Aberrant canal configuration of the maxillary first molar

Anshuman Kharbanda; Pooja Sood; Rajiv Bali; Haridarshan Sidhu

doi:10.4103/2454-3160.161819

CASE REPORT

Year : 2015 | Volume : 1 | Issue : 1 | Page : 62-65

Aberrant canal configuration of the maxillary first molar

Anshuman Kharbanda¹, Pooja Sood², Rajiv Bali³, Haridarshan Sidhu⁴
¹ Department of Conservative Dentistry and Endodontics, LuxmiBai Institute of Dental Sciences and Hospital, Patiala, Punjab, India
² Department of Conservative Dentistry and Endodontics, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India
³ Department of Conservative Dentistry and Endodontics, Desh Bhagat Dental College and Hospital, Muktsar, Punjab, India
⁴ Department of Pedodontics, Government Dental College Patiala, Baba Farid university of Health Sciences, Faridkot, Punjab, India

Date of Web Publication

30-Jul-2015

Correspondence Address:
Dr. Rajiv Bali
Department of Conservative Dentistry and Endodontics, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/2454-3160.161819

Abstract

Aberrations in the root canal anatomy are a commonly occurring phenomenon. A thorough knowledge of the basic root canal anatomy and its variations is necessary for successful completion of the endodontic treatment. Maxillary first molars usually have three roots and three or four canals (two mesiobuccal canals, one distobuccal and one palatal canal). The incidence of two palatal canals in a palatal root is quite rare. This case provides an evidence of variations in the root canals in palatal root of maxillary first molar. Clinicians should thoroughly examine the pulpal floor and radiographs for the possibility of additional canals. The clinician must know not only the normal root canal anatomy but also variation from the normal. It is also paramount for the clinician to seek out every possible aberration of root canal anatomy for all teeth undergoing treatment.

Keywords: Aberrant canal, maxillary molar, two palatal canals

How to cite this article:
Kharbanda A, Sood P, Bali R, Sidhu H. Aberrant canal configuration of the maxillary first molar. Saint Int Dent J 2015;1:62-5

How to cite this URL:
Kharbanda A, Sood P, Bali R, Sidhu H. Aberrant canal configuration of the maxillary first molar. Saint Int Dent J [serial online] 2015 [cited 2023 Mar 22];1:62-5. Available from: https://www.sidj.org/text.asp?2015/1/1/62/161819

Knowledge of both the normal and abnormal anatomies of the root canal system dictates the parameters for the execution of root canal therapy and this can directly affect the outcome of the endodontic therapy. ^[1] Many unusual canal configurations and anomalies in the maxillary first molars have been documented in case reports and several studies. There are numerous variations in the canal number and configuration in maxillary molars. ^[2] In maxillary first molars, mesiobuccal roots tend to have more variations in the canal system followed by the distobuccal root, whereas the palatal root has the least.

The maxillary first molar most commonly has three or four canals, with one canal in both the palatal and distobuccal roots and one or two in the mesiobuccal root. ^[1] Most of the clinical literature on the fourth canal in maxillary molars reports an additional mesiobuccal canal (MB2). In addition to these studies, the literature cites the variation in the palatal root of the maxillary molars as a single root with two separate orifices, two separate canals, and two separate foramina; two separate roots, each with one orifice, one canal, and one foramen; and a single root with one orifice, a bifurcated canal, and two separate foramen, with a trifurcation at the apical third in the palatal canal. ^{[3],[4],[5],[6]}

This case report intensifies the complexity of maxillary molar variation and is intended to reinforce the clinician's awareness of the rare morphology of root canals. It presents endodontic therapy of a permanent maxillary, first molar with two canals in a single palatal root.

Case Report

A 23-year-old male presented to the Department of Conservative Dentistry and Endodontics, with pain in the left, maxillary, first molar of 2 months duration. The clinical examination revealed a deep carious lesion in the same tooth. The preoperative radiographic evaluation of the involved tooth indicated caries, which approximated the pulp with the normal root canal anatomy and the widening of the periodontal ligament space [Figure 1]. The clinical and radiographic findings led to a diagnosis of apical periodontitis, for which nonsurgical endodontic therapy was attempted. The patient's medical history was found to be noncontributory. The tooth was anesthetized using 2% lidocaine with 1:100,000 adrenaline. After isolation using a rubber dam, a conventional endodontic access opening was made.

