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    ENDODONTIC MANAGEMENT OF MAXILLARY FIRST PREMOLAR WITH 3 ROOT CANALS…….A CASE REPORT

    Presented By:

    Dr Fahad Al Qahtani1, Dr Suheel Manzoor Baba, Dr Ahmed Abd Al Aziem Saleh,

    Department of RDS, College of Dentistry, King Khaled University Abha, Saudi Arabia

    Dr Suheel Manzoor Baba

     

    ABSTRACT

     

    Anatomical variations must be considered in clinical and radiographical evaluations during endodontic treatment. Access cavity modifications may be required for stress free entry to complex anatomy. Higher magnification and illumination can be useful for access cavity preparation and to recognize and locate additional canals. This article describes the diagnosis and clinical management of a clinical case of three rooted maxillary first premolar.

    Keywords: Three rooted maxillary first premolar, Endodontic treatment, Diagnosis

    INTRODUCTION

    A sound clinical knowledge of the number of roots and canals of a tooth receiving endodontic therapy is a pre-requisite to proper instrumentation, obturation and a successful outcome. One of the challenging tasks facing clinicians is performing proper endodontic therapy for maxillary first premolar because the roots and canal system of these teeth can vary significantly among different racial and ethnic group.

     Although three rooted maxillary premolars are rare, the possibility of extra roots or canals should be borne in mind to ensure successful endodontic treatment.

     The reported frequency of three roots in a maxillary first premolar varies from 0.5 to 6%, generally with one canal in each of three roots. The anatomy of three rooted maxillary premolars resembles that of a maxillary molar and therefore they are sometimes referred to as small molars or as being ‘Radiculous’.

      Although pre-operative radiograph gives a two dimensional image of a three dimensional object, precise interpretation can reveal external and anatomical details that suggests the presence of extra canals/roots. For this reason, whenever there is an abrupt straightening or loss of a radiolucent canal in the pulp cavity an extra canal should be suspected, either in the same root or in other independent roots. Also whenever the mesio- distal width of midroot image is equal to or greater than mesio-distal width of the crown, tooth most likely has three roots

      This article describes a clinical case of three rooted maxillary first premolar that is endodontically treated.

    CASE REPORT

      A 42 year old patient reported to the Department of Endodontics for treatment of his tooth 24(FDI).The tooth was tender to percussion. He had a history of spontaneous pain. The patient also gave a history of root canal treatment in the same tooth 1 year back.

      A pre operative periapical radiograph revealed root canal treated 24, but only one root canal had been obturated. Retreatment of the tooth followed by crown was decided.A rubber dam could not be placed as patient was a mouth breather and was not comfortable with application of rubber dam. The access cavity was modified. With the help of gutta percha solvent and H- file, the gutta percha was retrieved from the palatal canal. Also the buccal canal was located. As the size of buccal orifice was slighty larger, extension of orifice was carried out using a low speed round bur no 1 (Dentsply maillefer Switzerland). By exploring the extended buccal orifice with a DG 16 explorer both the mesiobuccal and disto buccal canals were detected.

     The working length was established by placing a No 15 file in each canal with the help of an apex locator, which was further reconfirmed with an IOPA radiograph. The X ray confirmed the presence of three canals.


    Fig 1  Preoperative radiograph

    .


    Fig 2  Radiographical confirmation of three
    root canals and determination
    of the working lengths.

      All the three canals were prepared using rotary protaper files (Dentsply maillefer Switzerland) upto size F1 in distobuccal canal and F2 in mesiobuccal and palatal canals with copious irrigation with 5.25% sodium hypochlorite and saline.

      Glyde (Dentsply maillefer Switzerland) was used to facilitate the instrumentation and for removal of smear layer.

     The canals were dried with paper points and obturation was done with the corresponding pro taper cones using AH plus sealer.


    Fig 3  Periapical radiograph after master cone

    .


    Fig 4  Periapical radiograph after the
    obturation and post
    endodontic restoration.

    DISCUSSION

      The possible anatomic configurations of maxillary premolars are well documented in the literature.5,6 High quality pre-operative radiographs and their careful examination are essential for the detection of additional root canals. 7 Walton recommended the use of two diagnostic radiographs. If a radiograph shows a sudden narrowing or even a disappearing pulp space, the canal diverges at that point into two parts that may either remain separate or merge before reaching the apex. A third canal should be suspected clinically when the pulp chamber does not appear to be aligned in its expected bucco palatal relationship. Additionally, if the pulp chamber appears to deviate from normal configuration and seems to be either triangular in shape or too large in a mesio distal plane, more than one root canal should be suspected.

     In a three rooted maxillary first premolars, the buccal orifice are often close to each other that are hard to locate. Direct positioning of endodontic explorer or a small size file will identify the anatomy. When confronted with unusual tooth anatomy as three rooted maxillary premolars, good illumination and magnification can make treatment easier. With the aid of an operating microscope or loop it is possible to locate all the root canal orifices. The higher magnification and illumination can be useful for access cavity preparation, instrumentation and obturation. 10 It can improve the clinician’s view of the complexity of the root canal anatomy and aid in the location of additional canals

    CONCLUSION

      Morphological variations in pulpal anatomy must be always considered before beginning treatment. Careful clinical and radio graphical examination is essential for successful endodontic treatment. Use of an operating microscope or loop can enhance the visualization of the pulp chamber and extra canal orifices.

    REFERENCES

    1. Atieh MA Root and canal morphology of  maxillary first premolar in Saudi population J contemp dent pract08 jan (9) 1; 046-053.
    2.  Javidi M, Zarei M, Vatanpour M. Endodontic treatment of a radiculous maxillary premolar: a case report. J  Oral  Sci. 2008;50:99–102.
    3.  Vertucci FJ, Gegauff A. Root canal morphology of the maxillary first premolar. J Am Dent Assoc. 79;99:194–
    198.
    4. Carns EJ, Skidmore AE. Configurations and deviations of root canals of maxillary first premolars. Oral Surg. 
    1973; 36: 880–886.
    5. Ingle JI, Walton RE, Lambert GL, Lambert C, Taintor JF, Zidell JD, Beveridge EE. Preparation for endodontic
    therapy.  In: Ingle JI, editor. Endodontics. 3. Philadelphia: Lea&     Febiger; 1985. pp. 54–101.
    6.  Malibaum WW. Endodontic treatment of a ‘radiculous’ maxillary premolar: a case report. Gen Dent 1989; 37: 340–341.
    7. Sieraski SM, Taylor GT, Kohn RA. Identification and endodontic management of three-canalled maxillary 
    premolars. J Endod. 1985; 15: 29–32.
    8.  Slowely RR. Radiographic aids in the detection of extra canals. Oral Surg, Oral Med Oral Pathol. 197444974;37:762–772.1974;37:762-772
    9. Walton RE. Endodontic radiographic techniques. Dent Radio Photoradio. 1973; 46: 51–59.
    10. Vertucci FJ. Root morphology of mandibular premolars. J Am Dent Assoc. 1978; 97: 47–50.

     

     

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