Diagnosis and root canal treatment of a mandibular second premolar with three root canals

Endodontic management of a four-canal mandibular second premolar; using an operative microscope: A case report

Key Clinical Message

Due to the complexities and variations of the root canal system's anatomy, mandibular premolars are among the most difficult teeth for endodontic treatment. The lack of clinician knowledge ultimately leads to treatment failure.

Abstract

Mandibular premolars are the most complicated teeth for endodontic treatment because of the variations in root canal anatomy. On the other hand, missing root canals can subsequently lead to failure of endodontic treatment, which causes the patient to become symptomatic. Therefore, the clinician's knowledge of the different types of root canal anatomy and the skill of using new equipment for proper root canal treatment improve the outcome. This study reported the successful endodontic treatment of a mandibular second premolar with four root canals by using an operative microscope.

Internal Morphology of Mandibular Second Premolars Using Micro-Computed Tomography

To examine root canal morphology of mandibular second premolars (Mn2P) of a mixed Swiss-German population by means of micro-computed tomography (micro-CT). Root canal configuration (RCC) of 102 Mn2P were investigated using micro-CT unit (µCT 40; SCANCO Medical AG, Brüttisellen, Switzerland) with 3D software imaging (VGStudio Max 2.2; Volume Graphics GmbH, Heidelberg, Germany), described with a four-digit system code indicating the main root canal from coronal to apical thirds and the number of main foramina. A total of 12 different RCCs were detected. 1-1-1/1 (54.9%) was most frequently observed RCC, followed by 1-1-1/2 (14.7%), 1-1-2/2 (10.8%), 1-2-2/2 (4.9%), 1-1-3/3 (3.9%), 1-1-1/3 (2.9%), 2-1-1/1 (2.9%) and less frequently 1-1-2/3, 1-2-1/2, 2-1-2/2, 1-1-2/5, 1-1-1/4 with each 1.0%. No accessory foramina were present in 35.3%, one in 35.3%, two in 21.6%, three and four in 2.9%, and five in 2.0%. In 55.9% Mn2Ps, accessory root canals were present in apical third and 8.8% in middle third of a root. Connecting canals were observed less frequently (6.9%) in apical and 2.9% in the middle third, no accessory/connecting canals in coronal third. Every tenth tooth showed at least or more than three main foramina. Almost two thirds of the sample showed accessory root canals, predominantly in apical third. The mainly single-rooted sample of Mn2Ps showed less frequent morphological diversifications than Mn1Ps.

A Microcomputed Tomographic Evaluation of Root Canal Morphology of Maxillary Second Premolars in a Pakistani Cohort

This study aimed to investigate variations in the root canal morphology of maxillary second premolar (MSP) teeth using microcomputed tomography (micro-CT). Sixty (N = 60) human extracted MSPs were collected and prepared for micro-CT scanning. The duration for scanning a single sample ranged between 30 and 40 min and a three-dimensional (3-D) image was obtained for all the MSPs. The images were evaluated by a single observer who recorded the canal morphology type, number of roots, canal orifices, apical foramina(s), apical delta(s), and accessory canals. The root canal configuration was categorized in agreement with Vertucci’s classification, and any configuration not in agreement with Vertucci’s classification was reported as an “additional canal configuration”. Descriptive statistics (such as mean percentages) were calculated using SPSS software. The most common types agreeing with Vertucci’s classification (in order of highest to lowest incidence) were types I, III, V, VII, II, and VI. The teeth also exhibited four additional configurations that were different from Vertucci’s classification: types 2-3, 1-2-3, 2-1-2-1, and 1-2-1-3. A single root was found in 96.7% and the majority of the samples demonstrated two canals (73.3%). Further, 80% of the teeth showed one canal orifice. The number of apical foramina’s in the teeth was variable, with 56.7% having solitary apical foramen. The accessory canal was found in 33.3%, and apical delta was found in only 20% of the samples. Variable morphology of the MSPs was detected in our study. The canal configuration most prevalent was type 1; however, the results also revealed some additional canal types.

Root canal morphology and symmetry of mandibular second premolars using cone-beam computed tomography

OBJECTIVES

The current study aims to investigate the morphology and symmetry of root canals of mandibular second premolar teeth via Cone-Beam Computed Tomography (CBCT) among a sample of the Saudi population.

METHODS

A total of 1200 CBCT images were examined in the study. The number of roots in the mandibular second premolars was identified, and canal configurations were classified according to Vertucci classification. Bilateral symmetry and association between gender and number of roots and root canal configuration were investigated using a chi-square test was utilized for data analysis and p value was set at 0.05 for significance.

RESULTS

Of the total 2400 Mandibular second premolars, 98.33% were single rooted and 1.67% were double rooted. The prevalence of double roots in females on the right side was significantly higher than that on the left side (p = 0.017), but the opposite was found among males. Only Type I and II canal configurations showed significant differences regarding gender and sides. 98.0% of teeth showed the symmetrical number of roots in both genders. The symmetry in canal configuration was 96.7% in males and 97.3% in females and 99.1% was Type I in both sides, 0.5% Type III, and 0.3% Type IV in both sides.

CONCLUSIONS

The root morphology of mandibular second premolars in the Saudi population demonstrated a high degree of variability. The vast majority of mandibular premolars have a single root with one canal and a low prevalence of two rooted teeth. Contralateral mandibular second premolars exhibited great symmetry of roots and root canal configuration.

