Jacobs Journal of Dentistry and Research Case Report Endodontic Management of a Permanent Mandibular First with Three Mesial Root Canals: Two Case Reports

Reza Sayyad Soufdoost1* and Ali Jamali Ghomi2 1Department of Endodontics, Dentistry Research Institute, School of Dentistry, Shahed University, Tehran, Iran 2Department of Prosthodontics, Faculty of Dentistry, Shahed University, Tehran, Iran *Corresponding author: Reza Sayyad Soufdoost, Department of Endodontics, Dentistry Research Institute, School of Dentistry, 26 Firouz dehghan Alley, Flistin st, Tehran, Iran; Mobile: +989123091861; Email: rezasoof@yahoo. com

Received Date: 05-02-2019 Accepted Date: 05-07-2019 Published Date: 05-21-2019 Copyright: © 2019 Reza Sayyad Soufdoost

Abstract An additional canal is one of the great number variations occurred in system. A comprehensive knowledge of the root canal anatomy is the mandatory factor which leads to successful endodontic treatment. In the case of mandibular - first molar with the possible occurrence of a fifth canal, precise clinical evaluation including multiple angulated radio graphs, through examination of chamber floor, CBCT and other adjunctive aids can help clinicians to overcome the failure treated endodontically. of endodontic treatment. This article describes two cases of mandibular first molar with three canals in mesial root which Keywords

Abbreviations:: Additional canal; Endodontic treatment; five root canals; Mandibular first molar; Middle mesial canal Introduction MM: Middle Mesial; CBCT: Cone Beam Computed Tomography; MB: Mesio-Buccal; ML: Mesio-Lingual.

Number and configuration of roots have been a constant challenge in over the years [1]. Many endodontic treatments were failed due to lack of knowledge of roots anatomy and complexity [2]. Generally, mandibular first molar is described as a - with two roots including two canals in mesial root and one or two in distal root [3]. Complete trust in pre-estimated number of root canals can lead clinicians to incomplete and failed endodontic treatment. The incidence of a first mandib ular molarCitation: with Soufdoost five RS roots and Ali has JG. Endodontic been reported Management between of a Permanent 1% to Mandibular 15% [4]. First During Molar with the Three development Mesial Root Canals: of the Two roots, Case Reports. secondary Jacobs J Dentistry Res 2019; 5(2): 043. . 2 apposition compresses the connective tissue result - partment of Shahed Dental School with chief complaint in forming a vertical wall which is known as an extra or ad of continuous pain in lower left back teeth. The patient’s - ditional canal [5]. Middle Mesial (MM) canal in mandibular medical history was noncontributory. Patient had history first molars was classified by Pomerans et al as confluent of pain more than 2 days. Clinical and radiographic exam - when the canal began from a separate orifice but met the inations were performed. Intraoral examination revealed a mesio-buccal (MB) or mesio-lingual (ML) canal, indepen deep distal caries on left mandibular first molar (tooth#19). the instrument could pass freely between the mesio-buc- dent if it drew from orifice to apex separately and fin, when The tooth was tender to vertical percussion. A vitality test affected tooth revealed an unusual anatomy of mesial root of the tooth was positive. Radiographic examination of the the groove between mesi-obuccal and mesio-ligual canals. with minimally two canals in mesial root and two canals in cal or mesio-lingual canals. MM canal is always located in distal root as well as a big disto-occlusal lesion with an in- - volvement of chamber (Figure 1). Around the apical Hence, this area should be checked for middle mesial canal - [6]. Also, advance diagnostic tools such as cone beam com and dental operating microscope have played an important - puted tomography (CBCT), micro-computed tomography portion of mesial root PDL was widened. According to sub role to increase the knowledge of clinicians about the root jective and objective findings, a diagnosis of irreversible pul pitis was made. After Inferior alveolar nerve block injection diagnosis and successful management of two cases of man- anatomy [7]. In the present clinical report, we described the of Lidocaine with 1:100,000 epinephrine (Daroupakhsh, - Tehran, Iran), access cavity was prepared on the occlusal dibular first molar with complex morphological variation surface and all carries was removed. The tooth was isolat treated endodontically. - and potential of an extra canal in mesial root which were ed by rubber dam. At the pulp chamber floor, disto-buccal, es were observed. Initial negotiation was carried out by K Case reports disto-lingual, mesio-buccal and mesio-lingual canal orific Case 1 file#15. After initial filing and several cleansing with 2.5% - sodium hypochlorite, still bleeding was detectable from the A 25-year-old man presented to endodontic de point between mesio-buccal and mesio-lingual orifices.

