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Practice Profile

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Randy Garland, DDS

Randy Garland, DDS

Exceeding expectations What can you tell us about your background?
I grew up in southern Orange County and earned a bachelor’s degree in biology at San Diego State University in 1983. There I met my future wife, Kim, at the...

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Scott A. Norton, DMD, MSD

Scott A. Norton, DMD, MSD

Focus on family, patients, friends, growth, and community What can you tell us about your background? For as long as I can remember, I wanted to make people smile. I always loved getting the class laughing in grade school. Looking back, I am sure...

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Dr. Fleur A. Blethen

Dr. Fleur A. Blethen

Empathy, tenacity, and perseverance are keys to this clinician’s flourishing practice  What can you tell us about your background? I was born and raised in Seattle, Washington, and lived there until I was 13 years old. My family relocated...

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Clinical Articles

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Management of a tooth with a large internal resorption defect

Management of a tooth with a large internal resorption defect

Dr. Robert Slosberg facilitates accurate mapping and obturation of the resportive defect with CBCT imaging Abstract
A patient presented with advanced internal root resorption of tooth No. 9. The prominent location of this tooth...

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Pulpal diagnosis of teeth presenting with condensing osteitis prior to endodontic treatment — a retrospective study

Pulpal diagnosis of teeth presenting with condensing osteitis prior to endodontic treatment — a retrospective study

Drs. Brian Shaughnessy, Margaret Jones, Ricardo Caicedo, Joseph Morelli, Stephen Clark, and Ms. Jennifer Osborne review the occurrence of teeth presenting with condensing osteitis and their associated pulpal diagnosis over a 2-year period. Introduction Read More...

GuttaCore® system: a step forward in the evolution of endodontics

GuttaCore® system: a step forward in the evolution of endodontics

Dr. Andrei Zoryan dispels some of the common myths surrounding carrier-based obturation Carrier-based gutta percha Carrier-based obturation (such as Thermafil®, GT® obturator, ProTaper® obturator [Dentsply Tulsa Dental Specialties]) is one...

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Practice Management

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Life after root canal — it’s not just about having enough money

Life after root canal — it’s not just about having enough money

Dr. Robert Fleisher ruminates on how to prepare for retirement There are so many articles about everything that you become pretty much overwhelmed and can never expect to read them all. So you pick and choose. You like to learn about the latest and...

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Superior customer service

Superior customer service

Dr. Roger Levin presents the 10 top ways to help create a perfect dental team With the changes brought on by the economy, top companies are bringing in the best resources they can find to evaluate where their organizations stand. They want to know...

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Office Matters: Hard-piped filtered water system vs. self-contained bottled water system

John Bednar helps avert problems coming down the pipe If your office currently has a hard-piped filtered water system, now is a good time to consider if and when you should change to a self-contained bottled water system. A hard-piped filtered water...

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Fig1e

Drs. S. Gupta, P. Saxena, and A. Chandra explore the diagnosis and clinical management of an unusual root canal system and its variations

Fig1aAbstract
Premolars have highly variable root canal morphology, but the presence of three roots is rare. This article describes the diagnosis and clinical management of a first maxillary premolar with three canals and three separate roots, with special reference to radiographic interpretation and access refinements. The uniqueness of this case was our detection of multiple roots in all of the patient’s premolars. It is suggested to search for the similar anatomic variation in contralateral and opposite teeth as well.

Introduction
Although three-rooted premolars are rare, the possibility of extra roots or canals should be borne in mind to ensure successful endodontic treatment. The most important reason for treatment failure is incoFig1bmplete cleaning and shaping of canals. Therefore, the first step for successful treatment is an exact diagnosis of the root canal system and recognition of its variations. One of the possible variations of premolars is the presence of extra root canals. The reported frequency of three-rooted maxillary first premolars varies from 0.5% to 6%.1 Three-rooted maxillary second premolars are very rare and frequency varies from 0% to 1 %,1 generally with one canal in each of three roots.2 We performed our study in an Indian (Asian) population, where single-rooted maxillary premolars are dominant3 and three-rooted forms are rare,3-5 reported to be 2.1% in the non-Asian population and 0.6% in the Asian population.1 The anatomy of three-rooted maxillary premolars resembles that of maxillary molars and, therefore, they are sometimes referred to as small molars or as being  “radicular,” or “pertaining to the root.”6,7 This anatomic abnormality is an additional challenge, which begins at case assessment and involves all operative stagesFig1c, including access cavity design, localization, and cleaning and shaping of the root canal system. Although preoperative radiography gives a two-dimensional image of a three-dimensional object, precise interpretation can reveal external and anatomic details that suggest the presence of extra canals or roots.
The purpose of this clinical report is to describe an anatomic abnormality that was detected during routine root canal treatment in a maxillary first premolar, which on subsequent investigation, showed the presence of more three-rooted premolars in the patient.

