|Year : 2020 | Volume
| Issue : 3 | Page : 274-278
Root canal treatment of maxillary second premolar with two roots and three canals: Two case reports
Yaser Mohammad Almazrou, Fahad Adeeb Edrees, Suliman Alaqeel, Faisal Alqahtani, Ayman Albihlal
Medical Services, Department of Dental Medicine, Prince Naif Security Campus, Riyadh, Saudi Arabia
|Date of Submission||03-Oct-2019|
|Date of Decision||25-Feb-2020|
|Date of Acceptance||25-Feb-2020|
|Date of Web Publication||27-Aug-2020|
Dr. Yaser Mohammad Almazrou
Department of Dental Medicine, Prince Naif Security Campus, P.O. Box 3643, Riyadh 11481
Source of Support: None, Conflict of Interest: None
The roots and canals of maxillary second premolar have different typical anatomical features, as well as a number of anatomical variations and extra canals. The present cases describe the successful endodontic therapy of two maxillary second premolars with three canals of healthy individuals, with the help of cone-beam computed tomography and dental operating microscope. The first case was diagnosed as symptomatic irreversible pulpitis with asymptomatic apical periodontitis, and the second case was diagnosed as necrotic pulp with normal periapical area. Follow-up visits reported no symptoms of both patients. The awareness toward atypical anatomy can be a critical factor in determining the success of endodontic treatment.
Keywords: Maxillary second premolar, operating dental microscope, root canal morphology, root canal treatment, Vertucci's classification
|How to cite this article:|
Almazrou YM, Edrees FA, Alaqeel S, Alqahtani F, Albihlal A. Root canal treatment of maxillary second premolar with two roots and three canals: Two case reports. Saudi Endod J 2020;10:274-8
|How to cite this URL:|
Almazrou YM, Edrees FA, Alaqeel S, Alqahtani F, Albihlal A. Root canal treatment of maxillary second premolar with two roots and three canals: Two case reports. Saudi Endod J [serial online] 2020 [cited 2020 Oct 30];10:274-8. Available from: https://www.saudiendodj.com/text.asp?2020/10/3/274/293569
| 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 number of anatomical variations and extra canals. Vertucci et al. studied the root canal anatomy of 200 human maxillary second premolars; they reported that 75% of the teeth has one canal at the apex; two canals were present in 24%; and 1% of the teeth studied has three canals. Of the 200 maxillary second premolars, 48% has Vertucci Type I pattern and 22% possessed Type II. Type VI configuration was presented in 5%, and three canals were present in 1% of the teeth studied. Pineda and Kuttler in their classic study found 0% of three canals' configuration. [Table 1] presents comparisons of the number of roots and canals in the maxillary second premolars between different studies. The percentage of three canals did not exceed 5%. Few cases of maxillary second premolars with three canals have been reported in the literature.,,,,,
|Table 1: Studies results about the percentage of number of roots and root canals in maxillary second premolar|
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The present case report describes the successful root canal therapy of two maxillary second premolars with three canals, with the help of cone-beam computed tomography (CBCT) as diagnostic tool and dental operating microscope (DOM).
| Case Reports|| |
A 27-year-old Saudi female of noncontributory medical history presented to endodontic clinic complaining of spontaneous lingering pain related to the upper right side which started 2 days ago and alleviated by ibuprofen. On clinical examination, the right maxillary second premolar has large distal carious lesion; on cold test, there was exaggerated response which lasted for 15 s. The tooth responded normally to percussion. Probing depth was normal around all the aspects of the tooth. Preoperative radiograph showed very deep caries and normal apical area [Figure 1]a. The tooth was diagnosed as symptomatic irreversible pulpitis with asymptomatic apical periodontitis. 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), three orifices of three canals were explored with DG 16 explorer [Figure 1]b. The working length was determined using Root ZX II apex locator (J. Morita Corp., Kyoto, Japan) and confirmed by radiograph [Figure 1]c. Two roots and three root canals, two buccal and one palatal, were seen. 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 and then flushed with saline. Sterile paper points were used to dry the canals, and then, the canals were obturated with the corresponding 35 ProFile® Gutta-Percha and Tubli-Seal sealer (Kerr, Romulus, MI, USA) using warm vertical condensation [Figure 1]d and e]. Access cavity was restored with composite Filtek™Z350 XT (3M, ESPE, St. Paul, MN, USA) [Figure 1]f. One week later, the patient did not have any symptoms at the recall visit.
