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| CASE REPORT |
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| Year : 2016 | Volume
: 7
| Issue : 1 | Page : 45-47 |
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Maxillary first molar with five canals
Prem Anand1, Sekar Mahalaxmi2
1 Private Practitioner, 'Smile with Us' Dental Clinic, Coimbatore, India
2 Professor and Head, Department of Conservative Dentistry and Endodontics, Bharathi Salai, Ramapuram, Chennai, Tamil Nadu, India
| Date of Web Publication | 16-Feb-2016 |
Correspondence Address:
Sekar Mahalaxmi
Department of Conservative Dentistry and Endodontics, SRM Dental College, Chennai - 600 089, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0976-433X.176477
Maxillary first molar usually has three roots namely, mesiobuccal, distobuccal, and palatal. The incidence of four canals in maxillary first molar ranges from 50.4% to 95%, the fifth canal is 2.25%, and few authors have reported cases with six and seven canals too. With this varying number of canals and canal configurations, endodontic treatment of the maxillary first molars is always a challenge. This clinical article describes a case report of a maxillary first molar with the unusual anatomy of five root canals and its endodontic management. Keywords: Canal configuration, extra canals, maxillary first molar, root canal anatomy, variations
How to cite this article:
Anand P, Mahalaxmi S. Maxillary first molar with five canals. SRM J Res Dent Sci 2016;7:45-7 |
| Introduction | |  |
Endodontic management of maxillary first molars presents a constant challenge, due to the complex anatomy of their roots and root canals. One of the major causes of root canal failure is the inability to identify, locate, and treat the entire root canal system.
Variations in the number and configuration of the roots and their canals have been reported in the literature over the years; the most common variation being the presence of a second mesiobuccal canal with incidence of more than 90%.[1] Even the rarely found two palatal canals have also been reported.[2],[3] The increasing reports of more than one mesiobuccal canal and additional distobuccal canals in the recent years can be attributed to the increased knowledge of the root canal complex morphology, advanced diagnostic tools such as cone-beam computed tomography (CBCT) and micro-computed tomography and using equipment such as dental operating microscope, ultrasonics, and specialized instruments.
Since naming these extra canals was still elusive, a new nomenclature was suggested for ease of communication.[4] The occurrence of more number of canals in the mesiobuccal (MB) root may be due to the broad bucco-palatal dimensions of the root.[5] The incidence of more than one canal in the distobuccal root has been reported to be more than 6%.[6] When performing endodontic treatment, the clinician should always assume the presence and look for signs of these variations. A thorough knowledge of root canal morphology and the use of magnification increase the chance of successful clinical results.
This case report discusses one such variation in the maxillary first molar; the detection of five canals, and the successful completion of its endodontic treatment with a one year follow-up.
| Case Report | | |
A 40-year-old male patient reported to the dental clinic with the complaint of pain in the left upper back tooth region. On clinical examination, a deep carious lesion was found in the left maxillary first molar; the nature of pain being continuous, dull and radiating to the left side of the head. The patient had pain on palpation and percussion. Radiographic examination revealed caries approximating the pulp with periapical radiolucency present along the apex of mesial root [Figure 1]a. Vitality test revealed early response to a cold test that lingered even after removal of the stimulus. The case was diagnosed as symptomatic irreversible pulpitis with symptomatic apical periodontitis in tooth no. 14. Hence, root canal treatment followed by postendodontic full coverage restoration was planned. | Figure 1: (a) Preoperative radiograph, (b) The floor of pulp chamber showing 2 mesiobuccal, 2 distobuccal (DB) and 1 palatal (P) canal orifices, (c) Master cone radiograph, and (d) Photograph of obturated canals
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Under local anesthesia (2% lignox, 1:80000 adrenaline), conventional access cavity preparation was done with Dentsply India Pvt. Ltd, India (to reach the pulp chamber). Extension and de-roofing of the pulp chamber were done to provide straight line access to the canals. Coronal pulp was removed. The three principal canals namely mesiobuccal, distobuccal, and palatal canals were identified. Small hemorrhagic spots were identified palatally to both mesiobuccal and distobuccal canals. The conventional triangular access was modified to a trapezoidal shape to improve the access. Five canals were located in the floor of the pulp chamber, namely two mesiobuccal, two distobuccal and one palatal [Figure 1]b.
