Endodontic management of maxillary permanent rst molar

with 6 root canals: 3 case reports

Denzil Valerian Albuquerque, BDS,
a
Jojo Kottoor, BDS,
a
Sonal Dham, BDS,
a
Natanasabapathy Velmurugan, MDS,
b
Mohan Abarajithan, MDS,
c
and Rajmohan Sudha, MDS,
d
Tamil Nadu, India
MEENAKSHI AMMAL DENTAL COLLEGE AND HOSPITAL
This article discusses the successful endodontic management of 3 permanent maxillary rst molars presenting
with the anatomical variation of 3 roots and 6 root canals. A literature review pertaining to the variable root canal
morphology of the permanent maxillary rst molar is also presented. Modications in the root canal access
preparation and methods for examination of the pulpal oor with the aid of magnication for identication of
additional canals are emphasized. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e79-e83)
The goal of root canal treatment is to clean and shape
the root canal system and obturate it in all of its
dimensions.
1
Aberrant root or root canal morphology
when present should be adequately detected and
treated. Failure to recognize any unusual canal cong-
uration would eventually lead to unsuccessful treatment
outcome.
2
Thus, a thorough knowledge of the root and
root canal morphology along with their various ana-
tomical variations is essential so as to reach this goal.
The root canal anatomy of maxillary rst molars has
been described as 3 roots with 3 canals and the common-
est variation is the presence of a second mesiobuccal canal
(MB
2
). The incidence of MB
2
has been reported to be
between 56.8% and 96.1%.
3-5
Apart from these usual
presentations, a wide variation of root canal congurations
of the maxillary rst molars have been documented in
numerous case reports. These range from a single root
canal in a single root,
6
C-shaped canals,
7
2 root canals,
2
5
root canals,
8
and 6 root canals.
9
Recently, Kottoor et al.
10
reported the endodontic management of a maxillary rst
molar with 7 root canals. Cleghorn et al.
3
reported that the
incidence of a second root canal in the distobuccal root is
1.7% and less than 1.0% in the palatal root. This article
discusses the successful nonsurgical endodontic manage-
ment of 3 permanent maxillary rst molars presenting
with the anatomical variation of 3 roots and 6 canals.
CASE REPORTS
These are the case reports of 3 patients treated in the Depart-
ment of Conservative Dentistry and Endodontics, Meenakshi
Ammal Dental College, Chennai, India. A thorough history was
recorded, and the cases were examined both clinically and ra-
diographically. The medical history of all patients was noncon-
tributory. Vitality testing of the involved tooth was carried out
with heated gutta-percha (Dentsply Maillefer, Ballaigues, Swit-
zerland), cold test (RC Ice, Prime Dental Products Pvt. Ltd.,
Mumbai, India), and electronic pulp stimulation (Parkel Elec-
tronics Division, Farmingdale, NY). Local anesthesia was ob-
tained with 1.8 mL (30 mg) of 2% lignocaine containing
1:200,000 epinephrine (Xylocaine, AstraZeneca Pharma Ind
Ltd, Bangalore, India). The entire procedure in each case was
carried out using rubber dam isolation under a surgical operating
microscope (Seiler Revelation Microscope, St. Louis, MO). The
working length was determined with the apex locator (Root ZX;
Morita, Tokyo, Japan) and conrmed radiographically. Cleaning
and shaping were performed using a crown-down technique with
ProTaper series Ni-Ti rotary instruments (Dentsply Maillefer,
Ballaigues, Switzerland) with irrigation using normal saline, 3%
sodium hypochlorite, and 17% EDTA (Prime Dental Product
Pvt. Ltd.). All canals were dried with absorbent points (Dentsply
Tulsa, Tulsa, OK) and obturated using cold, laterally compacted
gutta-percha and AH Plus sealer (Dentsply Tulsa). Each tooth
was then restored with a posterior composite resin core (P60; 3M
Dental Products, St Paul, MN). The patients were asymptomatic
in the subsequent follow-up period.
