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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 24  |  Issue : 1  |  Page : 105-109
Endodontic management of a maxillary second molar with three roots and seven canals using cone-beam computed tomography


1 Department of Conservative Dentistry and Endodontics, RUHS College of Dental Sciences, Rajasthan University of Health Sciences, Jaipur, India
2 Department of Endodontology, Oman Dental College, Muscat, Wattayah, Sultanate of Oman
3 Department of Oral Medicine and Radiology, RUHS College of Dental Sciences, Rajasthan University of Health Sciences, Jaipur, India
4 Department of Dentistry, New Medical College and Hospital, Kota, Rajasthan, India

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Date of Submission26-Dec-2020
Date of Decision29-Dec-2020
Date of Acceptance15-Feb-2021
Date of Web Publication05-Jul-2021
 

   Abstract 


The present case highlights the endodontic management of a maxillary second molar with three roots and seven canals. Root canal treatment was performed for the maxillary second molar diagnosed with symptomatic irreversible pulpitis. During the procedure under magnification, extra canals were detected in the mesiobuccal root. Cone-beam computed tomography (CBCT) evaluation confirmed four canals in the mesiobuccal root with Vertucci's Type XXI (4-1) pattern. The distobuccal root exhibited two canals with Vertucci's Type III (1-2-1) configuration. The palatal canal was single and large. A 4 year follow-up revealed satisfactory clinical and radiographic findings. Magnification and CBCT allow us to explore possible anatomic variations with insights to tackle such situations clinically.

Keywords: Cone beam computed tomography, magnification, maxillary second molar, seven canal system

How to cite this article:
Likhyani LK, Shivagange V, Sobti G, Gandhi M. Endodontic management of a maxillary second molar with three roots and seven canals using cone-beam computed tomography. J Conserv Dent 2021;24:105-9

How to cite this URL:
Likhyani LK, Shivagange V, Sobti G, Gandhi M. Endodontic management of a maxillary second molar with three roots and seven canals using cone-beam computed tomography. J Conserv Dent [serial online] 2021 [cited 2021 Aug 4];24:105-9. Available from: https://www.jcd.org.in/text.asp?2021/24/1/105/320685



   Introduction Top


Exploring and cleaning the intricate canal system is of utmost importance in endodontics. Maxillary molars often present with a wide variation in the number of roots and canals. Anatomic variations in maxillary first molars are extensively reported, with the number of canals ranging up to eight.[1] Endodontic literature supports a wide variety of anatomic variations in maxillary second molars too. The maxillary second molar usually has three roots and three canals. Case reports on maxillary second molars have shown the presence of up to a maximum of six canals.[2],[3],[4],[5] [Table 1] enlists the clinical publishments of maxillary second molars with >5 canals. This report is probably the first clinical case of a maxillary second molar with three roots and seven canals with a follow-up of 4 years. The combined use of magnification and cone-beam computed tomography (CBCT) is essential for diagnosing and managing maxillary molars with atypical canal configurations.
Table 1: Summary of the case reports of maxillary second molar with five or more than five canals

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   Case Report Top


A 34-year-old Indian male patient reported with a chief complaint of sensitivity to hot and cold and pain while biting concerning the upper right side last two teeth for 2 weeks. The patient gave a history of pain that persisted for about a few minutes even after removing the stimulus, and sometimes, it occurred spontaneously. The patient had good general health without any significant medical history. The patient gave an account of root canal treatment and crown placement in his upper right first molar tooth 2 years ago. On clinical examination, tooth 17 had mesial caries, and tooth 16 had a crown. There was no extraoral or intraoral swelling or sinus tract associated with the concerned teeth. The attached gingiva was normal in appearance and palpation. Both the teeth were nontender to percussion. Cold testing (Roeko Endo Frost, Coltene/Whaledent Inc., OH, USA) showed an immediate and prolonged response in tooth 17. Pre-operative periapical radiographs revealed caries almost approaching mesial pulp horns concerning tooth 16 and a typical periradicular architecture. Radiograph also revealed inadequately obturated tooth 16 and full coverage extra coronal restoration [Figure 1]A and [Figure 1]B. Tooth 17 was diagnosed with symptomatic irreversible pulpitis with normal periapical tissues. Tooth 16 was diagnosed with previously endodontically treated. We planned for a root canal treatment in tooth 17 and a nonsurgical retreatment for tooth 16. For the sake of convenience, we have limited the description to the treatment performed only on the maxillary second molar.
Figure 1: (A and B) Preoperative radiograph of tooth 17, 16. (C and F) Working length radiographs at different angulations. (D) Magnified view of the access showing three mesial canal orifices, the fourth one (*) only faintly visible. (E) Magnified view of the access opening after CBCT evaluation and shaping showing four mesial canal orifices. (G) Master Cone radiograph. (H and I) Post-obturation radiographs at different angulations. (J-L) Radiographs after one, two, and four years of follow up, respectively

