Endodontic management of maxillary second molar with two palatal roots using cone-beam computed tomography

Rajnish K Singhal; Anshul Arora; Ashtha Arya

doi:10.4103/endo.endo_65_17

CASE REPORT

Year : 2017 | Volume : 29 | Issue : 2 | Page : 173-175

Endodontic management of maxillary second molar with two palatal roots using cone-beam computed tomography

Rajnish K Singhal¹, Anshul Arora², Ashtha Arya²
¹ Department of Conservative Dentistry and Endodontics, Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh, India
² Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India

Date of Web Publication

6-Nov-2017

Correspondence Address:
Rajnish K Singhal
Department of Conservative Dentistry and Endodontics, Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/endo.endo_65_17

Abstract

Morphological variations are frequently observed in the roots of maxillary molars. Thorough knowledge of the root canal morphology and canal anatomy is mandatory for the success of the root canal procedure and the novel diagnostic aids such as four cone-beam computed tomography (CBCT) aids in the successful management of these cases. This case report describes the successful diagnosis and treatment of a maxillary second molar with two separate palatal roots using CBCT.

Keywords: Anatomical variation, cone-beam computed tomography, maxillary second molar, two palatal roots

How to cite this article:
Singhal RK, Arora A, Arya A. Endodontic management of maxillary second molar with two palatal roots using cone-beam computed tomography. Endodontology 2017;29:173-5

How to cite this URL:
Singhal RK, Arora A, Arya A. Endodontic management of maxillary second molar with two palatal roots using cone-beam computed tomography. Endodontology [serial online] 2017 [cited 2021 Apr 11];29:173-5. Available from: https://www.endodontologyonweb.org/text.asp?2017/29/2/173/217719

Introduction

Successful endodontic treatment is based on the clinical trial of diagnosis, chemomechanical preparation (includes cleaning and shaping and disinfection of the root canals), and obturation. The clinician should be aware of the possible root canal morphology and canal space anatomy. Any variation or deviation from the normal canal anatomy may limit the success rate of root canal treatment.

The maxillary second molars usually have three separate roots and root canals. Recent case reports have suggested the presence of additional palatal canals in maxillary molars.^{[1],[2],[3],[4],[5],[6],[7],[8]} Two or three palatal canals have been reported in such cases. The diagnosis has been confirmed by radiographs and/or cone-been computed tomography (CBCT). Although multiple canals have been reported in maxillary first molars, incidence of additional palatal canal in maxillary second molar is still scarce. The radiographic diagnosis is complicated by the fact that the palatal root is often superimposed by the zygomatic process.[9-11] The present case report describes the endodontic management of a maxillary second molar with two separate palatal canals, diagnosed with the help of computed tomography (CT) scans.

Case Report

A 60-year-old female patient reported with a chief complaint of food impaction, acute pain, and sensitivity to hot in the right upper posterior region. The pain was continuous and increased on lying down. Upon clinical examination, mesioproximal decay was located in the right maxillary second molar. Pulp sensitivity tests with heat and electric test revealed an exaggerated response as compared to the contralateral tooth. Radiograph revealed a deep mesial proximal caries approaching the pulpal space. The treatment options were discussed with the patient, and endodontic therapy followed by full-crown rehabilitation was planned. Following application of topical anesthesia, buccal and palatal anesthesia was administered. Mesial caries was excavated and an endodontic access cavity was prepared using a high-speed air turbine handpiece. The pulpal tissue was removed using a sharp spoon excavator. The cavity was rinsed with 3% sodium hypochlorite. Three canals were located (mesiobuccal, distobuccal, and palatal). An additional bleeding point was visible, mesial to the primary palatal canals [Figure 1]. The point was explored with an endodontic explorer followed by negotiation of canal with 10# K-files. A radiograph was obtained to rule out the perforation of the pulpal floor. Since the presence of zygomatic arch complicated the confirmation of additional palatal canals, a CBCT scan was planned. Informed consent was taken from the patient. CBCT scan was performed which revealed the presence of four separate root canals in the right maxillary second molar. The canal anatomy included two separate palatal roots, each with a distinct root canal having separate orifices and separate exits [Figure 2]. The root canals were negotiated and the working length was determined using an apex locator (Root ZX). Chemomechanical root canal preparation was performed using crown-down technique with ProTaper system. The canals were prepared till size F2. The canals were copiously irrigated with 3% sodium hypochlorite solution and 17% ethylenediaminetetraacetic acid. Finally, the canals were flushed with sterile saline solution and were completely dried with absorbent paper points. The canals were obturated using standardized gutta-percha points and AH-26 root canal sealer. A postoperative radiograph was taken to establish the quality of obturation [Figure 3]. After the completion of the root canal treatment, the tooth was restored with composite filling material. The patient was recalled after 1 month. The tooth was finally restored with a full-crown rehabilitation after 1 month.

Figure 1: Clinical presentation of the access opening showing separate orifices of two palatal canals

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Figure 2: Computed tomography slice at coronal, middle, and apical showing separate palatal canal

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Figure 3: Postobturation radiograph

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Discussion

This case report demonstrates the possible variation in the root canal anatomy of the maxillary second molars. In a retrospective analysis, Peikoff et al. reported six variations of a second maxillary molar. The study reported three distinct roots and canals (56%), three separate roots and four canals (two mesiobuccal canals) (22.7%), three roots and canals uniting mesiobuccal and distobuccal canals (9%), two separate roots and canals (6.9%), a single root with one canal (3.1%), and four roots or canals including two palatal canals (1.4%).^[12]

The presence of zygomatic arch and superimposition of anatomical structure complicates the radiographic diagnosis of extra canals in the maxillary molar region. Multiple radiographs with different angulations can help to overcome the superimpositions. The use of CT can help in such cases. Clinical confirmation can be helped with the visualization of the pulp chamber with an operating endodontic microscope. Although these variations are not common, it is important for clinicians to be aware of the unusual root morphologies and canal configurations. This can give support to the clinicians in the diagnosis and endodontic treatment of the maxillary molars to avoid incomplete root canal preparation and subsequently to decrease the treatment failure.

Conclusion

For successful endodontic treatment, clinician should have thorough knowledge of root canal morphology. Anatomic variations can occur in any tooth whereas maxillary second molar is not an exception. Thus, proper clinical examination and diagnostic tools aid in achieving good endodontic outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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