Case 1
A 55-year-old male patient presented with the chief com-
plaint of toothache in his left upper back tooth. The pain
was continuous and had intensied for 3 days, with a history
of intermittent pain over the preceding 3 months. Clinical
a
Postgraduate Student, Department of Conservative Dentistry and
Endodontics, Meenakshi Ammal Dental College and Hospital, Tamil
Nadu, India.
b
Professor and Head of Department, Department of Conservative
Dentistry and Endodontics, Meenakshi Ammal Dental College and
Hospital, Tamil Nadu, India.
c
Senior Lecturer, Department of Conservative Dentistry and End-
odontics, Meenakshi Ammal Dental College and Hospital, Tamil
Nadu, India.
d
Reader, Department of Conservative Dentistry and Endodontics,
Meenakshi Ammal Dental College and Hospital, Tamil Nadu, India.
Received for publication Mar 28, 2010; accepted for publication Apr
8, 2010.
1079-2104/$ - see front matter
2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2010.04.017
e79
examination revealed deep mesio-occlusal and disto-occlusal
decay in #14. Probing depths and mobility were within phys-
iological limits. The tooth was nontender to palpation and
percussion. Thermal tests caused an intense lingering pain,
whereas electronic pulp stimulation produced a premature
response. Radiographic examination revealed a radiolucent
lesion on the mesial and distal aspects of the coronal portion
extending toward the pulpal outline. The lamina dura was
intact with no apparent periodontal ligament space widening
(Fig. 1, A). These ndings led to a diagnosis of symptomatic
irreversible pulpitis for which endodontic treatment was sug-
gested to the patient.
Caries was excavated from the mesial and distal surfaces
of the tooth followed by composite resin restoration (P60; 3M
Dental Products) to allow for optimal isolation. After obtain-
ing adequate anesthesia, an endodontic access cavity was
established under isolation with rubber dam. Clinical exam-
ination of the pulpal oor with a DG-16 endodontic explorer
(Hu-Friedy, Chicago, IL) under a surgical operating micro-
scope presented the anatomy of the tooth as follows: 2 orices
in the mesiobuccal root (MB
1
, MB
2
), 2 orices in the disto-
buccal root (DB
1
, DB
2
), and 2 orices in the palatal root
(mesiopalatal [MP], distopalatal [DP]) (Fig. 1, B). Explora-
tion of the canals with a size 10 ISO K-le (Mani, Inc.,
Tochigi, Japan) revealed that the canals in each root fused
before exit as a single foramen. The working length was
determined (Fig. 1, C) and the canals were medicated with
calcium hydroxide and the tooth temporized using interme-
diate restorative material (IRM) (Dentsply De Trey GmbH,
Konstanz, Germany). At the next visit a week later, under
rubber dam isolation, instrumentation and obturation were
completed followed by composite restoration (Fig. 1, D).
Case 2
A 45-year-old male patient reported with the chief com-
plaint of pain in the right maxillary region for the preceding
2 weeks. Clinical examination revealed a carious right max-
illary rst molar (#3) that was tender to percussion. A diag-
nosis of necrotic pulp with symptomatic apical periodontitis
was made necessitating endodontic treatment (Fig. 2, A).
Inspection of the pulpal oor with an operating microscope
revealed 6 distinct orices (Fig. 2, B), similar to the previ-
ously described case (MB
1
, MB
2
, DB
1
, DB
2
, MP, DP). Canal
patency was established with #10 K-le (Mani, Inc.), which
revealed that the 2 canals in the palatal and the distobuccal
roots merged into a single canal before exit from the apical
foramen. However, in the mesiobuccal root, the 2 canals
remained separate along their entire length with 2 portals of
exit at the apex (Fig. 2, C). Working length was conrmed;
the canals were instrumented and medicated with calcium
hydroxide followed by temporization using IRM (Dentsply
De Trey GmbH). At the second appointment a week later, the
patient was asymptomatic. The canals were obturated and
access cavity was restored using composite restorative mate-
rial (Fig. 2, D).
Case 3
A 32-year-old female patient reported with the chief com-
plaint of sharp, continuous pain in the upper left region.
