Case Report treatment of a maxillary second with two palatal roots: A case report Gingu Koshy George, Anju Mary Varghese1, Aravindan Devadathan1 Department of Conservative Dentistry and Endodontics, 1Department of Orthodontics, Pushpagiri College of Dental Sciences, Thiruvalla, Kerala, India

Abstract Anatomical variations in root canal morphology are an enigma and it is this variability, which is often a complicating factor in a successful root canal treatment. To achieve success in endodontic therapy it is imperative that all the canals are located, cleaned and shaped and obturated three dimensionally. Maxillary first premolar having three separate roots has an incidence of 0.5-6%. Even rarer are reported clinical case reports of maxillary second premolar with three separate roots and three canals. This case report describes the endodontic management of maxillary second premolar with two palatal roots and one buccal root having three root canals Keywords: Maxillary second premolar; root canal treatment; three canaled

INTRODUCTION premolar adjacent to it had a proximal carious lesion associated with it. The second premolar was tender Anatomical variations in root canal morphology are to percussion. An intra oral periapical radiograph was an enigma. The outcomes endodontic procedures are advised and it showed distoproximal radiolucency of highly influenced by variable anatomic structures and, approximating the space of the maxillary therefore, the clinicians ought to be aware of complex right second premolar (Image 1). Multiple intra oral peri- root canal structures and cross-sectional dimensions.[1] apical radiographs were taken using Clark’s tube shift Maxillary first premolar having three separate roots has technique as the premolar showed multiple roots. Pulp an incidence of 0.5-6%.[2-7] The maxillary second vitality test with electric pulp tester (Digitest, Parkell show an even lesser incidence of 0.3 to 2% in laboratory Products, NY, USA) showed a delayed response for the studies.[8,9] Even rarer are reported clinical cases of maxillary second premolar. A diagnosis of irreversible maxillary second premolar with three separate roots pulpitis was made and endodontic treatment was and three canals.[10,11] Three rooted maxillary premolars initiated. look anatomically similar to the molars are sometimes called small molars or radicolous[12,13] and usually have a Access opening was done under local anesthesia mesiobuccal, a distobuccal and a palatal canal. The root (2% Lignocaine with 1:80,000 Adrenaline, Lignox, Indoco canal morphology of the maxillary second premolar in Remedies Ltd, India) after rubber dam isolation. The unusual Indians shows a higher incidence of type II configuration anatomy made it difficult to precisely discern, whether the (33.6%).[1] In this case report, we would like to describe the roots were located on the buccal or palatal aspect. The endodontic management of maxillary second premolar access cavity was modified as described by Balleri et al.,[14] with two palatal roots and one buccal root having with a tooth preparation at the bucco-proximo angle from independent root canals. the entrance of the buccal canal to the cavosurface angle resulting in a cavity with a T-shaped outline. But only one CASE REPORT buccal (B) [Image 2] and one palatal canal (P1) [Image 2] orifices could be located. A modification was again made A 32-year-old female reported to department with pain and the preparation was extended in the palato proximal in her upper right posterior region since one month. directions and the orifice of the third root canal (P2) On clinical examination an old amalgam restoration [Image 2] was located mesiopalatally in the palatal aspect. was seen on the maxillary right and the second Access this article online Address for correspondence: Quick Response Code: Dr. Gingu Koshy George, Department of Conservative Dentistry Website: and Endodontics, Pushpagiri College of Dental Sciences, www.jcd.org.in Thiruvalla - 686 548, Kerala, India. E-mail: [email protected]

Date of submission : 04.11.2013 DOI: Review completed : 03.12.2013 10.4103/0972-0707.131807 Date of acceptance : 25.02.2014

290 Journal of Conservative Dentistry | May-Jun 2014 | Vol 17 | Issue 3 George, et al.: RCT of maxillary premolar with two palatal roots

Figure 1: Composite image showing pre operative IOPA, access preparation, working length IOPA, master cone IOPA and obturation IOPA of a maxillary 3 rooted second premolar