|Figure 1: (a) Preoperative radiograph of the maxillary right second premolar normal apical area. (b) Clinical photograph of access cavity. (c) The working length radiograph of the two buccal and one palatal canals. (d) Postoperative radiograph with straight view showing three obturated canals. (e) Postoperative radiograph with distal angulation showing three obturated canals. (f) Clinical photograph after composite buildup|
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A 38-year-old Saudi male of noncontributory medical history referred to endodontic clinic for the root canal treatment of the upper left second premolar (#25). On clinical examination, the left maxillary second premolar has buccal and mesial carious lesion, and on cold test, there was negative response. The tooth responded normally to percussion. Probing depth revealed no periodontal pockets. Preoperative radiograph showed normal apical area [Figure 2]a. The tooth was diagnosed as necrotic pulp with normal periapical area. The CBCT images revealed that tooth had two separated roots and three distinct root canals (mesiobuccal [MB], distobuccal [DB], and palatal) [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f. Local anesthesia with 2% lidocaine HCl and 1:80,000 adrenaline was administered. Rubber dam was used for isolating the tooth, and then, access opening was done under an operating dental microscope. Two orifices at coronal part of the root, buccal, and palatal were seen and explored with DG 16 explorer. At the mid root, buccal orifice was divided into MB and DB. The working length was determined using Root ZX II apex locator and confirmed by radiograph [Figure 3]a. Cleaning and shaping were done using ProTaper Universal® Nickel Titanium system (Dentsply Maillefer, Ballaigues, Switzerland) up to file size F3 for palatal and F2 for MB and DB. The root canals were irrigated with 5.25% sodium hypochlorite solution and then flushed with saline; sterile paper points were used to dry the canals; and then, the canals were obturated with the corresponding F3, F2 ProTaper Universal® Gutta-Percha and Tubli-Seal sealer using warm vertical condensation [Figure 3]b, [Figure 3]c, [Figure 3]d. Access cavity restored CAVIT (3M, ESPE, St. Paul, MN, USA). Three months later, the patient did not have any symptoms at the recall visit and fiber post, and the core is done by prosthodontist [Figure 3]e.
|Figure 2: (a) Preoperative radiograph of the maxillary left second premolar normal apical area. (b) A cross-sectional cone-beam computed tomography image of tooth #25 (arrow) at pulp chamber level. (c) At coronal level of the root showing one palatal (arrow) and one buccal orifice. (d) At mid-root level showing one palatal (arrow) and two buccal canals. (e) At apical level showing one palatal (arrow) and two buccal canals. (f) A sagittal section cone-beam computed tomography image showing two (arrow) buccal canals|
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|Figure 3: (a) The working length radiograph showing two buccal and one palatal canals. (b) Postoperative radiograph with straight view.(c) Mesial angulation. (d) Distal angulation. (e) Three obturated canals. Three-month recall radiograph|
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| 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. Good examination of the preoperative radiographs should be done to explore anatomical variations of the root canal system. Features such as sudden disappearance of pulp space, abruptly straightening, broadening, or difficulty in tracing the continuity of canal indicate the presence of extra canal in the same root overlapping the first one. The presence of wider mesiodistal mid-root width when compared to that of the crown in maxillary premolars may hint for the presence of extra canals. Accurate preoperative radiographs (straight and angled) are essential to show the number of roots and canals that exist in a tooth.,, However, radiographic interpretations themselves are inadequate in obtaining a suitable abstraction of root and root canal system as evident in this case, necessitating the use of more advanced methods like CBCT as a diagnostic tool to determine the canal morphology. CBCT is a reliable method to detect canals that could be missed. In the first case, the use of CBCT was not possible because the patient refused to sign the CBCT form; instead, the DOM was used. For the second case, both CBCT and DOM were used. The root canal anatomy was characterized by three separated canals at the middle and apical third.
The DOM had changed the practice of endodontics where it enhanced the visualization of pulp chamber and canals and that will render cleaning and shaping the root canal system more efficiently. Magnification with loupes or microscope is an indispensable tool to locate the extra canals. The American Association of Endodontics has reported the benefits of magnification in locating hidden canals, removal of canal obstructions, refinement of the access preparations, and all aspects of endodontic microsurgery. Al-Fouzan reported a case where he managed to diagnose and treat successfully a mandibular second premolar with four canals using the DOM. In another case report that describes the root canal treatment of a right maxillary first molar with six root canals, two of the six canals were located while examining the pulpal floor under a DOM.
Based on such principles and modified access cavity preparation, one can have the ease of identification of extra canal anatomy. The access cavity for maxillary second premolars is usually oval in the buccopalatal direction. In maxillary premolar with three canals, the buccal orifices are usually close to each other and are hard to locate. Balleri et al. suggested a T-shaped access outline for three-rooted maxillary first premolars. This modification allows good access to the two buccal canals.
Clinically, important hint to be mentioned when treating premolars with such anatomy is that you can block one buccal canal with paper point while you obturate the other one, then you can easily manage to obturate and backfill it, especially when dealing with one canal that was splitted into two like the second case.
| Conclusion|| |
The root canal anatomy of the upper second premolars can be complicated and needs to be examined well before the commencement of the root canal treatment. Clinicians should utilize all the possible means to ensure the identification of all canals and hence proper preparation and obturation. The success of nonsurgical endodontic procedures is greatly influenced by negotiating the highly variable anatomic structures like what have been done in this report.
We would like to thank Prof Saad Al Nazhan for his general support and technical help.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vertucci F, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolar. Oral Surg Oral Med Oral Pathol 1974;38:456-64.
Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101-10.
Pécora JD, Sousa Neto MD, Saquy PC, Woelfel JB.In vitro
study of root canal anatomy of maxillary second premolars. Braz Dent J 1993;3:81-5.
Kartal N, Ozçelik B, Cimilli H. Root canal morphology of maxillary premolars. J Endod 1998;24:417-9.
Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al
. Root canal morphology of permanent maxillary teeth in the Han Nationality in Chinese Guanzhong Area: A new modified root canal staining technique. J Endod 2009;35:651-6.
Jayasimha Raj U, Mylswamy S. Root canal morphology of maxillary second premolars in an Indian population. J Conserv Dent 2010;13:148-51.
Al-Nazhan S, Al-Daafas A, Al-Maflehi N. Radiographic investigation ofin vivo
endodontically treated maxillary premolars in a Saudi Arabian sub-population. Saudi Endod J 2012;2:1-5. [Full text]
Elkady A, Allouba K. Cone beam computed tomographic analysis of root and canal morphology of maxillary premolars in Saudi subpopulation. Egypt Dent J 2013;59:3419-29.
Yang L, Chen X, Tian C, Han T, Wang Y. Use of cone-beam computed tomography to evaluate root canal morphology and locate root canal orifices of maxillary second premolars in a Chinese subpopulation. J Endod 2014;40:630-4.
Bulut DG, Kose E, Ozcan G, Sekerci AE, Canger EM, Sisman Y. Evaluation of root morphology and root canal configuration of premolars in the Turkish individuals using cone beam computed tomography. Eur J Dent 2015;9:551-7.
] [Full text]
Abella F, Teixidó LM, Patel S, Sosa F, Duran-Sindreu F, Roig M. Cone-beam computed tomography analysis of the root canal morphology of maxillary first and second premolars in a Spanish population. J Endod 2015;41:1241-7.
Elnour M, Khabeer A, AlShwaimi E. Evaluation of root canal morphology of maxillary second premolars in a Saudi Arabian sub-population: Anin vitro
microcomputed tomography study. Saudi Dent J 2016;28:162-8.
Alqedairi A, Alfawaz H, Al-Dahman Y, Alnassar F, Al-Jebaly A, Alsubait S. Cone-beam computed tomographic evaluation of root canal morphology of maxillary premolars in a Saudi population. Biomed Res Int 2018;2018:8170620.
Low D. Unusual maxillary second premolar morphology: A case report. Quintessence Int 2001;32:626-8.
Kustarci A, Ku.r sat ER, Akpinar KE. Root canal treatment of maxillary second premolar with three roots and three canals: Clinical cases. Braz J Oral Sci20076 2007;6:1411-4.
Pattanshetti N, Kandari AM, Gaidhane MP. Maxillary secondpremolar with three canals. Report of three cases. Saudi Dent J 2007;19:176-9.
Soares JA, Leonardo RT. Root canal treatment of three-rooted maxillary first and second premolars-a case report. Int Endod J 2003;36:705-10.
Barros DB, Tanomaru JM, Tanomaru-Filho M. Root canaltreatment of three-rooted maxillary second premolars: Reportof four cases. Aust Endod J 2009;35:73-7.
de Almeida-Gomes F, de Sousa BC, de Souza FD, Dos Santos RA, Maniglia-Ferreira C. Unusual anatomy of maxillary second premolars. Eur J Dent 2009;3:145-9.
Sieraski SM, Taylor GN, Kohn RA. Identification and endodontic management of three-canalled maxillary premolars. J Endod 1989;15:29-32.
Velmurugan N, Parameswaran A, Kandaswamy D, Smitha A, Vijayalakshmi D, Sowmya N. Maxillary second premolar with three roots and three separate root canals-case reports. Aust Endod J 2005;31:73-5.
Theruvil R, Ganesh C, George AC. Endodontic management of a maxillary first and second premolar with three canals. J Conserv Dent 2014;17:88-91.
] [Full text]
Blattner TC, George N, Lee CC, Kumar V, Yelton CD. Efficacy of cone-beam computed tomography as a modality to accurately identify the presence of second mesiobuccal canals in maxillary first and second molars: A pilot study. J Endod 2010;36:867-70.
AAE Special Committee to Develop a Microscope Position Paper. AAE Position Statement. Use of microscopes and other magnification techniques. J Endod 2012;38:1153-5.
Al-Fouzan KS. The microscopic diagnosis and treatment of a mandibular second premolar with four canals. Int Endod J 2001;34:406-10.
Karaththodiyil R, Kottoor J, Mathew J, George S, Mathew J. A maxillary first molar with six root canals. Saudi Endod J 2014;4:87-90. [Full text]
Krapež J, Fidler A. Location and dimensions of access cavity in permanent incisors, canines, and premolars. J Conserv Dent 2013;16:404-7.
Balleri P, Gesi A, Ferrari M. Primer premolar superior com tres raices. Endod Pract 1997;3:13-5.
[Figure 1], [Figure 2], [Figure 3]