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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 1  |  Page : 84-87

Maxillary first molar with two roots and two root canals: A rare case report


Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, Uttar Pradesh, India

Date of Web Publication4-Jun-2018

Correspondence Address:
Dr. Parul Bansal
58/6, Jagriti Vihar, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_69_17

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  Abstract 

A thorough knowledge of root canal morphology and good anticipation of their possible morphological variations may help to prevent iatrogenic errors and ensure success. The morphology of permanent maxillary first molar has been studied extensively with more emphasis on extra number of roots and root canals; however, the presence of two canals in two-rooted maxillary first molar has rarely been documented in the literature describing tooth and root canal anatomies. This case report documents the successful endodontic management of a two-rooted maxillary first molars with two canals, which was present bilaterally.

Keywords: Maxillary molar, two canals, two roots


How to cite this article:
Bansal P, Nikhil V, Malhotra P, Singh V. Maxillary first molar with two roots and two root canals: A rare case report. Endodontology 2018;30:84-7

How to cite this URL:
Bansal P, Nikhil V, Malhotra P, Singh V. Maxillary first molar with two roots and two root canals: A rare case report. Endodontology [serial online] 2018 [cited 2018 Sep 26];30:84-7. Available from: http://www.endodontologyonweb.org/text.asp?2018/30/1/84/233748


  Introduction Top


Success of a root canal therapy requires a thorough knowledge of root and root canal morphology. It is generally accepted that mostly maxillary first molar exists with three roots and three or four canals.[1] There is a wide range of variations in the literature with respect to frequency of occurrence of number of roots, number of canals in each root, and incidence of fusion of roots. In the literature, various cases of maxillary first molar have been found with more number of roots and root canals, but only very few cases have been reported with less number of roots and root canals.

Although two roots and two canals have been reported in some studies in relation to the maxillary second molar, only very few cases have been recorded in relation to maxillary first molar. When a thorough search of literature using PubMed was conducted, only a few case reports showing the unusual anatomy of two roots: one buccal and one palatal, in a maxillary first molar, were found. These cases along with the details of their canal system are summarized in [Table 1].[2],[3],[4],[5],[6],[7],[8] In all these teeth, primary canal pattern evident in each of the two roots was Vertucci's Type 1 canal configuration. In fused buccal roots of maxillary first molar only few cases with vertussi's type IV and only one case with type V have been reported. A total of 0.4% of maxillary first molars and 2.2% cases in maxillary second molars have been reported with fused buccal roots which leads to the formation of two-rooted maxillary molar.[9] The present case report documents the successful endodontic management of a maxillary first molar with two roots and two roots canals with Vertucci's Type I canal configuration which was diagnosed using cone-beam computed tomography (CBCT) as a diagnostic aid.
Table 1: Case reports showing unusual anatomy of maxillary first molar having one buccal root and one palatal root along with details of their canal system

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  Case Report Top


A 42-year-old male patient came to the department with the chief complaint of pain in his left maxillary first molar for the last 2 days. Patient's medical history was noncontributory. Clinical examination revealed grossly carious maxillary left first molar. The tooth was sensitive with early response to temperature variation and electric pulp test and was tender to vertical percussion. Radiographic examination showed radiolucency approaching the pulp. A diagnosis of irreversible pulpitis with apical periodontitis was established. On preoperative radiograph, radicular pattern gave suspicion of the presence of two roots only. CBCT was done to confirm the morphology of the tooth. CBCT revealed the presence of two roots – one buccal root and one palatal root and presence of single canal in each root [Figure 1]b. This finding was present bilaterally [Figure 1]a. Under local anesthesia and rubber dam isolation, access cavity was prepared. After the removal of caries, the roof of the chamber was removed completely. Dentinal map connecting two orifices only was seen after deroofing. One orifice was present in the buccal aspect, and other orifice was present in the palatal aspect [Figure 2]d. The diameter of the buccal orifice was larger than the typical mesiobuccal or distobuccal orifices in the maxillary first molar. The shape of access cavity was ovoid rather triangular or rhomboidal. Working length was determined with apex locator (Root ZX, J Morita Mfg. Corp., Japan) and confirmed radiographically [Figure 2]b. Since the buccal canal was large, it was prepared till ISO size no 80 followed by circumferential filing using ISO taper files. Palatal canal was prepared till F3 Protaper (Dentsply Maillefer, Switzerland) NiTi instrumentsusing crown down technique. 2.5% sodium hypochlorite and 17%EDTA were used as an irrigant. After drying the canals with paper points, large buccal canal was obturated with Gutta-percha cones (Dentsply, Maillefer, Switzerland) using lateral compaction technique and AH plus resin as a sealer (Dentsply, De Trey, Germany) whereas palatal canal was obturated with F3 Gutta-percha cones (Dentsply, Maillefer, Switzerland) [Figure 2]c, [Figure 2]e, [Figure 2]f. The access cavity was permanently restored with resin composite and crown was placed. The patient was asymptomatic during the follow-up period.
Figure 1: (a) Cone-beam computed tomography axial section at cervical third level, (b) cone-beam computed tomography axial section at middle third level, (c) cone-beam computed tomography axial section at apical third level, (d) cone-beam computed tomography coronal section, (e) cone-beam computed tomography sagittal section

