Maxillary first Molar with three canal orifices in MesioBuccal root.

The present case describes root canal treatment in a maxillary first molar with unusual anatomy. A male patient was referred for the treatment of maxillary left first molar tooth. Clinical examination of the pulpal floor revealed 3 orifices in the mesio buccal root. The tooth was treated successfully. Anatomic variations must be taken into consideration in clinical and radiographic evaluation during endodontic treatment.

INTRODUCTION

In a previous report, the prevalence of a second mesiobuccal (MB2) canal for type 2 (2-1) was found 42% in males and 37% in females; for type 4(2) was found in 29% and 27% males and females, respectively. However, the prevalence of a MB3 canal is infrequent. For type 8 (3), total prevalence in males and females was found 0%, for both additional types XVII (-3-1) and type XVIII (3-1) the total prevalence in males was found 1% and 0% was reported in females.[1] This article discusses the successful nonsurgical endodontic management of permanent maxillary first molar presenting with the anatomical variation of 3 roots and 5 canals (three mesiobuccal, one distobuccal and one palatal canal).

CASE REPORT

A 22 years old male patient was referred to the clinic for the treatment of maxillary left first molar tooth. Patient reported the complaint of pain for the preceding 2 weeks. Clinical examinations revealed a tooth with an amalgam restoration and fistula. Tooth had minor discomfort to percussion and palpation and failed to respond to electric pulp testing. Radiographic examination revealed a radiolucent lesion on the distal aspects of the coronal portion extending toward the pulpal outline [Figure 1a]. Clinical and radiographic examination lead to a diagnosis of asymptomatic apical abscess, indicating the need for endodontic treatment.

Figure 1

(a) Preoperative radiograph, revealing a radiolucent lesion on the distal aspects of the coronal portion extending toward the pulpal outline of the maxillary left first molar tooth (b) Access opening showing three root canal orifices of MB root, (c) Working length radiograph of MB canals in eccentric angulation, (c) Additional type XVIII configuration of the roots of the of maxillary left first molar (3-1), (e) Working length radiograph of maxillary left first molar, (f) Postobturation radiograph of maxillary left first molar

After the establishing the access cavity, clinical examination of the pulpal floor with an explorer under a magnification of 2.5x, and using magnification loupes presented the anatomy of the tooth as follows: 3 orifices in the MB root, 1 orifice in the disto- buccal root (DB), and 1 orifice in the palatal root (P). MB, DB, palatal roots had Vertucci's additional type XVIII [3-1], type I and type I configurations, respectively. [Figure 1b].[1] Exploration of the canals with a size 10 ISO K-file revealed that the canals in MB root fused before exit as a single foramen [Figures 1c–e]. All canals were instrumented using crown-down technique under copious irrigation with 2.5% sodium hypochlorite solution and Ethylene Diamine Tetra Acetic acid. The canals were dried with paper point and dressed with calcium hydroxide and sealed with Cavit (ESPE, Seefeld, Germany). One week later, the canals were obturated with gutta-percha and sealer [Figure 1f]. The tooth was restored with full veneer crown, and it was asymptomatic thereafter at 6-month follow-up.

DISCUSSION

Clinical instrumentation of maxillary first molar tooth, especially with respect to the MB root, can be complicated. Failure to detect and treat the MB2 and MB3 canal system will result in a decreased long-term prognosis.[2] In the all canals of the maxillary first molar, the MB2 and MB3 can be the most difficult to find and negotiate in a clinical situation. Knowledge from laboratory studies is essential to provide insight into the complex root canal anatomy.[3]

CONCLUSIONS

This report shows that the clinician must be conscious of anatomic variations during the diagnostic and treatment phases of maxillary first molars, so that correct root-canal therapy can be performed respecting the possible challenges of pulp space anatomy. The frequency of maxillary first molars with 5 root canals especially with three MB canals is rare; however, each case should be investigated carefully, clinically and radiographically, to detect the anatomical anomaly.