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Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 196-198

Root canal treatment of mandibular second premolar with four root canals

1 Consultant and Assistance Professor, Restorative Dentistry, Royals Clinics, Riyadh, Saudi Arabia
2 Department of Restorative Dental Sciences, Division of Endodontics, King Saud University, College of Dentistry, Riyadh, Saudi Arabia

Date of Web Publication26-Aug-2015

Correspondence Address:
Saad Al-Nazhan
Department of RDS, Division of Endodontics, King Saud University, College of Dentistry, P.O. Box 60169, Riyadh
Saudi Arabia
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Source of Support: Nil., Conflict of Interest: None

DOI: 10.4103/1658-5984.163630

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Variation in the morphology of the root canal system of mandibular premolars has been demonstrated. This diverse morphology challenges for the clinician to clean, shape, and fill the entire root canal system. A case report of a mandibular second premolar with four root canals separated at the apical third and underwent endodontic treatment is presented.

Keywords: Mandibular second molar, root canal morphology, root canal treatment

How to cite this article:
Al-Abdulwahhab B, Al-Nazhan S. Root canal treatment of mandibular second premolar with four root canals. Saudi Endod J 2015;5:196-8

How to cite this URL:
Al-Abdulwahhab B, Al-Nazhan S. Root canal treatment of mandibular second premolar with four root canals. Saudi Endod J [serial online] 2015 [cited 2023 Feb 1];5:196-8. Available from: https://www.saudiendodj.com/text.asp?2015/5/3/196/163630

  Introduction Top

Long-term success of root canal therapy usually achieved if all root canals are located, cleaned, and filled. In addition, a thorough understanding of root canal anatomy and morphology is very important when practicing Endodontics.[1] According to Slowey,[2] mandibular premolars are considered to be the most difficult teeth to endodontically treat. This is mainly due to the difficulty of recognizing the anatomical variations of the root canal morphology. Several factors could contribute to the anatomical variations including ethnicity, age, and gender have been reported.[3],[4],[5],[6] Presence of multiple canals and roots in mandibular premolars has been reported in numerous studies and reported cases.[7],[8],[9],[10],[11],[12] Additional canals may be found radiographically, but often are detected only through thorough clinical investigation of the pulpal floor and the pulp chamber.[2] The present case report describes a successful, nonsurgical root canal treatment of a mandibular second premolar with four root canals.

  Case Report Top

A 37-year-old Sudanese man with a non-contributing medical history was referred to the Endodontic clinic from the screening clinic. The patient had traumatic occlusion. Clinical examination showed occlusal composite resin restoration on tooth #35. The tooth was sensitive to percussion and palpation and did not respond to pulp testing. Cold and electric pulp test revealed no response. Radiographic examination revealed normal periapical area and an irregular root morphology consisting of at least three distinct roots in the apical region [Figure 1]. A diagnosis of necrotic pulp with acute apical periodontitis was made. The tooth was anesthetized with 1.8 ml. of 2% lidocaine with 1:100,000 epinephrine, and access opening was established under rubber dam isolation [Figure 2]a. The access was enlarged using Gates-Glidden burs (No. 3, 4, and 5). Four canals were negotiated. The pulp chamber was flushed with 2.5% sodium hypochlorite solution to remove debris and necrotic tissue. RootZx (J. Morita Corp., Kyoto, Japan) apex locator was used to determine the correct working lengths, then a radiograph was obtained with four files in place to confirm that four separate canals were indeed present [Figure 2]b.
Figure 1: Clinical view of the tooth with diagnostyic radiograph

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Figure 2: Acess opening (a) and established working length (b)

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The canals were prepared with hand files (Flexofiles, Dentsply-Maillefer, Ballaigues, Switzerland) up to #30 and irrigated with 2.5% sodium hypochlorite solution using crown-down technique. The root canals were dried with sterile paper points (Maillefer, Dentsply, Ballaigues, Switzerland) and filled with cold, laterally condensed gutta-percha (Maillefer, Dentsply, Ballaigues, Switzerland) and AH26 sealer (Maillefer, Dentsply, Ballaigues, Switzerland). The occlusal access opening was sealed temporarily with glassionomer cement. A final radiograph was taken [Figure 3].
Figure 3: Final radiographh

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  Discussion Top

Root canals harbor different types of micro-organisms that usually colonize at the root canal wall of teeth with necrotic pulp. The necrotic tissue remnants and dentin serve as a sufficient environment for the establishment of bacterial growth.[13],[14] Thorough biomechanical instrumentation with the aid of sodium hypochlorite usually renders the root canal system of a tooth bacteria-free.[15] Such treatment protocol was followed in the present case. A modified technique of root canal preparation using Gates Glidden burs for coronal flaring and a crown-down manner has been used in the present case.

