|Year : 2014 | Volume
| Issue : 3 | Page : 149-153
Endodontic management of maxillary first molar having five root canals with the aid of spiral computed tomography
Karthik Shetty, Amit Yadav, Vaitheeswaran Mohan Babu
Departments of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||6-Aug-2014|
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Light House Hill Road, Mangalore 575001, Karnataka
Source of Support: None, Conflict of Interest: None
A thorough knowledge of root canal anatomy is essential for the endodontic therapy.Aberrations in the root canal system, especially in multirooted teeth, can pose a considerable challenge to the endodontist during root canal treatment. The dentist should be familiar with various root canal configurations and their variations for successful endodontic therapy. It is important to evaluate each individual case for variations.There are rare variations in root canal number and configuration in maxillary molars, which could affect treatment outcome. The present case report presents the endodontic management of a maxillary first molar with a variant root canal anatomy, having five root canals, with mesiobuccal root havingtwocanals (Vertucci type II), distobuccal root having onecanal and the palatal root having twocanals (Vertucci type II). The variant root canal anatomywas confirmed using a spiral computed tomography (SCT).With 3D reconstruction of the SCT image of the tooth, it was possible to scrutinize the patency of the canal lumens, throughout the entire length of the palatal root.This case report highlights the value of a SCT scan as a supplement to plain radiographs for the accurate diagnosis and successful endodontic management of a complex morphological variation in root canals.It also serves to remind the clinicians that such anatomic variations should be kept in mind during the endodontic treatment of maxillary first molars.
Keywords: Maxillary first molar, root canal morphology, spiral CT, two palatal canals, Vertucci type II
|How to cite this article:|
Shetty K, Yadav A, Babu VM. Endodontic management of maxillary first molar having five root canals with the aid of spiral computed tomography. Saudi Endod J 2014;4:149-53
|How to cite this URL:|
Shetty K, Yadav A, Babu VM. Endodontic management of maxillary first molar having five root canals with the aid of spiral computed tomography. Saudi Endod J [serial online] 2014 [cited 2021 May 6];4:149-53. Available from: https://www.saudiendodj.com/text.asp?2014/4/3/149/138151
| Introduction|| |
The success of endodontic treatment is greatly dependent on the meticulousness of the root canal instrumentation and the quality of the obturation. The ability of the clinician to understand and navigate through the highly variable root canal system plays a prominent role.
Failure to detect and thus disinfect a canal specially in teeth with aberrant canal morphology is one of the main causes for failure of endodontic therapy.  The root canal anatomy of the maxillary first molar has been studied extensively and the most common configuration described is the presence of three roots with three canals, while the most frequent variation is the presence of second mesiobuccal canal (MB2).  Other variations include one,  two,  four  and five  roots and unusual morphology of root canals within individual roots, uptoeight canals  havebeen reportedin maxillary first molar [Table 1].
|Table 1: Case reports of number of root canals in permanent maxillary first molar and the method used to identify canals |
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Most of the previous case reports have used radiographs for the diagnosis and management of these cases. Since the radiographic image is a 2D image it has its limitation and a 3D imaging modality like a spiral computed tomography (SCT) or a cone-beam computed tomography (CBCT) provides the clinician with additional information which can be critical in the management of cases with such canal aberrations. The present case report discusses the successful endodontic management of a maxillary first molar with three roots and five canals. The unusual morphology was confirmed using SCT scans.
| Case report|| |
A 55-year-old male patient wasreferred to the Department of Conservative Dentistry and Endodontics with a chief complaint of intermittent, spontaneous pain with the right maxillary first molar for the past 2 days. The pain was throbbing in nature and intensified by thermal stimuli and on mastication. History revealed intermittent pain in the same tooth with hot and cold stimuli for the past 2 weeks. Patient's medical history was non-contributory.
Clinical examination revealed that the upper right firstmolar (#16) had deep dentinal caries, which was sensitive to probing, not tender on percussion andperiodontally sound with normal probing depth. Interestingly, this tooth had cusp of Carabelli of an unusually large size [Figure 1]b]. Radiographic examination of the concerned tooth revealed coronal radiolucency involving the pulp space and thickening of PDL space [Figure 1]a].
|Figure 1: (a) Pre-operative radiograph.(b)Pulp chamber floor showing fivecanal orifices. (c) Length-determination radiograph. (d) Postoperative radiograph|
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A diagnosis of symptomatic irreversible pulpitis and symptomatic apical periodontitis was made. Endodontic treatment was initiated under rubber dam isolation. The morphological variation of this tooth reflected in the internal anatomy too as two palatal root canals (DP and MP) were evident visually [Figure 1]b]. Two canals were also present in the mesiobuccal root (MB1 and MB2), while there was a single canal in the distobuccal root. To confirm this, intra-oral periapical radiograph (IOPA) was taken with files in the canals. It revealed two separate canals in a single palatal root which join in the apical third (Vertucci type II), the mesiobuccal root also revealed two separate canals which joined in the apical third (Vertucci type II), and the distobuccal root had a single canal [Figure 1]c].
