Q U I N T E S S E N C E I N T E R N AT I O N A L
ENDODONTICS
Jojo Kottoor
A permanent mandibular second molar with seven root canal systems Jojo Kottoor, MDS1/Kuriachan Kottanathu Paul, BDS2/Joy Mathew, MDS 3/Saira George, MDS 4/ Jain Mathew, MDS 5/Arun Roy, MDS6 This case report illustrates the nonsurgical endodontic management of a seven-canaled mandibular second molar. The root canal configuration presented as four mesial and three distal canals. Identification of the canal system was made with the aid of magnification, ultrasonics, and multiple angulated
radiographs. Postoperative examination at 18 months showed a clinically asymptomatic tooth with resolution of the periapical pathology. (Quintessence Int 2014;45:381–383; doi: 10.3290/j. qi.a31537)
Key words: four mesial root canals, root canal anatomy, root canal nomenclature, seven root canals, three distal root canals, tooth morphology
A sound knowledge of anatomical and morphologic characteristics of teeth and their possible variations is very important for any dental practitioner. These differences in root/canal morphology influence the success of endodontic treatment and the long-term prognosis of the tooth. In general, mandibular second molars have two roots, a mesial and distal, and usually three root canals.1 The presented case report is of a mandibular second molar with the unusual morphology of 1
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Ernakulam, Kerala, India.
2
Private Practice, Paulson Multispeciality Dental Clinic, Puthencruz, Ernakulam, Kerala, India.
3
Professor and Head, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala, India.
4
Reader, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala, India.
5
Professor, Department of Conservative Dentistry and Endodontics, St. Gregorios Dental College, Chelad, Ernakulam, Kerala, India.
6
Reader, Department of Pedodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala, India.
Correspondence: Dr Jojo Kottoor, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam PO, Ernakulam, Kerala, 686691, India. Email: [email protected]
VOLUME 45 • NUMBER 5 • MAY 2014
seven root canals contained within two roots. In the literature, such a configuration has neither been documented in any clinical or laboratory studies, nor been mentioned in clinical case reports.
CASE REPORT A 44-year-old man presented with the chief complaint of “toothache in his right lower back tooth”. Clinical examination revealed deep caries in his right mandibular second molar. The tooth was tender to palpation and percussion and the thermal tests caused an intense lingering pain. A diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis was made, necessitating endodontic treatment (Fig 1a). Local anesthesia was administered, rubber dam was applied, and a conventional endodontic access opening was established. Initial exploration of the pulp chamber floor revealed the most commonly associated four canals in a mandibular molar (mesiobuccal [MB], mesiolingual [ML], distobuccal [DB], and distolingual
381
Q U I N T E S S E N C E I N T E R N AT I O N A L Kottoor et al
MB L-MB DB MD DL
B-ML ML
a
b
c
d
e
f
Figs 1a to 1f (a) Preoperative radiograph of tooth 47. (b) The access opening shows seven root canal orifices named according to the nomenclature proposed by Valerian Albuquerque et al.2 (c and d) Eccentrically angulated radiographs to confirm the working length in the mesial (c) and distal roots (d). (e and f) Postobturation radiographs in eccentric angulations showing the four root canal systems of the mesial root (e) and three root canals in the distal root (f).
[DL]). The unusually wide distance between the two mesial orifices indicated the possibility of additional canals in the mesial root. The groove connecting the buccal and lingual orifices of the mesial and distal roots was viewed under magnification (Seiler loupes, 2.5× magnification). Further exploration with micro-openers resulted in the identification of additional canals both mesially and distally; ie linguo-mesiobuccal (L-MB), bucco-mesiolingual (B-ML), and middle distal (MD) (Fig 1b).2 Coronal enlargement was performed with a nickel-titanium (NiTi) ProTaper SX rotary file (Dentsply Maillefer). Working length was determined with the help of an apex locator (Root ZX mini, Morita) and later confirmed by radiographs (Figs 1c and 1d). The root canals were cleaned and shapened using ProTaper NiTi rotary instrumentation under copious irrigation with 2.5% NaOCl solution and 17% EDTA. The root canals were dried, dressed with calcium hydroxide paste, and coronally sealed with Cavit-G (3M Espe). The tooth was asymptomatic at the next appointment, 1 week later. The root canals were obturated with gutta-percha and AH-plus sealer (Dentsply De Trey) (Figs 1e and 1f). The access cavity was then
382
Fig 2
Follow-up radiograph after 18 months.
restored with Miracle Mix (GC Corp). After 18 months of follow-up, no clinical or radiographic concern was apparent (Fig 2).
