|Year : 2016 | Volume
| Issue : 1 | Page : 68-71
Endodontic management of variations in root canal configuration of maxillary first molar: Two case reports
Neelam Mittal, Reema Malik
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
|Date of Web Publication||21-Jun-2016|
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, BHU, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Thorough knowledge of root morphology and its associated root canal anatomy forms the prime basis for the success of any endodontic therapy. Although rare, variations in canal number and configuration could affect the treatment outcome. Managing these additional canals with abnormal morphology is a challenging task for every clinician. This case report presents the successful management of two maxillary first molars with aberrant root canal morphology. The first case has two palatal root canals with a total of five canals and the second case has two distobuccal canals.
Keywords: Endodontic therapy; five root canals; maxillary first molar; two canal system; two distobuccal canals; two palatal canals.
|How to cite this article:|
Mittal N, Malik R. Endodontic management of variations in root canal configuration of maxillary first molar: Two case reports. Endodontology 2016;28:68-71
| Introduction|| |
In an endodontic treatment, the root canal system is our road map to success. Proper three-dimensional shaping and obturation must be accomplished for a predictable endodontic treatment. Complex root canal anatomy is a clinical challenge which can often jeopardize the success of such therapy. ,
To appreciate the variations, one should have a sound knowledge of normal root canal anatomy. The maxillary first molar is the most voluminous tooth, and it is commonly associated with such variations in canal morphology as reported in several studies. ,,
Evaluation of the anatomy of 370 maxillary molar reported the presence of three canals in 75% of the first, 58% of the second, and 68% of the third molars. Four canals were located in 25%, 42%, and 32% of the maxillary first, second, and third molars, respectively. In the majority of cases, mesiobuccal roots have two canals.  The presence of a single canal in palatal and distobuccal root was a common finding with some variations. ,,, The incidence of second mesiobuccal canal (MB) varies between 18% and 96.1%. ,,
Stone and Stroner  reported four types of palatal canal, namely, a single palatal root with two separate orifices, canals, and foramina, two separate roots (each with a separate canal), single root with one orifice, and a bifurcated canal with two foramina. Evidence of two separate canals in palatal roots was least (≤1%).  Most of the studies report the presence of single distobuccal canal (DB) in 93.3% of the cases. Studies recording the presence of a second DB are scarce and its rate of occurrence has been reported to be as low as 1.7%.  Bond et al. in 1988 presented a case of a maxillary first molar, which was associated with two canals in all the three roots. 
In our study, we have reported the successful endodontic treatment of two rare cases of the maxillary first permanent molar with two palatal canals and two DBs, respectively.
| Case Reports|| |
Case report 1
A 19-year-old male patient, who had pain in the maxillary left molar tooth for the past 3 days reported to our Department of Conservative Dentistry and Endodontics. His medical history was unremarkable. The patient also reported that pain exaggerates on hot food intake. On intraoral examination, deep carious lesion was seen in the left maxillary first molar. Thermal pulp testing followed by radiographic examination confirmed the diagnosis of irreversible pulpitis [Figure 1]a. On the basis of clinical and radiographic outcome, decision to start nonsurgical endodontic therapy was made. The tooth was anesthetized and the operative field was isolated with rubber dam (GDC, India). Access cavity was made keeping in mind the basic principles. The pulp chamber was completely deroofed and cleaned so that the pulpal floor can be clearly visualized. The shape of the access cavity was triangular and four canals (MB, second MB [MB2], DB, and palatal [P]) were located. The presence of main palatal canal slightly more distal to its normal anatomical location provoked the further exploration of the pulpal floor with an endodontic explorer (DG-16). A small hemorrhagic spot was noted in the groove slightly mesial to the main palatal canal, which was negotiated earlier. Conventional triangular access was then modified to trapezoidal shape and the five canals, namely, MB, MB2, mesiopalatal canal, distopalatal canal, and DB were identified.
