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Randy Garland, DDS

Randy Garland, DDS

Exceeding expectations What can you tell us about your background?
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Scott A. Norton, DMD, MSD

Scott A. Norton, DMD, MSD

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Dr. Fleur A. Blethen

Dr. Fleur A. Blethen

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

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gomes4.5_front

Drs. F. de Almeida-Gomes, C. Maniglia-Ferreira, M. de Morais Vitoriano, N.L. de Lima Guimarães, N.S. Canuto, T. A. Ximenes, and R.A. dos Santos

Drs. F. de Almeida-Gomes, C. Maniglia-Ferreira, M. de Morais Vitoriano, N.L. de Lima Guimarães, N.S. Canuto, T. A. Ximenes, and R.A. dos Santos discuss treatment for a variety of unusual anatomical configurations in mandibular second molars

Educational aims and objectives
This clinical article aims to report and discuss treatment recommendations in four cases of different anatomical configurations that may occur in mandibular second molars.

Expected outcomes
Correctly answering the questions following this article, worth 2 hours of CE, will demonstrate you can describe the treatment recommendations for a variety of unusual occurrences of anatomical configurations in mandibular second molars. Click here to receive CE credit and to take the Gomez quiz.

gomesFigure-1AOne of the most important skills in endodontics is a thorough knowledge of internal root anatomy. This aspect, together with a correct diagnosis and appropriate shaping and cleaning of the root canal system, will usually lead to a successful outcome (Ravanshad, Nabavizade, 2008). Consistent, high levels of success in endodontic treatment requires an understanding of root canal anatomy and morphology, and that the entire root canal system is debrided, disinfected, and filled. Thus, it is necessary for the clinician to have knowledge of dental anatomy and its variations (Baratto-Filho et al, 2002).

Inferior technical quality of root fillings is considered to be the main cause of gomesFigure-1Bclinical failure. Incomplete obturation of the root canal leaves residual space for microbial colonization and proliferation, and may also imply that cleaning was incomplete (DeCleen et al, 1993; Ingle, 1985). Therefore, the correct location, shaping, cleaning, and obturation of all canals are indispensable procedures. Similarly, Almeida-Gomes et al (2009), Vertucci (1984), De Grood and Cunningham (1997), and Maniglia-Ferreira et al (2008) reported that a considerable number of failures could be assigned to anatomical variations, such as the presence of canals not usually found.

Although the mandibular second molar resembles the first molar, it is more variable than the first, and the roots are often fused. An in vitro investigation of mandibular second molar root canal morphology has reported that 73% of mesial roots have one canal at the apex and 27% have two canals at the apex. In the gomesFigure-2Adistal root, 95% have one canal at the apex (2007). Manning (1990) has studied the root canal anatomy of 149 extracted mandibular second molars using clearing techniques. He found that 22% had single roots, 76% had two roots, and 2% had three roots. Costa Rocha et al (1996) studied the external and internal anatomy of 628 extracted mandibular first and second molars. Analysis of mandibular second molar roots showed that 84.1% presented two separate roots, 15.9% fused roots, and 1.5% three roots (Rocha et al, 1998). Unusual root and root canal morphologies associated with the mandibular second molar have been recorded in several studies in the literature. Castellucci (1987) observed two cases of three-rooted mandibular second molars with one mesial and two distal roots in both specimens. Furthermore, root canal anatomy showed three canals, one mesial and two distal in one tooth, and four canals, two mesial and two distal, in the other.

Most endodontic textbooks and dental anatomy books describe the mandibular gomesFigure-2Bsecond molar as having two roots—one mesial and one distal with two, three, or four root canals (Ingle et al, 1994; Walton, Vertucci, 1996; Walker, 1998). However, a mandibular second molar with a conical root and wide single root canal is also reported (Skidmore, 1979). Weine (1988) stated that this tooth may have more anatomical variations than all other molar teeth. Researchers have shown that the anatomy of mandibular molars requires much attention because the number of roots and canals is quite variable.

gomesFigure-3AThe purpose of this study is to report, as well as discuss, treatment recommendations in four cases of different anatomical configurations that may occur in mandibular second molars.

Case report one
A 40-year-old woman was referred for endodontic treatment. The patient complained of pain in relation to the left mandibular posterior region. Intraoral examination revealed deep caries. These teeth were also tender on percussion. No swelling or fistula was present. Intraoral periapical radiographs of both the teeth revealed deep caries approximating the pulp with a periradicular radiolucency. Based on these findings, the condition was diagnosed as necrotic pulp. A detailed examination of the radiograph revealed the presence of a single root with a wide canal (Figure 1A).

The tooth was anesthetized, isolated with rubber dam, and the temporary gomesFigure-3Brestoration was removed. In order to verify the working lengths (WLs), an electronic apex locator was used (Root ZX®, J. Morita Inc). The root canal was prepared in a crown-down method with Gates Glidden drills (Dentsply-Maillefer) using numbers 2-5 at the cervical and middle-thirds of the root canals. The manual instrument size 20 was used to apical patency. Sodium hypochlorite (2.5%) and EDTA (17%) solutions were used as irrigants. The canal was filled by following Tagger’s technique of lateral condensation and thermomechanical compaction using gutta-percha points and root canal sealer (Endofill, Denstply) (Figure 1B).

