|Year : 2020 | Volume
| Issue : 1 | Page : 74-76
Root canal treatment of a maxillary second premolar with Type VI canal configuration
Yaser Mohammad Almazrou1, Yazeed Almuhizi2
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 Submission||28-Nov-2018|
|Date of Decision||26-Jan-2019|
|Date of Acceptance||15-Feb-2019|
|Date of Web Publication||27-Dec-2019|
Dr. Yaser Mohammad Almazrou
Presidency of State Security, Department of Medical Services, Riyadh 13624
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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.
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.
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. 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.
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.
| Case Report|| |
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|| |
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, and the current standard for the practice of endodontics necessitates the use of a microscope. 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.
Cone-beam computed tomography (CBCT) is a reliable method to detect canals that could be missed. 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. 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. 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. 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%. 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%.
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. 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.
| Conclusion|| |
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.
We thank Prof. Saad Al Nazhan for his general support and technical help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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