This case report represents assessment and management of a maxillary left first molar tooth containing five root canals by endodontic treatment. In this case Mesiobuccal 2 (MB2), Mesiopalatal (MP) and Distobuccal (DB) canals were missed as well as very poor obturation at palatal and mesiobuccal1(MB1) canal during previous treatment history. Three mesiobuccal (MB1, MB2, and MP), DB and palatal canals were identified and endodontic retreatment was done followed by final restoration. This case provides an evidence of variations in the root canals of the mesiobuccal root of maxillary first molar tooth. Complete clinical and radiographic examination and adequate knowledge of the morphology of this kind of teeth is necessary for successful clinical outcome.DOI: http://dx.doi.org/10.3329/bsmmuj.v5i1.11026 BSMMU J 2012; 5(1):61-64

Alam, Md. Shamsul

Islam, Mohammad Aminul

Bangabandhu Sheikh Mujib Medical University Journal

English

This case report represents assessment and management of a maxillary left first molar tooth containing five root canals by endodontic treatment. In this case Mesiobuccal 2 (MB2), Mesiopalatal (MP) and Distobuccal (DB) canals were missed as well as very poor obturation at palatal and mesiobuccal1(MB1) canal during previous treatment history. Three mesiobuccal (MB1, MB2, and MP), DB and palatal canals were identified and endodontic retreatment was done followed by final restoration. This case provides an evidence of variations in the root canals of the mesiobuccal root of maxillary first molar tooth. Complete clinical and radiographic examination and adequate knowledge of the morphology of this kind of teeth is necessary for successful clinical outcome.

DOI: http://dx.doi.org/10.3329/bsmmuj.v5i1.11026
 
BSMMU J 2012; 5(1):61-6

Mohammad Aminul Islam

Md. Shamsul Alam

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Five Root Canals for a Maxillary First Molar Tooth  A Case Report