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Figure 2: (a) Preoperative radiograph, (b) working length radiograph, (c) master cone radiograph, (d) access preparation photograph, (e) postobturation radiograph, (f) postobturation photograph

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  Discussion Top


Burns[10] described the maxillary first molar as “possibly the most treated, least understood, posterior tooth.” A thorough knowledge of the root canal system is an absolute necessity for the success of root canal treatment. A typical maxillary first molar is considered to have three roots and three or four canals, but the root and root canal morphology of teeth may vary greatly. In the literature, a wide range of variations with respect to the number of roots and root canals have been reported in the literature with respect to maxillary first molar [Table 2].[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] Case reports with four to five roots (Fahid and Taintor, 1998)[22] and four to six root canals (Benenati, 1985; Bond et al., 1988; Jacobsen, 1994; Martinez-Berna and Ruiz Badanelli, 1983) also have been reported. The presence of extra canal is more frequent rather than the presence of fused/less number of roots or canals, especially in the cases of permanent maxillary first molars. Only very few cases of maxillary first molar with less number of roots have been reported in the literature.
Table 2: Prevalence of the number of roots and root fusion in maxillary first molar according to different investigators

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Development of roots begins soon after enamel and dentin formation reaches the future cement enamel junction. In multirooted teeth, before root formation, root sheath forms the epithelial diaphragm which undergoes differential growth resulting in division of the root trunk into two, three, or more number of roots. Depending on the number of divisions, number of roots are formed. Two division forms two roots, three division forms three roots, and so on. In multirooted tooth, the epithelial diaphragm is genetically programmed to undergo differential growth, but under rarest condition, this differential growth may fail to take place and result in the formation of less number of roots/fused roots in the tooth.[23] Because of the morphological characteristics of the maxillary molar, this fusion between roots may occur in several ways depending on which roots are involved. Fusion of roots may take place between mesiobuccal and distobuccal roots, mesiobuccal and palatal roots, or distobuccal and palatal roots. In the present case, two buccal roots were fused together resulting in a single buccal root with large single buccal canal.

Preoperative intraoral periapical radiographs are essential before initiating endodontic treatment due to its usefulness in identifying variations from the normal, thus influencing the treatment plan. In certain cases, use of multiple preoperative radiographs or an additional radiograph from a 20° mesial or distal projection may be helpful in detecting unusual root canal morphology.[1] As radiographs are two-dimensional image of a three-dimensional object, erroneous interpretations are very much possible due to the superimposition of multiple anatomic structures questioning its reliability. In endodontic practice, CBCT is a diagnostic tool which offers a better understanding of root canal in axial, sagittal, and coronal planes. Tachibana and Matsumoto [24] studied the applicability of CT in endodontics. Kottoor et al. and La et al. have suggested the use of CBCT for the purpose of determining the root canal morphology in cases with aberrations.[25] In the present case, the presence of only two roots and two canals was suspected from multiple-angled radiographs and confirmed with CBCT.