Case report
A 45-year-old Indian man was referred to the Department of Conservative Dentistry and Endodontics, Government Dental College, Indore, for treatment of teeth Nos. 23 and 24 (FDI two-digit system). The patient had severe pain in relation to tooth No. 23, and both teeth Nos. 23 and 24 were tender on percussion. Fig1dEndodontic access cavity preparation had been performed on both the teeth, and open dressing was given by the referring dentist. The intraoral periapical (IOPA) radiograph of the area of concern showed the presence of three roots in tooth No. 24 (Figure 1A), which was later negotiated after proper anesthesia and isolation of the teeth. The access cavity had to be modified in order to make a triangular conformation at the base in the buccal direction for proper orifice location, resulting in a cavity with a “T” shape.8 We also noted a more apical position of the pulp chamber floor, which tends to make it more difficult to locate and obtain access to the root canals. The working length (WL) radiograph (Figure 1B) revealed that tooth No. 25 also had three roots. Tooth No. 23 was also debrided, and proper biomechanical preparation of both the teeth was performed. The teeth were disoccluded, and an intracanal medicament (calcium hydroxide) was placed. The patient was recalled a week later, and tooth No. 24 was obturated. The post-obturation radiograph (Figure 1D) clearly showed the presence of three roots with a single obturated canal in each root. According to the study of Sabala et al,9 the rarer the anomaly, the higher the chances of its bilateral occurrence. We followed his proposition and completed an orthopantomogram (OPG) of the patient (Figure 1E). The OPG showed that nearly all of the patient’s premolars had multiple roots, so IOPAs of teeth Nos. 14, 15, 34, 35, 44, and 45 were done at different angles, which confirmed the presence of three roots in teeth Nos. 14 and 15 (Figure 1F), three root canals in teeth Nos. 34 and 35 (Figure 1G), at least two root canals in tooth No. 44, and one canal in tooth No. 45 (Figure 1H).

Discussion
The morphology of the root and canals of the premolars can be complex and variable.10 Because of the varied morphology, endodontic treatment in the premolar is a challenging task. Therefore, the internal morphology must be identified precisely to achieve successful treatment. The anatomical landmarks of the pulp chamber floor may help to identify supplementary root canals or root canal aberrations.11

Many authors who have located three orifices in the pulp chamber of premolars reported one orifice in the lingual side and two in the buccal.12 One case had three atypical orifices, of which two merged in the distal half of the furcation area while the other opened on the mesial wall of the pulp chamber.11 Fig1eThe root shape, root position, and relative root outline should be carefully determined from the radiograph. Good quality preoperative radiographs and thorough radiographic examination are essential for the detection of additional root canals. Sudden narrowing or a disappearing pulp space (fast-break guideline) may indicate the presence of another canal or canals.12 In the present case, the radiographic features suggested the possibility of three canals. Fig1fHowever, visualization of three-canal premolars on operative radiographs is difficult, and because of the superimposition of roots, radiographic diagnosis of three canals is not always possible in all cases. Several clinical indications may be useful in the detection of a third canal in premolars. In some situations, a third canal may exist clinically when the pulp chamber does not appear to be aligned in its usual buccolingual relationship. Furthermore, if the pulp chamber appears to deviate from normal configuration and seems to be either triangular in shape or overly large in the mesiodistal direction, more than one canal should be suspected. Tactile examination of all the walls of the major canal with a small, precurved K-file tip is recommended in order to probe for a catch, which may indicate the orifice of an additional canal. However, using this technique without any previous idea about the location of the orifices may be time consuming and frustrating. The use of dyes, especially methylene blue, has been reported to be helpful in finding orifices.13Microscopes are commonly used to explore the pulp chamber in order to find orifices. The advantages of using a microscope for conventional endodontics include better visualization of the pulp chamber floor and walls, which prevents inadvertently missing orifices. Although we did not use a microscope, we do recommend it for better visualization. It is assumed that careful observation and inspection of the pulpal floor and pulpal wall is mandatory to avoid missing orifices that may result in unsuccessful endodontic treatment. Attention to the color changes on the pulpal floor and wall during inspection, instead of searching for defined places, might be helpful to locate orifices.
Sabala et al9 studied aberrant root and root canal morphology in 501 patient records. In the study, occurrence of the same aberration on the contralateral tooth varied according to the type of anomaly. Of the 4 patients, out of 501, who were found to have three-rooted maxillary first premolars, all were bilateral. Fig1hTheir study found that the rarer the anomaly, the greater the incidence of the anomaly occurring bilaterally. Those anomalies occurring less than 1% were found to occur bilaterally up to 90% of the time. The bilateral symmetry of the three-rooted premolars may be expected in many patients as this anomaly is quite rare. Keeping this fact in mind, we could successfully detect the multiple roots in nearly all premolars of the patient. Different radiographs confirmed the presence of three roots in teeth Nos. 14 and 15, three root canals in teeth Nos. 34 and 35, at least two root canals in tooth No. 44, and one canal in tooth No. 45. So, our study strongly suggests investigating the anomaly contralaterally, which may have been missed by earlier investigators.