Introduction:Both external & internal anatomy of a tooth is an importantaspect of root canal treatment. Failure to detect and treatthe second MB2 canal system will result in a decreasedlong-term prognosis.1 The main reasons for endodonticfailure are apical percolation and presence of microorganisms caused by incomplete instrumentation,inadequate cleaning, insufficient canal obturation andpresence of untreated canals2. Unusual root and root canalmorphology associated with molar teeth have beenrecorded in several studies in the literature.3,4 The maxillaryfirst molar is the largest tooth in volume and one of themost complexes in root and canal anatomy 5. In a literaturereview, the morphology of the MB root of 8399 maxillaryfirst molar teeth was assessed in 34 studies where two ormore canals were present in 56.8% in average of all studiesand one canal in 43.1%. And single apical foramen was61.6% while two apical foramina were 38.3 %.3 Thedistobuccal and palatal root was reported in 14 studiesincluded 2576 teeth where the common root canal systemconfiguration of the DB root canal was single 98.3% andtwo canals 1.7%, and the single apical foramina was present98% of the time as well as the palatal root with single canal99% and single apical foramina 98.8% respectively.3  Alsosome case reports have shown few anomalies like fourrooted maxillary first molar presenting mesiobuccal,distobuccal and two palatal root and each root containingsingle canal also five rooted with two MB, one DB andtwo palatal and each root containing single canal.6 ThreeFive Root Canals for a Maxillary First Molar Tooth – A Case ReportMohammad Aminul Islam1, Md. Shamsul Alam21MS student, 2Professor & Chairman, Department of Conservative Dentistry & Endodontics, Bangabandhu Sheikh Mujib Medical University,Dhaka.Abstract:This case report represents assessment and management of a maxillary left first molar tooth containing five root canalsby endodontic treatment. In this case Mesiobuccal 2 (MB2), Mesiopalatal (MP) and Distobuccal (DB) canals weremissed as well as very poor obturation at palatal and mesiobuccal1(MB1) canal during previous treatment history. Threemesiobuccal (MB1, MB2, and MP), DB and palatal canals were identified and endodontic retreatment was done followedby final restoration. This case provides an evidence of variations in the root canals of the mesiobuccal root of maxillaryfirst molar tooth. Complete clinical and radiographic examination and adequate knowledge of the morphology of thiskind of teeth is necessary for successful clinical outcome.Key Words: Maxillary first molar, Five root canals, Endodontic Treatment.[BSMMU J 2012; 5(1):61-64]Address for Correspondence: Mohammad Aminul Islam, MSstudent, Department of Conservative Dentistry & Endodontics,Bangabandhu Sheikh Mujib Medical University, Dhaka.splitted palatal canals in a single palatal root as well assingle MB and DB canal in corresponding root.7 Threeroots with 6 canals contain two MB, single DB and threepalatal canals.8 Two MB canal and a single C shaped canalform due to fusion of DB and palatal canal9.  And alsovery rarely single-rooted maxillary first molar with a singlecanal.10-11 In one study 9 shows 0.09% and anotherstudy12 shows 0.3% C shaped canal in maxillary first molartooth only.The mesiobuccal root of the maxillary first molar containsa double root canal system more often a single canal, inmost studies.3 Two or more canal system in MB root showshigher incidence like Sert S13 93.5%, Thomas14 73.6%,Acosta15 71.6%, Stropko16 73.2%, Neaverth17  80.3%,Nasonowitz18 64.6%. Some case published regarding tothree or more canals in MB root canal system of maxillaryfirst molar tooth. Richard19 and Favieri20 found 3 MB ,1DB and 1 Palatal canal in maxillary first molar tooth. NAdanir21 cited about  a four rooted maxillary first molarwhere MP root contain 2 canals and rest of MB, DB andpalatal roots have single canal.Case report:A 31 years old female patient was referred to the departmentof Conservative Dentistry & Endodontics at BangabandhuSheikh Mujib Medical University (Dhaka, Bangladesh)for better management of upper left second premolar andfirst molar tooth. At that time, the patient’s complaintsabout inability to enjoy taking food at left side of the jaw.She also reported about mild to moderate pain at severaltimes as well as pain during bite. She gave a previoushistory of dental treatment at her residence area on tooth25 (upper left second premolar) & 26 (upper left first molar)at two years back. On clinical examination, neither fistulanor oedema was observed. The tooth 25 had a grossproximal caries with occlusal filling and shows exaggeratedresponse of thermal test. The tooth 26 was tender duringpercussion with no thermal response & the coronalrestoration was not