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 Table of Contents  
Year : 2016  |  Volume : 6  |  Issue : 3  |  Page : 153-156

Cone-beam computed tomography of bilateral radiculous maxillary first premolars

1 Department of Endodontics, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia; Dental Department, Ministry of Health, Kuwait
2 Preventive Department, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia; Dental Department, Ministry of Health, Kuwait
3 Department of Restorative Dental Sciences, Division of Endodontics, King Saud University, College of Dentistry, Riyadh, Saudi Arabia

Date of Web Publication29-Aug-2016

Correspondence Address:
Mohammad Ahmad Alenezi
Department of Endodontics, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia; Dental Department, Ministry of Health, Kuwait

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.189352

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A deep knowledge of the internal and external anatomy of various human teeth is a backbone for a successful outcome of endodontic therapy. Usually, maxillary first premolar tooth has two roots, buccal and palatal. Three-rooted maxillary first premolar is scarce. The clinician has to expect any variation in root canal system and use the best diagnostic tools to manage the cases. The aim of this case report was to illustrate bilateral three-rooted maxillary first premolars and to describe the endodontic implication in preoperative assessment and during operative procedures.

Keywords: Cone-beam computed tomography, maxillary first premolar, root canal morphology, three roots

How to cite this article:
Alenezi MA, Tarish MA, Al-Nazhan S. Cone-beam computed tomography of bilateral radiculous maxillary first premolars. Saudi Endod J 2016;6:153-6

How to cite this URL:
Alenezi MA, Tarish MA, Al-Nazhan S. Cone-beam computed tomography of bilateral radiculous maxillary first premolars. Saudi Endod J [serial online] 2016 [cited 2023 Feb 1];6:153-6. Available from: https://www.saudiendodj.com/text.asp?2016/6/3/153/189352

  Introduction Top

The major purpose of root canal therapy is to carry out adequate biomechanical preparation, fill, and seal the entire root canal system. Failure to do that may lead to posttreatment complications and diseases.[1],[2] Therefore, the dental practitioners should have a sound knowledge of internal and external teeth morphology and their frequent variations to improve the predictability of root canal therapy.[3]

The maxillary first premolar teeth morphology has been studied by different methods.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] These teeth may reveal a considerable variation in their roots number, ranging from one to three. The percentage three-rooted maxillary first premolar has been reported to range from 0.4% to 4%.[4],[13],[14],[15],[16]

Bellizzi and Hartwell [17] and Carlsen [18] classified the external anatomical features of three-rooted maxillary premolars into three classes and categories [Table 1]. In addition, three-rooted maxillary molars teeth also named as radiculuos premolars, small molars, mini-molars, and miniature three-canalled maxillary molars.[19],[20],[21]
Table 1: Classification of the external anatomical features of three-rooted maxillary premolars

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  Case Report Top

An 18-year-old Saudi male with no history of any systemic diseases presented for periodontal treatment at Riyadh Colleges Dental Hospital. Radiographic evaluation by cone-beam computed tomography (CBCT) revealed that the maxillary right (#14) and left (#24) first premolar have three separated roots, two in the buccal side (mesiobuccal and distobuccal) and one in the palatal side [Figure 1].
Figure 1: The axial plane of cone beam computed tomography of the maxilla. White arrows denote tooth 14 and 24 with three roots

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  Discussion and Clinical Implications Top

Endodontic success of teeth having more canals than normally expected requires a careful diagnosis and correct clinical and radiographic inspection before beginning treatment.[22] Maxillary first premolars of Saudi Arabia population have been evaluated by different methods,[9],[12],[23] and the reported percentage of three-rooted teeth was 1.2%.[9]

Sabala et al.[24] reported that 60% of root canal aberrations are bilateral, and the most rare ones are 90% bilateral, which is the same in this case.

The clinical examination of three-rooted maxillary premolars usually shows a relatively large sized crown, particularly in the mesiodistal diameter, resembling a small molar.[21] Moreover, the presence other crown anomalies such as germination might as well indicate root canal morphology.[25]

Periodontal pocket and/or gingival recession may help in identifying the external root anatomy, such as root bifurcation. However, in three-rooted premolar teeth, the furcation is commonly located between the apical and middle third of the root length,[26] which is difficult to detection.[27]

The conventional radiographic appearance of three-rooted maxillary premolars can be identified on straight preoperative radiographs, in which the mesiodistal width of the mid-root image is equal or greater than the mesiodistal width of the coronal image.[19] Tracing the periodontal ligament space of each individual root is essential. Although the radiographic interpretation would become more difficult when the three roots lie close to each other or are fused, altering the horizontal angle can facilitate their detection.[2],[21],[28]

Recent advances in diagnostic radiographic techniques have provided promise in the detection and interpretation of root canal anatomy.[29],[30],[31],[32] CBCT can provide three-dimensional imaging with a low radiation dose and reasonably high resolution, producing images resembling that of modified canal staining and clearing techniques in identifying root canal anatomy.[30],[31] However, CBCT should be only considered when the conventional periapical radiographs fail to provide adequate information and details of the structures to be identified,[33] as CBCT views can also show some misleading findings.[34]

Furthermore, CBCT reconstructed scans are invaluable for assessing teeth with unusual anatomy, such as teeth with an unusual number of roots, dilacerated teeth, and dens in dente. The exact location and anatomy of the root canal system can be assessed, allowing successful management of the clinical cases.[29],[35] In general, two and three-dimensional radiographic images are valuable tools in providing useful information regarding the root and root canal anatomy; however, they should be correlated with the clinical picture to achieve proper morphological assessment.[2],[34]

Access cavity preparation is a critical step during which accessory roots or root canals are detected. Complete removal of the roof of the pulp chamber and all interferences to the root canal orifices should then give an indication of the internal morphology features of the root.[2] Better precision and enhanced visibility of the internal root anatomy can be achieved by utilizing some form of assisted vision, such as magnification and coaxial illumination.[2],[36]

In three-rooted maxillary premolar teeth, the access cavity should be wide buccally, in a mesiodistal direction, forming a “T” shape or triangular configuration,[19],[21],[37] resembling that of maxillary molar teeth, but smaller in size. The buccal canal orifices are located at the same horizontal line, and can often be clearly identified when the two canals open into the pulp chamber separately. The two orifice openings are shifted mesially and distally, respectively, relative to the palatal orifice.

The pulp chamber volume of the three-rooted maxillary premolars variant is variable and a distance of <1 mm between the most cervical region of the pulp chamber roof and the canal bifurcation can exist.[38] This requires great caution by using suitably sized access burs to prevent accidental perforation of the pulp chamber furcation.

  Conclusion Top

The occurrence of three-rooted maxillary premolar teeth with variable morphological features reflects their extreme anatomical variability. Therefore, sufficient awareness for their identification and management is necessary to prevent any undesirable consequences, if they are missed during root canal therapy. Advanced diagnostic tools such as CBCT and magnifying equipment can be applied to improve the clinical root canal therapy.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1]

This article has been cited by
1 Root and root canal morphology of maxillary premolars in the Saudi population: A review of literature
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[Pubmed] | [DOI]


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