|Figure 1: (a) Preoperative intraoral periapical radiograph; (b) working length intraoral periapical radiograph; (c) master cone intraoral periapical radiograph; (d) postoperative intraoral periapical radiograph|
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After the patency of all the canals was confirmed, the working length was assessed using electronic apex locator Root ZX (J. Morita MFG. Corporation, Kyoto, Japan) which was also confirmed by taking radiograph using 15 number K-files [Figure 1]b. All the five root canals were prepared with Protaper Next rotary nickel-titanium (Ni-Ti) System along with lubricant GLYDE (Dentsply Maillefer Company, USA) using crown-down technique. During preparation, 2.5% of sodium hypochlorite was used as irrigant in copious amount. The tooth was temporarily sealed with cavit after placing intracanal medicament of calcium hydroxide (Prime Dental Products, Thane).
In follow-up appointment after 1 week, the tooth was completely asymptomatic, so canals were irrigated with normal saline and dried using paper points. After taking master cone radiograph [Figure 1]c, canals were obturated with master Gutta-percha cone and AH Plus sealer (Dentsply Maillefer Company, USA) using lateral condensation technique [Figure 1]d. The tooth was provisionally sealed with cavit and the patient was recalled after 1 week for permanent restoration.
Case report 2
A 25-year-old male patient presented to our department with pain in the right maxillary first molar. Medical history was nonsignificant. Clinical and radiographic examination followed by pulp testing confirmed that the concerned tooth was symptomatic and endodontic intervention is necessary [Figure 2]aAfter achieving proper anesthesia, endodontic access was made conventionally. While exploring pulpal floor with endodontic explorer, a catch was found between the line joining the distobuccal and palatal canal, very close to the DB [Figure 2]b. A number 10 k-file was inserted into the suspected catch area and radiograph was taken for confirmation [Figure 2]c. Radiographically, the file reached the similar length as of DB without any bleeding or pain. Thus, four root canal orifices were present such as MB, DB, second DB, and palatal (P). During working length determination, it was observed that simultaneous placement of file in two DBs was difficult, since one of the instruments was hindered by the other (in the apical 3 rd area). It confirmed the fact that the two canals were joining in the apical 3 rd area. The root canal was prepared using Protaper next rotary Ni-Ti files with a crown-down technique (Dentsply Maillefer). Obturation was done with Gutta-percha points and AH plus sealer using lateral condensation technique [Figure 2]dand the tooth was permanently restored.
|Figure 2: (a) Preoperative intraoral periapical radiograph; (b) access cavity showing two distobuccal canals; (c) working length intraoral periapical radiograph; (d) postoperative intraoral periapical radiograph|
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| Discussion|| |
Cohen and Burns stated that the prime reason for not treating the canals is the inability to locate them.  Proper access cavity preparation not only helps in locating the canal orifice but also eliminates the future potential problems that may arise during biomechanical canal preparation and obturation. If the presence of any anomaly is suspected through a variety of preoperative radiographs at different angles, then generous coronal access will help in the correct localization of root canal orifices.
Various diagnostic aids which may be helpful in locating root orifices are multiple radiographs at different horizontal angles, thorough exploration of pulpal floor using a sharp explorer, refining of grooves with ultrasonic tips, visualizing hemorrhagic points on the chamber floor, staining the floor with 1% methylene blue dye, and champagne bubble test with sodium hypochlorite. The presence of palatogingival groove on the palatal surface of the crown and root increases the probability of the presence of two palatal canals. 
This case report presents a finding of maxillary first molar having two palatal canals with type III configuration (two different canals emerging on the root surface through two separate foramina) and two distobuccal root canals with type II configuration (two distinct root canals converging just short of the apex). 
