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Endodontic Management of a Maxillary First Molar with Eight Root Canal Systems Evaluated Using Cone-beam Computed Tomography Scanning: A Case Report
Abstract
Root canal treatment of maxillary molars presenting with complex root canal configurations can be diagnostically and technically challenging.
Nonsurgical endodontic therapy of a left maxillary first molar with three roots and eight root canals was successfully performed. This unusual morphology was diagnosed using a dental operating microscope (DOM) and confirmed with the help of cone-beam computed tomography (CBCT) images.
CBCT axial images showed that both the mesiobuccal and distobuccal root contained a Sert and Bayirli type XV canal, whereas the palatal root showed a Vertucci type II canal configuration.
The use of a DOM and CBCT imaging in endodontically challenging cases can facilitate a better understanding of the complex root canal anatomy, which ultimately enables the clinician to explore the root canal system and clean, shape, and obturate it more efficiently.
... The most commonly reported anatomic configuration in maxillary first molars is the presence of 3 roots (2 buccal and 1 palatal) and 4 canals: 2 in the mesiobuccal root, 1 in the distobuccal root and 1 in the palatal root 2 . A maxillary first molar should be considered a four-canal tooth until proved otherwise; however, a clinician should be aware of the possibility of variations in the number of roots, from 1 to 5 3,4 ; the number of root canals, from 1 to 8 [4][5][6][7][8] , or C-shaped root canal configuration which may or may not be split into two or more canals 9 . The first documented case of a maxillary first molar with a C-shaped root canal was published by Newton & McDonald in 1984 10 . ...
... The present study, based on a retrospective assessment of CBCT images, provides a description of the C-shaped anatomy of the first and second maxillary molars, estimated for the first time in an Argentine subpopulation. The term "C-shaped" in maxillary molars is used to describe root canals with large semilunar canal shape that can represent a whole root canal or a partial fusion of two or more canals 7,10,11,27,28 . In different studies, several methods were used to study root canal morphology, including radiographic technics, clearing technique, spiral computed tomography, sectioning technique and microcomputed tomography, all of which have some limitations. ...
... In different studies, several methods were used to study root canal morphology, including radiographic technics, clearing technique, spiral computed tomography, sectioning technique and microcomputed tomography, all of which have some limitations. The CBCT scans reveal anatomic details of external and internal anatomy, being an important tool for diagnosis and treatment in endodontic practice 4,7,20 . ...
Unlabelled:
The aim of the present study was to evaluate the presence of maxillary first and second molars with a C-shaped canal system in an Argentine subpopulation, and to classify them.
Materials and method:
Of the 332 CBCTs initially evaluated, 120 met the selection criteria. Once the presence of a C-shaped canal system had been established, the teeth were classified following Martins et al. Data were expressed as absolute frequencies, percentages with of 95% confidence intervals, according to the score test. Comparisons were analyzed by Chi-square test and Fisher' exact test, with 5% significance level.
Results:
It was found that 5 out of 120 first molars (4%) and 17 out of 152 second molars (11%) had a C-shaped canal system. Regarding the classification applied, of 5 C-shaped first molars, 2 corresponded to type E2 (40%), 2 corresponded to type C (40%), and 1 corresponded to type B1 (20%). Of 17 C-shaped second molars, 4 resembled a type A (24%), 7 resembled a type B1 (41%), 5 resembled a type B2 (29%), and 1 resembled a type C (6%). UC1 and UC2 configurations were the most common at all levels except apical level.
Conclusion:
The prevalence of C-shaped canal system pattern in maxillary first and second molars was estimated for the first time in an Argentine subpopulation, in vivo. Knowledge of these data should help clinicians during endodontic treatment.
... [1] The root canal anatomy of the maxillary first molar has been studied extensively and the most common configuration described is the presence of three roots with three canals, while the most frequent variation is the presence of second mesiobuccal canal (MB2). [2] Other variations include one, [3] two, [4] four [5] and five [6] roots and unusual morphology of root canals within individual roots, uptoeight canals [7] havebeen reportedin maxillary first molar [ Table 1]. ...
... Gopikrishna et al. [13] 2008 Spiral CT 4 2(fused) 2 India, 25-year-old woman de Almeida-Gomes et al. [14] 2009 Clinical RCT 6 2 2 2 Brazil, 26-year-old man Aggarwal et al. [15] 2009 Spiral CT 4 1 1 2 India, 23-year-old man Holderrieth and Gernhardt [16] 2009 Radiographs, Microscope 5 2 1 2 Germany, 21-,40-and 32-year old men and 39-year old woman Deepalakshmi et al. [17] 2009 Spiral CT 5 2 1 2 India, 24-year-old woman Kottoor et al. [18] 2010 CBCT 7 3 2 2 India, 37-year-old man Kottoor et al. [7] 2011 CBCT 8 3 3 2 India, 30-year-old man Leila Atash biz Yeganeh et al. [4] All the five canals were negotiated using K-flex files (Dentsply, Maillefer, Ballaigues, Switzerland). Working length was determined using an apex locator (Root ZX, Morita, Tokyo, Japan) and confirmed radiographically. ...
... Recently, Kottor et al. [18] reported the presence of seven canals in maxillary first molar (three in the mesial root, two in the distal root and two in the palatal root). Kottor et al. [7] also reported the presence of eight canals in the maxillary first molar with the help of CBCT imaging. ...
... The search strategy results are presented in Figure 1. A total of 138 studies were included in this systematic review [37 microCT studies , 4 CBCT experimental studies (9,(54)(55)(56), 38 CBCT clinical studies (2, 10, 57-92), 10 2D clinical studies (11,(93)(94)(95)(96)(97)(98)(99)(100)(101), 12 staining and clearing and root sectional studies (including one study for tooth sectioning) (7,(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112), 14 CBCT case reports (12,(113)(114)(115)(116)(117)(118)(119)(120)(121)(122)(123)(124)(125) and 22 2D case reports (13,]. For phase 1, the agreement between reviewers was 90.05% (Cohen's k=0.76 -substantial agreement). ...
... For case reports, results showed that all CBCT publications presented age and gender of patients, tooth type, and number of teeth. Three reports mentioned the ethnic group/population of the patients (115,116,119). In general, complete details for radiographic imaging specifications (Kv, mA, voxel size, FOV) were not provided in any report. ...
... In general, complete details for radiographic imaging specifications (Kv, mA, voxel size, FOV) were not provided in any report. However, incomplete information was provided in some reports; twelve reports mentioned details on machine type (12, 113-117, 119, 121-125), 7 reports for Kv and mA (12,116,117,119,121,122,124), and none for FOV. All reports provided details for qualitative analysis (mainly root and canal configuration). ...
Objective: Consistent reporting of publications in a given topic is essential. This systematic review aimed to identify and evaluate the reporting items in previous publications related to root canal anatomy in major Endodontic journals.
Methods: A systematic review was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed by 2 independent reviewers using a customized search strategy in major Endodontic journals through Scopus until November 2019. Studies investigating root and canal anatomy were included. The selected publications were divided into 7 categories according to the study design: micro-computed tomography (microCT) and cone-beam computed tomography (CBCT) experimental studies (extracted teeth), CBCT and 2D clinical studies, CBCT and 2D case reports in addition to others (i.e. staining and clearing method and root sectioning). The selected studies were evaluated according to three domains: 1) Criteria for study sample selection; 2) Criteria for methodological procedures and 3) Criteria for detection and evaluation. Results: After the removal of duplicated and irrelevant papers, 137 articles were included. Results showed
that microCT studies reported accurately the tooth type, number of teeth, classifications used, qualitative and/or quantitative analysis (if required) and the evaluation process. However, sample size calculation, calibration, and reproducibility were not reported in the majority of microCT studies. CBCT clinical studies presented information for the type of study, inclusion/exclusion criteria, number of patients, tooth type, and number of teeth. However, the majority did not report sample size calculation and calibration of examiners.
Radiographic exposure descriptions and classifications used were not reported adequately in CBCT and 2D case reports. Conclusion: Despite accurate presentation of certain items, there is considerable inconsistent reporting of root and canal morphology regardless of the type of study and experimental procedure used. The PROUD checklist protocol presented in this systematic review aims to provide an accurate description of root canal anatomy in experimental, clinical, and case report publications.
... An early investigation by Frank Vertucci [17], considered by many as one of the pioneers of root and root canal morphological studies, established an average prevalence range of between 30% and 40% for maxillary first molars with three canals and between 60% to 70% for four canals. There are also cases where anomalies are present outside these ranges [18]. ...
... Considering the relationship between age and root canals, age showed no statistically significant association with the total number of canals, canals in individual roots, or the presence of MB2, MB3 or MB4 canals. Some case reports have described the treatment of eight canals in the maxillary first molar [18]. In the present study, however, no first molars displayed anomalies (including one, two, or more than six canals). ...
Purpose: This study was conducted to investigate the root canal anatomy of maxillary first molars in Black South Africans.
Methods: Micro-computed tomography was used to investigate 101 maxillary first molars (53 teeth from the right, 48 from the left; 50 male and 51 female teeth). The number of root canals in each tooth was determined, and the relationship between side, sex and age was analyzed using chi-squared test. To determine intra- and inter-observer reliability, Cohen’s kappa coefficients were calculated.
Results: Intra- and inter-rater agreements of 96.92% and 98.08% were achieved, respectively. Most teeth contained either three or four canals, but a second, third and fourth mesio-buccal canal was found in 60.39%, 5.94% and 0.99% of teeth, respectively. The disto-buccal and palatal roots contained predominantly single canals, but additional canals were noted in 2.97% and 1.98% of teeth. Four canals were common in females and teeth on the right side often contained a second mesio-buccal canal. However, the prevalence of a third mesio-buccal canal was higher in males than in females.
Conclusion: The teeth studied showed diversity and variations between sexes and arch sides. These findings will aid clinicians in endodontic treatment and will be applicable for educational purposes.
... The number of root canals can vary greatly in maxillary first molars ranging from 1 to up to 8 root canals [11,12]. Literature shows a high frequency of a second MB root canal (MB2) in maxillary first molars ranging from 19% [13], 52% in a Chinese population [14], 80% in an Italian population [15], to more than 90% [8]. ...
... The occurrence of three root canals in the MB root of maxillary first molars has been documented in earlier studies and case reports [12,19]. Results from high-resolution micro-CT studies show a more complex anatomy in the MB root compared to CBCT and 2D radiographic imaging [15,17,18]. ...
This case report aims to present the detection, characterization, instrumentation, and filling of complex root canal configuration types in the mesio-buccal (MB) root of maxillary first molars. Three patients were referred for root canal treatment in first maxillary molars. Medical history, age, sex, and clinical findings were recorded. Intraoral periapical radiographs and cone beam computed tomography (CBCT) were used for diagnosis and pre-operative assessment. Using the classification system proposed by Ahmed et al. (2017), codes 3MaxM MB3-5-4-2 DB1-2-1 P1 (case 1), 3MaxM MB2-5-3-2 DB1 P1 (case 2), 3MaxM MB1-4-2-1-2 DB1 P1 (case 3) were identified. The use of the dental operating microscope, CBCT (if indicated) and troughing up to 3 mm allow identification of more than three canals in the MB root of maxillary first molars. The coding system proposed by Ahmed et al. (2017) allows the classification of MB roots with highly complex root canal configurations.
... CBCT is an essential diagnostic tool in endodontics for analyzing root canal anatomy and morphology of human dentition, and it gives images which are visualized from multiple orientations in very thin slices without disturbing the overlapping structures [9]. CBCT can provide images at a lower radiation dose with sufficient spatial resolution for endodontic diagnosis and treatment planning [16]. CBCT data have been instrumental in assessing the root and canal morphology in the present case. ...