perfectly done. And the periapicalradiograph showed thickened periodontal ligament andradiolucent area around the root apex. Also the tooth 26showed damaged pulpal floor due to previous faulty accessopening as well as very poor obturation of the MB andPalatal root canals while DB was untreated. The tooth 25suggests late stage of chronic pulpitis and the tooth 26suggest chronic periapical periodontitis. As a result, therewas no alternative better option to treat withoutendodontic treatment of both 25 and 26.Local anaesthesia was given and the operative field wasisolated for the tooth 26 (left maxillary first molar). Afterremoval of the remaining coronal restoration and prepationof the access cavity, exploration of the root canal entrancesrevealed 3 canals in the MB root, 1 canal in the DB rootand 1 canal in the palatal root. Where the canal orifices ofthe MB1 & MB2 were closer with same apical foramen andthe orifice of the MP was far and in between mesiobuccals& Palatal canal with isolated apical foramen. The MB2,MP and DB was untreated previously.  After exploring thefive canals, MB2, MP and DB was negotiated with  #10, #8and #10K files and the under obturated gutta percha wasremoved from the MB1, Palatal canal with the aid of H file.Then the workong length of the tooth was determinedradiographically based upon the initial radiograph (Fig-1).Here, The # 15 H file was used on MB1, #15 K file on MB2,#15 H file on MP canals as well as the #20 K file was usedon DB and #25 K file was on palatal canal respectively(Fig-2). Apical preparation of the MB1 & MB2 with #35 Hfile at 18 mm working length, and MP with #30 H file at16.5mm working length. The DB and palatal canal wasprepared with #35 H file & # 45 H file respectively at theworking length of 19.5mm & 21.5mm. After chemomechanical preparation, the canals were flushed with 2.5%sodium hypochlorite,  then dried and filled with calciumhydroxide as an intracanal medication. Root canal accesswas sealed with zinc oxide eugonol cement. After 7 days,the canals were emptied and the patency of the canals isrechecked with master apical file. Then the canals arecopiously flushed with 2.5% sodium hypochlorite anddried with paper point. Then master gutta percha conewere selected for each canal and all the canals were filledwith Sealer 26 (Dentsply, Brazil) using lateral condensationtechnique. After a temporary coronal restoration, a finalradiograph was taken to confirm the competences andextension of root canal filling (Fig-3). The permanentcoronal seal was done by crown prosthesis. Then up tosix months follow up visit, the patient was evaluatedclinically where there was no tenderness to percussionwith no sinus tract or any sign of periodontal disease orinfection and the tooth was functional.Fig-1: Intraoral pariapical radiograph (Pre operative)Fig-2: Intraoral pariapical radiograph (Per operative)Fig-3(a): Intraoral pariapical radiograph (Post operative)BSMMU J Vol. 5, Issue 1, January 201262Discussion:Despite the current high success rate achieved inendodontic treatments, the MB root is associated toconsiderable number of failures due to difficulty in locatingand filling the second or third MB canals 22, 23. Clinicalexperience and histological studies revealed that the MB2or the MP is commonly located within the developmentalgroove between the MB1 and palatal canal. To locate theMB2 or MP root canal systems, the clinician shouldprepare the access cavity mesially at expense of the mesialmarginal ridge. As well as to prepare straight line accessand to eliminate the pulpal roof.Anatomically the MB canals and related isthmus aspectsof the root canal system lie closer to the external furcalside concavity. A single MB canal is oval and widerbuccolingually, two or three canals are more circular.Generally a concavity exists on the distal aspect of theMB root, which makes the wall very thin.5  So, all the MBcanals specially MB2 and MP must be prepared moreconservatively and carefully to avoid future fracture orstrip perforation.Less variation was found in the distobuccal and palatalroot representing single canal. The palatal root is oftencurves buccally at the apical one third which may not beobvious on a standard radiograph. from its orifice, thepalatal canal is flat, ribbon like and wider in mesiodistaldirection. The distobucal root is conical and from its orifice,the canal first is oval and then becomes round as itapproaches the apical third. The incidence two canals inthe MB root canal system of maxillary first molar tooth ishigher (60.5%) in laboratory studies in compare with clinicalstudies (54.7%) on an average.3 But interestingly theincidence of location of a two canal system in clinicalstudies appears to be increasing with routine use of theSOM and other aids during the modified endodonticaccess opening procedure. 