Variation of Maxillary First Premolar with Three Root Canals

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http://dx.doi.org/10.5272/jimab.2014203.584 Journal of IMAB Journal of IMAB - Annual Proceeding (Scientific Papers) 2014, vol. 20, issue 3 ISSN: 1312-773X http://www.journal-imab-bg.org VARIATION OF MAXILLARY FIRST PREMOLAR WITH THREE ROOT CANALS

Janet Kirilova1, Snezhanka Topalova-Pirinska1, Dimiter Kirov2 1) Department of Conservative Dentistry 2) Department of Prosthetic Dentistry Faculty of Dental Medicine,Medical University Sofia, Bulgaria

ABSTRACT treatment of maxillary first premolar with three root canals Background: Successful endodontic treatment re- – different types. quires effective biomechanical preparation of the root canals and three-dimensional obturation of the root canal system. MATERIAL AND METHODS This can be achieved only by knowing and identifying the Maxillary first premolar with three roots and three variations in the root canal system of the endodontically independent root canals and independent orifices treated teeth. According to Vertucci et al. a maxillary first premo- The Aim: The aim of this article is to present cases lar with three separate roots can be observed in 4 % of the of endodontic treatment of maxillary first premolar with three cases. When the root canals are three and the orifices are in- root canals – different types. dependent at the level under the pulp chamber, the treatment Material and Methods: Five clinical cases of success- does not present a problem. Two of the root canals are al- ful endodontic treatment of patients with maxillary first ways vestibular. A close view of the pulp chamber and the premolar and three root canals are described. finding of two vestibular orifices is a prerequisite for success- Result and Discussion: It is noted that good endodon- ful treatment (Figure 1). tic practice requires good knowledge of dental anatomy and possible variations, accurate X-ray images, as well as use of Fig. 1. Pulp chamber of the maxillary first premolar magnifying equipment. with three separate orifices: a –intraoral; b– with magnifi- Conclusion: Knowledge of dental anatomy is funda- cation. mental for good endodontic practice.

Key words: Root canal anatomy, three roots, three canals, maxillary first premolar,

Successful endodontic treatment requires effective biomechanical preparation of the root canals and three-dimensional obturation of the root canal system. This can be achieved only by knowing and identifying the variations in the root canal system of the endodontically treated teeth. As one of the main reasons for unsuccessful endodontic treatment is identified the failure to find additional root canals due to anatomical variations [1, 2, 3]. The maxillary first premolars are described as having two roots and two root canals (56%) and one root and two root canals (40%) [4]. Although rarely, these teeth can also have three roots and three root canals and are identified in the literature as small molars, as the tooth structure and the positioning of the roots in these cases resemble those in mo- lar teeth [4, 5]. The term “ridiculous” is also used. Maxillary first premolars were first studied by Vertucci et al. in 1979 [4]. According to this study, 5% of 400 maxillary first premolars have three canals: 0.5 % of them are teeth with three canals in a single root, 0.5 % have three canals in two roots and 4 % have three canals in three roots. Carns et al. discovered three separate canals in 6 % of the upper fourth teeth. [6] The visualization of three root canals of the maxillary first molars with preoperative radiography is not always possible. This makes the cases requiring endodontic treatment of maxillary first premolars with three canals particularly difficult for successful treatment. The aim of this article is to present cases of endodontic

584 http://www.journal-imab-bg.org / J of IMAB. 2014, vol. 20, issue 3/ Clinical Case 1: The right maxillary first premolar with a large radicular carious lesion and diagnosis – chronic granulomatous diffuse periodontitis has three roots with three canals. Two of the root canals are buccal (mediobuccal and distobuccal) and one canal is palatal. The tooth’s buccal radicular de- fect made it possible to demonstrate the buccal root canals by placing markers in them (Figure 2a and 2b).

Fig. 2. Buccal canals of maxillary first premolar: a – definition of working lengths; b – drying.

Passages are created in the canals by means of hand instruments. They are prepared using the crown-down method and mechanical nickel-titanium canal instruments. After drug treatment, ozone treatment and intracanal medi- cation with calcium-hydroxide paste, they are filled with Thermafil obturators and sealer.

