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CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 74-76

Root canal treatment of a maxillary second premolar with Type VI canal configuration


1 Presidency of State Security, Department of Medical Services, Riyadh, Saudi Arabia
2 Security Forces Hospital, Department of Dental Medicine, Riyadh, Saudi Arabia

Date of Submission28-Nov-2018
Date of Decision26-Jan-2019
Date of Acceptance15-Feb-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Yaser Mohammad Almazrou
Presidency of State Security, Department of Medical Services, Riyadh 13624
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_133_18

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  Abstract 

The roots and canals of maxillary second premolar have several typical anatomical features, as well as a great number of anomalies. The awareness toward atypical anatomy can be a critical factor in determining the success of endodontic therapy. This case report of 32-year-old healthy female patient describes the successful endodontic therapy of a left maxillary second premolar with Type VI configuration according to Vertucci's classification. The pulp of the tooth was previously initiated with asymptomatic apical periodontitis. An operating dental microscope was used to locate the orifices of the canals. Recall radiograph shows reduction in the size of the apical radiolucency.

Keywords: Maxillary second premolar, root canal morphology, root canal treatment, Vertucci's classification


How to cite this article:
Almazrou YM, Almuhizi Y. Root canal treatment of a maxillary second premolar with Type VI canal configuration. Saudi Endod J 2020;10:74-6

How to cite this URL:
Almazrou YM, Almuhizi Y. Root canal treatment of a maxillary second premolar with Type VI canal configuration. Saudi Endod J [serial online] 2020 [cited 2020 Jan 26];10:74-6. Available from: http://www.saudiendodj.com/text.asp?2020/10/1/74/274182


  Introduction Top


Variations in root canal morphology have been demonstrated in many studies and case reports. The canals and roots of maxillary second premolar have several typical anatomical features, as well as a great number of anomalies. Pécora et al. stated that the complexity of internal and external anatomical variations makes it a challenge to do root canal treatment for maxillary second premolars. They also found that there are some difficulties in determining the border of the apex with radiographs.[1]

Vertucci et al. studied the root canal anatomy of 200 human maxillary second premolars; they reported that 75% of the teeth have one canal at the apex; two canals were present in 24%; and 1% of the teeth studied have three canals. Of the 200 maxillary second premolars, 48% has Vertucci Type I pattern and 22% possessed Type II. Type VI configuration was present in 5% of the teeth studied.[2]

Bulut et al. evaluated the root canal configuration of premolars. They found that 82.1% of maxillary second premolars had one canal and one root and 17.8% had two canals and two roots; Type VI canal configuration was found in 0.17% of 476 maxillary second premolars.[3] In a micro-computed tomography study conducted on 100 maxillary second premolars of Saudi Arabian individuals, there was no Type VI configuration in that sample.[4]

This case report describes the successful root canal therapy of a left maxillary second premolar with Type VI pattern according to Vertucci's classification of root canal morphology.[5]


  Case Report Top


A 32-year-old Saudi female patient, not aware about any illness, referred to endodontic clinic from a general practitioner clinic after pulp extirpation of the left maxillary second premolar. On clinical examination, the tooth responded normally to percussion. Probing depth was normal around all the aspects of the tooth. Preoperative radiograph showed apical radiolucency [Figure 1]a and [Figure 1]b. The tooth was diagnosed as previously initiated pulp with asymptomatic apical periodontitis.
Figure 1: Preoperative radiograph of the maxillary left second premolar showing apical radiolucency (a). Preoperative radiograph with exaggerated mesial angulation showing apical radiolucency (b). The working length radiograph of the buccal and palatal canals (c). Postoperative radiograph showing two obturated root canals (d). Postoperative radiograph with exaggerated distal angulation showing two obturated root canals that are joined in the mid-root region and separated at the apical third (e). Clinical photograph of the maxillary left second premolar after obturation (f). Six-month recall radiograph showing signs of healing (g). Six-month recall radiograph with exaggerated distal angulation showing signs of healing (h)