Case report two
A 45-year-old man with a noncontributory medical history was referred to our office complaining of severe discomfort associated with his mandibular right second molar. The intraoral clinical examination revealed a fractured amalgam restoration with occlusal caries in this tooth. The patient reported that the pain was initially caused by cold stimulus that ceased a few minutes after its removal. gomesFigure-3CAfter a short period, the pain ceased only with analgesics, and afterwards it became spontaneous, intense, and throbbing. The probable diagnosis was an acute pulpitis, and endodontic treatment was indicated.

The preoperative periapical radiograph showed the presence of two canals and one root, one mesial and one distal (Figure 2A). The coronal access was prepared, and the tooth was isolated. The initial radiographic exam showed only two root canals, one mesial and one distal. The canals were cleansed, and the length of each root canal was established using an electronic apex locator (Root ZX®, J. Morita Inc.). The root canals were prepared in a crown-down method. Sodium hypochlorite (2.5%) and EDTA (17%) solutions were used as irrigants. The canals were filled using the lateral condensation technique with gutta-percha points and root canal sealer (Endofill, Denstply). Treatment was executed in a single visit. After the filling, the gomesFigure-4Afinal radiographic exam showed the two root canals with distinct foramina (Figure 2B).

Case report three
A 55-year-old man was referred to the department of endodontics, faculty of dentistry, Fortaleza University, for a general dental examination. There was no contributory medical history. He related severe discomfort associated with his mandibular right second molar. The preoperative periapical radiograph revealed an unusual anatomy of the involved tooth with a single root and a single canal (Figure 3A). The intraoral clinical examination revealed occlusal caries in this tooth. The patient reported that the pain was initially caused by cold stimulus, which ceased a few minutes after its removal. After a short period, the pain ceased only with analgesics, and afterwards it became spontaneous, intense, and throbbing. There was no mobility, no periodontal inflammation, no sign of previous or current fistulae, and no pain upon palpation or percussion. The probable diagnosis was an acute pulpitis, and endodontic treatment was indicated.

gomesFigure-4BAfter anesthesia and isolation with rubber dam, an endodontic access cavity was made. Two orifices were seen, one in the distal and the other in the mesial. The pulpal floor presented the shape of the letter “C” (Figure 3B). The length of the root canal was determined using an electronic apex locator (Root ZX®, J. Morita Inc.). The C-shaped canal had only one apical foramina.

The canals were prepared using the step-back technique with sodium hypochlorite (2.5%) and EDTA (17%) solutions as irrigants. The canals were filled by using the System B/Obtura® II technique with gutta-percha points and root canal sealer (Endofill, Denstply) (Figure 3C).

Case report four
A 32-year-old man with noncontributory medical history was referred to our office complaining of discomfort associated with the left mandibular region.

Clinical and radiographic examinations revealed a temporary restoration in the right mandibular second molar (Figure 4A). The tooth was very sensitive to percussion, there was no tenderness to palpation, the buccal sulcus was not tender, nor was there any swelling, and it was non-responsive to Endo Ice® (Hygenic Corp.).

After the administration of local anesthetic (2% lignocaine with 1:100.000 epinephrine), the tooth was isolated, and the coronal access was prepared. On gomesFigure-4Centry into the pulp chamber, four different canal orifices were found, two mesials and two distals (Figure 4B). The access cavity was enlarged to a quadrangular outline. The canals were cleansed, and the length of each root canal was established using an electronic apex locator (Root ZX®, J. Morita Inc.). The root canals were prepared in a crown-down method using Gates Glidden drills and hand files (FlexoFile®, Dentsply Maillefer). Sodium hypochlorite (2.5%) and EDTA (17%) solutions were used as irrigants. After cleaning and shaping, the canals were dried and filled following the Tagger’s technique using gutta-percha points and root canal sealer (Endofill, Denstply).

Treatment was executed in a single visit. After the filling, the final radiograph showed the four root canals with distinct foramina (Figure 4C). A sterile cotton pellet was placed in the pulp chamber, the access cavity was sealed with Cavit (ESPE), and the patient was dismissed.

Discussion
Accurate preoperative radiographs—straight and angled, using a parallel technique—are essential in providing clues as to the number of existing roots (Silha, 1968).

Although various techniques have been used in studies evaluating canal morphology, it has been reported that the most detailed information can be obtained by demineralization and staining (Silha, 1968; Vertucci, 1984; Neaverth, Kotler, Kaltenbach, 1987), which is regarded as an excellent method for three-dimensional evaluation of root canal morphology.

Endodontic success in teeth with a number and morphology of canals above that normally found requires a correct diagnosis and careful clinical radiographic inspection. Morphological variations in pulpal anatomy must always be considered at the beginning of treatment.

According to Leonardo (1998), an inability to detect, locate, negotiate, and instrument all root canals may lead to endodontic failure. Textbooks describe in detail the “typical morphology” of any tooth, but one should always note published case reports presenting variations and/or irregularities of the pulp space.