To assess the complex root anatomy, SCT of the involved tooth was planned. Informed consent from the patient was obtained. A multislice helical or SCT imaging was performed in the Maxilla (GE BRIGHT SPEED, MD CT 16). A 3D image of the maxilla was obtained. The tooth in question was focused and its morphology was obtained in both longitudinal and cross-sections of 0.5 mm thickness [Figure 2].
|Figure 2: Axial section spiral computerized tomography (SCT) of the maxillary arch. (a) Cervical third. (b) Middle third. (c) Apical third SCT images showing fivecanals with twopalatal canals of tooth #16|
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A3D reconstruction of the SCT image of the tooth and scrutinizing the patency of the canal lumens throughout the entire length of the palatal root with the help of the SCT images werecarried out. This confirmed the presence of two separate root canals in the palatal rootand the mesiobuccal roots. The images revealed two root canals in the palatal and mesiobuccal roots which were meeting in the apical third.
All the five canals were negotiated using K-flex files (Dentsply, Maillefer, Ballaigues, Switzerland). Working length was determined using an apex locator (Root ZX, Morita, Tokyo, Japan) and confirmed radiographically. The canals were then prepared with ProTaper rotary instruments (Dentsply, Maillefer, Ballaigues, Switzerland) using copious amount ofGlyde (Dentsply, Maillefer, Ballaigues, Switzerland) as a lubricant during the preparation. Canal disinfection was performed using 2.5% sodium hypochlorite. After root canal cleaning and shaping, the canals were properly dried with absorbent paper points and the tooth was temporizedwith IRM cement (Dentsply De Trey GmbH, Konstanz, Germany). Two weeks later, once the tooth was asymptomatic, obturation was done with gutta-percha and AH plus sealer (Dentsply-DeTrey, Switzerland) [Figure 1]d]. The access cavity was sealed with a temporary restorative material and the patient was recalled for permanent restoration at a later date.
| Discussion|| |
A thorough knowledge of the anatomic morphology is essential for the success of root canal treatment. Specific clinical recommendations  have been given which may serve as a guideline for location and the number of root canals in any individual teeth, it is very important that careful attention is paid to any evidence of additional root canals. In the present case report the presence of an unusually large cusp of Carabelli suggested toward the presence of an additional root canal which was later confirmed clinically and in SCT scans. Another hint for the presence of two separate palatal canals is the observation of a palatogingival groove on the palatal surface of the crown and root;  however, this was not apparent in the presented case.
A secondmesiobuccal canal in the mesiobuccal root (MB2) is the most common variation for the root canal anatomy of maxillary first molar. It is found in 50.4-91% of the cases.  With the use of newer imaging modalities and dental operating microscope more number of canals are identified and disinfected. In the present case also, two canals were found in the mesiobuccal root which joined at the apical third.
Previous case reports [Table 1] havereportedthe incidence of two canals/roots in maxillary first molar inany of the rootswhich suggested that this anomaly should not be left out of consideration during the endodontic treatment of maxillary first molar.
Dentalradiographic evaluation is a fundamental tool for endodontic diagnosis. Conventional intraoral periapical radiographs are routinely employed during endodontic diagnosis to examine the tooth, identify the pathology and plan the treatment. However, a conventional radiograph is a 2D image of a 3D object and consequently has limitations. Numerousprior studies have demonstrated the effective use of SCT in the assessment of complex endodontic cases. ,,, With SCT, it is possible to reconstruct overlapping structures at arbitrary intervals and thus the ability to resolve small objects is increased.
With the use of SCT, detailed examination of the entire root canal system has now become possible as thin slices of dental roots and canal systems can be viewed. Additionally, advanced dental soft-wares allow 3D reconstructions of images across a multitude of planes.
Beatty  reported a maxillary first molar with five canals, three of them located in the mesiobuccalroot. StoneandStroner  described variations of the palatal root of maxillary molars, such as a single root with two separate orifices, two separate canals and two separate foramina, two separate roots each with one orifice, one canal and one foramen, single root with one orifice, a bifurcated canal and two separate foramina. Benenati  described a maxillary second molar with two palatal roots and a groovelocated on the palatal side of the tooth as a result of theformation of the two palatal roots. Bond et al.  described a case of a maxillary first molarwith six root canals, two in each root. Wong  reported a case of a maxillary firstmolar with the palatal canal trifurcating at the apical level, with three independent foramina. Recently, Kottor et al.  reported the presence of seven canals in maxillary first molar (three in the mesial root, two in the distal root and two in the palatal root). Kottor et al.  also reported the presence of eight canals in the maxillary first molar with the help of CBCT imaging.
