root canal anatomy. A recent CBCT study was conducted to detect the root canal morphology of 351 maxillary first molar teeth in Saudi Arabian patients. However, no tooth was found with a single canal which confirmed the rarity of this case. Although many published case reports worldwide showed maxillary first molars with a single canal,,,, none was able to show it with two apical foramina. On the other hand, Ratanajirasut et al. studied CBCT images of maxillary first and second molars and found a configuration (Type V) similar to our case only in 3 of 457 maxillary second molars. Our finding stresses on the importance of using CBCT in cases with unusual anatomy and a careful study of the root canal system before the treatment.
In conclusion, this case report presents an unusual morphology of a maxillary first molar with a single root canal that is bifurcated deeply with two foramina. The use of CBCT technology provides a better understanding of the root canal anatomy, especially in endodontic cases with unusual morphology, which ultimately guides the clinician to explore the root canal system and clean, shape, and obturate it more efficiently.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Friedman S. Prognosis of initial endodontic therapy. Endod Topics 2002;2:59-88.
Wolcott J, Ishley D, Kennedy W, Johnson S, Minnich S, Meyers J, et al.
A5 yr clinical investigation of second mesiobuccal canals in endodontically treated and retreated maxillary molars. J Endod 2005;31:262-4.
Jung IY, Seo MA, Fouad AF, Spångberg LS, Lee SJ, Kim HJ, et al.
Apical anatomy in mesial and mesiobuccal roots of permanent first molars. J Endod 2005;31:364-8.
Marroquín BB, El-Sayed MA, Willershausen-Zönnchen B. Morphology of the physiological foramen: I. Maxillary and mandibular molars. J Endod 2004;30:321-8.
Song M, Kim HC, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodontic treatment by microscopic inspection during endodontic microsurgery. J Endod 2011;37:1516-9.
AAE and AAOMR joint position statement: Use of cone beam computed tomography in endodontics 2015 update. J Endod 2015;41:1393-6.
Al-Shehri S, Al-Nazhan S, Shoukry S, Al-Shwaimi E, Al-Sadhan R, Al-Shemmery B. Root and canal configuration of the maxillary first molar in a Saudi subpopulation: A cone-beam computed tomography study. Saudi Endod J 2017;7:69-76. [Full text]
Holtzman L. Multiple canal morphology in the maxillary first molar: Case reports. Quintessence Int 1997;28:453-5.
Hülsmann M. A maxillary first molar with two disto-buccal root canals. J Endod 1997;23:707-8.
Di Fiore PM. A four-rooted quadrangular maxillary molar. J Endod 1999;25:695-7.
Fava LR. Root canal treatment in an unusual maxillary first molar: A case report. Int Endod J 2001;34:649-53.
De Moor RJ. C-shaped root canal configuration in maxillary first molars. Int Endod J 2002;35:200-8.
Baratto-Filho F, Fariniuk LF, Ferreira EL, Pecora JD, Cruz-Filho AM, Sousa-Neto MD, et al.
Clinical and macroscopic study of maxillary molars with two palatal roots. Int Endod J 2002;35:796-801.
Maggiore F, Jou YT, Kim S. A six-canal maxillary first molar: Case report. Int Endod J 2002;35:486-91.
Barbizam JV, Ribeiro RG, Tanomaru Filho M. Unusual anatomy of permanent maxillary molars. J Endod 2004;30:668-71.
Ferguson DB, Kjar KS, Hartwell GR. Three canals in the mesiobuccal root of a maxillary first molar: A case report. J Endod 2005;31:400-2.
Gopikrishna V, Reuben J, Kandaswamy D. Endodontic management of a maxillary first molar with two palatal roots and a single fused buccal root diagnosed with spiral computed tomography – A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e74-8.
Aggarwal V, Singla M, Logani A, Shah N. Endodontic management of a maxillary first molar with two palatal canals with the aid of spiral computed tomography: A case report. J Endod 2009;35:137-9.
Shigli A, Agrawal A. Permanent maxillary first molar with single root and single canal: A case report of a rare morphology. J Indian Soc Pedod Prev Dent 2010;28:121-5.
] [Full text]
Kottoor J, Velmurugan N, Sudha R, Hemamalathi S. Maxillary first molar with seven root canals diagnosed with cone-beam computed tomography scanning: A case report. J Endod 2010;36:915-21.
Kottoor J, Velmurugan N, Surendran S. Endodontic management of a maxillary first molar with eight root canal systems evaluated using cone-beam computed tomography scanning: A case report. J Endod 2011;37:715-9.
Kottoor J, Velmurugan N, Ballal S, Roy A. Four-rooted maxillary first molar having C-shaped palatal root canal morphology evaluated using cone-beam computerized tomography: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e41-5.
Martins JN, Quaresma S, Quaresma MC, Frisbie-Teel J. C-shaped maxillary permanent first molar: A case report and literature review. J Endod 2013;39:1649-53.
Chhabra N, Singbal KP, Chhabra TM. Type I canal configuration in a single rooted maxillary first molar diagnosed with an aid of cone beam computed tomographic technique: A rare case report. J Conserv Dent 2013;16:385-7.
] [Full text]
Badole GP, Warhadpande MM, Shenoi PR, Lachure C, Badole SG. A rare root canal configuration of bilateral maxillary first molar with 7 root canals diagnosed using cone-beam computed tomographic scanning: A case report. J Endod 2014;40:296-301.
Saxena A, Singh A, Ikhar A, Chandak M. A rare case of maxillary first molar with single root and single canal diagnosed using spiral computed tomographic scan. J Indian Soc Pedod Prev Dent 2014;32:242-5.
] [Full text]
Al-Habboubi TM, Al-Wasi KA. Maxillary first molars with six canals confirmed with the aid of cone-beam computed tomography. Saudi Endod J 2016;6:136-40. [Full text]
Tagger M, Tamse A, Katz A, Korzen BH. Evaluation of the apical seal produced by a hybrid root canal filling method, combining lateral condensation and thermatic compaction. J Endod 1984;10:299-303.
European Society of Endodontology, Patel S, Durack C, Abella F, Roig M, Shemesh H, et al.
European Society of Endodontology position statement: The use of CBCT in endodontics. Int Endod J 2014;47:502-4.
Glenn A, van AS. Use of the dental operating microscope in laser dentistry: Seeing the light. J Laser Dent 2007;15:122-9.
Kim S, Baek S. The microscope and endodontics. Dent Clin North Am 2004;48:11-8.
Ratanajirasut R, Panichuttra A, Panmekiate S. A cone-beam computed tomographic study of root and canal morphology of maxillary first and second permanent molars in a Thai population. J Endod 2018;44:56-61.
[Figure 1], [Figure 2]