Clinical Case 2: Following irreversible pulpitis of the left maxillary first premolar with three root canals, endodontic treatment was performed (Figure 4). Under a microscope were seen two vestibular orifices and a palatal orifice (Figure 1 a, b).

Fig. 4. Left maxillary first premolar with three root canals: a-pulp chamber; b- X-ray after filling.

The mesiobuccal root has a very curved root canal with an angle of 50º, as the curve starts from the middle and continues up to the tip of the root (Fig. 3 a, b).

Fig. 3. Maxillary first premolar with three canals: a – X-ray before treatment; b – X-ray after obturation of canals.

/ J of IMAB. 2014, vol. 20, issue 3/ http://www.journal-imab-bg.org 585 The root canals are prepared using the step-back Right maxillary first premolar with diagnosis: Peri- technique and are obturated through the cold lateral con- odontitis chronica granulomatosa exacerbatà sum fistulae. densation method. The patient comes for treatment following a trepanation and subsiding of the swelling. Besides periapical lesions PAI 5 Maxillary first premolar with three roots, three [7], the original X-ray shows tooth 14 with root anatomy root canals and a separate orifice and a common orifice. that does not suggest the presence of three separate root ca- A possible variation of maxillary first premolar with nals. The X-ray could possibly lead to assuming apical sepa- three roots and three independent root canals is the pres- ration of root canals from the floor of the pulp chamber and ence of a common buccal orifice, which subsequently splits unusual root morphology (Figure 6a). into two separate canals (see Figure 5 a, b). The clinical investigation performed under a microscope showed that the vestibular orifice is significantly Fig. 5. Maxillary first premolar with three canals: a– larger and almost immediately after the common beginning pulp chamber; b- pulp chamber with magnification. two separate orifices are formed (Figure 5b). The canal instruments placed in the open vestibular root canals are di- rected medially and distally (Figure 6b). The control X-ray, through gutta-percha points, shows two roots of the tooth – one vestibular and one palatal (Figure 6c). Similarly to the initial X-ray, the one with the points also leads to the conclusion that the centering of the x-ray is not in relation to tooth 14, but more probably in relation to 15 or even 16. Only after changing the radiography laboratory for the pur- pose of controlling the filling, three independent roots with two vestibular and one palatal root canal (Figure 6c) are dis- played. Both vestibular root canals have a very narrow lu- men (K file 008), which combined with their large length of 22 mm and the great curvature of the curve (45º) of the mesio-vestibular root makes this endodontic treatment one of the most difficult clinical cases (Figure 6c).

Fig. 6. Maxillary first premolar with three canals: a – pre-operative X-ray; b – definition of working lengths; c – X-ray after obturation.

Passage is made in the canals by means of hand Maxillary first premolar with two roots and three tools; after that the canals are shaped with mechanical root canals nickel-titan canal instruments using the crown-down tech- According to Vertucci in 0.5 % of the cases, the max- nique. After antibacterial treatment of the endodontic space illary first premolar has two roots and three root canals. (irrigation with sodium hypochlorite and chelator, ozone treatment and intracanal application of calcium hydroxide Clinical Case 1 paste), the three main canals are filled with Termafil Irreversible pulpitis is the diagnosis of a 21-year-old (Maillefer) obturators and Seal Apex (Kerr) sealer [5, 8]. patient with spontaneous pain in the left maxillary first premolar and a carious lesion covering the medial surface and part of the central fissure of the tooth. The X-ray inspection shows two roots, but due to the overlapping of

586 http://www.journal-imab-bg.org / J of IMAB. 2014, vol. 20, issue 3/ shades, their apical configuration is not clear enough and Fig. 8. Maxillary first premolar with one merged root the presence of a third root canal has not been assumed. and three root canals a – preoperative X-ray; b – Treatment follows the vital extirpation method. Af- preoperative X-ray; c – definition of working lengths; d – ter the excochleation of the contents of the pulp chamber X-ray after obturation. two orifices are discovered – a vestibular one and a palatal one. The drilling of the canals reveals that the vestibular orifice is an entrance to two independent root canals with respective lengths – mediobuccal 19.5 mm and distobuccal 19 mm with the buccal cusp as a reference point. The separa- tion of the two independent canals is about halfway of the root length or at reference point 12-13 mm. The palatal canal is 20 mm long with the palatal cusp as a reference point. The preparation of the root canals is performed by step-back technique, while the obturation is performed using the cold lateral condensation method, with master gutta-percha points for mediobuccal 02.35, for the distobuccal 02.35 and for the palatal canal 02:30 and sealer of VDW, Germany. Radiography of the filled canals is performed with a slight displacement of the X-rays from the distal side (Figure 7).

