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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 443-445
Spiral CT diagnosis and endodontic management of an anatomically variant palatal root with two canals in a maxillary first molar

Department of Conservative Dentistry & Endodontics, Ragas Dental College & Hospital, Uthandi, Chennai, India

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Date of Submission05-Nov-2009
Date of Decision06-Jan-2010
Date of Acceptance21-May-2010
Date of Web Publication29-Sep-2010


This case report presents the endodontic management of an anatomically variant palatal root with 2 canals (Vertucci type II) in a maxillary first molar, which was confirmed with the help of spiral computed tomography (SCT). This serves to remind clinicians that such anatomic variations should be taken into account during the endodontic treatment of maxillary molars and highlights the invaluable aid of the SCT in accurate diagnosis and in negotiating the complex morphologic variations in root canals, thus enabling successful endodontic management.

Keywords: Two palatal canal, maxillary first molar, spiral CT

How to cite this article:
Deepalakshmi M, Miglani R, Indira R, Ramachandran S. Spiral CT diagnosis and endodontic management of an anatomically variant palatal root with two canals in a maxillary first molar. Indian J Dent Res 2010;21:443-5

How to cite this URL:
Deepalakshmi M, Miglani R, Indira R, Ramachandran S. Spiral CT diagnosis and endodontic management of an anatomically variant palatal root with two canals in a maxillary first molar. Indian J Dent Res [serial online] 2010 [cited 2019 Sep 16];21:443-5. Available from:

   Introduction Top

A thorough knowledge of both the external and internal anatomy of the teeth is an important aspect of root canal treatment. Often, in everyday endodontic practice, clinicians encounter teeth with aberrant canal configurations. Failures to diagnose these aberrant root canals and to identify extra roots are the major reasons for failure of the endodontic therapy.

The dental radiographic diagnostic methods give a two dimensional view of 3-dimensional anatomy of the area radiographed. Anatomic and pathologic structures of intraoral hard tissues in radiographs are prone to overlap artifacts and thus it reveals limited aspects of the three-dimensional anatomy. The benefits of three-dimensional computer tomography (CT) imaging are already well established in dental specialities. Tachibana and Masumoto reported the versatile application of CT in endodontics which allowed the observation of morphology of root canals and roots, the appearance of tooth in every direction, allowing both qualitative and quantitative examination and its successful management of complex root canal anatomy. CT data offers significant advances in the ability to reconstruct the tissues of the tooth before and after instrumentation and obturation with optimum detail and they also remain fully retrievable for future evaluations.

This article reports a case of maxillary first molar with two canals in a single palatal root which was confirmed and managed with the help of spiral CT

   Case Report Top

A 24-year-old female patient presented to the Department of Endodontics, Ragas Dental College and Hospital, with the chief complaint of intermittent pain in the upper left back teeth for the past 3 months. Her past dental history revealed that she visited a general dental practitioner with the same complaint 3 months back and after due examination, root canal treatment was commenced, but the patient discontinued the treatment. Her medical history was found to be non-contributory. Clinical examination revealed a symptomatic tooth #16 with caries on buccal and lingual walls with open access cavity and accumulation of food debris. The tooth exhibited tenderness to percussion. Intraoral periapical (IOPA) radiograph revealed a prepared access cavity with normal root canal anatomy and widening of periodontal ligament space of the involved tooth [Figure 1]. The clinical and radiographic findings lead to a provisional diagnosis of apical periodontitis of the left maxillary first molar (#16), which was marked for non-surgical endodontic therapy.
Figure 1: Pre-operative radiograph

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The tooth was anesthetized using 2% lidocaine with 1:80,000 adrenaline (Lignox, Indoco Remedies Ltd, Mumbai, India). After isolation with rubber dam, the access cavity was modified using a round bur (Dentsply-Maillefer, Ballaigues, Switzerland). Clinical evaluation of the internal anatomy of the pulp chamber revealed 3 principal root canal orifices: mesiobuccal, distobuccal, and palatal. The pulp chamber was frequently flushed with 5% sodium hypochlorite to remove pulp tissue remnants. On probing with a DG-16 endodontic explorer (Hu-Friedy, Chicago, IL), a small hemorrhagic point was noted at the same orifice level approximately 2 mm distally from the orifice of the main palatal canal. The access cavity was further modified to get better access to the additional canal. Inspection of the pulp chamber with magnifying loupes (Seiler loupes, 3× magnification) revealed 4 distinct orifices, 2 buccally and 2 palatally. The additional canal patency was checked with a #10 K-file (Mani ILC, Tochigi, Japan). Working length radiograph confirmed the presence of 2 canals in the palatal root [Figure 2]. The appointment was then concluded with the application of sterile cotton pellets and IRM cement (Dentsply DeTrey GmbH, Konstanz, Germany). To confirm the presence of the additional canal and its morphology in the palatal root, spiral computed tomography (SCT) was scheduled. To ascertain more precisely the 3-dimensional (3D) relationship of the tooth structure, CT imaging was performed using the 3D (General Electric, Siemens, 64 slice, 120 kV, 90 mA). From the 3D reconstruction (interval of 0.6 mm) image it was confirmed that the tooth #16 revealed 2 separate orifices (2.5 mm interorifice distance) and a single exit (Vertucci type II) indicating 2 separate canals in the palatal root [Figure 3] and [Figure 4]. A thin dentinal separation between the two canals till the apical third was evident.
Figure 2: Initial radiograph-a #15 size K-file evident in the additional palatal canal

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Figure 3: CT image of maxillary arch

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Figure 4: CT image - Coronal, middle and apical region