... The higher magnification and illumination can be used for locating supernumerary canals and improving the discovery of root canal orifices [17]. Studies have shown that the combined use of magnification and CBCT images significantly facilitates the location and negotiation of root canals in upper molars [16,18]. ...
Background
The objective of this report was to highlight the importance of using a dental operating microscope (DOM) to locate supernumerary canals and diagnose variations in root canals using cone-beam computed tomographic (CBCT) images.
Case presentation
A 35-year-old Chinese female had repeated swelling in the upper right posterior maxilla for 3 months and was referred to evaluate symptomatic apical periodontitis and mesotaurodonts for upper right first permanent molar and upper right second permanent molar. Root canal therapy was proposed and conducted with the use of DOM and CBCT.
Conclusions
Proper diagnosis and careful clinicoradiological examination are necessary, and it is essential to reinforce the knowledge of the rare morphology of root canals for clinicians.
... However, numerous studies and case reports also presented maxillary first molars with various anatomical alterations resulting in an enormous diversity in the number of roots and canals. For example, rare cases of single, two-, or even five-rooted maxillary first molars were described [3,[5][6][7] as well as three-rooted versions with multiple canals [8][9][10]. ...
... (Figure 4, Suppl. Table 2. [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. e funnel plot demonstrated that four of the 49 included studies were outside the margins of the 95% confidence interval. ...
Objectives. The majority of human maxillary first molars is usually described as having three roots, but different morphologies were documented in several studies and case reports. One very rare and less investigated anatomical anomaly is the occurrence of four radicular structures in the upper first molars. This communication aimed to define the prevalence of four-rooted maxillary first molars on a meta-analytical basis. The external and internal morphology of these teeth was described by the collection of published case reports. Materials and Methods. Six electronic databases were accessed to collect case reports dealing with four-rooted maxillary first molars, as well as population-based cone-beam computed tomography (CBCT) studies. Afterward, the publications were selected according to predefined inclusion/exclusion criteria and evaluated using the Joanna Briggs Institute Critical Appraisal tool. The teeth of the chosen case reports were then independently analyzed by two dental professionals according to different dental classifications. Furthermore, the population studies were meta-analyzed to calculate the global and regional prevalence of four-rooted maxillary molars. Results. Included were forty-nine population-based CBCT studies containing 26663 maxillary first molars. Upon these data, the global incidence of four-rooted maxillary molars was meta-analytically determined as 0.047% (95%-CI:0.011–0.103%). In combination with the case reports, it was pointed out that this anomaly is distributed worldwide. Furthermore, forty-eight case reports were included containing fifty-three maxillary molars with four roots. The analyzed teeth exhibited Versiani´s pulpal chamber floor Types A and B. The majority of four-rooted maxillary first molars were classified as Type I regarding Christie's configuration. But, also 7.54% of the altered teeth could not be described by this classification. 62.34% exhibited four root canals, but also variations with five, six, or seven canals were identified. Furthermore, a significant difference was found in the occurrence rate between male and female patients. Conclusion. Due to the worldwide occurrence, dental professionals should be aware of this rare anomaly to avoid treatment errors, especially during endodontic or surgical therapies.
1. Introduction
For centuries, anatomists have investigated dental anatomy to describe each human tooth by determining its coronal and radicular structures. Human maxillary first molars are generally characterized to possess four or five cusps (the additional mesiolingual cusp of Carabelli) and three roots [1, 2]. These roots were designated due to their anatomical position as mesiobuccal, distobuccal, and palatal root, usually exhibiting four root canals (mesiobuccal root with a second canal, whereas the other roots commonly contain only one canal) [3, 4]. However, numerous studies and case reports also presented maxillary first molars with various anatomical alterations resulting in an enormous diversity in the number of roots and canals. For example, rare cases of single, two-, or even five-rooted maxillary first molars were described [3, 5–7] as well as three-rooted versions with multiple canals [8–10].
Another rare aberration was described by Thews et al. 1979 [11], who identified radiographically four separate roots during endodontic treatment. This unlikely morphological anomaly was classified upon the radicular shape and the degree of root separation by Christie et al. in 1991 [12]. Their characterization was based mainly on studying endodontic treated or extracted maxillary molars and identified three different radicular configurations. Type I maxillary molars have widely divergent, long, and tortuous palatal roots with “cow-horn” shaped buccal roots. Type II maxillary molars have four, shorter, parallel running roots with blunt apices. By definition, “a type III maxillary molar is constricted in root morphology with the mesiobuccal, mesiopalatal, and distopalatal canal encaged in a web of root dentin” [12]. Furthermore, Baratto-Filho et al. in 2002 demonstrated an endodontic case with fused mesiobuccal and mesiopalatal roots and suggested an additional class IV [13] (Figure 1).
... Several studies have reported that the permanent maxillary first molar has 5 root canals, 3 of which were present in the MB root (15,16). Kottoor et al (15,17) reported root canal therapy of permanent maxillary first molar using cone beam computed tomography (CBCT) that had 7 and 8 canals respectively. ...
... A study by Goga et al (28) indicated the limitation of conventional radiography in creating two-dimensional images of the tooth and superimposition of roots and canals in multi-rooted teeth which leads to difficulty in detecting additional canals. Therefore, multiple-angled radiographs before, during and after treatment are needed to facilitate observation of the canals (15,17). Recently, CBCT is employed to detect anatomic variation and additional canals (29). ...
... [3] Apart from these common anatomical configurations, a few rare variations of the root canal complex in the maxillary first molars have been reported in the literature. These include maxillary first molars having one root and one canal, [4] two root canals, [5] five root canals, [6] six root canals, [7] seven root canals, [8] and eight root canals [9] as well. The occurrence of an additional palatal root [10] and C-shaped canal [11] in maxillary first molars has also been documented. ...
Variations in the root canal anatomy of a maxillary first molar are often challenging to diagnose and treat; thus, clinicians must have a thorough knowledge of the same. This case report highlights the successful nonsurgical endodontic management of a maxillary first molar with an unusual morphology of three roots and six root canals. A total of six root canals (mesiobuccal [MB] 1, MB2, MB3, distobuccal [DB] 1, DB2, and palatal) were detected after initiating root canal therapy and access cavity preparation. Conventional root canal treatment was completed, and postoperative cone-beam computed tomography scanning was done to verify the total number of canals and ensure the adequacy of root canal fillings. Managing such cases with rare variations in the root canal systems could be arduous and thus, clinicians should be well-versed in the methods to identify and manage such complexities to facilitate the successful outcomes of endodontic treatment.
... 54,55 A report is also available of treating an eight-canal tooth. 56 No micro-CT specifi c reports giving an account of fi rst molars with one, two or more than fi ve canals could be identifi ed in Africa or South Africa. ...
The complexity of root canal morphology can influence cleaning and shaping of the root canal system and, ultimately, treatment outcomes. Undiscovered root canal morphology can greatly reduce the prognosis of endodontic treatment due to the preservation of offending organisms and their by products. The maxillary first molar has been identified as one of the most challenging teeth to treat endodontically due to its complex internal anatomy, the presence of additional and accessory canals and intricate root canal configurations. This paper is the second of two that provide a micro computed tomography (micro-CT)-focused overview of available literature on various aspects of the root and canal morphology of the maxillary first permanent molar. The aim of this paper is to provide an overview of relevant aspects of the internal root morphology in different populations. The content is supported by illustrative micro-CT images and clinical cases or images.
... have suggested a 40-degree mesial angulation of the X-ray beam to identify additional canals. CBCT is also a useful tool for the preoperative diagnosis of complex root canal anatomy [15] . Regarding working length, it is difficult to the radiographic interpretation of some accessory roots and their root apices due to their proximity to each other [16] , and also there exists a possibility of superimposition by other roots. ...
Perfect cleaning and shaping is the key to successful root canal treatment. Therefore, a careful understanding of the internal anatomy and structure of the root canal system is an important factor when performing cleaning and cosmetic procedures. Mandibular premolars are among the most complicated teeth to treat with root canals due to their abnormal root canal anatomy. Furthermore, it varies in different ethnic groups. Therefore, it is needed to evaluate and search for an abnormal root canal anatomy in a failed root canal. In light of these observations, this case report provides a case of previously root canal treated mandibular first premolar tooth which was failed due to different root canal patterns. The tooth was subjected to re-root canal treatment and after completion of the therapy, the tooth was symptomless and patient was referred to the Department of Prosthodontics for a full veneer crown. Introduction Successful results of endodontic treatment require a thorough knowledge of the internal anatomy and morphology of the endodontic system [1-2]. Due to the complexity of the endodontic system, there is a high risk of missing anatomy during endodontic treatment. It has been reported that 42% of missing canals or roots of teeth require retreatment [3]. Furthermore, the changes in the canal morphology are considered one of the most likely causes of inflammation and root canal failure. Therefore, untreated root canals can be associated with symptoms ranging from asymptomatic teeth to acute reactions to hot and cold stimuli, mild sensitivity to percussion, and/or palpation to acute abscesses. Mittal, et al. (2014) [4] stated that variations in the endodontic anatomy of mandibular premolars present endodontic treatment challenges for successful treatment. The incidence of roots and root canals in these teeth varies considerably in the literature. Zillich and Dowson (1973) [5] analyzed that 23.1% of mandibular first premolars had 2 or 3 root canals radiographically. Vertucci [6] found that 25.5% of 400 mandibular premolars had two apical foramens and 0.5% of teeth had 3 apical foramens. The shape of the root canal varies according to race. However, the dental literature is not unique in the study of ethnic and gender variation, as higher incidences of teeth with additional canals and roots have been reported in India, China, Australia, and sub-Saharan Africa, and the lowest incidences in West Eurasian, Japanese, and American Arctic populations [7]. Therefore, the root and root canal morphology of this tooth is needed for careful evaluation prior to root canal treatment due to the abnormal configuration of the root canal. In light of these observations, this case report provides a case of a previously root canal-treated mandibular first premolar tooth with different canal patterns and successfully treated with conventional endodontic treatment.
... Since these molecules regulate root formation, they could help to understand the mechanisms determining the number of canals. However, the precise factors determining the number of canals in a tooth are still unknown, since there are case reports of single-rooted teeth with four canals (9), molars with a single root and single canal (16), and maxillary (17) and mandibular molars (18) with eight canals. ...
Background: Although millions of root canal treatments are performed globally on a daily basis, factors that determine the number of main root canals in a tooth have not yet been elucidated. Variations in the number of root canals in different teeth is of utmost importance in clinical practice. However, clinicians aren´t aware about the determinants of such number, let alone these determinants have been approached in the literature, to the best of our knowledge. Purpose: This narrative review aimed to integrate the potential mechanisms involved in determining the number of main canals in a permanent tooth. Methods: We used the search terms "root canal number," "root canal morphology," "tooth morphology," "root development," and "root formation" to identify articles from the PubMed and Scopus databases. Results: 57 articles and 2 books were obtained. A multifactorial basis is plausible considering the influence of anthropological, demographic, environmental, genetic, epigenetic, tooth size related mechanisms and the pivotal role of Hertwig's epithelial root sheath. Live-cell imaging techniques, mathematical models, quantitative genetics and dental phenomics could provide insightful information in the near future. Conclusions: Overall, it seems that the potential mechanisms determining the number of main canals in a tooth have a multifactorial basis. The orchestrating role of the Hertwig's epithelial root sheath seems pivotal, although the specific regulatory signals that induce or repress its diaphragmatic processes remain unknown. However, there is a dire need for molecular studies that help unveil these and other potential mechanisms involved.
... Based on the current report and corresponding literature, it is evident that adequate knowledge of morphological variations is critically important in the success of an endodontic treatment. Abnormalities in root canal anatomy commonly occur in maxillary molars, especially in maxillary second molars, where it can be diagnostically and technically challenging [43,44]. In the presented case, CBCT images helped clinicians better evaluate the complex root canal morphology and facilitate the location of extra canals. ...