DISCUSSION Mandibular molars routinely have significant variations within what is commonly referred to as “normal anatomy”. Clinicians need to explore the mesial root for
VOLUME 45 • NUMBER 5 • MAY 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Kottoor et al
additional orifices that may be eccentrically positioned or located within the groove between the MB and ML orifices. The buccolingually wide distal root commonly contains an extra canal, which may be separate along its length or become contiguous following cleaning and shaping procedures. More recently, a new anatomically based nomenclature for root canals was proposed by Kottoor et al3 and Valerian Albuquerque et al,2 with one aim to provide a clear picture of any existing root and canal anatomy in maxillary and mandibular molars, respectively. In the present case, the root canal orifices were named as per the guidelines laid down by this nomenclature.2 Multiple angulated radiographs confirmed that the mesial root had four root canal orifices and two exiting foraminae (Fig 1c), while the distal root had a Vertucci Type VIII root canal pattern (Figs 1d to 1f).
VOLUME 45 • NUMBER 5 • MAY 2014
CONCLUSION The incidence of variations, especially the multiplicity of canals in mandibular molars, is not common. However, their documentation provides important awareness for clinicians as these published case reports draw attention to the possibility of their existence. Thus, mandibular second molars with similar anatomy may be recognized and be adequately treated endodontically.
REFERENCES 1. Burns RC, Herbranson EJ. Tooth morphology and access cavity preparation. In: Cohen S, Burns RC (eds). Pathways of the Pulp. St Louis: Mosby, 2002:173– 229. 2. Valerian Albuquerque D, Kottoor J, Velmurugan N. A new anatomically based nomenclature for the roots and root canals-part 2: mandibular molars. Int J Dent 2012;2012:814789. 3. Kottoor J, Albuquerque DV, Velmurugan N. A new anatomically based nomenclature for the roots and root canals-part 1: maxillary molars. Int J Dent 2012;2012:120565.
383
ENDODONTICS
Jojo Kottoor
A permanent mandibular second molar with seven root canal systems Jojo Kottoor, MDS1/Kuriachan Kottanathu Paul, BDS2/Joy Mathew, MDS 3/Saira George, MDS 4/ Jain Mathew, MDS 5/Arun Roy, MDS6 This case report illustrates the nonsurgical endodontic management of a seven-canaled mandibular second molar. The root canal configuration presented as four mesial and three distal canals. Identification of the canal system was made with the aid of magnification, ultrasonics, and multiple angulated
radiographs. Postoperative examination at 18 months showed a clinically asymptomatic tooth with resolution of the periapical pathology. (Quintessence Int 2014;45:381–383; doi: 10.3290/j. qi.a31537)
Key words: four mesial root canals, root canal anatomy, root canal nomenclature, seven root canals, three distal root canals, tooth morphology
A sound knowledge of anatomical and morphologic characteristics of teeth and their possible variations is very important for any dental practitioner. These differences in root/canal morphology influence the success of endodontic treatment and the long-term prognosis of the tooth. In general, mandibular second molars have two roots, a mesial and distal, and usually three root canals.1 The presented case report is of a mandibular second molar with the unusual morphology of 1
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Ernakulam, Kerala, India.
2
Private Practice, Paulson Multispeciality Dental Clinic, Puthencruz, Ernakulam, Kerala, India.
3
Professor and Head, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala, India.
4
Reader, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala, India.
5
Professor, Department of Conservative Dentistry and Endodontics, St. Gregorios Dental College, Chelad, Ernakulam, Kerala, India.
6
Reader, Department of Pedodontics, Mar Baselios Dental College, Kothamangalam, Ernakulam, Kerala, India.
Correspondence: Dr Jojo Kottoor, Department of Conservative Dentistry and Endodontics, Mar Baselios Dental College, Kothamangalam PO, Ernakulam, Kerala, 686691, India. Email: [email protected]
VOLUME 45 • NUMBER 5 • MAY 2014
seven root canals contained within two roots. In the literature, such a configuration has neither been documented in any clinical or laboratory studies, nor been mentioned in clinical case reports.