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In the next session, the MB2 canal was negotiated with the help of ultrasonic tips, and the correct working lengths were established by means of an apex locator (Morita, Tri auto ZX2). All the canals were instrumented by the crown down technique using protaper nickel-titanium rotary instruments (Maillefer-Dentsply, Ballaigues, Switzerland) with 5% sodium hypochlorite solution and EDTA (Glyde, Maillefer, Dentsply). All the instrumented canals were medicated with Ca(OH) 2 and the tooth was then temporized with IRM cement. After 1 week, the canals were obturated with AH plus resin sealer (Dentsply DeTrey Konstanz, Germany) and cold laterally condensed with gutta-percha (Maillefer-Dentsply, Tulsa, OK) and sealed with IRM cement. Postobturation radiograph revealed Vertucci type II root canal morphology in the palatal root [Figure 5].
Figure 5: Postoperative radiograph shows the endodontically treated maxillary 1st molar with 2 canals in a single palatal root

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   Discussion Top

The present case report details the endodontic management of an anatomically variant palatal root with 2 canals (Vertucci type II) in a maxillary first molar, which was confirmed with the help of CT. Various published literature describes the human maxillary first molar as having 3 roots; or 3-4 root canals (1 canal in each palatal and in distobuccal root and 1 or 2 in the mesiobuccal root. [1] In the past, most of the literature concentrated on the morphology of mesiobuccal root, particularly on the MB2 canal. In addition to these studies, the literature cites many anomalies associated with maxillary molars, such as single-rooted maxillary molars, 2 distobuccal root canals, 5 canals in the maxillary first molar, with 3 of them located in the mesiobuccal root. [2] Anatomic variations involving the number of root canals or number of roots in the palatal root of permanent maxillary molar are unusual and rare (less than 1%) and also infrequently reported. [3]

All the case reports mentioned above were based on radiographic examinations of the teeth. Usually, the interpretation of the radiograph along with a careful inspection of the pulp chamber floor by probing and by proper visualization allows the operator to understand the root canal configuration. In the present case, the IOPA did not reveal the presence of 2 palatal canals, but clinically after the modification of the access cavity, an additional palatal orifice was suspected. Because of the inherent limitations of radiographs and to confirm the presence of 2 palatal canals, CT was performed, which gave more precise information of the canal configuration of tooth #16. It confirmed the presence of 2 palatal canals (Vertucci type II) along with the MB1, MB2, and DB.

Compared with radiographs, CT permits a more accurate diagnosis of the aberrant root canals with accurate identifications and measurements in multiple planes,, [4] which may not be readily identifiable with IOPA radiographs even if taken at different angles. An extensive review of the literature showed that the SCT has been used to identify and understand the anatomic variation of the maxillary first molar morphology. [5] Vivek et al. [1] reported that there are 2 palatal canals in the maxillary first molar, using SCT, which aided in a successful endodontic management. This article is probably the second case to be reported where a maxillary first molar with 2 canals in a single palatal root, which was confirmed and managed with the help of SCT.

Adequate access cavity preparation is the initial step in canal preparation to eliminate many potential problems during canal preparation and obturation. The access cavity outline of maxillary first molar will be a square shaped or trapezoidal rather than triangular. [2] Furthermore, the clinician should be attentive to the clinical signs of anatomic variations during access cavity preparation as in the present case, a bleeding spot in the pulp chamber floor was noticed, suggesting the presence of an additional palatal canal. Some of the other indications could be the eccentric location of an endodontic file on a radiograph during working length determination, inconsistent apex locator readings, a sinus tract that traces laterally away from the main canal, or the feeling of a "catch" on the canal wall during instrumentation of a wide and unobstructed main canal. If only 1 orifice is found and it is not in the centre of the tooth, it is probable that another canal could be present. In a few cases with necrotic pulp or when canals are pulpless, the presence of an apical rarefaction on the lateral side of the root may suggest the presence of an extra canal. [6]

Failure to treat a missed canal is an obvious reason for root canal treatment failure. [7] Awareness and understanding of the presence of unusual canal morphology during diagnosis and treatment phase of the teeth can contribute largely to a successful outcome of the treatment. With this anatomic basis, the use of advanced supplementary aids can now be rationally used, not as gimmicks but as a valuable tool for conducting successful root canal treatment.

   References Top

1.Vivek A, Mamta S, Ajay L, Shah N. Endodontic management of a maxillary first molar with two palatal canals with the aid of spiral computed tomography: A case report. J Endod 2009;35:137-9.  Back to cited text no. 1      
2.Stephen J. Unusual maxillary first molars with two palatal canals within a single root. J Can Dent Assoc 2001;67:211-3.  Back to cited text no. 2      
3.Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human permanent maxillary first molar: A literature review. J Endod 2006;32:813-20.  Back to cited text no. 3      
4.Gündüz E, Rodríguez-Torres C, Gahleitner A, Heissenberger G, Bantleon HP. Bone regeneration by bodily tooth movement: Dental computed tomography examination of a patient. Am J Orthod Dentofacial Orthop 2004;125:100-6.  Back to cited text no. 4      
5.Gopikrishna V, Reuben J, Kandaswamy D. Endodontic management of a maxillary first molar with two palatal roots and a single fused buccal root diagnosed with spiral computed tomography: A case report. Oral Surg Oral Med Oral Pathol 2008;105:74-8.  Back to cited text no. 5      
6.Kabak YS, Abbott PV. Endodontic treatment of mandibular incisors with two root canals: Report of two cases. Aust Endod J 2007;33:27-31.  Back to cited text no. 6      
7.Stone LH, Stroner WF. Maxillary molars demonstrating more than one palatal root canal. Oral Surg Oral Med Oral Pathol 1981;51:649-52.  Back to cited text no. 7      

Correspondence Address:
Mohanavelu Deepalakshmi
Department of Conservative Dentistry & Endodontics, Ragas Dental College & Hospital, Uthandi, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.70801

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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