Having a thorough knowledge of root canal configuration is essential for a successful endodontic treatment. Clinicians should always pay attention to the unusual canal configuration so as to avoid missing extra canals. This paper describes a non-surgical retreatment of a maxillary second molar with two missing root canals; diagnosed by cone-beam computed tomographic (CBCT) imaging. The tooth had three roots and five canals: a C-shaped buccal root fused by mesiobuccal (MB) and distobuccal (DB) roots with three canals (CBCT scanning showed that the second MB canal was closer to the palatal than the buccal side), a mesiopalatal root with one canal, and a distopalatal root with one canal. The purpose of this case report is to remind clinicians of the importance of anatomical variations, and thus, detection of extra canals.
... They identified three mesiobuccal canals, three distobuccal canals, and one palatal canal [11]. Kottoor et al reported the endodontic management of the maxillary first molars with seven and eight canals, respectively [12,13]. This case report discusses the endodontic management of an unusual root canal configuration in a maxillary first molar showing three roots and seven canals. ...
... Next, Vertucci et al. [9] used the clearing and dye penetration technique to offer a more complete classification. Previous studies have shown variability in the number and shape of third molar roots and canals in different ethnic groups [10], males and females [11], and different races [12][13][14]. Lack of knowledge about this topic significantly increases the risk of failure of such treatments. ...
Introduction:
Adequate knowledge about the anatomy of the roots and canals of mandibular third molars is imperative for a successful treatment. This study aimed to use cone-beam computed tomography (CBCT) to evaluate the morphology of the roots and canals of mandibular third molars and their symmetry.
Methods and materials:
Totally, 110 CBCT images of bilateral mandibular third molars were evaluated in terms of the number of roots and canals, canal type, isthmus location, location of accessory canals, degree of root curvature and its direction, age and sex of patients and the symmetry of variables in the right and left sides of the mandible. The descriptive statistics, t-test and chi-square test were applied to analyze data.
Results:
Of all, 71.36% of mandibular third molars had two roots, 20.9% had one single root and 7.72% had three roots. The distal root had one single canal in 89.08%. The mesial root had one single canal in 44.25% and two canals in 49.42%. The Vertucci's types I (45.40%) and IV (34.48%) had the highest frequency in the mesial root while type I (91.95%) had the highest frequency in the distal root. The deviation of mesial root was towards the distal while distal roots were mainly straight.
Conclusion:
The symmetry between the right and left mandibular third molars was significantly high. In case of encountering anatomical complexities in dental treatment of a mandibular third molar, dental clinicians should consider the high possibility of presence of the same condition in the contralateral mandibular third molar.
... Although PMFMs have three roots, four root canals have been found in more than half of the cases, in which the mesiobuccal (MB) root has two canals (3). Variants with more than four root canals are uncommon; however, a maximum of eight root canals have been detected clinically: three in the MB root, three in the distobuccal (DB) root, and two in the palatal (P) root (4). The present study provided insight into the internal anatomy of the PMFM with six root canals and suggestions for detecting and managing multiple root canals. ...
Purpose: This study aimed to report the diagnosis and management of a permanent maxillary first molar (PMFM) with unusually complex root canal morphology. Case report: A 30-year-old male patient was referred to the endodontic department to continue endodontic treatment of the left PMFM. The referring dentist could not establish the patency of the canals in the mesiobuccal and distobuccal roots. Radiographically, the tooth had three almost straight roots associated with periapical radiolucencies, indicating periapical periodontitis. The examination of the pulp chamber floor, using a dental operating microscope, revealed the presence of six root canal orifices, three in the mesiobuccal root, two in the distobuccal root, and one in the palatal root. No confluence of multiple canals was detected using the electronic apex locator and K-files. The canals were shaped and cleaned with reciprocating nickel-titanium instruments and obturated using gutta-percha cones and a bioceramic sealer. After 2 years, the patient was asymptomatic and the tooth was clinically and radiographically without pathological findings. Conclusions: Careful examination of the pulp chamber floor using magnification and illumination is important for successfully managing complex canal morphologies. During endodontic treatment, dentists must consider that the PMFM may have more than four root canals.
... Furthermore, the detection of the pulp chamber anatomy during coronal access and adequate intracanal dentin removal contribute to the correct clinical location of the root canal orifices [12]. Cone beam-computed tomography (CBCT) is also a diagnostic imaging modality recommended for approaching the complex root canal anatomy [18,19]. Despite CBCT providing high-quality, accurate, three-dimensional (3D) representations of the anatomical dental structures, the presence of metallic restorations (e.g., amalgam restorations, metal posts and/or crowns) or even gutta-percha can determine significant radiographic artefacts which can impact the visualization of the root canal anatomy and pathological conditions, such as root resorption and root fractures [20]. ...
The aim of this case series is to contribute to the better knowledge and management of the complex anatomical configurations of maxillary premolars with four canals. The paper explains the endodontic treatment of five maxillary premolars with four canals, with three buccal and one palatal orifices, in different patients. The cases report several approaches in the treatment of four-canal maxillary premolars including a conservative canal preparation with a hybrid shaping technique, endodontic microsurgery and the application of biomaterials. The use of an operating dental microscope, different operating strategies and the critical evaluation of radiographs are all necessary steps for the correct and safe endodontic management of these teeth.
... Understanding the anatomy and anatomic deviations of roots and their root canals enhances the success rate of root canal retreatment. Moreover, judicious utilization of a DOM and CBCT facilitates the location and negotiation of root canals in upper molars [21]. ...
The root canal systems of maxillary second molar (MSM) variations are complicated, especially the prevalence of fused roots and consequent merged and C-shaped canals, which represent a clinical challenge because canal configurations can be irregular and unpredictable. The purpose of this article was to present 2 cases with a C-shaped configuration diagnosed during root canal retreatment and perform a literature review of this MSM anatomy. Case 1 reports that two palatal root canals fused into a C-shaped configuration that finally formed an apical foramen, which was classified as Type D. Case 2 reflects the fusion of the distobuccal canal and palatal canal into a C-shaped configuration and the configuration was Type C, which was first reported in a case report. Nonsurgical retreatments were proposed and conducted. Evaluation at a 24-month recall revealed that the two patients were symptom‐free, and radiographic examination revealed normal periapical tissue. This report serves to remind clinicians of the complexities of the root canal system and that possible anatomic variation should always be anticipated when formulating an effective root canal treatment plan. The use of CBCT imaging coupled with an operative dental microscope will be helpful in locating and identifying supernumerary canals when a preoperative periapical radiograph shows signs of a fused-rooted MSM.
... Cone-beam computed tomography (CBCT) is commonly used for many dental procedures and has applications in endodontic procedures as well [3] such as detection and follow-up of periapical lesions, detection of vertical root fractures, assessment of root proximity to anatomical structures [4,5], identification of traumatic injuries, and preoperative assessments. Also, CBCT enables three-dimensional (3D) assessment of the complex root canal anatomy, which is an advantage [6,7]. CBCT scans can also be used for detection of the MB2 of maxillary molars [8,9]. ...
Objectives:
The percentage of failure of endodontically treated maxillary molars is relatively high; one main reason is that the second mesiobuccal canal (MB2) is missing. Some techniques have been proposed for detection of the MB2. This study was aimed at assessing the diagnostic accuracy and agreement of the dental microscope and cone-beam computed tomography (CBCT) in comparison with microcomputed tomography (micro-CT) for detection of the MB2 of maxillary first molars in vitro.
Materials and methods:
This in vitro, experimental study evaluated 71 permanent maxillary first molars that were stored in 100% humidity at room temperature. The teeth were mounted in 9 silicone dental arches to the level of their cementoenamel junction (8 teeth in each arch). The blocks underwent CBCT in a XG3D scanner. Access cavity was then prepared, and the teeth were inspected by a surgical microscope for negotiation of the MB2. Also, micro-CT images were obtained from the teeth to serve as the gold standard. CBCT and micro-CT images were observed by two examiners twice with a 2-week interval.
Results:
The frequency of the MB2 detected by dental microscope was significantly lower than micro-CT (P < 0.001) and CBCT (P = 0.008); no significant difference existed between micro-CT and CBCT in this respect. The sensitivity, specificity, positive predictive value, and negative predictive value of CBCT for detection of MB2 were 92.6%, 100%, 100%, and 81%, respectively.
Conclusion:
CBCT is superior to the dental microscope for detection of the MB2 of maxillary first molars and can be used for this purpose in the clinical setting with adequate accuracy.
... In-depth knowledge of the internal and external features of the root can shrink the chances of not finding a canal during root canal treatment, increasing the success rate of root canal treatment. [3] Prior to the start of root canal treatment, several periapical radiographs are usually taken from different angles to determine the number of root canals. [4,5] Multiple periapical radiographs are needed since these radiographs provide a twodimensional image of a complex three-dimensional anatomy. ...
Introduction: Effective endodontic treatment requires identification of all root canals. The inability of dentists to locate all root canals can lead to failure in endodontic treatment. Consequently, an accurate diagnostic device is essential to detect all root canals. The aim of this study was to examine the accuracy of cone-beam computed tomography (CBCT) as a diagnostic tool to detect the root canals of maxillary first premolars in a selected Iranian population. Material & Methods: In this in vitro study, 48 human extracted maxillary first premolar teeth were scanned by CBCT, and then all teeth were sectioned. In the current study, sectional method was chosen as the gold standard. The CBCT scans were observed by an oral and maxillofacial radiologist, and the sections were evaluated by an endodontist using stereomicroscope. Finally, the collected data were entered into SPSS-22 and analyzed by Kappa coefficient and Chi-square test. Significance level was set at 0.05. Results: The agreement between CBCT and sectional methods for root canal detection was 97.2% which was significant (95.8% in the first section, 97.9% in the second and third sections), (p <0.001). Conclusion: It seems that CBCT is a safe and non-invasive tool that can be used to detect root canals if other low-dose radiation imaging techniques do not provide acceptable results.
... There is a strong emphasis in the use of cone beam computed tomography (CBCT) for the evaluation of the complex internal anatomy of teeth (12), and CBCT examination has been shown to be a valid method to detect the MB2 root canal in upper molars (13). One study reported that CBCT has a sensitivity of 96% and a specificity of 100% for the location of the MB2 root canal in endodontically treated upper molars (14). ...
Background
Several investigations have determined whether the use of a dental operating microscope (DOM) in combination with selective dentine removal with ultrasonic tips increases the percentage of location of the Mesiobuccal 2 (MB2) root canal in maxillary first molars (MFM). However, these studies did not report the performance of in vivo measurements with the comparison with a gold standard. The aim of this study was to determine the validity of the DOM and selective dentin removal with ultrasonic tips to locate the MB2 root canal in MFM using Cone Beam Computed Tomography (CBCT) as the gold standard.
Material and Methods
The initial sample size was 91 patients, but 7 were excluded, so the sample size was 84 patients who signed the informed consent. Inclusion criteria: MFM indicated for root canal treatment. An expert blinded observer identified the MB2 in the CBCT. Two standardized examiners (Kappa=91%) performed the clinical assessment in three stages: Stage 1, canal location with an endodontic explorer and a mirror; Stage 2, use of DOM and Stage 3, use of DOM plus selective dentine removal with ultrasonic tips. The validity of each stage was calculated.
Results
The prevalence of MB2 using CBCT was 79%, by clinical location was 68%. Sensitivity was 79%, 82%, 86% for stage 1, 2 and 3, respectively. Specificity and Positive Predictive Values were 100% for all methods. Negative Predictive Value was 56%, 60%, 67%, respectively. Positive Likelihood Ratio tends to infinity for all methods, Negative Likelihood Ratio= 0.21, 0.18 and 0.14 and Accuracy= 83%, 86% and 89%, respectively.