CASE REPORT A 44-year-old man presented with the chief complaint of “toothache in his right lower back tooth”. Clinical examination revealed deep caries in his right mandibular second molar. The tooth was tender to palpation and percussion and the thermal tests caused an intense lingering pain. A diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis was made, necessitating endodontic treatment (Fig 1a). Local anesthesia was administered, rubber dam was applied, and a conventional endodontic access opening was established. Initial exploration of the pulp chamber floor revealed the most commonly associated four canals in a mandibular molar (mesiobuccal [MB], mesiolingual [ML], distobuccal [DB], and distolingual
381
Q U I N T E S S E N C E I N T E R N AT I O N A L Kottoor et al
MB L-MB DB MD DL
B-ML ML
a
b
c
d
e
f
Figs 1a to 1f (a) Preoperative radiograph of tooth 47. (b) The access opening shows seven root canal orifices named according to the nomenclature proposed by Valerian Albuquerque et al.2 (c and d) Eccentrically angulated radiographs to confirm the working length in the mesial (c) and distal roots (d). (e and f) Postobturation radiographs in eccentric angulations showing the four root canal systems of the mesial root (e) and three root canals in the distal root (f).
[DL]). The unusually wide distance between the two mesial orifices indicated the possibility of additional canals in the mesial root. The groove connecting the buccal and lingual orifices of the mesial and distal roots was viewed under magnification (Seiler loupes, 2.5× magnification). Further exploration with micro-openers resulted in the identification of additional canals both mesially and distally; ie linguo-mesiobuccal (L-MB), bucco-mesiolingual (B-ML), and middle distal (MD) (Fig 1b).2 Coronal enlargement was performed with a nickel-titanium (NiTi) ProTaper SX rotary file (Dentsply Maillefer). Working length was determined with the help of an apex locator (Root ZX mini, Morita) and later confirmed by radiographs (Figs 1c and 1d). The root canals were cleaned and shapened using ProTaper NiTi rotary instrumentation under copious irrigation with 2.5% NaOCl solution and 17% EDTA. The root canals were dried, dressed with calcium hydroxide paste, and coronally sealed with Cavit-G (3M Espe). The tooth was asymptomatic at the next appointment, 1 week later. The root canals were obturated with gutta-percha and AH-plus sealer (Dentsply De Trey) (Figs 1e and 1f). The access cavity was then
382
Fig 2
Follow-up radiograph after 18 months.
restored with Miracle Mix (GC Corp). After 18 months of follow-up, no clinical or radiographic concern was apparent (Fig 2).
DISCUSSION Mandibular molars routinely have significant variations within what is commonly referred to as “normal anatomy”. Clinicians need to explore the mesial root for
VOLUME 45 • NUMBER 5 • MAY 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Kottoor et al
additional orifices that may be eccentrically positioned or located within the groove between the MB and ML orifices. The buccolingually wide distal root commonly contains an extra canal, which may be separate along its length or become contiguous following cleaning and shaping procedures. More recently, a new anatomically based nomenclature for root canals was proposed by Kottoor et al3 and Valerian Albuquerque et al,2 with one aim to provide a clear picture of any existing root and canal anatomy in maxillary and mandibular molars, respectively. In the present case, the root canal orifices were named as per the guidelines laid down by this nomenclature.2 Multiple angulated radiographs confirmed that the mesial root had four root canal orifices and two exiting foraminae (Fig 1c), while the distal root had a Vertucci Type VIII root canal pattern (Figs 1d to 1f).
VOLUME 45 • NUMBER 5 • MAY 2014
CONCLUSION The incidence of variations, especially the multiplicity of canals in mandibular molars, is not common. However, their documentation provides important awareness for clinicians as these published case reports draw attention to the possibility of their existence. Thus, mandibular second molars with similar anatomy may be recognized and be adequately treated endodontically.
REFERENCES 1. Burns RC, Herbranson EJ. Tooth morphology and access cavity preparation. In: Cohen S, Burns RC (eds). Pathways of the Pulp. St Louis: Mosby, 2002:173– 229. 2. Valerian Albuquerque D, Kottoor J, Velmurugan N. A new anatomically based nomenclature for the roots and root canals-part 2: mandibular molars. Int J Dent 2012;2012:814789. 3. Kottoor J, Albuquerque DV, Velmurugan N. A new anatomically based nomenclature for the roots and root canals-part 1: maxillary molars. Int J Dent 2012;2012:120565.
383
