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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 108-110

A maxillary second molar with an unusually positioned root and canal systems


1 Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
2 

Date of Submission19-Nov-2019
Date of Decision26-Feb-2020
Date of Acceptance13-Mar-2020
Date of Web Publication18-Jun-2020

Correspondence Address:
Thakur Veerandar Singh
Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad - 501 101, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_79_19

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  Abstract 


Variations in the root canal anatomy can occur in any tooth, if not identified and treated accordingly; they may lead to endodontic treatment failure. A typical maxillary second molar usually has three separate roots with one canal in each. The present case report elucidates the successful endodontic treatment of a rare and unusual root canal anatomy of maxillary left second molar using cone-beam computed tomography as a diagnostic aid.

Keywords: Anatomical variation, cone-beam computed tomography, maxillary second molar, unusual root canal anatomy


How to cite this article:
Singh TV, Gaddala N, Sheoran K. A maxillary second molar with an unusually positioned root and canal systems. Endodontology 2020;32:108-10

How to cite this URL:
Singh TV, Gaddala N, Sheoran K. A maxillary second molar with an unusually positioned root and canal systems. Endodontology [serial online] 2020 [cited 2020 Oct 26];32:108-10. Available from: https://www.endodontologyonweb.org/text.asp?2020/32/2/108/287074




  Introduction Top


The complex nature of the root canal system and presence of any anatomical variations always pose a difficult challenge to deliver a successful endodontic treatment. Variations in conventional anatomy are inevitable in every tooth with maxillary second molar being no exception.[1] Variations in root anatomy include the presence of a single root, two roots, fused roots, and extra palatal root.[2],[3] Variations in internal anatomy include the second mesiobuccal (MB) canal, three canals in MB root, second distobuccal (DB) canal, two canals in the palatal root, and “C”-shaped palatal canal.[3] Application of cone-beam computed tomography (CBCT) in endodontics serves the purpose of aiding in diagnosis and also improves the treatment planning, thereby enhancing the treatment outcomes.[4] This clinical case report presents a successful endodontic treatment of a maxillary second molar with unusual root canal anatomy having only two roots and four canals using CBCT as a diagnostic aid.


  Case Report Top


A 34-year-old female patient reported to the clinic with pain in the upper left back tooth for a week. Based on clinical, radiographic, and pulp sensibility tests, a diagnosis of symptomatic irreversible pulpitis with apical periodontitis of the left maxillary second molar was made, and a nonsurgical endodontic treatment was planned. The left maxillary third molar was advised for extraction due to compromised tooth structure because of caries. The tooth was anesthetized by using 1.8 ml of 2% lidocaine containing 1:80,000 epinephrine (Lignox 2% A, Indoco Remedies Ltd). Under rubber dam isolation, a conventional endodontic access cavity was made using an Endo Access Bur (Dentsply Tulsa, Tulsa). A thorough inspection of the pulp chamber floor with a DG16 endodontic explorer (Hu-Friedy, Chicago, IL, USA) revealed four distinct root canal orifices, two on the mesial side, and two on the distal side [Figure 1]a. The two distal canals were seen to be in close proximity. The number and location of canal orifices seemed to be unusual. Moreover, the intraoral periapical radiograph did not reveal the number and morphology of the roots clearly [Figure 2]a. Therefore, it was decided to perform CBCT imaging (Kodak 9000 three-dimensional [3D], Carestream Dental LLC Vaughan, Canada) of the tooth after obtaining informed consent from the patient. The axial CBCT images revealed that the left maxillary second molar had mandibular molar like root anatomy. The tooth presented mesial and distal roots with the absence of a palatal root. Each of the roots had two separate root canals, namely, mesiobuccal (MB) canal, mesiopalatal(MP) canal in mesial root, distobuccal (DB) and distopalatal (DP) canal in distal root [Figure 1]b.
Figure 1: (a) Pulp chamber view, (b) cone-beam computed tomography image

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Figure 2: (a) Preoperative radiograph, (b) working length, (c) obturation

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After exploring the four root canals with #10 K files (Mani, Inc., Tochigi, Japan), the working lengths were determined with the radiographic method [Figure 2]b and confirmed with an electronic apex locator (Root ZX; Morita, Tokyo, Japan). Cleaning and shaping were performed using ProTaper Gold rotary instruments (Dentsply Sirona) using a crown down technique. All the four canals were enlarged to size F2 [Figure 2]b. Irrigation was performed using 2.5% sodium hypochlorite solution (Prime Dental Products Pvt Ltd) and 17% ethylenediaminetetraacedic acid (RC-HELP, Prime Dental Products Pvt Ltd) during cleaning and shaping; 2% chlorhexidine (V-Consept, Vishal Dentocare Pvt Ltd) was used as the final rinse. Later, the root canals were dried with absorbent points, and calcium hydroxide intracanal medicament was placed, and the access cavity was sealed with Cavit (3M ESPE Dental Products, St Paul, MN). The next appointment was scheduled after 1 week, where the patient was found to be asymptomatic. The intracanal medicament was removed with the last file used for canal preparation along with copious irrigation of 2.5% sodium hypochlorite. Later, the canals were dried. Obturation was done by using cold lateral compaction of Guttapercha (Dentsply, Maillefer) and AH Plus resin sealer (Dentsply Maillefer, Konstanz, Germany). A radiograph was taken to assess the quality of the obturation [Figure 2]c. After completion of root canal treatment, the tooth was restored with a composite resin core followed by appropriate coronal restoration.