Examination of the pulp chamber floor may offer clues to the location of orifices and to the type of canal systems present. Krasner and Rankow[16] in a study of 500 pulp chambers demonstrated that definite patterns of the pulp chamber floor and wall anatomy exists.

Optimum opening of the access cavity has the advantages of reducing stress on the files used to shape and clean the root canal system. In addition, instrument fracture and canal transportation will be minimized. Furthermore, carrying out coronal flaring before proceeding into the apical regions of the root canal system will remove the majority of the infected tissue early in preparation and also prevent the inoculation of periapical tissues with bacteria that may be carried down the root canal system with hand files.[17],[18]

An apex locator was used to estimate the root canal lengths prior to taking a working length estimation radiograph. The use of an apex locator improves the chances of estimating the correct lengthfirst time, especially when canals are likely to be superimposed on a radiograph.[19] Depending on radiograph only in such a complex case is of rather limited value.

Mandibular premolars are the most difficult teeth to manage from the standpoint of endodontic treatment. They tend to have multiple root canals, apical deltas, and lateral canals, as well as relatively small access cavities and poor visualization opportunities. A clinician must be aware of possible anatomical variation of teeth undergoing endodontic treatment. A thorough knowledge of biology, physiology, and root canal anatomy and careful radiographic interpretation as well as proper access opening is very important for successful endodontic therapy.

  References Top

De Almeida-Gomes F, de Sousa BC, dos Santos RA. Unusual anatomy of mandibular premolars. Aust Endod J 2006;32:43-5.  Back to cited text no. 1
Slowey RR. Root canal anatomy. Road map to successful endodontics. Dent Clin North Am 1979;23:555-73.  Back to cited text no. 2
de Souza-Freitas JA, Lopes ES, Casati-Alvares L. Anatomic variations of lowerfirst permanent molar roots in two ethnic groups. Oral Surg Oral Med Oral Pathol 1971;31:274-8.  Back to cited text no. 3
Trope M, Elfenbein L, Tronstad L. Mandibular premolars with more than one root canal in different race groups. J Endod 1986;12:343-5.  Back to cited text no. 4
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. 5
Awawdeh LA, Al-Qudah AA. Root form and canal morphology of mandibular premolars in a Jordanian population. Int Endod J 2008;41:240-8.  Back to cited text no. 6
Zillich R, Dowson J. Root canal morphology of mandibularfirst and second premolars. Oral Surg Oral Med Oral Pathol 1973;36:738-44.  Back to cited text no. 7
Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent Assoc 1978;97:47-50.  Back to cited text no. 8
Serman NJ, Hasselgren G. The radiographic incidence of multiple roots and canals in the human mandibular premolars. Int Endod J 1992;25:234-7.  Back to cited text no. 9
Macri E, Zmener O. Five canals in a mandibular second premolar. J Endod 2000;26:304-5.  Back to cited text no. 10
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. 11
Al-Attas H, Al-Nazhan S. Mandibular second premolar with three root canals: Report of a case. Saudi Dental J 2003;15:145-7.  Back to cited text no. 12
Sundqvist G. Bacteriologic studies of necrotic dental pulps [PhD thesis]. Umea: University of Umea; 1976.  Back to cited text no. 13
Sassone LM, Fidel RA, Faveri M, Guerra R, Figueiredo L, Fidel SR, et al. A microbiological profile of symptomatic teeth with primary endodontic infections. J Endod 2008;34:541-5.  Back to cited text no. 14
Bystrom A, Sundqvist G. Bacteriological evaluation of the effect of 0.5% sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol 1983;55:307-12.  Back to cited text no. 15
Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. J Endod 2004;30:5-16.  Back to cited text no. 16
Marshall F, Pappin J. A crown-down pressureless preparation root canal enlargement technique. Technique manual. Portland: Oregon Health Sciences University; 1980.  Back to cited text no. 17
Saunders WP, Saunders EM. Effect of non-cutting tipped instruments on the quality of root canal preparation using a modified double flared technique. J Endod 1992;18:32-6.  Back to cited text no. 18
Goldberg F, Marroquın BB, Frajlich S, Dreyer C.In vitro evaluation of the ability of three apex locators to determine the working length during retreatment. J Endod 2005;31:676-8.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
Kirikkale Üniversitesi Tip Fakültesi Dergisi. 2022; : 45
[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]


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