Home Print this page Email this page Users Online: 173
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 187-190

Root canal treatment of three-rooted mandibular second premolar using cone-beam computed tomography

1 Department of Restorative Dentistry, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia
2 Diploma in Endodontics, Capital Heath Region, Ministry of Health, Kuwait

Date of Web Publication26-Aug-2015

Correspondence Address:
Mohammad Ahmad Alenezi
Department of Restorative Dentistry, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Postal box 84891 Riyadh-11681
Kingdom of Saudi Arabia
Login to access the Email id

Source of Support: Nil., Conflict of Interest: None

DOI: 10.4103/1658-5984.163621

Rights and Permissions

A careful knowledge of root canals anatomy of different teeth is a corner stone for a successful outcome of root canal therapy. This reported case illustrates root canal therapy of a mandibular second premolar with three separated roots and root canals. An 18-year-old Saudi male presented for non-surgical endodontic treatment of mandibular right second premolar. Radiographic and clinical examinations revealed the presence of three roots and three root canals. The case was successfully managed with the help of cone-beam computed tomography (CBCT). In conclusion, the clinicians should always suspect the event of anatomical varieties and use all the available tools to diagnose and manage their cases.

Keywords: Anatomic variations, cone-beam computed tomography, mandibular second premolar, root canal treatment

How to cite this article:
Alenezi MA, Tarish MA, Alenezi DJ. Root canal treatment of three-rooted mandibular second premolar using cone-beam computed tomography. Saudi Endod J 2015;5:187-90

How to cite this URL:
Alenezi MA, Tarish MA, Alenezi DJ. Root canal treatment of three-rooted mandibular second premolar using cone-beam computed tomography. Saudi Endod J [serial online] 2015 [cited 2023 Mar 21];5:187-90. Available from: https://www.saudiendodj.com/text.asp?2015/5/3/187/163621

  Introduction Top

The main aim of root canal therapy is to perform proper cleaning and shaping as well as filling the entire root canal system. Failure to do that may lead to post-treatment disease and complications.[1],[2] Therefore; the clinicians should have a sound knowledge of internal and external teeth morphology and their frequent variations to improve the predictability of root canal therapy.[3]

Mandibular premolar is the most difficult tooth for endodontic therapy because of its complicated root canals morphology.[4] Several studies have correlated gender and ethnicity with anatomic variations and complexity of the root canal system in mandibular second premolars.[5] Serman and Hasselgren[6] found that males have higher prevalence number of roots and root canals in mandibular premolars than females.

The root canals morphology of the mandibular second premolar has been studied by different ways.[7],[8],[9] Premolars may show a variation in their roots numbers, the percentage of mandibular second premolars having three roots approximately 0.1%.[8]

  Case Report Top

An 18-years-old Saudi male with no history of any systemic diseases presented for endodontic treatment of his mandibular right second premolar tooth (#45). The patient was referred to the Department of Endodontics; Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia with a chief complaint of seeking continuation of treatment mandibular right second premolar tooth. (#45). Radiographic evaluation revealed normal periodontium and presence of more than one root [Figure 1]. Based on the clinical and radiographic examinations, the tooth was diagnosed as having a previously initiated pulp with normal periapical tissues.
Figure 1: preoperative radiograph tooth #45 (white arrows denote three roots)

Click here to view

Cone-beam computed tomography (CBCT) was carried out for confirming numbers of roots and canals of mandibular right second premolar. The CBCT images were taken out using three-dimensional (3D) Accuitomo scanner (J. Morita, Kyoto, Japan), with Viewer Plus software (J. Morita), which produced a smallest field of view images, to reduce the radiation dosage. A three roots with three canals were found, two roots buccally and one root lingually [Figure 2]. A non-surgical root canal treatment was planned accordingly.
Figure 2: The axil plane of CBCT of #45 showing three roots and three canals.

Click here to view

The patient received local anesthesia with 2% lidocaine and 1:100,000 epinephrine and the rubber dam placement. Following the removal of temporary filling, careful examination of the pulpal floor under dental operating microscope (Global Dental Microscopes, Global Surgical Corporation, U.S.A) revealed three separate mesiobuccal, distobuccal and lingual orifices. The access cavity outline was modified into triangular shape to establish straight-line access for all root canals. The working length was established using Root ZX II (J. Morita, Tokyo, Japan) and confirmed radiographically [Figure 3]. Instrumentation is achieved with ProTaper universal files (Dentsply, Maillefer, Ballaigues, Switzerland) to size F2, copious irrigation with 2.5% NaOCl and 17% EDTA was carried out during the instrumentation phase. All canals were dried with sterile paper points and then filling using matching gutta-percha cones and AH-plus sealer (Dentsply Maillefer, Ballaigues, Switzerland) until canal orifices and then the pulp chamber was filled using Obtura III (Max System, Obtura Spartan U.S.A). Finally, the access cavity was filled with Fuji resin-modified glass ionomer filling (ChemFil, Dentsply Detrey, Germany) [Figure 4] and the patient was referred to prosthodontic clinic to fabricate a full coverage crown.
Figure 3: Radiographic view after determining the working length

Click here to view
Figure 4: Postoperative radiograph

Click here to view

  Discussion Top

Proper endodontic therapy requires adequate biomechanical instrumentation and 3D filling of the entire root canal space. Missed canals are recognized as a main reason for failure of root canal therapy.[1],[2] Mandibular second premolar is one the most difficult teeth for endodontic therapy because its root canal morphology is complicated.[4] Previous case reports of mandibular second premolars having three roots[10],[11],[12],[13],[14],[15],[16],[17],[18] presented in [Table 1].
Table 1: Previous case reports of mandibular second premolars having three roots

