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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 23-25

Management of maxillary first molar with six canals


Department of Conservative Dentistry and Endodontics, ACPM Dental College and Hospital, Dhule, Maharashtra, India

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Pritesh Kisanlal Agrawal
Staff Quarters, ACPM Dental College and Hospital, Dhule - 424 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_7_19

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  Abstract 


Thorough cleaning and achieving a complete three dimensional seal of the root canal system is essential for success of endodontic treatment. Maxillary first molar is the tooth with most complex root canal morphology. Usually, it has three roots with three or four root canals. This case report presents a case of maxillary first molar with an unusual anatomy of having six root canals. This case was managed successfully with the help of dental operating microscope.

Keywords: Dental operating microscope, maxillary first molar, root canal anatomy


How to cite this article:
Agrawal PK. Management of maxillary first molar with six canals. Indian J Oral Health Res 2019;5:23-5

How to cite this URL:
Agrawal PK. Management of maxillary first molar with six canals. Indian J Oral Health Res [serial online] 2019 [cited 2019 Jul 19];5:23-5. Available from: http://www.ijohr.org/text.asp?2019/5/1/23/261153




  Introduction Top


Thorough chemical and mechanical cleansing of the root canal system followed by achieving a three dimensional seal is the prime objective of root canal treatment. One of the main causes of failure of the root canal treatment is incomplete debridement of the root canal system.[1] Thorough knowledge of root canal anatomy and its variations is the prerequisite for achieving a successful root canal treatment. Maxillary first molar is the least understood posterior tooth with the most complex root canal anatomy. In general, it has three roots and three or four canals.[2] Additional canals have been found in distobuccal and palatal roots also. Other rare variations include presence of two roots, single root, four roots, or C-shaped root canal system.[3] Traditional procedures for canal detection mostly rely on the dentist's tactile sense and mental image of the canal system.[1],[4] Dental operating microscope (DOM) has proved to be a boon to endodontics as the ability to visualize the canal orifices is greatly enhanced. It enables the operator to effectively search for extra canals.

The present article discusses the successful endodontic management of a maxillary first molar presenting with three roots and six root canals successfully treated with the help of DOM.


  Case Report Top


A 31-year-old male patient reported to the dental office with a chief complaint of pain with upper left back tooth region. Old restoration was seen with 26. There was no significant medical history. The pain increased by thermal stimuli and chewing. Pulp sensibility testing with dry ice (RC Ice; Prime Dental Products Pvt. Ltd., Mumbai, India) caused severe lingering pain, whereas electronic pulp test caused a premature response with 25 and 26. Mobility and periodontal probing around the teeth was normal. Intraoral radiograph showed deep restoration approaching pulp with 26 and deep proximal caries approaching pulp with 25 [Figure 1]a. Tenderness on percussion was positive with 26 and negative with 25. Based on the clinical and radiographic findings, a diagnosis of symptomatic apical periodontitis with 26 and symptomatic irreversible pulpitis with 25 was established. Endodontic treatment was planned with 25 and 26.
Figure 1: Intraoral radiographs: (a) Preoperative, (b-d) working length determination

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The tooth was anesthetized with 1.8 mL 2% lignocaine containing 1:80,000 epinephrine (Xylocaine; AstraZeneca Pharma India Ltd., Bengaluru, India.) followed by rubber dam isolation. An endodontic access cavity was prepared under a DOM (Labomed Prima DNT). Four canals were normally located and prepared. Close observation under DOM showed a small hemorrhagic point palatal to the MB2 canal suggestive of an additional canal. Similarly, one more distobuccal canal (DB2) was located around 2 mm palatal to DB1 canal with the help of DG-16 endodontic explorer (Hu-Friedy, Chicago, IL, USA) and microscope [Figure 2]. Working length radiographs at different angulations confirmed the presence of additional canals [Figure 1]b, [Figure 1]c, [Figure 1]d. Working length was confirmed with an electronic apex locator (Root ZX; Morita, Tokyo, Japan).
Figure 2: Clinical picture: Access opening showing six canal orifices under dental operating microscope

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Cleaning and shaping was performed using hand K files (Mani Inc.,) followed by ProTaper rotary instruments (Dentsply Maillefer) with a crown-down technique. Irrigation was done using 5% sodium hypochlorite solution and 17% liquid EDTA (Canalarge, Ammdent; Amrit Chemicals and Minerals Agency, Mohali, Punjab, India). Activation of the irrigant was done with an endoactivator. The canals were dried with paper points and obturation was performed using cold lateral compaction of gutta-percha (Dentsply Maillefer) and AH Plus resin sealer (Maillefer, Dentsply, Konstanz, Germany) [Figure 3]a and b]. Final restoration was done with composite resin core (Filtek Bulk Fill 3M ESPE Dental Products 2510 Conway Ave, St. Paul, MN, USA). The patient was advised a full-coverage crown.
Figure 3: Intraoral radiographs: (a) Postoperative and (b) postoperative at different angulation showing six canals

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  Discussion Top


Success of endodontic treatment depends on complete chemical and mechanical debridement of the root canal system followed by achieving a three-dimensional seal. Prime reason for failure of endodontic treatment is the inability to detect extra root canals.[2]

The maxillary first molar is considered one of the most complex teeth in the dental arch.[2] Anatomical variations are commonly observed in maxillary first molar.[5] The incidence of second mesiobuccal (18.6%–96.1%), second distobuccal (1.6%–9.5%), and mesiopalatal (56.8%) and the prevalence of distopalatal (1.7%) canals have been reported in various studies.[2],[6]