Conclusion
When root canal treatment is to be performed, the clinician should be aware that both external and internal anatomy may be abnormal. Knowledge of possible variations in internal anatomy of human teeth is important. Although the three-root forms are very rare, it is essential for every dentist to be aware of the possible existence of three canals in premolars; the knowledge of such variations will assist clinicians in successfully diagnosing and treating endodontic cases.

Fig1g

 

Saurabh Kumar Gupta, MDS, is Assistant Professor, Government Dental College, Indore, India.

Payal Saxena, MDS, is Senior Resident, Chhatrapati ShahuJi Maharaj Medical University, Lucknow, India.

Anil Chandra, MDS, is Professor, Chhatrapati ShahuJi Maharaj Medical University, Lucknow, India.

References

1. Ingle J, Bakland L, Baumgartner JC (2008) Ingle’s Endodontics, ed 6. BC Decker Inc, Hamilton.

2. Vertucci FJ, Gegauff A (1979) Root canal morphology of the maxillary first premolar. J Am Dent Assoc 99(2):194-198.

3. Aoki K (1990) Morphological studies on the roots of maxillary premolars in Japanese. Shikwa Gakuho 90(2):181-199.

4. Walker RT (1987) Root form and canal anatomy of maxillary first premolars in southern Chinese population. Endod Dent Traumatol 3(3):130-134.

5. Loh HS (1998) Root morphology of the maxillary first premolar in Singaporeans. Aust Dent J 43(6):399-402.

6. Maibaum WW (1989) Endodontic treatment of a “ridiculous” maxillary premolar: a case report. Gen Dent 37(4):340-341.

7. Goon WW (1993) The “ridiculous” maxillary premolar: recognition, diagnosis, and case report of surgical intervention. Northwest Dent 72(2):31-33.

8. Sieraski SM, Taylor GN, Kohn RA (1989) Identification and endodontic management of three-canalled maxillary premolars. J Endod 15(1):29-32.

9. Sabala CL, Benenati FW, Neas BR (1994) Bilateral root or root canal aberrations in a dental school patient population.
J Endod 20(1):38-42.

10. Ash MM Jr (2003) Wheeler’s dental anatomy, physiology and occlusion, 8th ed. W.B. Saunders, Philadelphia: 151-156.

11. De Moor RJG, Calberson FLG (2005) Root canal treatment in a mandibular second premolar with three root canals.
J Endod 31(4):310-313.

12. Hargreaves KM, Cohen S  (2006) Pathways of the Pulp, 9th ed. Mosby, Elsevier: 148-232.

13. Bahcall JK, Barss JT (2001) Fiberoptic endoscope usage for intracanal visualization. J Endod 27(2):128-129.

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Research has shown that irrigants are more effective when they are electro-mechanically activated.

Acoustic streaming and cavitation have been proven to significantly enhance cleaning of difficult anatomy. Studies have shown that low frequency (Sonic) oscillation (160-190Hz) was not sufficient to create acoustic streaming or cavitation within the canal space.

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