Conclusions
The use of DOM with selective dentine removal with ultrasonic tips is the most valid method for locating MB2 canal in MFM. There was an increase in the location of the MB2 root canal with the DOM and ultrasonic tips, which definitely help the clinician.
Key words:Cone beam computed tomography, microscopy, second mesiobuccal canal, sensitivity and specificity, validity.
... So, 6 canals were visible (MB, MB2, DB, DB2, MP & DP) Obturation was performed using gutta-percha (Dentsply Maillefer) and root canal sealer (Endomethasone N, Septodont) Fig. 1 The tooth was restored with Dental Amalgam and PFM crown was advised to the patient. Table 1: Literature review of maxillary first molar with anatomical variations Arturo Martinez-Berna (1983) (2 cases) 10 6 canals with 3 mesiobuccal, 2 distobuccal and 1 palatal Lior Holtzman (1997) (2 cases) 11 5 canals with 2 mesiobuccal, 1 distobuccal and 2 palatal Michael Hulsmann (1997) 12 4 canals with 2 distobuccal, 1 mesiobuccal and 1 palatal Peter M. Di Fiore (1999) 13 4 rootsdistobuccal, distopalatal, mesiobuccal and mesiopalatal L. R. G. Fava (2001) 14 2 rootsbuccal and palatal, with Weine's type IV configuration in the buccal root R. J. G. De Moor (2002) (4 cases) 15 C-shaped canal configuration F. Baratto-Filho et al. (2002) 16 2 palatal roots, each with separate canal i.e., 2 palatal canals and 1 mesiobuccal and distobuccal canal F. Maggiore, Y. T. Jou & S. Kim (2002) 17 26 Eight root canals ...
The clinician must have to be familiar with the morphology of the roots of all teeth, and the associated intricate root canal anatomy, to achieve proper access to the canals, effective debridement and obturation for successful endodontic treatment. This case report intensifies the complexity of maxillary molar morphologic variation and represents successful endodontic treatment of maxillary first molar with 3 roots and 6 canals having 2 separate palatal canals which is rarely discussed in literature.
... A narrow field of view, which is associated with lower radiation exposure and higher spatial resolution, is advised in circumstances where a CBCT scan is deemed appropriate [10]. This is in an agreement with Kottoor et al. and La et al., as they have recommended the use of CBCT to determine the root canal morphology and canal configurations in cases with aberrations which coincides with the recent update of the American Association of Endodontics (AAE) and American Academy of Oral and Maxillofacial Radiology recommendations [10][11][12][13]. ...
Root canal anatomy of mandibular second molars differs among individuals. With the aid of the latest dental technologies in endodontics, the present case report highlights the diagnostic tools required to confirm the morphology of the root canal, and the treatment of uncommon root anatomy of a single-canal single-rooted mandibular second molar. Clinicians should be aware of the various anatomic variations that each tooth may present in order to achieve a satisfactory result. Furthermore, in order to improve the quality of care delivered to their patients, practitioners must have the necessary knowledge and abilities to utilize the diagnostic and therapeutic instruments at their disposal.
... Her 3 vakanın da bir yıllık takipte lezyonlarının iyileştiği gösterilmiştir. (19). ...
ZET: Bu olgu serisinde geniş periapikal lezyonlu ve kemik kaybı olan kronik apikal periodontitis tanısı konan üç adet mandibular büyük azı dişe cerrahi olmayan kök kanal tedavisi yapılıp 12 ay süre ile klinik ve radyografik olarak değerlendirilmiştir. Dişler rubber dam ile izole edildikten sonra giriş kavitesi hazırlanıp çalışma boyu apeks bulucu ile belirlenmiştir. Kanallar Reciproc R25(VDW) ile şekillendirilip preparasyonu sırasında %5 NaOCl ve sonunda %17 EDTA, %5 NaOCl ardından distile su ve %2 klorheksidin irrigasyon solüsyonları ile irrige edilmiştir. İki hafta boyunca kalsiyum hidroksit kanal içi medikament olarak kullanılmıştır ve lateral kondensasyon tekniği ile dolum yapılmıştır. Tedavi sonrası birinci ve üçüncü ay kontrollerinde alınan radyografilerde periapikal lezyonlarda iyileşme görülmüştür. Tedavi öncesi ve 12. Ayda çekilen takıp röntgenlerin karşılaştırılması ile defekt boyutundaki azalma ve tedavinin başarılı olduğunu tespit edilmiştir. Dişlerin 12.ay klinik kontrollerinde asemptomatik olduğu gözlenmiştir. Anahtar Kelimler: Endodontik tedavi, kalsiyum hidroksit, periapikal lezyon ABSTRACT: In this case series, three mandibular molars with large periapical lesion and bone loss diagnosed as chronic apical periodontitis were treated with non-surgical root canal treatment and evaluated clinically and radiographically for 12 months. The teeth were isolated with a rubber dam, the access cavity was prepared and the working length was determined with the apex locator. The canals were shaped with Reciproc R25(VDW) and irrigated with 5% NaOCl irrigation solution during preparation and finally with 17% EDTA, 5% NaOCl, then distilled water and 2% chlorhexidine irrigation solutions at the end of the preparation. Calcium hydroxide was used as an intracanal medicament for two weeks and three-dimensional filling was performed with the lateral condensation technique. In periapical lesions, improvement was detected in the periapical radiographs taken at the first and third month controls. The reduction in the size of the defect showed that the treatment was successful by comparing the follow-up x-rays taken before the treatment and at the 12th month. The teeth were asymptomatic at the 12th month clinical controls.
... Con respecto a la configuración de Vertucci, en este estudio se encontró que, la configuración tipo I fue la más prevalente con 91 %, seguida del tipo III (6,7 %), tipo V (1,6 %), tipo VII (0,4 %), y finalmente el tipo II (0,1 %) y otros (2-1-2-1) con 0,1 %, configuración que pertenece al tipo IV de la clasificación de Gulabivala. 14 Estos resultados son similares a los encontrados en un estudio en el que se encontró que las configuraciones más prevalentes fueron la tipo I con un 75 % y la tipo III con un 23,0 %, 46 al igual que en otros estudios donde se encontraron resultados similares, siendo el tipo I el más prevalente, seguido del tipo III. 5,34,47 En el presente estudio no se presentaron otras configuraciones según Vertucci en ambos incisivos mandibulares. ...
Objetivo: Evaluar la morfología de conductos radiculares en incisivos mandibulares permanentes usando tomografía computarizada de haz cónico (CBCT). Materiales y métodos: Se analizaron 187 archivos de CBCT de pacientes cuencanos, valorando un total de 748 imágenes tomográficas. Las CBCT fueron obtenidas usando un tomógrafo Morita 3D Accuitomo 170 (J. Morita Inc., Kyoto, Japan) con tamaño de vóxel de 0.330 mm; parámetros de exposición de 90 kV, 6 mA; campo de visión de 170 x 170; grosor de corte de 0.66mm. La configuración de los conductos radiculares fue analizada de acuerdo a la clasificación de Vertucci. La influencia del género en la distribución de conductos y la simetría de bilateralidad fueron analizados estadísticamente; el nivel de significancia fue p <0.05. Resultados: Todos los dientes presentaron 1 raíz. La prevalencia de dos conductos radiculares fue del 9%. En dientes con dos conductos radiculares, la configuración de Vertucci más prevalente fue el tipo III (6,7%), seguido del tipo V (1,6%). Además, el 68,7% de los dientes con dos conductos radiculares presentaron la bifurcación en el tercio medio de la raíz. No hubo diferencias estadísticamente significativas respecto a la influencia del género y la simetría de bilateralidad. Conclusiones: La prevalencia de dos conductos en incisivos mandibulares en una subpoblación cuencana fue del 9% aproximadamente, siendo la configuración de Vertucci III la más prevalente.
... [11,12] Three-dimensional complex root canal anatomies can be easily detected with cone-beam computed tomography (CBCT), but the resolution of CBCT is lower than that of modern two-dimensional intraoral imaging, and besides, since CBCT also has disadvantages such as an expensive technique, exposing the person to more radiation, modern two-dimensional radiography is still shown as the most appropriate technique in the diagnosis, treatment and follow-up process in the field of endodontics. [13][14][15] Inflammatory destruction of periradicular tissues resulting from microbial infection within the root canal system is defined as apical periodontitis. [16,17] To treat apical periodontitis, it is the root canal preparation with hand or rotary system files, followed by the sealing of the root canal to prevent reinfection after disinfection with intracanal medicaments using irrigation solutions. ...
Bioceramic-based dentin replacement and repair materials are mainly calcium silicate
and calcium phosphate compounds which exhibit biocompatibility due to their
similarity with biological compounds, like hydroxyapatite and have the ability to
induce a regenerative response in the organism. For older academics or clinicians, this
change might be viewed as the death of conventional dental materials, but for most
others, this is the birth of true biomaterials. Mineral trioxide aggregate has been a
revolutionary material in endodontics. Since its introduction in the 1990s several
studies have demonstrated its use in various clinical applications. Indications were
primary/secondary root canal infection, traumatic dental injury, root resorptions,
combined endodontic lesions, single-visit apexification, apical/periodontal surgery.
New materials, such as OrthoMTA (BioMTA, Seoul, Korea) are newly developed
mineral trioxide aggregate cement for root canal obturation. According to the
manufacturer, orthograde mineral trioxide aggregate grafting technique is called
―Biofilling‖ of the root canal system with OrthoMTA. The purpose of the report was to
compose fully documented cases treated with the orthograde mineral trioxide
aggregate canal grafting technique in teeth with large periapical lesions and then the
treatment is finished and the prognosis is presented.
... Importantly, it has been proved as a more accurate method for precise and detailed detecting of the root canal morphology in clinical conditions, especially in the maxillary region 9,14,15 . A literature that deals with the use of CBCT for revealing root canal anatomy presents and describes wide variations in morphological features of maxillary first molars, but reports are mostly focused on the number and configuration of mesio-buccal root canals, supernumerary roots or root canals [16][17][18][19] . ...
Background / Aim. Maxillary first molars are one of the most challenging teeth for endodontic therapy. There are certain disparities in number of roots and canals, and canal inter-relationship within the same root, particularly in those with fused roots. The aim was to evaluate ex vivo features of roots, root canals and canal walls in maxillary first molars with fused roots. Methods. Sixty-four extracted maxillary first molars with fused roots were included for cone-beam computed tomographic and microscopic studies. Tooth dimensions at the level of pulp chamber floor, number, location and distance between orifices, number and canal morphology, canal wall thickness, and features of apical foramina were examined and measured. Results. Incidence of maxillary first molars with root fusion was 17.5%, of which 60.0% was palatal fused to disto-buccal root. At the level of pulp chamber floor bucco-palatal dimension was significantly larger with 10.4 mm than mesio-distal with 7.0 mm. Four canal orifices were detected in 65.6%, with the shortest distance of 1.95 mm between mb1 and mb2. In fused roots most frequently were two or three canals strongly correlating to the number of major apical foramina. No fusion of canals was found in fused roots. The thinnest canal wall in mesio-buccal and disto-buccal fused root was mesial with 1.25 mm, and distal with 1.31 mm, while for the palatal root the thinnest was palatal wall with 1.97 mm. Conclusion. The most frequent type of fusion was between palatal and disto-buccal root. Bucco-palatal dimension at the level of pulp chamber floor was significantly larger than mesio-distal, with the shortest inter-orifice distance between mb1 and mb2 orifice. Number of canals was either two or three, strongly coinciding with the number of major apical foramina. There was no fusion of the canals in fused roots. The thinnest canal wall was either mesial or distal.
... The molars represent the most complex issue in endodontic treatment, which is accounted for by their remote location in the dental arch, significant structural variations, and frequent observed deviations in the expected number of roots and canals, all this meaning that studying the variant morphology of permanent molars is of fundamental and applied value [1,21,28]. ...
