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Table of Contents   
CASE REPORT  
Year : 2019  |  Volume : 30  |  Issue : 3  |  Page : 478-480
Endodontic management of maxillary first molar with an anatomical variation of two palatal canals: A case report


1 Department of Endodontics and Conservative Dentistry, Balaji Dental and Craniofacial Hospital, 30, Kavignar Bharathidasan Road, Teynampet, Chennai, Tamil Nadu, India
2 Department of Dentistry, Balaji Dental and Craniofacial Hospital, 30, Kavignar Bharathidasan Road, Teynampet, Chennai, Tamil Nadu, India

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Date of Web Publication9-Aug-2019
 

   Abstract 

An in-depth knowledge of the root canal anatomy is important for any successful root canal treatment; however, complexities exist within the root canal morphology. The maxillary first molar has variations in its root morphology and canal configurations. In literature, this variation is only observed in an estimated 1.12%-1.17%. One such case is described in this case report which provides the endodontic management of a left maxillary first molar with two palatal canals using loupes magnification.

Keywords: Anatomical variation of two palatal canals, complex root canal morphology, endodontic management, loupes magnification, maxillary first molar, successful root canal treatment, two palatal canals

How to cite this article:
Sriganesh A, Saravana Priyan G L. Endodontic management of maxillary first molar with an anatomical variation of two palatal canals: A case report. Indian J Dent Res 2019;30:478-80

How to cite this URL:
Sriganesh A, Saravana Priyan G L. Endodontic management of maxillary first molar with an anatomical variation of two palatal canals: A case report. Indian J Dent Res [serial online] 2019 [cited 2019 Aug 24];30:478-80. Available from: http://www.ijdr.in/text.asp?2019/30/3/478/264135

   Introduction Top


The basic concept of root canal treatment is thorough mechanical cleaning and complete debridement with copious amounts of irrigation followed by three-dimensional obturation thereby obtaining a hermetic seal. The concept of a hermetic seal was first termed by Grossman in 1967.[1] It is necessary to identify the aberrant anatomy of the root canal prior to treatment, as failure to recognize such variations may lead to unsuccessful treatment.

The normal anatomy of maxillary first molar is three roots (two buccal and one palatal) with three canals (one mesiobuccal, one distobuccal and one palatal). The occurrence of two palatal roots in a maxillary first molar is a rare phenomenon. The occurrence of two palatal roots is rare but a few cases were reported by Stone and Stroner with anatomical variations.[2] In literature, this variation is only observed in an estimated 1.12-1.17%.[3]

This case report discusses the successful endodontic management of maxillary first molar with an anatomical variation of three roots and five canals.


   Case Report Top


An 18-year-old female patient presented with dull, aching pain in her left upper back tooth region for the past 2 weeks. The patient's medical history was non-contributory. On clinical examination, mesioproximal decay was seen in the left maxillary first molar. The tooth was tender on percussion. Radiographic examination revealed a deep mesioproximal caries extending up to the pulp chamber [Figure 1]a. These findings led to the diagnosis of symptomatic irreversible pulpitis for which root canal treatment was deemed necessary.
Figure 1: (a, b, c, d, e) Pre-op of the left maxillary first molar, Working length determination of left maxillary first molar with five canals, Two palatal canals in left maxillary first molar, Master cone placed in left maxillary first molar, Obturation done in the maxillary left first molar

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Topical anesthesia of 20% Benzocaine was applied at the injection site. Local anesthesia of 2% lidocaine with 1:80,000 epinephrine was administered. Caries excavated with the help of a round bur. Access cavity was prepared using endo access bur. Safe-ended access bur used for complete deroofing. Coronal enlargement was done using Gates Glidden (GG) drills for straight line access. The pulp tissue was removed using 3% sodium hypochlorite. Mesiobuccal distobuccal and palatal canals were located. Troughing was done using an ultrasonic tip. Following which mesiobuccal 2 and a second palatal canal was negotiated with the help of DG-16 endodontic explorer under endodontic loupes and was confirmed radiographically.

The working length was determined using an Apex locator and RVG with #15 K- files [Figure 1]b and [Figure 1]c. Intracanal medicament (calcium hydroxide) placed and closed dressing given with Zinc Oxide Eugenol. The patient was asked to return after a week.

At the second visit, the patient was asymptomatic. Initial instrumentation was done up to #25 K- file to full working length with copious Sodium hypochlorite irrigation (2.5%) and normal saline (0.9%). Final instrumentation was done using ProTaper Gold up to F2 with 17% Ethylenediaminetetraacetic Acid (EDTA).

Upon instrumentation, the MB1 and MB2 canals merged into one complete canal. Final irrigation was done with copious amount of saline.