Figure 1: Preoperative radiograph

Click here to view

The clinical evaluation of the internal anatomy of the pulp chamber revealed three principal root canal orifices (the MesioBuccal, the DistoBuccal, and the Palatal). The pulp chamber was frequently flushed with 5.25% sodium hypochlorite to remove the tissue debris. Examination of the floor of the pulp chamber with an endodontic explorer revealed four canal orifices, one MB2, one distobuccal canal, and two palatal orifices On probing with DG-16 endodontic explorer, a deep groove was noted at the same orifice level, approximately 2 mm distally from the orifice of the main palatal canal. The access cavity was further modified. Inspection of the pulp chamber revealed four distinct orifices, two buccal, and two palatal. K-type files were used to clean and shape the canal system. Frequent irrigation with 5.25% sodium hypochlorite was also carried out.

A working length radiograph confirmed the presence of two canals (Vertucci's Type II) in the palatal root. All the canals were instrumented by the crown down technique using protaper nickel-titanium rotary instruments (Maillefer Dentsply, Ballaigues, Switzerland) with 5.25% sodium hypochlorite solution and ethylenediaminetetraacetic acid (Glyde, Maillefer, Dentsply). [Figure 2] shows the photograph of the chamber floor after instrumentation. Master cone radiograph was taken [Figure 3]. Final irrigation was done with sodium hypochlorite followed by a rinse with normal saline. The canals were dried with paper points and obturated with gutta-percha (Mailllefer, Dentsply, Tulsa, OK) with an AH plus resin sealer (Dentsply, DeTrey Konstanz, Germany). The access was then sealed with intermediate restorative material cement. The postobturation radiograph revealed a Vertucci's Type II root canal morphology in the palatal root [Figure 4] and [Figure 5].

Figure 2: Clinical view post instrumentation photograph of chamber floor MB: Mesiobuccal, DB: Distobuccal, P1: Palatal first, P2: Palatal second

Click here to view

Figure 3: Master cone radiograph, MB: Mesiobuccal, DB: Distobuccal, P1: Palatal first, P2: Palatal second

Click here to view

Figure 4: Postobturation radiograph MB: Mesiobuccal, DB: Distobuccal, P1: Palatal first, P2: Palatal second

Click here to view

Figure 5: After crown cementation MB: Mesiobuccal, DB: Distobuccal, P1: Palatal first, P2: Palatal second

Click here to view

Discussion

Success in root canal treatment is achieved after thorough cleaning and shaping followed by the complete obturation of the root canal system. Hence, thorough knowledge of both the external and internal anatomy of teeth is an important aspect of root canal treatment. Vertucci ^[1] proposed a standardized method for categorizing known root canal anatomic variations, and a more clinically relevant classification of the root canal anatomy was described by Weine ^[2] . However, in everyday endodontic practice, clinicians have to treat teeth with atypical configurations. ^[7] Extra roots or root canals if not detected are a major reason for failure. ^[8]

In vitro and in vivo studies have demonstrated substantial variation in human maxillary molar anatomy regarding the number of roots and root canals. Most endodontic and dental anatomy texts describe the human maxillary first molar with three roots and three or four root canals. ^[8],[9],[10] Unusual canal anatomy associated with the maxillary molars has been investigated in several studies. ^[3],[4],[5] However, the prevalence of maxillary first molars with two palatal canals is rare. However, Christie et al., ^[5] have reported a variation in the number of roots and an unusual morphology of root canal systems in maxillary molars. Similarly, the present report highlights the unusual anatomy of a maxillary first molar with two separate palatal canals.