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After taking informed consent, local anesthesia was administered using lidocaine hydrochloride 2% with adrenaline 1:80,000 (Lignospan Special; Septodont, Saint-Maur-Des-Fosse, France). Access opening was made under rubber dam isolation and magnification (OPMI Pico Carl Zeiss Meditec AG, Jena, Germany). Three mesial canals, one distobuccal (DB), and one palatal canal were detected on exploration. Coronal flaring was done (Hyflex 25/08) after negotiation with a no. 10 and 15 k file. A soft, sticky catch between the MB 3 and MB2 created doubt for the presence of the fourth mesial canal as well [Figure 1]D. The access was temporized, and a limited Field of View (FOV 5 cm × 5 cm) CBCT scan (Carestream CS9300 imaging system; Carestream Health, Inc., New York) was advised to confirm the findings.

Image volume was reconstructed with isotropic isometric 90 μm × 90 μm × 90 μm voxels. The workstation comprised the dual monitors (Dell 24-inch nonglossy monitor (1920 × 1200 resolution) with a Dell Precision Workstation using CS 3D software (v3.5.7). CBCT revealed four canals in the mesiobuccal root, two canals in the DB root, and one palatal canal. The configuration of mesial canals was (4-1). What we had located were MB1, MB2, and MB4. A small opening for MB3 was present between MB2 and MB4, merging with MB4 in the middle third. MB1, MB2, and MB4 all joined together as one canal in the apical one third [Figure 2]A,[Figure 2]B,[Figure 2]C,[Figure 2]D,[Figure 2]E,[Figure 2]F. There was one canal orifice at the floor for the DB canal, dividing into two and then reuniting again in the middle third and continuing as a single canal till the apex exhibiting Vertucci's Type III (1-2-1) pattern [Figure 2]A,[Figure 2]B,[Figure 2]C,[Figure 2]D,[Figure 2]E,[Figure 2]F.
Figure 2: (A and B) CBCT images of right maxillary arch showing serial axial sections at different levels. (a-F) Enlarged axial section images of tooth 17 at different levels showing Vertucci's Type XXI (4-1) pattern in the mesiobuccal root and Vertucci's TYPE III (1-2-1) pattern in the distobuccal root (white arrows). (G- J) Post-obturation CBCT Images of the enlarged axial sections of tooth 17 at different levels confirming the complete obturation of the diagnosed canal pattern (black arrows).

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In the next visit, working length was established using an electronic apex locator (Canal Pro, Coltene/Whaledent, GmbH + Co. KG, Germany) and reconfirmed by periapical radiographs from different angulations [Figure 1]C and [Figure 1]F. Canals were shaped using Hyflex CM (Coltene/Whaledent Inc., OH, USA) files up to the following sizes: MB1-25/06, MB2-25/04, MB3-25/04, MB4-25/04 [Figure 1]E. The DB was shaped till 30/04, and the palatal canal up to size 40/04. After taking a master cone radiograph [Figure 1]G, the final irrigation protocol was employed. Sodium hypochlorite was activated using Endoactivator (Dentsply Maillefer, Ballaigues Switzerland) followed by 17% ethylenediaminetetraacetic acid for 1 min per canal.[14] Normal saline was used as the final flush. The canals were dried using paper points and obturated using AH Plus sealer (Dentsply, DeTrey, GmbH, Germany) employing warm vertical compaction (Elements, Sybron Endo, Glendora, CA) technique. The access cavity was restored with composite resin (Filtek P 60,3M ESPE, USA) [Figure 1]H and [Figure 1]I. A post obturation CBCT investigation confirmed satisfactory obturation in all the canals [Figure 2]G,[Figure 2]H,[Figure 2]I,[Figure 2]J. Photographs were taken directly through the microscope's eyepiece by smartphone (Moto G3, Motorola Mobility, Lenovo, China) as a beam splitter, and camera accessories were not available for documentation.