Master cone radiograph was taken [Figure 1]d. The canals were dried with absorbent paper points. The canals were obturated using standardized 6% taper 25 size gutta-percha points and AH-Plus root canal sealer. The coronal portion of gutta-percha cones were sheared off using C-Blade Wireless Gutta Percha Point Cutter and sealed using a heated instrument [Figure 1]e. Entrance filling was given and a double seal was achieved using Type-2 GIC and Composite.


   Discussion Top


Poor oral hygiene in a localized area or fissure that is difficult to clean leads to decay, which is caused by the release of proteolytic enzymes by cariogenic bacteria. It leads to the destruction of the organic matrix by chelation. Chelation refers to a negatively charged chelating agent which releases positively charged calcium ions from enamel and dentin. This leads to detachment of organic crystals from one another thereby leading to cavitation. Exposure of blood vessels, lymphatic's and nerves to the decaying area leading to do dental infection/abscess.

Endodontic infection develops in root canals devoid of host defenses, as a consequence of pulp necrosis (as a sequel to caries, trauma, periodontal disease, or invasive operative procedures) or pulp removal in incomplete root canal treatment.

In advanced stages of the endodontic infectious process, bacterial organizations resembling biofilms can be observed adhered to the canal walls.[4] Depending on several bacterial and host-related factors, endodontic infections can lead to acute (symptomatic) or chronic (asymptomatic) apical periodontitis.

This article presents with a variation of the maxillary first molar which the dental practitioners do not frequently consider. The unusual anatomy of the maxillary first molar is difficult to diagnose because of its location. Superimposition of the anatomical structures on the radiographs may result in difficulty to diagnose a second palatal canal. Several radiographs from different angles may help to overcome the superimpositions and enable the clinician to identify this rare abnormality. One of the most important reasons for endodontic treatment failure is due to the presence of micro-organisms as a result of incomplete instrumentation, inadequate cleaning, insufficient obturation and missed canals.[5]

Cone beam computed tomography (CBCT) is a diagnostic imaging modality that can be used in endodontics for effective evaluation of unusual root canal morphology. It counteracts many disadvantages with respect to the traditional periapical radiograph as it creates a geometrically correct three-dimensional image. This can especially be useful in the maxillary molar area where periapical radiographs can sometimes be difficult to interpret.[6]

Thorough knowledge of the root canals and its variations is essential to reduce endodontic failures. Vertucci's proposed a classification for root canal morphology in the year 1984. Christie et al. proposed a classification system for four-rooted maxillary first molar variations depending on root separation level and divergence [Table 1] and [Figure 2].[7]
Table 1: Classification of four-rooted maxillary first molar (Christie et al., 1991)[7]

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Figure 2: Classification of four-rooted maxillary first molar

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The incidence of a maxillary first molar with two separate canals is less than 1%.[8]

Endodontic loupes aid in proper visualization and identification of root canal morphology and their variations. Although these variations are not common, it is important for the clinicians to be aware of the unusual root morphologies to avoid incomplete root canal treatment and thereby minimizing root canal treatment failures.


   Conclusion Top


This article demonstrates the successful management of a left maxillary first molar with five canals. Clinicians should have a thorough knowledge of unusual anatomical variations and canal configurations. It is also essential to look for anatomical variations even in a seemingly normal tooth. Proper clinical examination and visualization are essential for a successful endodontic treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Grossman LI. Rationale of endodontic treatment. Dent Clin North Am 1967:483-90.  Back to cited text no. 1
    
2.
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. 2
    
3.
Zheng QH, Wang Y, Zhou XD, Wang Q, Zheng GN, Huang DM. A cone-beam computed tomography study of maxillary first permanent molar root and canal morphology in a Chinese population. J Endod 2010;36:1480-4.  Back to cited text no. 3
    
4.
Molven O, Olsen I, Kerekes K. Scanning electron microscopy of bacteria in the apical part of root canals in permanent teeth with periapical lesions. Endod Dent Traumatol 1991;7:226-9.  Back to cited text no. 4
    
5.
Siqueira JF Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod 2008;34:1291-301.  Back to cited text no. 5
    
6.
Scarfe WC, Levin MD, Gane D, Farman AG. Use of cone beam computed tomography in endodontics. Int J Dent 2009;2009:634567.  Back to cited text no. 6
    
7.
Christie WH, Peikoff MD, Fogel HM. Maxillary molars with two palatal roots: A retrospective clinical study. J Endod 1991;17:80-4.  Back to cited text no. 7
    
8.
Thews ME, Kemp WB, Jones CR. Aberrations in palatal root and root canal morphology of two maxillary first molars. J Endod 1979;5:94-96.  Back to cited text no. 8
    

Top
Correspondence Address:
Dr. A Sriganesh
Department of Endodontics and Conservative Dentistry, Balaji Dental and Craniofacial Hospital, 30, Kavignar Bharathidasan Road, Teynampet, Chennai - 600 018, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_854_18

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