Fig. 7. Maxillary first premolar with two roots and three root canals after obturation of canals

From the respective center-point, the control X-ray after filling shows three canals, but does not take into ac- count their autonomy. The filling is performed through Termafil (Maillefer) obturators and Seal Apex (Kerr) sealer The treatment in this case is particularly difficult, [5, 7]. because one canal in the vestibular root leaves the pulp chamber and about 7 mm from the apex separates into two RESULTS AND DISCUSSION canals, which end with separate foramen – type V accord- One of the major challenges in endodontic therapy ing to Vertucci. As a favorable circumstance, the canals are is to treat teeth with variable anatomic configurations. not very curved, but nevertheless are difficult to be The careful examination of pre-operative radiographs instrumentally processed and filled. The preparation of the root canals is performed by is essential. In case of a doubt regarding possible variations step-back technique, while the obturation is performed us- in dental anatomy, two diagnostic X-ray images are recom- ing the cold lateral condensation method. mended [1, 2, 3, 5]. If suddenly the X-ray image of a wide and well-shaped root canal narrows or disappears, it is as- Clinical Case 2 sumed that there is a special root anatomy and probably a Tooth 24, diagnosed with irreversible pulpitis, has one split of the root canal [5, 8, 9]. merged root and three root canals. The preoperative X-ray Of primary importance in such cases is the clinical shows root canals that are not clearly defined (Figure 8a). study of the root canals with a surgical microscope or a This necessitates the use of an endodontic microscope when magnifying glass. The careful inspection of the shape of the shaping the pulp chamber. The microscope revealed three root pulp chamber might be a signal for a greater number of root canal orifices, but of special interest is their positioning in a canals [3, 5, 10, 11]. The buccal pulp horn is larger than straight line (Figure 8b). The X-ray picture performed with the palatal pulp horn. The mean distance between the most gutta-percha points (Figure 8c) shows vestibular root canals cervical region of the pulp chamber roof and the canal bi- that cross each other but remain independent. furcation and trifurcation is 3.13 and 5.08 mm [12].

/ J of IMAB. 2014, vol. 20, issue 3/ http://www.journal-imab-bg.org 587 Establishing the presence of three root canals in the dle part of the root in the X-ray is equal to or greater than presented endodontic treatments of maxillary first premolars the width of the tooth’s crown, it is possible that we have is a prerequisite for successful endodontic practice. three roots in the maxillary first premolar [14]. The study of the anatomy of the maxillary first premolar reveals significant anatomical variations. The es- CONCLUSION tablishment of three canals in maxillary first premolars Knowledge of dental anatomy is fundamental for ranges from 1.2 % to 6 % according to various authors [2, good endododntic practice. Although the frequency of max- 6, 10. Definitely much rarely three canals of maxillary first illary second premolars with three root canals is rare, each premolar can be observed in Asian population [3, 10,13, ]. case should be investigated carefully and radiographically, An interesting anatomical feature has been reported to detect the anatomical anatomy. by Sieraski et al. When the mesio-distal width of the mid-

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Please cite this article as: Kirilova J, Topalova-Pirinska S, Kirov D. Variation of Maxillary First Premolar with three root canals. J of IMAB. 2014 Jul-Sep;20(3):584-588. DOI: http://dx.doi.org/10.5272/jimab.2014203.584

Received: 07/07/2014; Published online: 19/09/2014

Address for correspondence: Dr Janet Kirilova, PhD Department of Conservative Dentistry, Faculty of Dental Medicine, 1, St. George Sofiiski Str., 1431 Sofia, Bulgaria E-mail: [email protected]

588 http://www.journal-imab-bg.org / J of IMAB. 2014, vol. 20, issue 3/