The ability to differentiate between the two closely located canals within a root has always been a matter of concern for the clinician. Barrato et al.  stated that when indistinct images of palatal roots are presented in preoperative X-ray images, the clinician must consider the possibility of two palatal roots. In such a situation the possibilities that the newer imaging solutions, which remove the subjectivity from the diagnostic process, offer us are very encouraging.
| Conclusion|| |
With the usage of better imaging modalities which are now available at our disposal, it is now possible to visualize areas of the root canals which were previously hidden from view, due to the limitations of the IOPA. SCT also has the added advantage of being a commonly available tool as compared to the dental-specific variants like Tuned-aperture computed tomography (TACT) and CBCT. This case report demonstrates the value of a SCT scan as a supplement to plain radiographs in selected endodontic clinical situations. The result of its use was a more exact diagnosis and safer clinical management of the case.
| References|| |
|1.||Siqueira JF Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod 2008;34:1291-301.e3. |
|2.||Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccalroot of maxillary first and second molars. J Endod 1990;16:311-7. |
|3.||Gopikrishna V, Bhargavi N, Kandaswamy D. Endodontic management of a maxillary first molar with a single root and a single canal diagnosed with the aid of spiral CT: A case report. J Endod 2006;32:687-91. |
|4.||AtashBiz Yeganeh L, Adel M, Vahedi R, Tofangchiha M. Endodontic management of a maxillary first molar with two palatal canals and a single buccal canal: A case report. Case Rep Dent 2012;2012:389387. |
|5.||Christie WH, Peikoff MD, Fogel HM. Maxillary molars with two palatal roots: A retrospectiveclinical study. J Endod 1991;17:80-4. |
|6.||Barbizam JV, Ribeiro RG, TanomaruFilho M. Unusual anatomy of permanent maxillarymolars. J Endod 2004;30:668-71. |
|7.||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. |
|8.||Cecic P, Hartwell G, Bellizzi R. The multiple root canal system in the maxillary firstmolar: A case report. J Endod 1982;8:113-5. |
|9.||Bond JL, Hartwell G, Portell FR. Maxillary first molar with six canals. J Endod 1988;14:258-60. |
|10.||Holtzman L. Multiple canal morphology in the maxillary first molar: Case reports. Quintessence Int 1997;28:453-5. |
|11.||Johal S. Unusual maxillary first molar with 2 palatal canals within a single root: A case report. J Can Dent Assoc 2001;67:211-4. |
|12.||Poorni S, Kumar A, Indira R. Maxillary first molar with aberrant canal configuration: A report of 3 cases. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2008;106:e53-5. |
|13.||Gopikrishna V, Reuben J, Kandaswamy D. Endodontic management of a maxillaryfirst molar with two palatal roots and a single fused buccal root diagnosed withspiral computed tomography-a case report. Oral Surg Oral Med Oral PatholOral RadiolEndod 2008;105:e74-8. |
|14.||de Almeida-Gomes F, Maniglia-Ferreira C, Carvalho de Sousa B, Alves dos Santos R. Six root canalsin maxillary first molar. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2009;108:e157-9. |
|15.||Aggarwal V, Singla M, Logani A, Shah N. Endodontic management of a maxillary firstmolar with two palatal canals with the aid of spiral computed tomography: A casereport. J Endod 2009;35:137-9. |
|16.||HolderriethS, GernhardtCR. Maxillary molars withmorphologic variations of the palatal root canals: A reportof four cases. J Endod2009;35:1060-5. |
|17.||Deepalakshmi M, Miglani R, Indira R, RamachandranS. Spiral CT diagnosis and endodontic management ofan anatomically variant palatal root with two canals in amaxillary first molar. Indian J Dent Res2010;21:443-5. |
|18.||KottoorJ, 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. |
|19.||Kaushik M, Mehra N. Maxillary first molars with six canals diagnosed with the aid of cone beam computed tomography: A report of two cases. Case Rep Dent 2013;2013:406923. |
|20.||Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor. J Endod 2004;30:5-16. |
|21.||Benenati FW. Maxillary second molar with two palatal canals and a palatogingivalgroove. J Endod 1985;11:308-10. |
|22.||Baratto-Filho F, Fariniuk LF, Ferreira EL, Pecora JD, Cruz-Filho AM, Sousa-Neto MD. Clinical and macroscopic study of maxillary molars with two palatal roots. IntEndod J 2002;35:796-801. |
|23.||Reddy YP, Karpagavinayagam K, Subbarao CV. Management of dens invaginatus diagnosed by spiral computed tomography: A case report. J Endod 2008;34:1138-42. |
|24.||Ballal S, Sachdeva GS, Kandaswamy D. Endodontic management of a fused mandibular second molar and paramolar with the aid of spiral computed tomography: A case report. J Endod 2007;33:1247-51. |
|25.||Robinson S, Czerny C, Gahleitner A, Bernhart T, Kainberger FM. Dental CT evaluation of mandibular first premolar root configurations and canal variations. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2002;93:328-32. |
|26.||Sponchiado EC Jr, Ismail HA, Braga MR, de Carvalho FK, Simões CA. Maxillary central incisor with two root canals: A case report. J Endod 2006;32:1002-4. |
|27.||Beatty RG. A five-canal maxillary first molar. JEndod1984;10:156-7. |
|28.||Stone LH, Stroner WF. Maxillary molars demonstrating more than one palatal root canal. Oral Surg Oral Med Oral Pathol1981;51:649-52. |
|29.||Wong M. Maxillary first molar with three palatal canals. J Endod 1991;17:298-9. |
[Figure 1], [Figure 2]