Fig. 1. A, Preoperative radiograph of the maxillary left rst molar (tooth #14). B, Access cavity preparation showing the location
of the 6 canal orices on the pulpal oor. MB, mesiobuccal; DB, distobuccal; MP, mesiopalatal; DP, distopalatal. C, Working
length radiograph demonstrating Vertucci Type II canal conguration in the 3 roots. D, Postoperative radiograph.
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e80 Albuquerque et al. October 2010
Clinical examination revealed a carious mesio-occlusal lesion
in #14. A diagnosis of symptomatic irreversible pulpitis was
made necessitating endodontic treatment (Fig. 3, A). Inspec-
tion of the pulpal oor with an operating microscope revealed
6 distinct orices (Fig. 3, B). Exploration of the canals re-
vealed a canal conguration similar to that previously de-
scribed in the rst case (Fig. 3, C). The canals were instru-
mented and obturated. The access cavity was restored using
composite restorative material (Fig. 3, D).
DISCUSSION
Martinez-Berna and Ruiz-Badanelli
9
were the rst to
report 3 cases of maxillary rst molars with 6 canals: 3
canals in the mesiobuccal root, 2 in the distobuccal
root, and 1 in the palatal root (3 MB, 2 DB, and 1
palatal). Other authors have also reported cases with 6
or more root canals in the maxillary rst molar (sum-
marized in Table I).
9-14
The present cases describe 3
different root canal congurations in the maxillary rst
molar with 6 canals. In the rst and third cases, each
root had 2 canals that fused to form a single canal
before exit into a single apical foramen (Vertucci Type
II canal conguration).
15
In the second case, the palatal
and distobuccal roots presented with a Vertucci Type II
canal conguration, whereas the mesiobuccal root had 2
canals that did not fuse along their course and exited as 2
separate foramina (Vertucci Type III canal congura-
tion).
15
Although the incidence of such root canal varia-
tions is rare, as far as the prognosis of individual cases is
concerned, their importance should not be underestimated.
A thorough understanding of tooth morphology
16
and
multiple angulated preoperative radiographs
17
are invalu-
able prerequisites for endodontic treatment. Modied ac-
cess cavity preparation is often required for successful
management of teeth with extra canals.
18
To achieve a
straight-line access, the conventional triangular access
cavity can be modied into many shapes such as clover
leaflike (shamrock),
19
heart,
20
trapezoidal,
8,21
rectan-
gular,
22
rhomboidal,
23
and ovoid
24
shapes, depending on the
particular clinical situation. Pulp chamber oor and wall
anatomy provide a guide to determine what morphology is
actually present.
25
Krasner and Rankow
26
put forth laws
that are valuable aids to the clinician in searching for
elusive canals. Weller and Hartwell
27
found that examin-
ing the grooves and exploring them with ultrasonics in-
creases the number of fourth canals found and treated in
maxillary molars.
27
Use of magnication was also shown
to increase the percentage of located and treated extra
canals in maxillary molars.
28
The search for an extra
orice is further aided by the use of ber-optic transillu-
mination to locate the developmental line between the
Fig. 2. A, Preoperative radiograph of the maxillary right rst molar (tooth #3). B, Access cavity preparation showing the location
of the 6 canal orices on the pulpal oor. MB, mesiobuccal; DB, distobuccal; MP, mesiopalatal; DP, distopalatal. C, Working
length radiograph showing the Vertucci Type II canal conguration in the distobuccal and palatal roots, and Vertucci Type III
canal conguration in the mesiobuccal root. D, Postobturation radiograph.
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Volume 110, Number 4 Albuquerque et al. e81
mesiobuccal and mesiolingual orices. A DG-16 end-
odontic probe used as a pathnder determines the angle at
which the canals depart from the main chamber. Adjunc-
tive diagnostic measures such as staining the chamber
oor with 1% methylene blue dye, performing the sodium
hypochlorite champagne bubble test, and visualizing
canal bleeding points are important aids in locating root
canal orices.
25
The clinician should be suspicious of
additional canals if endodontic les are not well centered
in the canal either clinically during exploration of the
canals or radiographically during working length determi-
nation.
8
Although there are inherent limitations, radio-
graphs provide a clue to the type of canal conguration
present.