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Local anesthesia with 2% lidocaine HCl and 1:80,000 adrenaline was administered. Rubber dam (HYGENIC ®) was used for isolating the tooth, and then, access opening was done. Under an operating dental microscope (Zeiss ®, Carl Zeiss, Jena, Germany), two orifices of two canals were explored with DG16 explorer. The working length was determined using different angulations [Figure 1]c. It was found to be Vertucci's Type VI pattern. Cleaning and shaping were done by crown-down technique using ProFile® nickel–titanium system up to file size 35–04 taper (Dentsply/Tulsa Dental Co., Tulsa, Okla). The root canals were irrigated with 5.25% sodium hypochlorite solution. Sterile paper points were used to dry the canals; then, the canals were filled with calcium hydroxide dressing (Calasept®, Nordiska Dental, Upplands Väsby, Sweden), and Cavit™ (3M, ESPE, St. Paul, MN, USA) was used to seal the access cavity. At the second appointment, the canals were flushed with 5.25% sodium hypochlorite and saline and obturated with the corresponding 35 ProFile® gutta-percha (Dentsply/Tulsa Dental Co., Tulsa, Okla) and Tubliseal sealer (Kerr, Romulus, MI) using warm vertical condensation [Figure 1]d, [Figure 1]e, [Figure 1]f. One week later, the patient did not have any symptoms at the recall visit. After 6 months, she has been recalled again for evaluation and the tooth was found to be asymptomatic. Recall radiographs were taken, and they were showing signs of healing such as reduction in the size of the apical radiolucency [Figure 1]g and [Figure 1]h.


  Discussion Top


The awareness toward uncommon and complicated root canal anatomy can be a critical factor in determining the success of root canal treatment. Clinicians should utilize all the possible means to ensure identification of all canals and hence proper preparation and obturation.

The dental-operating microscope had changed the practice of endodontics where it enhances the visualization of the pulp chamber and canals form and that will render cleaning and shaping the root canal system more efficiently. It is more accepted by young-aged endodontists,[6] and the current standard for the practice of endodontics necessitates the use of a microscope.[7] Al-Fouzan reported a case where he managed to diagnose and treat successfully a mandibular second premolar with four canals using the dental operating microscope.[8]

Cone-beam computed tomography (CBCT) is a reliable method to detect canals that could be missed.[9] Moreover, the diagnostic efficacy of four methods for detecting the second mesiobuccal canal (MB2) was tested on 147 extracted human maxillary molars. The authors concluded that CBCT was the most accurate method for detecting MB2.[10] However, the American Association of Oral and Maxillofacial Radiology and the American Association of Endodontists recommend that CBCT should not be used as a routine diagnostic tool in endodontics.[11] They preferred to obtain acquisitions with small field of view and voxel aiming to reduce the radiation dose if necessary. In this case, the use of CBCT was not possible because it was not available; instead, the dental-operating microscope was used. The root canal anatomy was characterized by two separate canals at the coronal part and then they joined into a single canal in the mid-root part of the tooth, and then, it divided again to two separate canals in the apical third of the root (Vertucci Type VI). The root canal morphology has been investigated in the Guanzhong region in China. The authors found that more than two-thirds of the upper second premolars had two canals with Type II, IV, or VI pattern.[12] Kartal et al. examined 300 maxillary second premolars; almost half of them had Type I pattern, whereas the incidence for Type II to Type VII patterns was 50.64%.[13] In Indian subpopulation, root canal morphology of the upper second premolars has been investigated using stereomicroscopy. They found that two-thirds of the teeth had a single-root canal at the apical third of the root and one-third of the teeth had two root canals at the apical third. Of the 200 upper second premolars, 33% had Type II pattern and 31% had Type IV pattern, whereas Type VI pattern presented in 1.2%.[14]