Click here to view

Careful interpretation of diagnostic periapical radiographs taken at more than one angle is important to detect teeth morphological variations.[19],[20] Advanced radiographic methods such as CBCT are very helpful to diagnose morphological variations if conventional radiographic techniques provide limited information and more details are required.[21] CBCT is advanced practical tool for non-invasive and 3D reconstruction imaging and it is more accurate diagnostic tool for effective assessment of root canal morphology.[22]

Furthermore, use of magnification with the help of a loupe or a microscope and visual enhancement with the use of fiber optics, sodium hypochlorite bubble technique and staining with 1% methylene blue dye might help to locate additional root canals.[23]

  Conclusion Top

Although the probability of having three roots in mandibular second premolars is rare, this variation should be considered while treating these teeth to improve root canal treatment outcome. A preoperative radiographs, correct access cavity outline and proper inspection of pulpal floor are important to diagnose and treat teeth of anatomical variations. In addition, CBCT the dental operating microscope are recommended to use to perform better endodontic treatment.

  References Top

Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics 2005;10:3-29.  Back to cited text no. 1
Cantatore G, Berutti E, Castellucci A. Missed anatomy: Frequency and clinical impact. Endod Topics 2006;15:3-31.  Back to cited text no. 2
Friedman S. Prognosis of initial endodontic therapy. Endod Topics 2002;2:59-88.  Back to cited text no. 3
Slowey RR. Root canal anatomy. Road map to successful endodontics. Dent Clin North Am 1979;23:555-73.  Back to cited text no. 4
Cleghorn BM, Christie WH, Dong CC. The root and root canal morphology of the human mandibular second premolar: A literature review. J Endod 2007;33:1031-7.  Back to cited text no. 5
Serman NJ, Hasselgren G. The radiographic incidence of multiple roots and canals in human mandibular premolars. Int Endod J 1992;25:234-7.  Back to cited text no. 6
Zaatar EI, Alkandari AM, Alhmaidah 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. 7
Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30:391-8.  Back to cited text no. 8
Caliskan MK, Pehlivan Y, Sepetcioglu F, Turkun M, Tuncer SS. Root canal morphology of human permanent teeth in a Turkish population. J Endod 1995;21:200-4.  Back to cited text no. 9
Shapira Y, Delivanis P. Multiple-rooted mandibular second premolars. J Endod 1982;8:231-2.  Back to cited text no. 10
Fischer GM, Evans CE. A three-rooted mandibular second premolar. Gen Dent 1991;40:139-40.  Back to cited text no. 11
Rödig T, Hülsmann M. Diagnosis and root canal treatment of a mandibular second premolar with three root canals. Int Endod J 2003;36:912-9.  Back to cited text no. 12
Mukhaimer R. Bilateral mandibular second premolars with three separate roots. Saudi Endod J 2012;2:156-60.  Back to cited text no. 13
  Medknow Journal  
Gandhi B, Patil AC. Root canal treatment of a mandibular second premolar with three roots and canals-An anatomic variation. J Dent (Tehran) 2013;10:569-74.  Back to cited text no. 14
Fathi Z, Rahimi S, Tavakoli R, Amini M. A three-rooted mandibular second premolar: A case report. J Dent Res Dent Clin Dent Prospects 2014;8:184-6.  Back to cited text no. 15
Hariharavel V, Kumar AA, Ganesh C, Annamalai S, Ramar K, Aravindhan R. Root canal treatment of mandibular second premolar with three separate roots and canals using spiral computed tomographic. Case Rep Dent 2014;2014:816576. Available from:http://dx.doi.org/10.1155/2014/816576 [Last accessed on 2015 Jan].  Back to cited text no. 16
Paul B, Dube K. Endodontic treatment of a mandibular second premolar with three roots and three canals. Case Rep Dent 2014;2014:973410. Available from:http://dx.doi.org/10.1155/2014/973410 [Last accessed on 2015 Feb].  Back to cited text no. 17
Saberi EA, Rasooli H, Movassagh Z. Retreatment of a mandibular second premolar with three roots: A case report. Iran Endod J 2014;9:158-60.  Back to cited text no. 18
Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg Oral Med Oral Pathol 1974;37:762-72.  Back to cited text no. 19
Fava LR, Dummer PM. Periapical radiographic techniques during endodontic diagnosis and treatment. Int Endod J 1997;30:250-61.  Back to cited text no. 20
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. 21
Durack C, Patel S. Cone beam computed tomography in endodontics. Braz Dent J 2012;23:179-91.  Back to cited text no. 22
Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20:55-61.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

This article has been cited by
1 Root and Canal Morphology of Mandibular Premolars in a Saudi Subpopulation: A Cone-Beam Computed Tomography Study
Saad M. Al-Zubaidi, Moazzy I. Almansour, Ahad S. Alshammari, Nada N. Al Mansour, Ahad F. Alshammari, Yazeed S. Altamimi, Ahmed A. Madfa, Luca Testarelli
International Journal of Dentistry. 2022; 2022: 1
[Pubmed] | [DOI]
2 Evaluation of root canal morphology of mandibular premolars in a Saudi population using cone beam computed tomography: A retrospective study
Hussam Alfawaz,Abdullah Alqedairi,Yousef Hamad Al-Dahman,Asma Suliman Al-Jebaly,Faisal Abdullah Alnassar,Sarah Alsubait,Ziad Allahem
The Saudi Dental Journal. 2018;
[Pubmed] | [DOI]


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
Case Report
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded369    
    Comments [Add]    
    Cited by others 2    

Recommend this journal