When anatomic variations are detected clinically, treatment can be performed with conventional or rotary instrumentation and root canal system filling techniques, respecting technical and biological principles. The use of an apex locator can be important to determine the WL. Additional anatomic information about the root canals can be obtained by careful observation of the positioning and deformation of instruments (Jerome, Hanlon, 2003).

This study presented, as well as discussed, the treatment recommendations for four cases of different anatomical configurations that may occur in second mandibular molars. Determining the developmental origin of this anatomical anomaly appeared to have clinical significance.

Conclusion
Sound knowledge of dental anatomy is fundamental for good endodontic practice. The frequency of mandibular second molars with an abnormal anatomic configuration is common; however, each case should be investigated carefully clinically and radiographically to detect the anatomical anomaly.

Fábio de Almeida-Gomes,  DDS, PhD, is in the Department of Endodontics, University of Fortaleza, Brazil.

Claudio Maniglia-Ferreira DDS, PhD, is in the Department of Endodontics, University of Fortaleza, Brazil.

Marcelo de Morais Vitoriano is in the Department of Endodontics, University of Fortaleza, Brazil.

Nadine Luisa Soares de Lima Guimarães is in the Department of Endodontics, University of Fortaleza, Brazil.

Natalia Siqueira Campos Pontes Canuto is in the Department of Endodontics, University of Fortaleza, Brazil.

Roberto Alves dos Santos is in the Department of Endodontics, University of Pernambuco, Brazil.

Tatyana Albuquerque Ximenes is in the Department of Endodontics, University of Fortaleza, Brazil.

 

References

Almeida-Gomes F, Sousa BC, Souza FD, et al (2009) Three root canals in the maxillary second premolar. Indian J Dent Res 20(2):241-242.

Baratto-Filho F, Fariniuk LF, Ferreira EL, et al (2002) Clinical and macroscopic study of maxillary molars with two palatal roots. Int Endod J 35:796-801

Castellucci A (1987) Endodonzia. Ed Odontoiatriche: Il Tridente De Grood ME, Cunningham CJ (1997) Mandibular molar with five canals: report of a case. J Endod 23(1):60-62.

DeCleen MJH, Schuurs AHB, Wesselink PR, et al (1993) Periapical status and prevalence of endodontic treatment in an adult Dutch population. Int Endod J 26(2):112-119.

Ingle JI (1985) Endodontics, 3rd edition. Saunders, Philadelphia, PA.

Ingle JI, Bakland LK, Peters DL, et al (1994) Endodontic cavity preparations. In: Ingle JI, Bakland LL: Endodontics, 4th edition. Williams & Wilkins, Baltimore, MD, USA:92-227.  

Jerome CE, Hanlon RJ Jr (2003) Identifying multiplanar root canal curvatures using stainless-steel instruments. J Endod 29(5):356-358.

Leonardo MR (1998) Aspectos anatômicos da cavidade pulpar: relações com o tratamento de canais radiculares. In: Leonardo MR, Leal JM, eds. Endodontia: tratamento de canais radiculares. 3rd ed. Panamericana, São Paulo:191.

Maniglia-Ferreira C, Almeida-Gomes F, Sousa BC, et al (2008) A case of unusual anatomy in second mandibular molar with four canals. Eur J Dent 2:217-219.

Manning SA (1990) Root canal anatomy of mandibular second molars. Part I. Int Endod J 23(1):34-39.

Neaverth EJ, Kotler ML, Kaltenbach RF (1987) Clinical investigation (in vivo) of endodontically treated maxillary first molar. J Endod 13(10):506-512.

Peiris R, Takahashi M, Sasaki K, et al (2007) Root and canal morphology of permanent mandibular molars in a Sri Lankan population. Odontology 95(1):16-23.

Ravanshad S, Nabavizade MR (2008) Endodontic treatment of a mandibular second molar with two mesial roots: report of a case. Iranian Endodontic Journal 3(4):137-140.

Rocha LF, Sousa Neto MD, Fidel SR, et al (1996) External and internal anatomy of mandibular molars. Braz Dent J 7(1):33-40.

Silha RE (1968) Paralleling long cone technique. Dent Radiogr Photogr 41:3-19.

Skidmore AE (1979) The importance of preoperative radiographs and the determination of root canal configuration. Quintessence Int Dent Dig 10(3): 55-61.

Vertucci FJ (1984) Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 58(5):589-599.  

Walker RT (1998): Pulp space anatomy and access cavities. In: Pitt Ford TR, ed. Harty’s Endodontics in Clinical Practice, 4th edition. Wright, Oxford:16-36.

Walton RE, Vertucci FJ (1996): Internal anatomy. In: Walton RE, Torabinejad M, eds. Principles and Practice of Endodontics, 2nd edition. W.B. Saunders Co., Philadelphia:166-179.

Weine FS, Pasiewicz RA, Rice RT (1988) Canal configuration of the mandibular second molar using a clinically oriented in vitro method. J Endod 14(5):207-213.

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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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