16, 24, 25  So dental practitionershould utilize maximum use of diagnostic aids to findmissing canals though in these case the five canals wereidentified with naked eye using a canal explorer withanatomical guidance after creating straight line access.Now a days, the commonly used canal finding aids arecanal explorers, magnification, dye, multiple obliquelyangled radiographs, dental operative microscope, wearloupes, fibre optic hand piece, piezoelectric ultrasonic unit,computed tomography etc. but the most important factorto find missing canal is to create a complete access openingand assembling proper internal and external anatomy ofthat tooth.Conclusion:Inability to find and treat the extra canal which is usuallyvery common in mesiobuccal root of maxillary first molarmay cause treatment failure. But a proper clinical guideline and every effort from the clinician may be helpful tofind  and treat extra canal successfully.References:1. Wolcott J, Ishley D, Kennedy W, Johnson S, Minnich S.Clinical investigation of second mesiobuccal canals inendodontically treated and retreated maxillary molars. JEndod 2002;28:477-9.2. Siqueira JF Jr., Rocas IN. Clinical implications and microbiologyof bacterial persistence after treatment procedures. J Endod2008;34: 1291-301.3. Blaine, William and Cecilia. Root and root canal morphologyof the human permanent maxillary first molar: A literaturereview. J Endod 2006;32:(9) 813-21.4. Flares et al. Analysis of the internal anatomy of maxillaryfirst molars by using different methods. J Endod2009,35:(3):337-342.5. Vertucci, Haddix, Britto: Ch.7, Tooth Morphology and AccessCavity preparation. Cohen, Hargreaves editors: Pathways ofthe Pulp, 9th ed., Mosby Yearbook Co., 2006.6. Barbizam JV, Ribeiro RG, Tanomaru Filho M. Unusual anatomyof permanent maxillary molars. J Endod 2004;30:668-71.7. Wong M. Maxillary first molar with three palatal canals. JEndod 1991;17:298-9.8. Maggiore F, Jou YT, Kim S. A six-canal maxillary first molar:case report. Int Endod J  2002;35:486-91.9. De Moor RJ. C-shaped root canal configuration in maxillaryfirst molars. Int Endod J 2002;35:200-8.10. Francisco et al . Single-rooted maxillary first molar with asingle canal: endodontic retreatment. Oral Surg Oral MedOral Pathol Oral Radiol Endod 2008;106: e66-e68.Fig-3(b): Intraoral pariapical radiograph (Postoperative)Five Root Canals for a Maxillary First Molar Tooth – A Case Report Mohammad Aminul Islam et al6311. C. Wang & K. Prasad. Single Rooted Maxillary First Molar: ARare Case. People’s Journal of Scientific Research. Vol. 4(1),Jan. 2011,68-70.12. Yang ZP, Yang SF, Lee G. The root and root canal anatomy ofmaxillary molars in a Chinese population.  Endod DentTraumatol 1988;4:215- 8.13. Sert S, Bayirli GS. Evaluation of the root canal configurationsof the mandibular and maxillary permanent teeth by genderin the Turkish population. J Endod 2004;30:391-8.14. Thomas RP, Moule AJ, Bryant R. Root canal morphology ofmaxillary permanent first molar teeth at various ages. IntEndod J 1993;26:257-67.15. Acosta Vigouroux SA, Trugeda Bosaans SA. Anatomy of thepulp chamber floor of the permanent maxillary first molar. JEndod 1978; 4: 214-9.16. Stropko JJ. Canal morphology of maxillary molars: clinicalobservations of canal configurations. J Endod 1999;25:446-50.17. Neaverth EJ, Kotler LM, Kaltenbach RF. Clinical investigation(in vivo) of endodontically treated maxillary first molars. JEndod 1987; 13: 506-12.18. Nosonowitz DM, Brenner MR. The major canals of themesiobuccal root of the maxillary 1st and 2nd molars. N Y JDent 1973;43:12-5.19. Richard g. Beatty. A five-canal maxillary first molar. Journalof endodontics. 1984:10(4):156-157.20. Favieri, Barros,Campos. Root Canal Therapy of a MaxillaryFirst Molar with Five Root Canals: Case Report. Braz Dent J(2006) 17(1): 75-78.21. N Adanir. An unusual maxillary first molar with four roots andsix canals: a case report. Australian Dental J 2007; 52: (4):333-35.22. Vertucci FJ. Root canal anatomy of the human permanentteeth. Oral Surg Oral Med Oral Pathol 1984;58:589-599.23. Fogel HM, Christie WH, Peikoff MD. Canal configuration inthe mesiobuccal root of the maxillary first molar: a clinicalstudy. J Endod 1994;20:135-137.24. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect ofmagnification on locating the MB2 canal in maxillary molars.J Endod 2002;28:324-7.25. Sempira HN, Hartwell GR. Frequency of second mesiobuccalcanals in maxillary molars as determined by use of an operatingmicroscope: a clinical study. J Endod 2000;26:673-4.BSMMU J Vol. 5, Issue 1, January 201264

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Five Root Canals for a Maxillary First Molar Tooth A Case Report

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