A thorough knowledge of root canal morphology and a good anticipation of their possible morphologic variation is must before initiation of root canal therapy as it may help to eliminate iatrogenic errors as well as to reduce endodontic failure. Common iatrogenic access opening errors are caused in search of missed canals. In the present case, the presence of only two roots and two canals was confirmed with CBCT, so no further attempt was made to search for any other canal, which could cause iatrogenic errors. These iatrogenic errors during access preparation may include perforation and/or removal or excessive tooth structure which may ultimately make the tooth weak or jeopardize the prognosis.

Sabala et al.[9] observed that unusual root morphology was bilateral approximately 60% of the time and stated that rarer the aberration, greater would be the probability of it being bilateral. In the present case, maxillary first molars with two roots and two canals were present bilaterally. The existence of similar configuration in the contralateral molar was confirmed with CBCT axial images.


  Conclusion Top


The present case report discusses the endodontic management of an unusual case of a maxillary first molar with two roots and two canals and also highlights the role of CBCT to confirm the presence of number of roots and root canals in cases where the conventional radiographic examination is not conclusive. Although the incidence of presence of two roots and two canals is not high, it is important to take these variations into consideration during root canal treatment of maxillary molar to prevent iatrogenic errors and to ensure success.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gopikrishna V, Bhargavi N, Kandaswamy D. Endodontic management of a maxillary first molar with a single root and a single canal diagnosed with the aid of spiral CT: A case report. J Endod 2006;32:687-91.  Back to cited text no. 1
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Ma L, Chen J, Wang H. Root canal treatment in an unusual maxillary first molar diagnosed with the aid of spiral computerized tomography and in vitro sectioning: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e68-73.  Back to cited text no. 4
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Yilmaz Z, Tuncel B, Serper A, Calt S. C-shaped root canal in a maxillary first molar: A case report. Int Endod J 2006;39:162-6.  Back to cited text no. 5
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Shakouie S, Mokhtari H, Ghasemi N, Gholizadeh S. Two-rooted maxillary first molars with two canals: A case series. Iran Endod J 2013;8:29-32.  Back to cited text no. 7
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9.
Sabala CL, Benenati FW, Neas BR. Bilateral root or root canal aberrations in a dental school patient population. J Endod 1994;20:38-42.  Back to cited text no. 9
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Burns RC, Herbranson EJ. Tooth morphology and cavity preparation. In: Cohen S, Burns RC, editors. Pathways of the Pulp. 8th ed. St. Louis: Mosby, An Imprint of Elsevier; 2002. p. 173-229.  Back to cited text no. 10
    
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Neelakantan P, Subbarao C, Ahuja R, Subbarao CV, Gutmann JL. Cone-beam computed tomography study of root and canal morphology of maxillary first and second molars in an Indian population. J Endod 2010;36:1622-7.  Back to cited text no. 11
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Ng YL, Aung TH, Alavi A, Gulabivala K. Root and canal morphology of Burmese maxillary molars. Int Endod J 2001;34:620-30.  Back to cited text no. 13
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Hou GL, Tsai CC. The morphology of root fusion in Chinese adults (I). Grades, types, location and distribution. J Clin Periodontol 1994;21:260-4.  Back to cited text no. 15
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Thomas RP, Moule AJ, Bryant R. Root canal morphology of maxillary permanent first molar teeth at various ages. Int Endod J 1993;26:257-67.  Back to cited text no. 16
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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.  Back to cited text no. 17
    
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Gray R, Bjornal AM, Skidmore AE. The maxillary first molar anatomy and morphology of permanent teeth. University of Low College of Dentistry; 1983.  Back to cited text no. 19
    
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Baratto Filho F, Zaitter S, Haragushiku GA, de Campos EA, Abuabara A, Correr GM, et al. Analysis of the internal anatomy of maxillary first molars by using different methods. J Endod 2009;35:337-42.  Back to cited text no. 21
    
22.
Christie WH, Peikoff MD, Fogel HM. Maxillary molars with two palatal roots: A retrospective clinical study. J Endod 1991;17:80-4.  Back to cited text no. 22
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24.
Tachibana H, Matsumoto K. Applicability of X-ray computerized tomography in endodontics. Endod Dent Traumatol 1990;6:16-20.  Back to cited text no. 24
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25.
Kottoor J, Velmurugan N, Surendran S. Endodontic management of a maxillary first molar with eight root canal systems evaluated using cone-beam computed tomography scanning: A case report. J Endod 2011;37:715-9.  Back to cited text no. 25
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