— High-resolution microfocus computed tomography performed on a Skyscan 1176 (Bruker) device was used to study morphological features of the canal-root systems of the upper jaw first molars in residents of the European part of Russia. An analysis of coronal, axial and sagittal sections of 134 upper jaw first permanent molars removed for medical reasons revealed variations in the canal-root system structure. In 85.8% of the cases, the first upper molars had three separate roots: two vestibular and one palatal; in 14.2% of the cases the roots make up different fusions. The palatal root bent in the buccal direction in 52.9% of the cases, while the mesiobuccal root bent in the distal direction in 87.9% of the cases. The greatest variety of curvatures was observed in the distal-buccal root: towards the mesial side — in 28.3% of the cases, another 21.6% of cases being curved towards the distal side. The palatal root in 90.3% of the cases had one canal; 9.7% of the cases featured two canals, while the distal-buccal root in 73.9% of the cases had one canal, and two canals — in 26.1% of the cases. In 89.6% of the cases, the mesiobuccal root had two canals; in 10.4% of the cases — one canal. The mesiobuccal root of the first upper molars was of an oval shape, elongated in the vestibular-oral direction, the most common structures being those of Type IV (43,3%), II (25.4%), III (8.2%) and VI (7.4%) by F. J. Vertucci. The occurrence rate of extra types of root canal structure was 7.4%.
... CBCT helped to interpret that this tooth had a single C-shaped canal beginning from the pulp chamber to apex without any furcation. [7,8] Melton et al., in 1991, had proposed a classification of C-shaped canals based on their cross-sectional shape. [9] Fan et al., in 2004, modified Melton's classification into the following categories: [10] 1. Category I (C1): The shape was an interrupted "C" with no separation or division. ...
... Case reports with five, 10 six, 11 seven, 12 and even eight canals were reported. 13 Currently, technological advances have been developed, and different techniques have been introduced to facilitate the assessment of internal anatomic variations of root canals. The purpose of the present case report is to highlight the endodontic management of two rare cases of maxillary first molars with three roots and six canals each. ...
Aim: This Case Report describes two rare cases of clinical management of maxillary first molars with six root canals with special reference to radiographic interpretation and diagnosis. Background: The study reports 2 clinical cases of endodontic treatment of maxillary first molars with six root canals. Case Description: The access cavity was prepared using a slow speed round bur. The teeth were diagnosed with irreversible pulpitis and then anesthetized for an endodontic access cavity preparation. Clinical evaluation of the internal anatomy revealed 3 principle root canal systems: mesiobuccal (MB), distobuccal (DB), and palatal in each tooth. The working length was determined and the radiographs were taken for all the roots i.e mesiobuccal, distobuccal and palatal separately after placing instruments in each. The cleaning and shaping was performed using ProTaper Universal rotary instruments. Irrigation between each instrument was done. The canals were dried and obturation was performed using cold lateral compaction of gutta-percha and a resin-based sealer. The teeth were then restored with a posterior composite restoration. The patients were advised a full-coverage crown. Conclusion: A good knowledge of tooth morphology, careful interpretation of angled radiographs, proper access cavity preparation and a detailed exploration of the interior of the tooth is needed to ensure a proper endodontic treatment. Clinical Significance: Prevalence of teeth with such complex internal anatomy is a rare anomaly. However, a sound knowledge of the internal anatomy can aid in its adequate management. Keywords: maxillary molar, six canals, altered anatomy
... 5 Variation of having eight canals in maxillary molars has been broadcasted in the literature till now. 6 Failure of endodontic treatment can be ascribed to various reasons and among all, recognizing and negotiating missed canals stays an essential explanation for retreatment. 7 The present case report portrays effective endodontic treatment of a maxillary first molar having a profoundly exceptional morphological variation with two palatal canals. ...
The accomplishment of endodontic treatment is enormously subjected to the fastidiousness of the biomechanical preparation and the obturation providing a tight seal. The capacity of the clinician to comprehend and explore through the exceptionally distinct root canal anatomy assumes a conspicuous job. Incapacity to identify any extra canals in teeth having unique morphological variations would result in an unforeseeable result. The present case report portrays effective endodontic treatment of a maxillary first molar having a profoundly exceptional morphological variation with two palatal canals.
... For example, in case MB2 was in the form of type II VC, then both canals in the mesiobuccal roots will share the same apical foramen, therefore there are high chances of iatrogenic cleaning and shaping errors, such as; over-enlarging the apical foramen, ledging, transportation and blockage of one of the canals [37]. Clinicians can avoid such errors by carefully selecting their cleaning and shaping protocol or clean and shape one of the canals to the full length while the other to the joining level [38,39]. Another example are the clinical challenges related to MB2 in the form of type III VC, in which the MB2 orifice might not always be at the CEJ or pulp floor level but can start deeper apically. ...
Background
The aim of this study was to analyze the root and canal morphology of the maxillary permanent first molars in an Emirati population using cone-beam computed tomography (CBCT).
Methods
Two hundred and sixty-one CBCT scans were acquired. The data were extracted and anonymized to remove all patient identifiers. Two observers (an endodontic resident and an endodontist) evaluated all scans on diagnostic quality monitors.
Results
The prevalence of a second mesiobuccal canal (MB2) was 80.1% in all examined samples. Type II Vertucci classification, was the most common canal configuration (59%) in the mesiobuccal root, followed by Types I (19.9%) and IV (15.3%), while Type III was the least common (5.7%). Types I, II, and IV were significantly more common in the 21–40-year age group (P < 0.001), while Type III was observed significantly more often in the < 20-year age group (P < 0.001). No significant effect of gender on the prevalence of Vertucci classification in the mesiobuccal root of maxillary first molars (P = 0.74) was found. Analysis of bilateral symmetry showed that 80% teeth had perfect bilateral symmetry, whereas 20% were asymmetrical. Type II canal configuration showed the highest prevalence of bilateral symmetry (48.7%), followed by Type I (15%) and Type IV (10%), while Type III showed the least prevalence of symmetry (3%).
Conclusions
This was the first study to analyze the prevalence of MB2 canal in an Emirati population. Our results indicate high prevalence of MB2 (80.1%) and emphasize the importance of using advanced techniques to locate the MB2 canal.
... Previous studies have shown that the MSF may expand to the alveolar bone in nearly 50% of patients, forming alveolar crypts and extending between adjacent teeth or their roots. 3 During ordinal eruption of molars, the sinus floor moves occlusally, covering the root apices of the first premolar to the third molar. 4 The alveolar ridge height continues to reduce with age, as does the distance between the MSF and PMRs. 5 Surgical procedures (e.g., root canal therapy, tooth extraction, or implant treatments) can cause sinusitis, oroantral fistulae, and root displacement. ...
Objective
This study aimed to assess the positional relationships between the maxillary sinus and the first and second molars in a western Chinese population by using cone-beam computed tomography.
Methods
This study included 212 patients (652 maxillary molars and 1956 roots). Patient demographics (sex and age) and cone-beam computed tomography data regarding the relationship between molar roots and the maxillary sinus were obtained. This relationship was stratified into four types for statistical analysis.
Results
Sex and side did not significantly influence the distance between maxillary molar roots and the maxillary sinus. However, the distance between maxillary molar roots and the maxillary sinus increased with age. The mesiobuccal root of the second molar was nearest to the maxillary sinus. The most common relationship type involved absence of root contact with the sinus border and presence of a maxillary sinus cross-section above the root apex.
Conclusions
Compared with other teeth, the maxillary posterior teeth have a complex anatomical structure and are closely related to the sinus. These findings may serve as reference information for root canal treatment, tooth extraction, dental implant, and other dental clinical procedures among patients in western China.
... The most common pulp chamber floor configuration for the maxillary first molar is the presence of four root canal orifices, 1 but configurations ranging from one to eight root canals have also been reported. [1][2][3] Root fusion with main root canals merging 4 or even C-shaped anatomies (5) have also been documented. ...
The maxillary first molar has been presented as a tooth with an enormous variety of root canal system configurations. The purpose of this paper is to present two cases of maxillary first molars displaying an uncommon seven root canal system morphology. After a proper access opening of the maxillary molars undergoing a root canal treatment, two dark developmental grooves were seen connecting both the main buccal canals to the palatal one. Under the magnification and illumination of a dental operating microscope, these two grooves were explored with ultrasonic tips, which allowed identifying several other root canal orifices in both buccal roots complemented by a single palatal root canal in one case, and two in the other. Embryological reasons and the best clinical approaches to these complex morphologies are also debated. Bearing in mind the complexities of internal anatomy can help maximize the success rates of endodontic treatment. © 2019 Sociedade Portuguesa de Estomatologia e Medicina Dentária.
... However, available data describes morphotypes of heterogeneous root canals in the maxillary molars. The number of root canals ranging from one to eight has been reported (Kottoor, Velmurugan, Sudha, & Hemamalathi, 2010;Kottoor, Velmurugan, & Surendran, 2011;Martins & Anderson, 2013). In view of anatomic variations and associated complexities, maxillary first molars have the highest rates of root canal therapy failure (Briseño-Marroquín, Paqué, Maier, Willershausen, & Wolf, 2015;Lee et al., 2014). ...
Objective:
The aim of this study was to assess whether analyzed groups from two historical periods: Late Medieval (LMP), and Modern (MP) from Radom varied in the number of tooth roots and root canal system morphology.
Methods:
Root morphology of 229 permanent human teeth were analyzed using Cone Beam Computed Tomography. Additionally, the mitochondrial DNA (mtDNA) of 29 individuals from the LMP and 31 from the MP was analyzed.
Results:
In LMP, the maxillary first premolars were dominated by one root, while in MP second and third roots also appeared. Maxillary first molars in LMP presented three roots, while two-rooted forms occurred in MP. All mandibular first molars from the LMP and almost all (98%) from MP presented two roots. The greatest diversity in terms of root canal number occurred in one-rooted maxillary first premolars, the mesiobuccal root of the maxillary first molars, and the mesial and distal roots of the mandibular first molars in both groups. A few haplogroups from outside Europe (C, N, and R) were recorded in the MP Radom population. Moreover, this population had substantially higher haplogroup diversity compared with the LMP population.
Conclusion:
Odontological research indicates an increase in the diversity in the number of roots and the shape of root canals in MP. This information corresponds to genetic research, which also indicates an increase in the diversity of haplogroups during the MP.
... Additionally, it has been inferred from several CBCT studies that the incidence of C-shaped root canals in maxillary first molars ranges from 0.3% to 1.1% with an average equal to 0.83% [11]. Other anatomical anomalies such as maxillary first molars with One canal [103], five canals [106], six canals [107], seven canals [108], eight canals [109], and hypertaurodontism [110] are extremely rare and have been documented as case reports. ...
Adequate knowledge of the tooth morphology is of paramount importance for
clinicians worked in the different branches of dentistry in order to maintain good
oral health. Unfortunately, tooth morphology shows a high level of complexity and
variability. These anatomical variations have been reported to be related to many
factors including age, gender and ethnicity. The permanent first molars are the
largest teeth in the maxilla which play an important role in mastication. Because of
their early eruption, they are more vulnerable to caries and subsequent pulp and
periapical pathoses. This chapter will summarize the internal and external morphologic
features of these teeth with the reported variations in relation to age, gender
and population in order to provide clinicians with the morphological knowledge
necessary for performing successful dental treatments.