Thorough knowledge of root canal anatomy is the "single most important aspect for the successful treatment of endodontically treated teeth." Finding all of the root canals in an endodontic case is essential to long-term treatment success. In other words, due to lack of knowledge of the anatomical variations, some clinicians are not efficient to find all the root canals and this affects the treatment prognosis of the tooth.

Even though anatomical variations in maxillary first molars are documented in the literature, variations in the anatomy of these teeth are not recognized by a great many dentists. ^[6] It is important to know when to be suspicious. When a preoperative radiograph reveals an atypical tooth shape and an unusual contour, further radiographs should be taken with different angulations to confirm any unusual anatomical feature. Buccolingual views, 20° from mesial and 20° from distal, reveal the basic information on the tooth's anatomy and root canal system required for endodontic treatment. ^[11] Patients are rarely happy to have more radiographs, but the new technologies for digital radiography help to decrease the radiation exposure to our patients and improve acceptance of additional radiographs.

We should always search for more canals if files are not well centered in the canal on the radiograph or clinically as they protrude from the canal orifice. It helps to examine the placement of the file in the canal and how it relates to the root dimensions. Looking at the dentinal map on the floor of the pulp chamber helps improve the likelihood of finding additional canals. Even the use of magnification (loupes and dental operating microscopes) is of great benefit in diagnosing additional canals.

Recent technique of computerized tomography (CT) allowed the observation of the morphology of the root canals and the roots and the appearance of the tooth in every direction. A major concern with the use of a CT scan is its high radiation dosage. ^[12] Cone beam computed tomography (CBCT) is another advanced technology which procures three-dimensional images with much reduced exposure. Furthermore, with the use of CBCT, probability of finding more canals was possible.

Conclusion

When root canal treatment is to be performed the clinician should be aware that both external and internal anatomy may be abnormal. A clinician should open his/her mind to the various possible canal morphologies and should not stick only to a limited and standard number of canal patterns. Careful examination of radiographs and internal anatomy of teeth is essential. If left undetected extra roots or root canals are a major reason for the treatment failure. Hence, the ability to locate all the canals in the root canal system is an important factor in determining the eventual success of a case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99. [PUBMED]
2.	Weine FS. Endodontic Therapy. 6 ^th ed. St. Louis: Mosby; 2004. p. 109-10.
3.	Sidow SJ, West LA, Liewehr FR, Loushine RJ. Root canal morphology of human maxillary and mandibular third molars. J Endod 2000;26:675-8.
4.	Baratto-Filho F, Fariniuk LF, Ferreira EL, Pecora JD, Cruz-Filho AM, Sousa-Neto MD. Clinical and macroscopic study of maxillary molars with two palatal roots. Int Endod J 2002;35:796-801.
5.	Christie WH, Peikoff MD, Fogel HM. Maxillary molars with two palatal roots: A retrospective clinical study. J Endod 1991;17:80-4.
6.	Hommez GM, Braem M, De Moor RJ. Root canal treatment performed by Flemish dentists. Part 1. Cleaning and shaping. Int Endod J 2003;36:166-73.
7.	Slowey RR. Root canal anatomy. Road map to successful endodontics. Dent Clin North Am 1979;23:555-73. [PUBMED]
8.	Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg Oral Med Oral Pathol 1974;37:762-71. [PUBMED]
9.	Weine FS. Endodontic Therapy. 4 ^th ed. St. Louis, MO, USA: C. V. Mosby Co., 1989. p. 245-51.
10.	Ingle JI, Backland LK, Peters DD, Buchanan S, Mullaney TP. Endodontic cavity preparations. In: Ingle JI, Backland LK, editors. Endodontics. 4 ^th ed. Baltimore, MD, USA: Williams and Wilkins; 1994. p. 92-227.
11.	Ingle JI, Heithersay GS, Hatwell GR. Endodontic diagnostic procedures. In: Ingle JI, Bakland LF, editors. Endodontics. 5 ^th ed. London: BC Decker Inc.; 2001. p. 203-58.
12.	Cotti E, Campisi G. Advanced radiographic techniques for the detection of lesions in bone. Endod Topics 2004;7:52-72.