Figure 1:

Periapical (A) and Bitewing (B) radiographs of a patient with mandibular left first molar involvement (tooth#19). 3

- Operating microscope (OPMI pico, Zeiss, Jena, ran, Iran). All canals were obturated by lateral condensation along other canals (Figure 2) - Germany) was used to find MM canal and it was prepared technique with gutta-percha (Dentsply Maillefer, Switzer . An electronic apex locator land) and root canal sealer (AH-26, DeTrey, Dentsply, Kon (Raypex5, VDW GmbH and Munich, Germany) was used to stanz, Germany). in root canals and then initial radiograph was taken with determine the initial working lengths. Five Initial files set straight angulation (Figure 3A)

. In first radiograph, files in second radiograph with the mesial angulation was request- ML and MM canals were superimposed on each other. So, a distinctly (Figure 3B) ed. In the second radiograph, all five canals were separated met each other near the middle third of the mesio-lingual . Files in MM canal and ML canal were

- root. The instrumentation of distal and mesial root canals was performed up to 35#k files (Mani, Tochigi, Japan). Be sides, a rotary system (Protaper, Dentsplysirona, newyork - city, USA) was used to complete the canal preparation. In rite was used as an irrigant to digest pulp tissue. In addi- order to remove pulp completely, 2.5% sodium hypochlo Figure 2: several times during procedure to remove smear layer. All tion, 17% EDTA (Dentonics, North Carolina, USA) was used three mesial root canals. - Clinical photograph of access opening showing canals were dried by sterile paper points (Aria Dent, Teh

Figure 3

: Working length radiographs with straight angulation (A) and mesial angulation (B). 4

Figure 4:

Final periapical radiograph of tooth#19 with five root canals (A) and periapical radiograph of tooth #19 after 6 months of follow-up (B). - - The final radiograph confirmed an ideal condensed surface and all carries was removed. The tooth was isolat tal root canals (Figure 4A) root filling material and working length in mesial and dis ed by rubber dam. At the pulp chamber floor, disto-buccal, . In the same visit, the access disto-lingual, mesio-buccal and mesio-lingual canal orifices - cavity was restored with Amalgam. At 6 months follow-up were observed. The instrumentation of distal and mesial visit, the patient was asymptomatic clinically and the ra root canals was performed up to 35#k files (Mani, Tochigi, periradicular tissue (Figure 4B). diographic examination showed healthy periodontium and Japan). Case 2 -

A 27-year-old man presented to endodontic de partment of Shahed Dental School with chief complaint of continuous pain in lower right back teeth. The patient’s medical history was normal. Patient had history of pain for 2 months and tissue around the tooth#30 was swollen. Intraoral examination revealed a deep distal caries on left vertical percussion. A vitality test of the tooth was negative. mandibular first molar (tooth#30). The tooth was tender to and bite-wing of the affected tooth revealed minimally two Radiographic examination including panoramic, periapical canals in mesial root and a big disto-occlusal lesion with an involvement of pulp chamber (Figure 5A, 5B, 5C). diagnosis of pulp necrosis with chronic apical periodonti- According to subjective and objective findings, a Figure 5: tis was made. After Inferior alveolar nerve block injection - Panoramic (A), Periapical (B) and Bitewing (C) of Lidocaine with 1:100,000 epinephrine (Daroupakhsh, radiographs of a patient with mandibular right first mo Tehran, Iran), access cavity was prepared on the occlusal lar(tooth#30). 5