Case reports of five to eight root canals have been reported. As in our case, Martínez-Berná and Ruiz-Badanelli reported six root canals with three mesiobuccal, two distobuccal, and one palatal canal.[7] Six root canals with two mesiobuccal, two distobuccal, and two palatal have been reported by de Almeida et al. and Bond et al.[8],[9] Maggiore et al. reported the maxillary first molar with two mesiobuccal, three palatal, and one distobuccal canal.[10] Adanir reported a case of maxillary first molar having four roots (mesiobuccal, mesiopalatal, distobuccal, and palatal) and six canals with one mesiobuccal, two mesiopalatal, two distobuccal, and one palatal.[11] Kottoor et al. reported three roots and seven canals with three mesiobuccal, two distobuccal, and two palatal canals.[6] Almeida et al. reported a case of maxillary first molar having three roots and eight root canals with three mesiobuccal, three distobuccal, and two palatal canals.[12]

It is very difficult to predict the root canal anatomy on the basis of preoperative radiograph alone. There are various methods for locating extra canals such as examination of the pulp floor with DG 16 explorer, troughing of grooves with ultrasonic tips, use of dye, champagne bubble test, and visualizing canal bleeding points.[13] However, using magnification during endodontic treatment has particular advantages. It increases the confidence level of the operator and allows selective removal of dentin precisely avoiding perforation, increased illumination and resolution, improved ergonomics, documentation, and, most importantly, increased chances of locating extra canals.[1],[14]

Das et al. in their clinical study showed that use of magnification leads to MB2 canal detection rate almost twice than that of the nonmagnification group.[4] Buhrley et al. described the successful identification of MB2s in 312 maxillary first and second molars in 57.4% of the cases when using the operating microscope, 55.3% with dental loupes, and 18.2% with unaided vision.[15] In a study, Monea et al. found that the success rates of endodontic treatment of necrotic teeth with chronic apical periodontitis increased with the help of DOM.[14]

In our case also, it was not possible to locate all the additional canals without the use of microscope. The presence of extra canals was later confirmed with intraoral radiographs taken at different angulations. The distobuccal root presents with a Vertucci type II canal pattern. The mesiobuccal root showed a Sert and Bayirli type XVIII canal configuration (3-1), i.e., MB1, MB2, and MB3 join together and exit as one apical foramen.

Cone-beam computed tomography (CBCT) should not be used as a substitute for conventional two-dimensional (2D) radiographs; rather, it should be used as a supplemental examination when it is expected that the 3D scan will provide additional information, with the potential to enhance the diagnosis or treatment. In our case, all the canals could be clearly visualized under microscope and subsequently confirmed on radiographs. Considering the risk–benefit ratio, we did not advice CBCT in this patient to avoid unnecessary exposure to radiation.


  Conclusion Top


This case report discusses the endodontic management of an unusual case of a maxillary first molar with three roots and six root canals and also emphasizes the importance of DOM as an objective analytic tool to ascertain root canal morphology.

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.



 
  References Top

1.
Iandolo A, Valletta A, Carratu P, Castiello G, Rengo S. Endodontic retreatment of maxillary first molar: The importance of the fourth canal. G Ital Endod 2016;30:27-32.  Back to cited text no. 1
    
2.
Madan N, Gwalani H, Raisingani D, Prasad A, Srivastava H. Management of maxillary first molar with six canals using cone beam computed tomography. J Oper Dent Endod 2017;2:36-9.  Back to cited text no. 2
    
3.
Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human permanent maxillary first molar: A literature review. J Endod 2006;32:813-21.  Back to cited text no. 3
    
4.
Das S, Warhadpande MM, Redij SA, Jibhkate NG, Sabir H. Frequency of second mesiobuccal canal in permanent maxillary first molars using the operating microscope and selective dentin removal: A clinical study. Contemp Clin Dent 2015;6:74-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kaushik M, Mehra N. Maxillary first molars with six canals diagnosed with the aid of cone beam computed tomography: A report of two cases. Case Rep Dent 2013;2013:406923.  Back to cited text no. 5
    
6.
Kottoor J, Velmurugan N, Sudha R, Hemamalathi S. Maxillary first molar with seven root canals diagnosed with cone-beam computed tomography scanning: A case report. J Endod 2010;36:915-21.  Back to cited text no. 6
    
7.
Martínez-Berná A, Ruiz-Badanelli P. Maxillary first molars with six canals. J Endod 1983;9:375-81.  Back to cited text no. 7
    
8.
de Almeida-Gomes F, Maniglia-Ferreira C, Carvalho de Sousa B, Alves dos Santos R. Six root canals in maxillary first molar. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e157-9.  Back to cited text no. 8
    
9.
Bond JL, Hartwell G, Portell FR. Maxillary first molar with six canals. J Endod 1988;14:258-60.  Back to cited text no. 9
    
10.
Maggiore F, Jou YT, Kim S. A six-canal maxillary first molar: Case report. Int Endod J 2002;35:486-91.  Back to cited text no. 10
    
11.
Adanir N. An unusual maxillary first molar with four roots and six canals: A case report. Aust Dent J 2007;52:333-5.  Back to cited text no. 11
    
12.
Almeida G, Machado R, Sanches Cunha R, Vansan LP, Neelakantan P. Maxillary first molar with 8 root canals detected by CBCT scanning: A case report. Gen Dent 2015;63:68-70.  Back to cited text no. 12
    
13.
Karaththodiyil R, Kottoor J, Mathew J, George S, Mathew J. A maxillary first molar with six root canals. Saudi Endod J 2014;4:87-90.  Back to cited text no. 13
  [Full text]  
14.
Monea M, Hantoiu T, Stoica A, Sita D, Sitaru A. The impact of operating microscope on the outcome of endodontic treatment performed by postgraduate students. Eur Sci J 2015;11:305-11.  Back to cited text no. 14
    
15.
Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod 2002;28:324-7.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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Case Report
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