In the present reports, extracanals were located with the naked eye using a canal explorer and anatomical guidance once straight line access was ensured. However, sometimes, it may be difficult to visualize the variations radiographically, hence the use of electronic apex locator and operating microscope can be helpful. Recent advancements in radiographic techniques such as cone beam or spiral computed tomography have facilitated the detection of any variation in shape or number of root canal present, much easily in comparison to the previously available techniques. ,, The success of root canal treatment depends on the precise location and treatment of all the present canals. The suspicion of extraroot or extracanal must be there in every clinician's mind.
| Conclusion|| |
The presence of two MBs in the maxillary first molar is high, but the incidence of either two DBs or two palatal canals is rare. The present case report along with the previous literature enhances the understanding of the complex root canal morphology. Thus, it makes it necessary for every practitioner to be vigilant and knowledgeable enough to successfully manage such aberrant anatomical morphology.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Chen G, Yao H, Tong C. Investigation of the root canal configuration of mandibular first molars in a Taiwan Chinese population. Int Endod J 2009;42:1044-9.
de Pablo OV, Estevez R, Péix Sánchez M, Heilborn C, Cohenca N. Root anatomy and canal configuration of the permanent mandibular first molar: A systematic review. J Endod 2010;36:1919-31.
Frank J. Vertucci, James E. Haddix, Leandro R. Britto. Tooth morphology and access cavity preparation. In: Cohen S, Hargreaves KM, editors. Pathways of the Pulp. 9 th
ed., Ch. 7. Mosby Yearbook Co.; 2006. p. 148-232.
Cleghorn BM, Christi WH, Cecilia CS. Root and root canal morphology of the human permanent maxillary first molar: A literature review. J Endod 2006;32:813-21
Filho FB, Zaitter S, Haragushiku GA, de Campos EA, Abuabara A, Correr GM. Analysis of the internal anatomy of maxillary fi rst molars by using different methods. J Endod 2009;35:337-42.
Pécora JD, Woelfel JB, Sousa Neto MD, Issa EP. Morphologic study of the maxillary molars. Part II: Internal anatomy. Braz Dent J 1992;3:53-7.
Hartwell G, Appelstein CM, Lyons WW, Guzek ME. The incidence of four canals in maxillary first molars: A clinical determination. J Am Dent Assoc 2007;138:1344-6.
Ferguson DB, Kjar KS, Hartwell GR. Three canals in the mesiobuccal root of a maxillary first molar: A case report. J Endod 2005;31:400-2.
Fogel HM, Peikoff MD, Christie WH. Canal configuration in the mesiobuccal root of the maxillary first molar: A clinical study. J Endod 1994;20:135-7.
Malagnino V, Gallottini L, Passariello P. Some unusual clinical cases on root anatomy of permanent maxillary molars. J Endod 1997;23:127-8.
Hartwell G, Bellizzi R. Clinical investigation of in vivo
endodontically treated mandibular and maxillary molars. J Endod 1982;8:555-7.
Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod 1990;16:311-7.
Stone LH, Stroner WF. Maxillary molars demonstrating more than one palatal root canal. Oral Surg Oral Med Oral Pathol 1981;51:649-52.
Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human permanent maxillary first molar: A literature review. J Endod 2006;32:813-21.
Bond JL, Hartwell G, Portell FR. Maxillary first molar with six canals. J Endod 1988;14:258-60.
Cohen S, Burns RC. Pathways of the Pulp. 7 th
ed. Missouri: Mosby; 1998.
Benenati FW. Maxillary second molar with two palatal canals and a palatogingival groove. J Endod 1985;11:308-10.
Baratto Filho F, Zaitter S, Haragushiku GA, de Campos EA, Abuabara A, Correr GM. Analysis of the internal anatomy of maxillary first molars by using different methods. J Endod 2009;35:337-42.
Low KM, Dula K, Bürgin W, von Arx T. Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery. J Endod 2008;34:557-62.
Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of cone-beam computed tomography to identify root canal systems in vitro
. J Endod 2008;34:87-9.
[Figure 1], [Figure 2]