29
In the presented cases, a modied access cavity
was prepared under the surgical operating microscope
(Fig. 1, B, Fig. 2, B, Fig. 3, B); ultrasonic troughing of the
dentin located between the major orices was also needed
to detect the extra canals.
Previous reports have used recent imaging technol-
ogies like spiral computed tomography (SCT)
6,21
and
cone-beam computed tomography (CBCT)
10,30
as an
adjunctive aid for detection and management of vari-
able root canal morphology. These recent imaging tech-
nologies and the use of operating microscopes may be
helpful in detecting variations of root canals in doubtful
circumstances related to unusual root canal anatomy. In
Fig. 3. A, Preoperative radiograph of #14. B, Access cavity preparation showing the location of the 6 canal orices on the pulpal
oor. MB, mesiobuccal; DB, distobuccal; MP, mesiopalatal; DP, distopalatal. C, Working length radiograph showing the Vertucci
Type II canal conguration in all 3 roots. D, Postoperative radiograph.
Table I. Summary of case reports of maxillary rst molars presenting with 6 or more root canals
Root conguration
No. of
canals
Root canal anatomy
Reference Mesiobuccal Distobuccal Palatal
3 roots 6 3 2 1 Martnez-Bern and Ruiz-Badanelli
(1983) (3 cases)
9
3 roots 6 2 2 2 Bond et al. (1988)
11
3 roots 6 2 1 3 (apical third trifurcation) Maggiore et al. (2002)
12
4 roots (MB, MP, P, DB) 6 MB, MP, M, P, DP, DB Adanir (2007)
13
3 roots 6 2 2 2 de Almeida-Gomes et al. (2009)
14
3 roots 6 2 2 2 Present cases
3 roots 7 3 2 2 Kottoor et al. (2010)
10
MB, mesiobuccal; MP, mesiopalatal; P, palatal; DB, distobuccal; DP, distopalatal; M, mesial.
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e82 Albuquerque et al. October 2010
the present case, radiographs of different angulations
and clinical examination of the oor of the pulp cham-
ber clearly depicted the variable anatomy. Hence, ad-
vanced imaging techniques (SCT and CBCT) were not
used. Although these imaging modalities offer an in-
sight into the anatomical variations of the root or root
canal conguration, they also potentially increase the ef-
fective dose of radiation exposure for the patient.
31
Addi-
tionally, such equipment may not always be present in
practice.
CONCLUSION
Reports of cases with unusual morphology have an
important didactic value. Their documentation in case
reports may facilitate the recognition and successful
management of similar cases should they require end-
odontic therapy. These case reports may intensify the
complexity of maxillary rst molar variation and are
intended to reinforce clinicians awareness of the vari-
able morphology of root canals.
REFERENCES
1. Cohen S, Burns RC, editors. Pathways of the pulp. 7th ed. St.
Louis, MO: Mosby Co; 1998. p. 258-368.
2. Ma L, Chen J, Wang H. Root canal treatment in an unusual
maxillary rst molar diagnosed with the aid of spiral computer-
ized tomography and in vitro sectioning: a case report. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2009;107:e68-73.
3. Cleghorn BM, Christie WH, Dong CCS. Root and root canal
morphology of the human permanent maxillary rst molar: a
literature review. J Endod 2006;32:813-21.
4. Imura N, Hata GI, Toda T, Otani SM, Fagundes MI. Two canals
in mesiobuccal roots of maxillary molars. Int Endod J
1998;31:410-4.
5. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of
magnication on locating the MB2 canal in maxillary molars. J
Endod 2002;28:324-7.
6. Gopikrishna V, Bhargavi N, Kandaswamy D. Endodontic man-
agement of a maxillary rst 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.
7. De Moor RJG. C-Shaped root canal conguration in maxillary
rst molars. Int Endod J 2002;35:200-8.
8. Johal S. Unusual maxillary rst molar with 2 palatal canals
within a single root: a case report. J Can Dent Assoc 2001;67:
211-4.
9. Martinez-Bern A, Ruiz-Badanelli P. Maxillary rst molars with
six canals. J Endod 1983;9:375-81.