A 25-year-old female existing with mild pain and discomfort during mastication in her right posterior maxillary tooth. On clinical examination, the maxillary first molar tooth was restored with a composite filling. The tooth did not respond to heat or cold test, and it was tender to percussion. Radiograph examination revealed poor obturation of the canals and the periodontal ligament space was broad but there was no definitive periapical radiolucency. Conservative non-surgical root canal treatment was performed; a total of seven root canals were detected and they were obturated by using the calcium-based sealer. Radiograph with RVG and CBCT also confirmed that all seven canals were properly obturated. Twelve months later, there were no clinical or radiographic changes of the treated tooth. These findings suggested that careful examination of the floor of the pulp chamber with RVG and CBCT help to find extra root canals.
Con el uso de herramientas diagnósticas como microscopia óptica, tomografía computarizada Cone Beam (CBCT) y radiovisiógrafo se ha facilitado la identificación de órganos dentales con anatomía atípica que representan un reto importante para el cirujano dentista y el endodoncista. Los primeros molares superiores comunmente presentan tres raíces con cuatro conductos, un segundo conducto mesiovestibular (MB2) representados con un 56,8% y 96,1% de los casos. Martínez-Berna reportó 3 casos de primeros molares superiores con 6 conductos radiculares (3 en MV, 2 en DV y 1 en raíz palatina) en los que el uso de CBCT, ya que es un método valioso para la identificación y evaluación de la morfología interna de los órganos dentarios. La incidencia de primeros molares maxilares con 6 conductos radiculares es poco frecuente, sin embargo, es probable que esto se deba al bajo uso de técnicas como el CBCT que permiten mejor visibilidad de la anatomía radicular. Palabras clave: CBCT, primer molar maxilar, tratamiento de conductos, anatomía infrecuente.
Background:
Root canal variations frequently occur in maxillary first molars, which greatly affects the success of its treatment. The second mesiobuccal (MB) root canal is the most common root canal variation. However, only a few studies have been conducted on palatal root canal variations. Herein, we report the presence of two separate root canals in a palatal root of the maxillary first molar.
Case summary:
A 39-year-old woman complained of pain in the maxillary right region for 1 year, which recently worsened. Clinical examination revealed a poorly restored right maxillary first molar and caries detected at the filling marginal. Cold and heat test results indicated severe pain in the right maxillary first molar. The patient was diagnosed with irreversible pulpitis, and subsequently, root canal treatment (RCT) was performed. In total, five root canals were found in the maxillary first molar, including two separate root canals in the palatal root. RCT was successfully performed using an endodontic microscope and cone-beam computed tomography (CBCT). The CBCT image revealed a vertucci type I canal morphology in the distobuccal root, while the MB and palatal root canals were type Ⅳ. At the 1-mo follow-up, the maxillary first molar was completely asymptomatic, and the X-ray results indicated a successful RCT. Finally, the ceramic crown restoration was performed.
Conclusion:
An endodontic microscope and CBCT are useful in effectively identifying and treating root canal variations.
Cone-Beam Computed Tomography Evaluation of Root Canal Morphology and Crown-to-Root Ratio of Mandibular Premolars in Middle Anatolian Population
Objective: The purpose of this retrospective study was to investigate morphological configurations of root canal anatomy and crown-to-root ratio of mandibular premolar teeth by gender, age intervals and occurrence of bilateral harmony using cone-beam computed tomography scanning.
Material and Methods: A total of 1200 cone-beam computed tomographic images of mandibular first and second premolar teeth were obtained from 300 patients. The images were evaluated considering i) morphology of the root canal configurations, ii) crown length, iii) root length, iv) total tooth length, v) crown-to-root ratio; according to gender, age, and unilateral harmony. The data were analyzed with independent sample t-test and one-way analysis of variance (ANOVA). The p value was established as <0.05.
Results: Significant differences were present in gender, age and symmetrical comparisons both mandibular first and second premolar teeth (p<0.05). According to Vertucci's classification, the examined teeth exhibited six different root canal configurations as type I trough out type VI. Significant differences were found between age intervals in determination of crown length, root length, total teeth length and crown-to-root ratio (p<0.05).
Conclusion: In mandibular first premolar teeth, the frequency of two canals was approximately two times higher than second premolar teeth. The crown length and crown-to-root ratio decreased; otherwise, the root length increased by age.
Keywords: Mandibular premolar teeth, cone-beam computed tomography, crown-to-root ratio, root canal morphology
Aberrations in root canal anatomy can often pose challenges during an endodontic treatment. Failure to obturate all the root canals holistically can lead to sure endodontic failure. Thorough knowledge of such root canals together with technicality can aid us surpass the hurdles posed during a root canal treatment. This case report illustrates a root canal therapy performed in a pulpally involved maxillary first molar with seven root canals.
One of the fundamental basis of the endodontic specialty is the knowledge of root canal anatomy. Over the last century, the internal and external anatomies of teeth were well documented by different methods. Recently, technological advancements in three-dimensional computed tomographic imaging have given rise to more accurate methods for clinical and laboratory evaluations of the root canal morphology. Essentially, it has been demonstrated that the root canal is a complex system usually composed of the main root canal and important lateral components such as isthmuses, fins, accessory canals (furcation, lateral, and secondary canals), and apical ramifications. These anatomical complexities are undoubtedly the main obstacles for shaping, cleaning, and disinfecting the root canal system. This chapter is focused not only on the description of the current studies on root and root canal anatomy using CBCT and micro-CT imaging technologies, but also on the discussion of diagnostic approaches, treatment techniques, and management strategies to successfully deal with anatomical complexities.
The present case highlights the endodontic management of a maxillary second molar with three roots and seven canals. Root canal treatment was performed for the maxillary second molar diagnosed with symptomatic irreversible pulpitis. During the procedure under magnification, extra canals were detected in the mesiobuccal root. Cone-beam computed tomography (CBCT) evaluation confirmed four canals in the mesiobuccal root with Vertucci's Type XXI (4-1) pattern. The distobuccal root exhibited two canals with Vertucci's Type III (1-2-1) configuration. The palatal canal was single and large. A 4 year follow-up revealed satisfactory clinical and radiographic findings. Magnification and CBCT allow us to explore possible anatomic variations with insights to tackle such situations clinically.
Background:
As the complex anatomy of maxillary first molars is one of the major challenges in endodontic therapy, knowledge of the complicated root canal anatomy and configuration is crucial to ensure the success of endodontic treatment and prognosis. This article presents an endodontically managed left maxillary first molar with an unusual palatal root morphology. The available literature on the anatomic variation of maxillary first molars is also reviewed.
Case summary:
A 36-year-old man with no medical history presented to the Stomatology Department of Peking University Third Hospital complaining of a toothache during mastication in the maxillary left posterior region for approximately 3 mo. He had a spontaneous and intermittent toothache that had worsened, particularly at night. The diagnosis based on clinical examination, X-ray imaging, and cone beam computed tomography (CBCT) was symptomatic irreversible pulpitis. Nonsurgical endodontic therapy was performed for the left maxillary first molar. Five root canals revealed by CBCT included a special palatal root canal (1-2-1-shaped), two mesiobuccal root canals, and one distobuccal root canal. Evaluation of the CBCT images confirmed the root canal morphology and the clinician performed more effective cleaning, obturation, and therapy. Finally, the tooth was restored using composite resin, and the patient was satisfied with the result.
Conclusion:
CBCT and a complete review of the literature may be beneficial for investigating the root canal system to achieve a biological and functional therapeutic effect.
Objectives
To assess the internal and external morphologies of the mesiobuccal (MB) root of maxillary molars presenting a third root canal (MB3), using micro-computed tomography (micro-CT).Material and methodsTwo-hundred and sixty-five extracted maxillary first and second molars with different root configurations were imaged in a micro-CT scanner at 19.6-μm pixel size. Sixteen teeth presenting MB3 canal were selected and evaluated regarding root configuration, minimal dentine thickness 2 mm under the furcation area, canal configuration of the MB root, MB3 canal morphology (location, independent or confluent orifice, and anatomy types), and the apical anatomy (aspect ratio, number of accessory canals and foramina, presence of isthmus, and independent MB3 foramen).ResultsOverall, a high variability in canal configuration was detected in the MB root. MB3 canal was observed in 10 maxillary first molars and 6 maxillary second molars (n = 16). Minimal dentine thickness related to the MB3 canal at the coronal third was smaller than that of the MB1 canal. A complex internal anatomy comprising 13 different root canal configurations was observed. A high number of independent MB3 orifices at the pulp chamber floor was observed in the first molars (7 out of 10 teeth), while most of the specimens (n = 14) showed a confluent anatomy of the MB3 canal. A varied number of accessory canals and foramina were observed. At the apical third, isthmus could be observed in 6 specimens, while an independent MB3 foramen was present in 37.5% of the MB roots.ConclusionsMB3 canal is a rare anatomical variation present in maxillary first and second molars. Its presence can be associated to a complex internal anatomy of the MB root which includes the presence of isthmuses and multiple accessory canals and foramina at the apical third, but also a thin dentine thickness at the coronal third and a confluent anatomy of the MB3 with the other main canals.
Evaluating morphology of a root canal is important in determination of a successful endodontic therapy. This article highlights the need to be aware of different morphologies, which can exist in the root canal system of upper molars. This is usually associated with buccal root and has been documented in several studies in literature. On the other hand, it is not often that we come across variations in the palatal roots. These cases discuss such a case where two canals were discovered in palatal root during root canal treatment of maxillary first molar. It is essential to evaluate pre-operative radiographs and have proper knowledge of anatomy of the root canal system before initiating the treatment. All roots must be explored carefully to ensure that all canals are negotiated, debrided and obturated to ensure successful endodontic outcome. This case report shows a case series in endodontic management of a maxillary first molar with two palatal canals.
Together with diagnosis and treatment planning, a good knowledge of the root canal system and its frequent variations is a necessity for successful root canal therapy. The selection of instrumentation techniques for variants in internal anatomy of teeth has significant effects on the shaping ability and cleaning effectiveness. The aim of this study was to reveal the differences made by including variations in the internal anatomy of premolars into the study protocol for investigation of a single instrumentation technique (hand ProTaper instruments) assessed by microcomputed tomography and three-dimensional reconstruction.
Five single-root premolars, whose root canal systems were classified into one of five types, were scanned with micro-CT before and after preparation with a hand ProTaper instrument. Instrumentation characteristics were measured quantitatively in 3-D using a customized application framework based on MeVisLab. Numeric values were obtained for canal surface area, volume, volume changes, percentage of untouched surface, dentin wall thickness, and the thickness of dentin removed. Preparation errors were also evaluated using a color-coded reconstruction.
Canal volumes and surface areas were increased after instrumentation. Prepared canals of all five types were straightened, with transportation toward the inner aspects of S-shaped or multiple curves. However, a ledge was formed at the apical third curve of the type II canal system and a wide range in the percentage of unchanged canal surfaces (27.4-83.0%) was recorded. The dentin walls were more than 0.3 mm thick except in a 1 mm zone from the apical surface and the hazardous area of the type II canal system after preparation with an F3 instrument.
The 3-D color-coded images showed different morphological changes in the five types of root canal systems shaped with the same hand instrumentation technique. Premolars are among the most complex teeth for root canal treatment and instrumentation techniques for the root canal systems of premolars should be selected individually depending on the 3-D canal configuration of each tooth. Further study is needed to demonstrate the differences made by including variations in the internal anatomy of teeth into the study protocol of clinical RCT for identifying the best preparation technique.
The aim of this study was to investigate the root and canal morphology of maxillary first and second molars in an Indian population by using cone-beam computed tomography (CBCT).
Maxillary first (n = 220) and second (n = 205) molars were collected from an indigenous Indian population and scanned by using a CBCT scanner at a constant slice thickness of 125 μm/slice. Volume rendering and multiplanar volume reconstruction were performed. The number of root canals was examined, and root canal system configurations were classified by using historical and contemporary classifications.