  Discussion Top


Generally, a maxillary second molar has three roots and each of these roots has a single canal. The considerable number of variations has been observed in terms of a number of roots and root canals present in a maxillary second molar; the presence of a second MB canal being the most common one.[1],[2],[3] Among the studies which examined the number of roots of maxillary second molars, three rooted anatomies were the most prevalent, while four rooted anatomies were the least.[1],[2],[3]

The presence of two roots in the maxillary second molar is a rare occurrence. Zhang et al.,[5] Nikoloudaki et al.,[6] Peikoff et al.,[1] and Libfeld and Rotstein [2] have reported the frequency of occurrence of two rooted maxillary molars as 8%, 8.25%, 6.9%, and 12%, respectively. Usually, when two rooted maxillary second molar is present, they have a single canal in each root. The two roots can either be mesial and distal or buccal and lingual roots, as reported by Zhang et al. in their radiographic study using CBCT.[5] The presence of four canals in a two rooted second maxillary molar is a rare entity.

Unlike some cases which reported the presence of extra palatal root in maxillary second molars, our case reveals the absence of a palatal root. In addition, in our report, the two roots of maxillary second molar are positioned mesially and distally and each with two root canals, thus making it rare and unusual. Till date, only three case reports have been reported, where a maxillary second molar had two separate mesial and distal roots with two canals in each root.[7],[8],[9] In the present case, both the canals in each root were of Weine's type II root canal configuration, similar to the one reported by Ashraf et al.[7] Sathyanarayanan and Poornima have reported almost similar cases, wherein the distal root showed Vertucci Type VI canal configuration.[8] Anatomical variations, when present in any tooth, may lead to errors in proper diagnosis and treatment planning, leading to endodontic treatment failures. Therefore, a comprehensive knowledge and understanding of normal root canal anatomy, as well as any possible variations are essential for the successful outcome of endodontic treatment.

With the advent of current diagnostic technologies, there has been an enormous refinement in diagnostic potential as well as the treatment approach. Current radiographic advancement involves aids which focus on the 3D examination of the area of interest, providing the clinician with a complete and clear perspective. 3D CBCT has a wide range of applications in endodontics and has been utilized effectively.[4] The accuracy of CBCT in determining the root canal systems has been known to be more precise in comparison with the conventional radiographs. Hence, it is highly recommended to utilize this aid in cases with suspected root canal variations or abnormalities. One of the limitations of using CBCT is increased radiation exposure compared to conventional radiography. However, the presence of unusual root anatomy justifies the use of CBCT in the present case, and moreover, keeping the principles of ALARA (as low as reasonably achievable) in mind, the radiation doses were adjusted accordingly. Thus, in the present case, report usage of CBCT enabled us to study the root canal morphology more explicitly, eventually leading to successful endodontic treatment.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peikoff MD, Christie WH, Fogel HM. The maxillary second molar: Variations in the number of roots and canals. Int Endod J 1996;29:365-9.  Back to cited text no. 1
    
2.
Libfeld H, Rotstein I. Incidence of four-rooted maxillary second molars: Literature review and radiographic survey of 1,200 teeth. J Endod 1989;15:129-31.  Back to cited text no. 2
    
3.
Ghasemi N, Rahimi S, Shahi S, Samiei M, Frough Reyhani M, Ranjkesh B. A review on root anatomy and canal configuration of the maxillary second molars. Iran Endod J 2017;12:1-9.  Back to cited text no. 3
    
4.
Scarfe WC, Levin MD, Gane D, Farman AG. Use of cone beam computed tomography in endodontics. Int J Dent 2009;2009:634567.  Back to cited text no. 4
    
5.
Zhang R, Yang H, Yu X, Wang H, Hu T, Dummer PM. Use of CBCT to identify the morphology of maxillary permanent molar teeth in a Chinese subpopulation. Int Endod J 2011;44:162-9.  Back to cited text no. 5
    
6.
Nikoloudaki GE, Kontogiannis TG, Kerezoudis NP. Evaluation of the root and canal morphology of maxillary permanent molars and the incidence of the second mesiobuccal root canal in Greek population using cone-beam computed tomography. Open Dent J 2015;9:267-72.  Back to cited text no. 6
    
7.
Ashraf H, Dianat O, Hajrezai R, Paymanpour P, Azadnia S. Endodontic treatment of a double-rooted maxillary second molar with four canals: A case report. Iran Endod J 2014;9:304-6.  Back to cited text no. 7
    
8.
Sathyanarayanan K, Poornima L. Endodontic management of maxillary second molar with vertucci Type VI root canal morphology diagnosed using cone-beam computed tomography. Contemp Clin Dent 2018;9:494-7.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Sımşek N, Keleş A, Bulut ET. Unusual root canal morphology of the maxillary second molar: A case report. Case Rep Dent 2013;2013:138239.  Back to cited text no. 9
    


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