Type VI canal configuration (two separate canals leave the pulp chamber but join at the midpoint and divide again into two separate canals with two separate apical foramina) is very rare. In a study conducted on CBCT views of 230 upper premolars of Saudi Arabian population, 36% of all maxillary second premolars showed Type I pattern, 11% Type II, and 13% Type III. Vertucci Type VI was not found in their study.[15] In a similar study, Alqedairi et al. showed that the most upper second premolars had single root (85.2%) and 49.4% have Type I canal pattern, while 1.6% have Type VI canal configuration.[16]


  Conclusion Top


The root canal anatomy of the upper second premolars can be complicated and needs to be examined well before the commence of root canal treatment. Clinicians should utilize all the possible means to ensure identification of all canals and hence proper preparation and obturation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We thank Prof. Saad Al Nazhan for his general support and technical help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pécora JD, Sousa Neto MD, Saquy PC, Woelfel JB.In vitro study of root canal anatomy of maxillary second premolars. Braz Dent J 1993;3:81-5.  Back to cited text no. 1
    
2.
Vertucci F, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolar. Oral Surg Oral Med Oral Pathol 1974;38:456-64.  Back to cited text no. 2
    
3.
Bulut DG, Kose E, Ozcan G, Sekerci AE, Canger EM, Sisman Y, et al. Evaluation of root morphology and root canal configuration of premolars in the Turkish individuals using cone beam computed tomography. Eur J Dent 2015;9:551-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Elnour M, Khabeer A, AlShwaimi E. Evaluation of root canal morphology of maxillary second premolars in a Saudi Arabian sub-population: An in vitro microcomputed tomography study. Saudi Dent J 2016;28:162-8.  Back to cited text no. 4
    
5.
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. 5
    
6.
Alrejaie M, Ibrahim NM, Malur MH, AlFouzan K. The use of dental operating microscopes by endodontists in the Middle East: A report based on a questionnaire. Saudi Endod J 2015;5:134-7.  Back to cited text no. 6
  [Full text]  
7.
AAE Special Committee to Develop a Microscope Position Paper. AAE position statement. Use of microscopes and other magnification techniques. J Endod 2012;38:1153-5.  Back to cited text no. 7
    
8.
Al-Fouzan KS. The microscopic diagnosis and treatment of a mandibular second premolar with four canals. Int Endod J 2001;34:406-10.  Back to cited text no. 8
    
9.
Blattner TC, George N, Lee CC, Kumar V, Yelton CD. Efficacy of cone-beam computed tomography as a modality to accurately identify the presence of second mesiobuccal canals in maxillary first and second molars: A pilot study. J Endod 2010;36:867-70.  Back to cited text no. 9
    
10.
De Carlo Bello M, Tibúrcio-Machado C, Dotto Londero C, Branco Barletta F, Cunha Moreira CH, Pagliarin CML, et al. Diagnostic efficacy of four methods for locating the second mesiobuccal canal in maxillary molars. Iran Endod J 2018;13:204-8.  Back to cited text no. 10
    
11.
Special Committee to Revise the Joint AAE/AAOMR Position Statement on use of CBCT in Endodontics. AAE and AAOMR joint position statement: Use of cone beam computed tomography in endodontics 2015 update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120:508-12.  Back to cited text no. 11
    
12.
Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al. Root canal morphology of permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: A new modified root canal staining technique. J Endod 2009;35:651-6.  Back to cited text no. 12
    
13.
Kartal N, Ozçelik B, Cimilli H. Root canal morphology of maxillary premolars. J Endod 1998;24:417-9.  Back to cited text no. 13
    
14.
Jayasimha Raj U, Mylswamy S. Root canal morphology of maxillary second premolars in an Indian population. J Conserv Dent 2010;13:148-51.  Back to cited text no. 14
    
15.
Elkady A, 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. 15
    
16.
Alqedairi A, Alfawaz H, Al-Dahman Y, Alnassar F, Al-Jebaly A, Alsubait S, et al. Cone-beam computed tomographic evaluation of root canal morphology of maxillary premolars in a Saudi population. Biomed Res Int 2018;2018:8170620.  Back to cited text no. 16
    


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