- Besides, a rotary system (Protaper, Dentsplysirona, ta-percha (Dentsply Maillefer, Switzerland) and root canal newyork city, USA) was used to complete the canal prepa sealer (AH-26, DeTrey, Dentsply, Konstanz, Germany). The material and working length in mesial and distal root ca- ration. 2.5% sodium hypochlorite was used as an irrigant final radiograph confirmed an ideal condensed root filling nals (Figure 7A) to digest pulp tissue and control the bleeding, but due to - - continuous bleeding calcium hydroxide was placed in all . In the same visit, the access cavity was - tient was asymptomatic clinically and the radiographically canals as an intracanal medication. Cavit (3M, Seefeld, Ger restored with Amalgam. At 6 months follow-up visit, the pa (Figure 7B). many) was placed in access cavity in order to make a cor onal seal. In second visit, after injection and isolating the tooth #30, all temporary filling and calcium hydroxide was - removed. The floor of pulp chamber carefully was examined with endodontic explorer and MM orifice was found be tween mesio-buccal and mesio-lingual orifices with a little bit shifting toward mesio-bucall orifice. An electronic apex used to determine the initial working lengths. Five Initial locator (Raypex5, VDW GmbH and Munich, Germany) was files set in root canals and then initial radiograph was taken. canals (Figure 6) The initial radiograph verified the working length of all root . According to initial radiograph files in MM canal and MB canal were met each other near the apical third of the mesio-buccal root. Preparation of all five canals - was completed. Cleansing of canals was done regularly with 2.5% sodium hypochlorite. In addition, 17% EDTA (Den procedure to remove smear layer. All canals were dried tonics, North Carolina, USA) was used several times during Figure 6: - by obturation by lateral condensation technique with gut- by sterile paper points (Aria Dent, Tehran, Iran) followed lation. Working length radiographs with straight angu

Figure 7:

Final periapical radiograph of tooth#30 with five root canals (A) and periapical radiograph of tooth #30 after 6 months of follow-up (B). 6

Discussion diographs display two dimensional images from three di- Anatomical variation of the root canal system is using dental operating microscope could help clinicians to considered as one of the most important reasons of end- mensional objects [13]. According to Karapinar et al [14], - odontic treatments results in inadequate treatment and in- find accessory and additional canals by improving dentist odontic treatment failure. Missing a root canal during end visualization as we used dental operating microscope to recommended to achieve arbitrary viewpoints of root ca- of the root canal system of necrotic or infected pulp tissues find MM canal. More recently, three dimensional models are complete elimination of microorganisms [8]. Debridement - - nals. If periapical radiographs are not useful alone to find is a key factor for a successful endodontic treatment [9]. Af - nals system might be re-infected due to remained microor- third mesial canal (MM) in first mandibular molar, using ter a while, teeth with incomplete debridement of root ca dental operating microscope, cone beam computed tomog gain more information about the root morphology and ca- considered as an important land mark for presence of an raphy (CBCT) and other adjunctive tools could be used to ganisms in the root canal space. Developmental grooves are nal distribution. - gle to rectangular in both mesial and distal roots should be Conclusion extra canal. Thus, modification of access cavity from trian

- considered to facilitate the finding of the extra canal orifices This article describes two cases of mandibular first molar [10]. In addition, an endodontic explorer is a helpful adjunc - with five canals which treated endodontically. Moreover, tive tool which helps dentists to find the additional canals, - tinal bridge should be removed by small bur or ultrasonic using dental operating microscope, precise inspection of however, in order to expose the developmental groove, den ed radiographs enhances the ability of clinicians to identify chamber floor with endodontic explorer and multi angulat is the inevitable part to identify unusual canal morpholo- tip. Precise radiographic examination and interpretation theAcknowledgement MM canal. radiograph with a good quality and an appropriate angu- No gy associated with mandibular first molar [11]. A preapical lation could render primary comprehensive information about root anatomy and morphology which is important Conflict of interest for future treatment plan and achieving long-term success

AuthorsReferences have no conflicts of interest to disclose radiograph was employed during endodontic procedure of the [12]. Traditionally, a preapical whether to make diagnosis or to determine working length. 1. Anand P, Mahalaxmi S. with five In the current cases, radiographs in mesial angulation were canals. SRM Journal of Research in Dental Science 2016; used to determine the unusual root canal configurations as 7(1): 45-47. it has been recommended in previous studies. Also, these - 2. Snigdha S, Vanita G and Ourvind JS. Mandibular First cases supported previous reports of existence of third canal Molar with 5 Canals- A Rare Case Report. Journal of . in mesial root of mandibular first molar. Reyhani et al, re Universal College of Medical Sciences 2015; 3(12): 46- ported fifth canal in first mandibular molar with a confluent 49 MM canal which met MB root canal while we stated 2 cases considerations of the middle mesial canal of mandibu- that in case # 1, MM canal met ML root canal and in case#2, 3. Pomeranz H, Eidelman D and Goldberg M. Treatment MM canal met MB root canal. lar first and second molars. J Endod 1981; 7(12): 565- In some clinical situations, the use of a conventional morphologic structure of root canals since conventional ra- 568. - intraoral radiograph alone is not enough to find the variable 4. Baugh D and Wallace J. Middle mesial canal of the man 7 -

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