Working length was determined with apex locator and Accurate preoperative radiographs (straight and angled) are confirmed with intra oral peri-apical radiograph [Image 3]. essential to reveal the number of roots and canals that exist The three canals were initially enlarged with hand files until in a tooth.[15,16,19] But radiographic analysis themselves are the 15 K file (Mani Inc. Tochigi, Japan) freely glided through inadequate in obtaining a suitable abstraction of root and the canal, following which the canals were enlarged to size pulp canal system as evident in this case necessitating the F2 ProTaper rotary files ((Dentsply Maillefer, Ballaigues, use of more advanced methods like CBCT as a diagnostic Switzerland) sequentially. During canal preparation Glyde tool to determine the canal morphology. (Dentsply Malliefer, Ballaigues, Switzerland) was used as a lubricant and the root canals were copiously irrigated with A general guideline for the identification of a three-rooted 3% sodium hypochlorite (Prime Dental Product, Mumbai, maxillary premolar on preoperative radiograph is that India) and 0.9% normal saline (Baxter India Pvt Ltd., if the mesial-distal width of the mid-root image appears Alathur, India) after the use of each instrument. The root equal to or greater than the mesial-distal width of the [18] canals were properly dried with absorbent paper points crown image, then the tooth most likely has three canals. and obturated with gutta-percha (Elements Obturation This guideline may act as a good visual clue but is not necessarily absolute. system, Sybron Endo, USA) and resin based sealer (AH plus, Dentsply De Trey, Konstanz, Germany) [Images 4 and 5]. The access cavity for maxillary second premolars is usually The access cavity was then sealed with IRM (DENTSPLY oval[20] in the bucco-palatal direction. In three rooted Caulk, Milford, USA). The patient was recalled after seven maxillary premolar, the buccal orifices are usually close to days for the permanent restoration and then referred to each other and are hard to locate. Balleri et al., suggested the Department of Prosthetic Dentistry for a full coverage a T-shaped access outline for three rooted maxillary first crown Figure 1 contains the sub images 1-5. premolars.[14] This modification allows good access to the two buccal canals. But in this case a further modification DISCUSSION had to be done as the canals were on the palatal aspect of the tooth and not buccally as expected from the Extra roots present an additional challenge, which necessitates radiographic interpretation necessitating an extension of modifications from the initial assessment stage to the the access preparation palato proximally to reveal the third design of the access preparation, cleaning and shaping and orifice mesiopalatally. obturation of the tooth. So awareness of abnormal variation in the internal anatomy of the tooth is essential for success In today’s endodontic practice aberrant anatomy has become of an endodontically treated tooth. Velmurugan et al.,[15] have more common than before and, therefore, clinicians should reported that out of 220 maxillary second premolar teeth that be constantly on the lookout for variations in anatomy as were endodontically treated from Indian population, only the successful outcome of any case that depends on the three of these had three roots and three canals. complete debridement and disinfection of all canals.

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REFERENCES 12. Maibaum WW. Endodontic treatment of a “radiculous” maxillary premolar: A case report. Gen Dent 1989;37:340-1. 13. Goon WW. The “radiculous” maxillary premolar: Recognition diagnosis, 1. Jayasimha Raj U, Mylswamy S. Root canal morphology of maxillary and case report of surgical intervention. Northwest Dent 1993;72:31-3. second premolars in an Indian population. J Conserv Dent 14. Balleri P, Gesi A, Ferrari M. Primer premolar superior com tres raices. 2010;13:148-51. Endod Pract 1997;3:13-5. th 2. Cohen S, Burns RC. Pathways of the Pulp. 5 ed. St. Louis: Mosby; 15. Velmurugan N, Parameswaran A, Kandaswamy D, Smitha A, 2002. p. 173-228. Vijayalakshmi D, Sowmya N. Maxillary second premolar with three roots th 3. Weine FS. Initiating endodontic treatment. Endodontic Therapy. 6 ed. and three separate root canals-case reports. Aust Endod J 2005;31:73-5. St Louis: Mosby; 2004. p. 104-63. 16. Soares JA, Leonardo RT. Root canal treatment of three-rooted maxillary 4. Bellizzi R, Hartwell G. Radiographic evaluation of root canal anatomy first and second premolars — a case report. Int Endod J 2003;36:705-10. of endodontically treated maxillary premolars. J Endod in vivo 17. Poorni S, Karumaran CS, Indira R. Mandibular first premolar with two 1985;11:37-9. roots and three canals. Aust Endod J 2010;36:32-4. 5. Carns EJ, Skidmore AE. Configurations and deviations of root canals of 18. Sieraski SM, Taylor GN, Kohn RA. Identification and endodontic management maxillary first premolars. Oral Surg Oral Med Oral Pathol 1973;36:880-6. of three-canalled maxillary premolars. J Endod 1989; 15:29-32. 6. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic 19. Theruvil R, Ganesh C, George AC. Endodontic management of a maxillary investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol first and second premolar with three canals J Conserv Dent 2014;17:88-91. 1972;33:101-10. 20. Krapež J, Fidler A. Location and dimensions of access cavity in permanent 7. Vertucci FJ, Gegauff A. Root canal morphology of the maxillary first , canines, and premolars. J Conserv Dent 2013;16:404-7. premolar. J Am Dent Assoc 1979;99:194-8. 8. Vertucci F, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolar. Oral Surg Oral Med Oral Pathol 1974;38:456-64. How to cite this article: George GK, Varghese AM, Devadathan A. 9. Pecora JD, Sousa Neto MD, Saquy PC, Woelfel JB. In vitro study of root Root canal treatment of a maxillary second premolar with two canal anatomy of maxillary second premolars. Braz Dent J 1993;3,81-5. 10. Ferreira CM, de Moraes IG, Bernardineli N. Three-rooted maxillary palatal roots: A case report. J Conserv Dent 2014;17:290-2. second premolar. J Endod 2000;26:105-6. 11. Low D. Unusual maxillary second premolar morphology: A case report. Source of Support: Nil, Conflict of Interest: None declared. Quintessence Int 2001;32:626-8.

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