Single-rooted first and second molars commonly showed types I, IV (0.5%) and type III (1%) canal systems, respectively. Buccal roots of two-rooted first molars showed 2 canal systems, type I and type IV, whereas second molars with 2 roots showed wide variations in canal anatomy. The most common canal morphology in the mesiobuccal roots of three-rooted first and second molars was type I (51.8% and 62%, respectively), followed by type IV (38.6% and 50%, respectively). The distobuccal and palatal roots of first and second molars showed predominantly type I canal morphology. Additional canal types were identified in 2.2% and 9.3% of the first and second molars, respectively.
The root number, morphology, and canal morphology of Indian maxillary molars showed features that were different from both Caucasian and Mongoloid traits. CBCT is an exciting and clinically useful tool in studying root canal morphology.
This article discusses the successful endodontic management of 3 permanent maxillary first 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 first molar is also presented. Modifications in the root canal access preparation and methods for examination of the pulpal floor with the aid of magnification for identification of additional canals are emphasized.
In this clinical article we report an unusual anatomy that was detected in a maxillary first molar with 6 root canals. The possibility of 6 root canals in this tooth is quite small; however, it must be taken into account in clinical and radiographic evaluation during endodontic treatment. Many times their presence is noticed only after canal treatment, owing to continuing postoperative discomfort.
This in vitro study investigated the presence of second (MB2) root canals and the number of apical foramina found in mesiobuccal roots of the permanent maxillary first molars; in addition, the study evaluated the effectiveness of magnification to detect MB2 canals. One hundred extracted maxillary first molars were collected from Jordanian patients. The number of roots (as well as their morphology) was investigated. The number of canal orifices in mesiobuccal root was assessed, with and without magnification, and findings were compared. The number of apical foramina and the distance between mesiobuccal and second canal orifices were investigated under magnification. Of the 97 specimens that were subject to additional investigation, all teeth had three separated roots, except for three specimens that had either mesiobuccal or distobuccal roots fused with the palatal root. The number of MB2 canals that were detected increased from 55 (56.7%) to 61 (62.9%) teeth when magnification was used. Within the limits of this in vitro study, it was concluded that the Jordanian population had a high percentage of MB2 canals in the mesial buccal roots. Moreover, the use of clinically used magnifying devices increased the number of MB2 canals detected.
This case report presents an unusual maxillary right first molar with four roots and six canals. Endodontic treatment was provided and final restoration was accomplished with composite resin. Treating extra canals in maxillary first molars may be challenging. Inability to find and properly treat the root canals may cause failures. Complete clinical and radiographic examination and a thorough knowledge of the morphology of these teeth is necessary for successful clinical results.
The assurance of the quality of a service rendered by a member of the dental profession is an essential feature of any system of peer review in dentistry. This document addresses two essential elements: (i) appropriateness of treatment modality and (ii) quality or level of treatment rendered. In revising these guidelines the European Society of Endodontology is responding to a public and professional need. In receiving care of a specialized nature such as endodontic treatment, patients need and deserve treatment that meets the standard of care generally given by competent practitioners. The European Society of Endodontology has the expertise and professional responsibility necessary to assist the dental profession by instituting guidelines on the standard of care in the special area of Endodontics. In accepting this responsibility the European Society of Endodontology formulated treatment guidelines that are intended to represent current good practice. This document is the revised version of an earlier consensus report [International Endodontic Journal (1994) 27, 115-24]. As there is not one single way of performing treatment, these guidelines have been formulated in broad terms.
The hard tissue repository of the human dental pulp takes on numerous configurations and shapes. A thorough knowledge of tooth morphology, careful interpretation of angled radiographs, proper access preparation and a detailed exploration of the interior of the tooth are essential prerequisites for a successful treatment outcome. Magnification and illumination are aids that must be utilized to achieve this goal. This article describes and illustrates tooth morphology and discusses its relationship to endodontic procedures. A thorough understanding of the complexity of the root canal system is essential for understanding the principles and problems of shaping and cleaning, for determining the apical limits and dimensions of canal preparations, and for performing successful microsurgical procedures.
Two digital imaging systems, a video camera and analog-to-digital converter, and a charge-coupled device linear photodiode array slide scanner, were tested for their suitability in quantitative studies of periodontal disease. The information content in the original films was estimated, and digital systems were assessed according to these requirements. Radiometric and geometric performance criteria for the digital systems were estimated from measurements and observations. The scanner-based image acquisition (digitization) system had no detectable noise and had a modulation transfer function curve superior to that of the video-based system. The scanner-based system was equivalent to the video-based system in recording radiographic film densities and had more geometric distortion than the video-based system. The comparison demonstrated the superiority of the charge-coupled device linear array system for the quantification of periodontal disease extent and activity.
The mesiobuccal roots of 208 teeth were sectioned buccolingually from the mesial aspect and the canal configurations were categorized. One hundred one (48.5 per cent) had a single canal, 78 (or 37.5 per cent) showed two canals which merged toward a single apical foramen, and twenty-nine (14.0 per cent) displayed two distinct canals with separate apical foramina.The frequency of occurrence of the bifurcated or double canal must be taken into consideration when surgical treatment is planned and as a possible cause of otherwise unexplained failure.Case histories are presented to illustrate these situations.
To observe the morphology of the root canal system of the maxillary first molar mesiobuccal root using micro computed tomography and compare it to current canal classifications.
Twenty mesiobuccal roots were resected from randomly selected extracted human maxillary first molar teeth and prepared for scanning using a SkyScan micro CT scanner (SkyScan 1172 X-ray microtomograph, Antwerp, Belgium) at a slice thickness of 11.6μm. Three-dimensional images were produced and analysed to record the number and configuration of the canals, the presence of accessory canals, connections between the canals and number of canal orifices and foramina.
The majority of roots had complex root canal systems with a second mesiobuccal canal present in 90% of the roots examined. Intercanal communications were observed in 55% of the roots. A single apical foramen was found in 15% of roots, two foramina were present in 20% and three or more foramina were present in 65%. In half of the roots, there were two orifices at the furcation level; 40% had one orifice and 10% had three orifices. Accessory canals were present in 85% of the roots. Only 60% of root canals could be classified using the classification of Weine et al. (1969) and 70% using the classification of Vertucci (1984).
Micro computed tomography offers an ability to examine root canal anatomy in fine detail and confirms that the morphology of the mesiobuccal root of the maxillary first molar teeth is complex and that present morphology classifications do not fully reflect the complexity.
This clinical article describes 4 different case reports of maxillary first molars with unusual anatomy of 6 root canals and their endodontic management. Treating these additional canals in maxillary first molars might be challenging. Inability to locate and properly treat these extra canals might lead to failures. A thorough knowledge of root canal morphology and the proper use of microscopes increase chances for successful clinical results. Because presence of these extra canals is not unusual and naming these canals still remains elusive, a new nomenclature is suggested for ease of communication.
To increase our understanding of the root canal system, we examined the mesiobuccal (MB) roots of maxillary first and second molars, which are considered to be one of the most complex root canal systems.
Uninstrumented MB roots from 153 teeth were imbedded, sectioned, and observed at 8x using a stereomicroscope for main canal numbers, isthmus presence, and dimensional size of canals and dentin walls.
The number of canals observed in maxillary first and second molars was 20% and 38.1% for one canal, 79.8% and 60.3% for two canals, and 1.1% and 1.6% for three canals, respectively. The buccal canal was larger than lingual or middle canals at all levels of the root. The average distance between the two main canals was 1.2 +/- 0.6 mm in first molars and 1.78 +/- 0.6 mm in second molars. Isthmus tissue increased greatly at 3.6 mm from the apex, suggesting optimal root resection at this level. Little differences in thickness between mesial and distal canal walls were seen until reaching the coronal sections of the root where the average canal wall thickness was found to be thinner (33%) on the distal, suggesting a "danger zone" for maxillary molars at a level where the root joins the crown of the tooth.
The observations made here provide a more precise understanding of the maxillary MB root system. Orthograde and retrograde root canal therapy might be improved with a comprehensive understanding of pulpal morphology throughout the entire MB root.
The purpose of this article was to emphasize the importance of having a thorough knowledge about the root canal anatomy.
This case report presents the endodontic management of a maxillary first molar with three roots and seven canals. The clinical detection of the seven canals was made using a surgical operating microscope and confirmed using cone-beam computed tomography (CBCT) scanning.
CBCT axial images showed that both the palatal and distobuccal root have a Vertucci type II canal pattern, whereas the mesiobuccal root showed a Sert and Bayirli type XV canal configuration.
This report describes and discusses the variation in canal morphology of maxillary first molar and the use of latest adjuncts in successfully diagnosing and negotiating them.
This case report presents the endodontic management of maxillary right second molar exhibiting 5 roots and 5 root canals. The diagnosis was confirmed with the help of cone beam computerized tomography (CBCT). The article also describes the varied morphology associated with maxillary second molar and the use of a high-end diagnostic imaging modality like CBCT in diagnosing and negotiating these anatomic variations.
This case report describes an unusual maxillary first molar variant of a single fused buccal root canal. This morphology of root canal was further confirmed by spiral computerized tomography and transverse sectioning of contralateral tooth in vitro.
The complex anatomic configuration of the maxillary first molar mesiobuccal (MB) root canal system has been the subject of several studies. The purpose of this investigation was to analyze the 3-dimensional (3D) characteristics of the maxillary first molar MB canal system using micro-computed tomography (microCT).
Extracted maxillary first molars (46) were scanned by microCT and their canals reconstructed by 3D modeling software.
In these MB roots, nearly two-thirds (65.2%) had 2 canals, fewer than one-third (28.3%) had only 1 canal, and a few (6.5%) had 3 canals. The most common root canal configuration was 2 distinct canals (type III: 37.0%), followed by 1 single canal (type I: 28.3%), 2 canals that joined together (type II: 17.4%), 1 canal that split into 2 (type IV: 10.9%), and 3 canals (type V: 6.5%).
MicroCT provided an in-depth analysis of canal configurations, as well as length, curvature, and location of calcified segments.
The phenomenon of cavitation was investigated in an Enac-Osada ultrasonic unit using a #15 Cavi-Endo file 25-mm long. The observed cavitation was incorporated in a subsequent study which investigated the effects of cavitaion on debridement. One group of 10 teeth was subjected to the cavitating file while a second group served as a control. Scanning electron microscopic observations revealed that there was no difference in cleanliness between the two groups of teeth studied. Cavitation might have resulted in the formation of pits in some of the canals and should not be regarded as an important mechanism of debridement.
The success of endodontic treatment depends on the identification of all root canals so that they can be cleaned, shaped, and obturated. This study investigated internal morphology of maxillary first molars by 3 different methods: ex vivo, clinical, and cone beam computed tomography (CBCT) analysis. In all these different methods, the number of additional root canals and their locations, the number of foramina, and the frequency of canals that could or could not be negotiated were recorded. In the ex vivo study, 140 extracted maxillary first molars were evaluated. After canals were accessed and detected by using an operating microscope, the teeth with significant anatomic variances were cleared. In the clinical analysis, the records of 291 patients who had undergone endodontic treatment in a dental school during a 2-year period were used. In the CBCT analysis, 54 maxillary first molars were evaluated. The ex vivo assessment results showed a fourth canal frequency in 67.14% of the teeth, besides a tooth with 7 root canals (0.72%). Additional root canals were located in the mesiobuccal root in 92.85% of the teeth (17.35% could not be negotiated), and when they were present, 65.30% exhibited 1 foramen. Clinical assessment showed that 53.26%, 0.35%, and 0.35% of the teeth exhibited 4, 5, and 6 root canals, respectively. Additional root canals were located in this assessment in mesiobuccal root in 95.63% (27.50% could not be negotiated), and when they were present, 59.38% exhibited 1 foramen. CBCT results showed 2, 4, and 5 root canals in 1.85%, 37.05%, and 1.85% of the teeth, respectively. When present, additional canals showed 1 foramen in 90.90% of the teeth studied. This study demonstrated that operating microscope and CBCT have been important for locating and identifying root canals, and CBCT can be used as a good method for initial identification of maxillary first molar internal morphology.