10. Kottoor J, Velmurugan N, Sudha R, Hemamalathi S. Maxillary
rst molar with seven root canals diagnosed with cone-beam
computed tomography scanning: a case report. J Endod 2010;36:
915-21.
11. Bond JL, Hartwel G, Portell FR. Maxillary rst molar with six
canals. J Endod 1988;14:258-60.
12. Maggiore F, Jou YT, Kim S. A six-canal maxillary rst molar:
case report. Int Endod J 2002;35:486-91.
13. Adanir N. An unusual maxillary rst molar with four roots and
six canals: a case report. Aust Dent J 2007;52:333-5.
14. de Almeida-Gomes F, Maniglia-Ferreira C, Carvalho de Sousa
B, Alves dos Santos R. Six root canals in maxillary rst molar.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:
e157-9.
15. Vertucci FJ. Root canal anatomy of the human permanent teeth.
Oral Surg Oral Med Oral Pathol 1984;5:589-99.
16. Burns RC, Herbranson EJ. Tooth morphology and access cavity
preparation. In: Cohen S, Burns RC, editors. Pathways of the
pulp. 8th ed. St Louis, MO: Mosby Inc; 2002. p. 173-229.
17. Fava LR, Dummer PM. Periapical radiographic techniques dur-
ing endodontic diagnosis and treatment. Int Endod J 1997;30:
250-61.
18. 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.
19. Ingle JI, Backland LK, Peters DD, Buchanan S, Mullaney TP.
Endodontic cavity preparation. In: Ingle JI, Backland LK, edi-
tors. Endodontics. 4th ed. Baltimore, MD: Williams and Wilkins;
1994. p. 96-8.
20. Neaverth EJ, Kotler LM, Kattenback RF. Clinical investigation
of endodontically treated maxillary molars. J Endod 1997;13:
506-12.
21. Aggarwal V, Singla M, Logani A, Shah N. Endodontic manage-
ment of a maxillary rst molar with two palatal canals with the
aid of spiral computed tomography: a case report. J Endod
2009;35:137-9.
22. Ghoddusi J, Mesgarani A, Gharagozloo S. Endodontic re-treat-
ment of maxillary second molar with two separate palatal roots:
a case report. Iranian Endodontic Journal 2008;3:83-5.
23. Stropko JJ. Canal morphology of maxillary molars: clinical ob-
servations of canal congurations. J Endod 1999;25:446-50.
24. Christie WH, Thompson GK. The importance of endodontic
access in locating maxillary and mandibular molar canals. J Can
Dent Assoc 1994;60:527-32, 535-6.
25. Vertucci FJ. Root canal morphology and its relationship to end-
odontic procedure. Endod Topics 2005;10:3-29.
26. Krasner P, Rankow HJ. Anatomy of the pulp-chamber oor.
J Endod 2004;30:5-16.
27. Weller RN, Hartwell GR. The impact of improved access and
searching techniques on detection of the mesiolingual canal in
maxillary molars. J Endod 1989;15:82-3.
28. Gorduysus MO, Gorduysus M, Friedman S. Operating micro-
scope improves negotiation of second mesiobuccal canals in
maxillary molars. J Endod 2001;27:683-6.
29. Hildebolt CF, Vannier MW, Pilgram TK, Shrout MK. Quantita-
tive evaluation of digital dental radiograph imaging systems.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1990;
70:661-8.
30. Kottoor J, Hemamalathi S, Sudha R, Velmurugan N. Maxillary
second molar with 5 roots and 5 canals evaluated using cone
beam computerized tomography: a case report. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2010;109:e162-5.
31. Patel S, Dawood A, Whaites E, Pitt Ford T. New dimensions in
endodontic imaging: part 1. Conventional and alternative radio-
graphic systems. Int Endod J 2009;42:447-62.
Reprint requests:
Jojo Kottoor, BDS
Postgraduate Student
Department of Conservative Dentistry and Endodontics
Meenakshi Ammal Dental College and Hospital
Alapakkam Main Road
Maduravoyal, Chennai 600 095
Tamil Nadu, India
drkottooran@gmail.com
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Volume 110, Number 4 Albuquerque et al. e83