Canal negotiation and glide path was established with a no 10 K file (Mani Inc., Tochigi, Japan) using Ethylenediaminetetraacetic acid (EDTA) gel (Endo Prep RC, Anabond Stedman Pharma Research Ltd., Tamil Nadu, India) as a lubricant. Working length determination was done using electronic apex locator Root ZX mini (J. Morita Mfg. Corp., Kyoto, Japan). Initially, canals were prepared with hand instruments up to size 20 K file. Coronal third enlargement and middle third shaping of the canals was done using 6% rotary instruments 30, 25, 20, size (Hero Shapers, Micro Mega, SA, France) and apical third enlargement done using 4% rotary instruments 20, 25, and 30 size. The final preparation was 30 size and 6% taper for the palatal canal and 30-4% for other four canals. Sodium hypochlorite 3% solution was used as an irrigant throughout the shaping procedure. Final rinse was done with 2 ml of 17% EDTA solution (DESMEAR, Anabond Stedman Pharma Research Ltd., Tamil Nadu, India).
Obturation was done using 30-4% Gutta-percha points and 30-6% Gutta-percha points, by warm vertical condensation done using hot pluggers [Figure 1]c and [Figure 1]d. Access cavity was restored using composite resin material. The patient was recalled for the crown. Follow-up evaluations at 6 months and 1-year were done.
| Discussion | | |
The success of endodontic treatment largely depends upon the identification, shaping, cleaning, and obturation of the complex root canal system. It is known that maxillary first molar has one of the most complex root canal morphology [Figure 2]. Baratto Filho et al. have shown that the use of a dental operating microscope and CBCT clinically enhances the ability to identify and locate extra canals.[7]
This case report emphasizes the importance of the use of magnification for exploring the canals and modification of access cavity to ensure the proper endodontic treatment. Weller and Hartwell showed that modification of the access cavity from a conventional triangular to rhomboidal shape, exploration of the groove running from the MB to palatal and removal of any projections that may conceal the canal orifice enhances the chances of locating the additional MB canals.[8]
According to the literature, the occurrence of the fourth canal in maxillary first molar ranges greatly. A literature review by Cleghorn et al. on the root and root canal morphology states that incidence of two canals in the MB root was higher in laboratory studies (60.5%) compared to the clinical studies (54.7%).[9] Less variations were reported in distobuccal and palatal roots. In recent years, this percentage has been alarmingly on the rise, mainly due to advanced diagnostic technics with enhanced anatomical knowledge and the operator's keenness in detecting these variations. Clinical studies have always shown a higher prevalence of the second canal in the MB and distobuccal roots.[7],[9]
It can thus be safely concluded that adequate knowledge and experience, and the use of suitable diagnostic adjuncts helps in enhancing the success of endodontic treatment of maxillary first molars.
| Conclusion | | |
This case report contributes to our understanding of root canal morphology found in a maxillary first molar. Hence, dentists performing endodontic treatment in maxillary first molars should always assume more number of canals and complex canal systems unless proven otherwise.
We would like to thank Dr. Marco Versiani, Brazil for granting permission to use an image from their website. We also thank Dr. K. Karthikeyan for helping us with the editing of the manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod 2002;28:324-7.  |
| 2. | Stone LH, Stroner WF. Maxillary molars demonstrating more than one palatal root canal. Oral Surg Oral Med Oral Pathol 1981;51:649-52. |
| 3. | Aggarwal V, Singla M, Logani A, Shah N. Endodontic management of a maxillary first molar with two palatal canals with the aid of spiral computed tomography: A case report. J Endod 2009; 35:137-9. |
| 4. | Karthikeyan K, Mahalaxmi S. New nomenclature for extra canals based on four reported cases of maxillary first molars with six canals. J Endod 2010;36:1073-8. |
| 5. | Ahmad IA, Al-Jadaa A. Three root canals in the mesiobuccal root of maxillary molars: Case reports and literature review. J Endod 2014;40:2087-94. |
| 6. | 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. |
| 7. | 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. |
| 8. | 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. |
| 9. | 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. |
[Figure 1], [Figure 2]
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