Apical periodontitis is an infectious disease caused by microorganisms colonizing the root canal system. For an optimal outcome of the endodontic treatment to be achieved, bacterial populations within the root canal should be ideally eliminated or at least significantly reduced to levels that are compatible with periradicular tissue healing. If bacteria persist after chemomechanical preparation supplemented or not with an intracanal medication, there is an increased risk of adverse outcome of the endodontic treatment. Therefore, bacterial presence in the root canal at the time of filling has been shown to be a risk factor for posttreatment apical periodontitis. About 100 species/phylotypes have already been detected in postinstrumentation and/or postmedication samples, and gram-positive bacteria are the most dominant. However, it remains to be determined by longitudinal studies if any species/phylotypes persisting after treatment procedures can influence outcome. This review article discusses diverse aspects of bacterial persistence after treatment, including the microbiology, bacterial strategies to persist, the requisites for persisting bacteria to affect the outcome, and future directions of research in this field.
The anatomy of the mesiobuccal (MB) root of 51 maxillary first and 32 maxillary second molars was studied. Initially, an attempt was made to locate all canals using a standard access and hand instruments. A bur was next used carefully to locate any additional second mesiobuccal (mesiolingual (ML)) canals. Finally, after crown removal, the teeth were reduced horizontally in 1-mm increments and examined by microscope. A second ML canal was located in the coronal half of 95.2% of the roots: by hand instruments in 54.2%; bur in 31.3%; and microscope in 9.6%. There were no root perforations when the bur was used as described. The ML canal orifice averaged 1.82 mm lingual to the MB canal orifice. The difference in incidence of ML canals between the first and second molars was not statistically significant. The canal systems were type 1, 4.8%; type 2, 49.4%, and type 3, 45.8%.
The C-shaped canal is unusual. It is most frequently reported in mandibular molars. A case of bilateral C-shaped canals in maxillary molars is reported here.
A case report is presented concerning a maxillary first molar with six canals. The morphology is unique because it is characterized by two canals in the mesiobuccal root, two in the distobuccal root, and two in the palatal root.
A patient with a five-canal maxillary first molar wasreferred for endodontic treatment due to the mesiobuccal root which radiographically appeared to be calcified. Nonsurgical endodontic therapy revealed three root canals in the mesiobuccal are.
Two thousand four hundred human permanent teeth were decalcified, injected with dye, and cleared in order to determine the number of root canals and their different types, the ramifications of the main root canals, the location of apical foramina and transverse anastomoses, and the frequency of apical deltas.
The aim of this study was to determine the percentage of anatomical canal configurations of the mesiobuccal root of the maxillary first molar in Japanese patients.
Three hundred teeth were obtained from general dentists who knew absolutely that they were extracted from Japanese patients. The distobuccal and palatal roots were amputated for radiographic convenience. Preoperative radiographs were taken of the remaining crown and mesiobuccal root (MBR) from mesiodistal and buccopalatal directions for each tooth. Routine endodontic access cavities were prepared and size 08 files were placed through the orifice into the MBR until they were seen at the apex. In some cases preparation of the canal orifice with a long shank round burr was necessary to gain access. In seven teeth, no access to the apex was possible and these teeth were eliminated. In the other 293 teeth, the MBR canal(s) was (were) enlarged up to size 15 file. If another canal opening was found at the apex a 08 file was inserted into the second opening and passed coronally. Postoperative radiographs with file(s) in place were taken from the two directions, as before.
Of the 293 teeth, 123 (42.0%) were Type II, 89 (30.4%) showed Type III systems and 10 (3.4%) were Type IV. Suggestions for identification and treatment of the second canal in the MBR are presented.
The proportion of cases with two canals in the mesiobuccal root of maxillary first molars from Japanese patients was high and similar to that described from studies of other ethnic populations.
The endodontic treatment of a maxillary molar with an aberrant root morphology can be diagnostically and technically challenging. This case report is presented to illustrate and describe the endodontic treatment of a four-rooted maxillary molar with a quadrangular root trunk morphology.
To study the root canal morphology of Burmese mandibular molars using a canal staining and tooth clearing technique.
Mandibular molars (331) were collected from indigenous Burmese patients and designated; first (139), second (134), third (58) molars. Following pulp tissue removal and staining of the canal systems with Indian ink, the teeth were decalcified and rendered clear with methyl salicylate. Under magnification (x3), the following features were evaluated: (i) root number and morphology, (ii) number of canals per root, (iii) root canal configuration (Vertucci's classification), (iv) number of apical foramina per root, (v) number and location of lateral canals and (vi) the presence of intercanal communications.
Most of the mandibular molars had two separate roots (90% in first molars, 58% in second molars, 53% in third molars) and three-rooted teeth were (10%) confined to first molars. C-shaped roots occurred in 22.4% of mandibular second molars and a further 14.9% had two fused roots. The majority (81-100%) of conical distal roots possessed a simple type I (single canal) configuration. Whilst the canal system of mesial roots was more complex: 52-85% contained two canals, of which type II (two orifices, one foramen) and type IV (two separate canals) were the most prevalent. A broad range of 6.5-70% had intercanal communications. Fused/single-rooted molars had a wide variety of canal system types but intercanal communications were rare except in C-shaped roots (33%) of second molars. The majority of roots of all molars contained one or two apical foramina (91-96%) and the apical third had the highest prevalence of lateral canals.
There was a high prevalence of three-rooted mandibular first molars and C-shaped roots/canals in mandibular second molars from a Burmese population. Conical roots tend to have simple canal systems, whilst flatter/broader roots have more complex canal systems.
The purpose of this study was to determine if the surgical operating microscope and/or dental loupes could enhance the practitioner's ability to locate the second mesiobuccal canal (MB2) canal of maxillary molars in an in vivo, clinical setting. The participating endodontists documented 312 cases of root canal therapy on maxillary first and second molars. Participants that used the microscope or dental loupes located the MB2 canal with a frequency of 57.4% and 55.3%, respectively. Those using no magnification located the MB2 canal with a frequency of 18.2%. When no magnification was used, significantly fewer MB2 canals were located based by Chi-square analysis at p < 0.01. There was no significant difference between the use of the microscope and dental loupes in the frequency of locating the MB2 canal. When the maxillary first molars were considered separately, the frequency of MB2 canal detection for the microscope, dental loupes, and no magnification groups was 71.1%, 62.5%, and 17.2%, respectively. The results of this study show that the use of magnification in combined groups leads to a MB2 detection rate approximately three times that of the nonmagnification group and that the use of no magnification results in the location of significantly fewer MB2 canals. Based on these results, more emphasis should be placed on the importance of using magnification for locating the MB2 canal.
The aim of this case report is to describe an unusual six-canal maxillary first molar tooth.
The maxillary left first molar of a young African-American male was treated as an emergency at the first visit. At the second visit, the five canals (MB1 and 2, Pal1 and 2 and DB) were easily identified at high magnification of 16-25 under an operating microscope. The canals were then instrumented and filled using the Microseal technique. A careful radiographic examination of the final fill indicated that there was a third canal in the palatal root as suggested by a slight extrusion of the filling material between the two canals. At the third visit, the fillings of the palatal canals were removed and the apical 4mm was re-examined. The existence of a third palatal canal exiting between the two apices was verified and subsequently instrumented and obturated.
It should be assumed that all molar teeth have more than the traditionally expected three canals. The location of root canals should be identified at high magnification under the microscope. Careful radiographic re-examination of the fillings should be done in order to identify possibly missed canals.
A key objective of successful nonsurgical endodontic treatment is obturation of the root canal systems. One factor in achieving this goal is the knowledge of possible root canal morphologies. Root canal morphology may exhibit variation as a result of many factors, including ethnic origin. In this study, 1400 male and 1400 female extracted mandibular and maxillary permanent teeth were evaluated for patterns in root canal morphology. The mandibular and maxillary teeth were divided into seven groups of tooth type (e.g. centrals, laterals, canines, first premolars, second premolars, first molars, and second molars), subdivided into gender, and classified by root canal morphologies. Vertucci's classification was taken as a reference during the evaluation. Although a majority of the specimens corresponded to this classification scheme, the analysis of this large data set revealed 14 additional root canal morphologies.
Nickel-titanium rotary instruments are important adjuncts in endodontic therapy. This review attempts to identify factors that influence shaping outcomes with these files, such as preoperative root-canal anatomy and instrument tip design. Other, less significant factors include operator experience, rotational speed, and specific instrument sequence. Implications of various working length definitions and desired apical widths are correlated with clinical results. Despite the existence of one ever-present risk factor, dental anatomy, shaping outcomes with nickel-titanium rotary instruments are mostly predictable. Current evidence indicates that wider apical preparations are feasible. Nickel-titanium rotary instruments require a preclinical training period to minimize separation risks and should be used to case-related working lengths and apical widths. However, and despite superior in vitro results, randomized, clinical trials are required to evaluate outcomes when using nickel-titanium instruments.
The purpose of this study was to investigate a new diagnostic approach to the examination of the canal configuration of the mesiobuccal root of the maxillary first molar.
High-resolution computed tomography (CT) was compared with histology in vitro. There were 152 teeth investigated and classified according to Weine and Vertucci.
CT describes the exact canal configuration, verifying information identical to histology, and thus serving as the "gold standard" in vitro. With regard to canal position, 9 (5.92%) of the teeth examined were Vertucci type 1, 48 (31.58%) were Vertucci type 2, 91 (59.87%) were Vertucci type 4, 1 (0.66%) was Vertucci type 5, 1 (0.66%) was Vertucci type 6. Of the 152 teeth examined, 3 (1.97%) could not be classified using Weine, 2 (1.31%) could not be classified according to either Weine or Vertucci, and no Vertucci types 3, 7 or 8 were identified.
CT offers complete information on the number and configuration of root canals. As the root canal configuration of the adult does not change rapidly, CT investigations can be used for multiple subsequent treatments.
The aim of this article is to present an endodontically managed maxillary first molar with an unusual morphology of a single root and a single canal, which has not been reported in the literature so far. An accurate assessment of this unusual morphology was made with the help of a Spiral computed tomography. This report extends the range of known possible anatomical variations to include teeth with lesser number of roots and canals. This report also highlights the role of Spiral computed tomography as an objective method to confirm the three-dimensional anatomy of teeth.
The objective of this study was to review the literature with respect to the root and canal systems in the maxillary first molar. Root anatomy studies were divided into laboratory studies (in vitro), clinical root canal system anatomy studies (in vivo) and clinical case reports of anomalies. Over 95% (95.9%) of maxillary first molars had three roots and 3.9% had two roots. The incidence of fusion of any two or three roots was approximately 5.2%. Conical and C-shaped roots and canals were rarely found (0.12%). This review contained the most data on the canal morphology of the mesiobuccal root with a total of 8399 teeth from 34 studies. The incidence of two canals in the mesiobuccal root was 56.8% and of one canal was 43.1% in a weighted average of all reported studies. The incidence of two canals in the mesiobuccal root was higher in laboratory studies (60.5%) compared to clinical studies (54.7%). Less variation was found in the distobuccal and palatal roots and the results were reported from fourteen studies consisting of 2576 teeth. One canal was found in the distobuccal root in 98.3% of teeth whereas the palatal root had one canal in over 99% of the teeth studied.
Tooth morphology and access cavity preparation
- Burns
Burns RC, Herbranson EJ. Tooth morphology and access cavity preparation. In:
Cohen S, Burns RC, eds. Pathways of the pulp. St Louis, MO: Mosby Elsevier;
2002:173–229.
Ultrasonic debridement of root canals: acoustic cavitation and its relevance
- Ahmad