Metal ceramic crowns were given for both the teeth. A 1, 2, and 4-year follow-up radiographs [Figure 1]J,[Figure 1]K,[Figure 1]L showed normal periradicular findings.


   Discussion Top


The maxillary second molar's mesiobuccal root usually has two canals with a prevalence ranging from 11.5% to 93.7%. Case reports have documented the presence of three canals in the mesial root as well.[3],[6],[7],[8],[9] There are probably no clinical reports with four mesiobuccal canals in the maxillary second molar. We report a Vertucci's Type XXI (4-1) configuration for the maxillary second molar's mesiobuccal root. Among all comprehensive ex vivo studies, only one documents four mesiobuccal canals in the maxillary second molar.[15] The pattern exhibited was Sert and Bayirli Type XI (1-2-3-4) and a new type (2-3-1-3-1-4) in male and female patients' teeth.

Maxillary second molar usually has a single distal root with a single canal. A few reports document the presence of two or more distal canals.[2],[3],[5] Distal root in the present case had two canals with Vertucci's Type III pattern. This pattern is not very common for the distal root. The reported incidence of this variation ranges from 1.3% to 2.4%.[16],[17] The most common pattern for the distal root in the Indian population is Vertucci's Type IV, followed by Type III and Type II. The present case is probably the first to report a Vertucci's Type III configuration in the maxillary molars DB root in a clinical situation.

The palatal canal was large and single.

The contralateral maxillary second molar was missing. The patient got it extracted a few years ago due to failed endodontic treatment. Therefore, it is not possible to comment on the bilateral presence of atypical anatomy.

Magnification has become an absolute necessity to identify and manage complex anatomies. It helped in the successful management of the present case. We did not have a beam splitter and a camera mount with our microscope, so for documentation, pictures were directly clicked from the microscope's eyepiece using a smartphone without any accessories. Devices and extensions are also available to facilitate smartphone photography directly from dental operating microscopes.[18]

CBCT is a salient diagnostic tool in clinical endodontics.[19] It helped us diagnose four mesiobuccal canals and a Vertucci's Type III pattern in the DB root.


   Conclusion Top


This case report highlights the micro endodontic management of a maxillary second molar with three roots and seven canals aided with CBCT. It is probably the first case of a maxillary second molar to report Vertucci's Type XXI (4-1) configuration in the mesiobuccal root and Vertucci's Type III pattern in the DB root. Complex canal systems can be diagnosed and managed successfully with the combined use of magnification and CBCT.

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.



 
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Kandaswamy D, Venkateshbabu N, Arathi G, Roohi R, Anand S. Effects of various final irrigants on the shear bond strength of resin-based sealer to dentin. J Conserv Dent 2011;14:40-2.  Back to cited text no. 14
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Sert SB. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30:391-8.  Back to cited text no. 15
    
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Neelakantan P, Subbarao C, Ahuja R, Subbarao CV, Gutmann JL. Cone-beam computed tomography study of root and canal morphology of maxillary first and second molars in an Indian population. J Endod 2010;36:1622-7.  Back to cited text no. 17
    
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Yahya H, Ayuba GI. Smartphone photomicrography: A quick, easy, useful technique for the clinician. Niger J Clin Pract 2017;20:1-2.  Back to cited text no. 18
    
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Correspondence Address:
Dr. Lalit Kumar Likhyani
Department of Conservative Dentistry and Endodontics, RUHS College of Dental Sciences, Subhash Nagar, Jaipur - 302 016, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcd.jcd_652_20

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