Root Canal Treatment of Mandibular Second Premolars with Three Root Canals-Report of Four Rare Cases

Background/Aim: The aim of root canal treatment is the thorough cleaning, shaping and obturation of the root canals. Variations in root canal anatomy increase the difficulty of the root canal treatment and therefore the possibility of failure. The mandibular premolars often present complex anatomy and the existence of mandibular second premolars with three root canals is very scarce. This report presents the successful endodontic management of four mandibular second premolars with three root canals.

Cases Report: In all cases working length was estimated using the working length radiograph and an apex locator. Canal orifices were enlarged with Gates-Glidden drills and manual instrumentation performed with Stainless Steel reamers and Hedstroem files, using either step-back or crown-down technique. Sodium hypochlorite (NaOCl) 2.5% was used as an irrigant. Root canal obturation were then performed using the cold lateral condensation technique with gutta-percha points and Roth’s 801 canal sealer. The cases were scheduled for clinical and radiographic follow-up examination. Clinically in all follow-up examinations the teeth were asymptomatic. For the three cases with periapical lesions, post treatment radiographs, demonstrated periapical healing. Additionally, in the case without periapical lesion, the 9 months recall radiograph revealed healthy periapical conditions.

Conclusions: Mandibular premolars should never be underestimated and the clinician should always be alerted for anatomic variations.

Endodontic Management of Mandibular Second Premolar with Type IX Canal Configuration Using Cone-Beam Computed Tomography as a Diagnostic Aid: A Rare Case Report

Successful endodontic treatment requires knowledge of the root canal anatomy, cleaning, and shaping followed by three-dimensional filling of the root canals. With the advent of newer diagnostic aids such as cone-beam computed tomography (CBCT) and magnifying tools such as dental operating microscope and loupes, it has become easier for an operator to identify the root canal anatomy of teeth and reduce the risk of procedural accidents and failures. Variations in root canal configuration require modification in access cavity preparation, disinfection, and obturation of the canals. Mandibular premolars are identified to have unusual root and canal anatomy which increases the risk of endodontic failure when additional canals remain undiagnosed. The present case report elaborates successful endodontic management of a mandibular second premolar with Type IX root canal configuration using CBCT as a diagnostic tool.

Unusual root canal morphology of mandibular first premolar and its management: A rare case report

Clinicians proceed the canal exploration according to the literature so far reported. At times, there are apparent variations in the teeth. These discrepancies should be thoroughly surveyed and piled up to date. One such rare complexity of canal morphology was discussed in the present case. A 48-year-old female patient referred to the endodontic clinic for full-mouth rehabilitation. On intraoral hard-tissue examination, decay was noted in multiple teeth which were confirmed by an orthopantomogram and endodontic treatment plan was suggested. The patient was prepared for the access opening of right mandibular first premolar (tooth #44) before which endodontic treatment of first and second quadrants was completed. The cone-beam computed tomography (CBCT) images revealed that tooth # 44 had two separate roots and four distinct root canals (mesiobuccal, mesiolingual, distobuccal, and distolingual). Root canal treatment was completed in two visits. Postoperative CBCT was advised to confirm the obturation of all the canals.

Cone beam computed tomography aided diagnosis and treatment of endodontic cases: Critical analysis

Although intraoral radiographs still remain the imaging method of choice for the evaluation of endodontic patients, in recent years, the utilization of cone beam computed tomography (CBCT) in endodontics showed a significant jump. This case series presentation shows the importance of CBCT aided diagnosis and treatment of complex endodontic cases such as; root resorption, missed extra canal, fusion, oblique root fracture, non-diagnosed periapical pathology and horizontal root fracture. CBCT may be a useful diagnostic method in several endodontic cases where intraoral radiography and clinical examination alone are unable to provide sufficient information.

Endodontic Considerations in Three-canalled Premolars: A Practical Update

The most difficult clinical considertions in orthograde root canal treatment are generally related to the anatomy of the teeth. Three-canalled maxillary and mandibular premolars (mini-molars) have been reported in several studies. The purpose of this paper was to review various aspects of three-canalled premolars including incidence, clinical and radiographic diagnosis, racial predisposition, access cavity preparation, instrumentation and obturation.

Endodontic and clinical considerations in the management of variable anatomy in mandibular premolars: a literature review

Mandibular premolars are known to have numerous anatomic variations of their roots and root canals, which are a challenge to treat endodontically. The paper reviews literature to detail the various clinically relevant anatomic considerations with detailed techniques and methods to successfully manage these anomalies. An emphasis and detailed description of every step of treatment including preoperative diagnosis, intraoperative identification and management, and surgical endodontic considerations for the successful management of these complex cases have been included.

Root anatomy and root canal configuration of human permanent mandibular premolars: a systematic review

Introduction. Mandibular premolars have been reported with complex anatomical aberrations, making them one of the most difficult teeth to manage endodontically. Methodology. An exhaustive search was undertaken to identify associated anatomic studies of mandibular premolars through MEDLINE/PubMed database using keywords, and a systematic review of the relevant articles was performed. Chi-square test with Yates correction was performed to assess the statistical significance of any anatomic variations between ethnicities and within populations of the same ethnicity. Documented case reports of variations in mandibular premolar anatomy were also identified and reviewed. Results. Thirty-six anatomic studies were analyzed which included 12,752 first premolars and nineteen studies assessing 6646 second premolars. A significant variation in the number of roots, root canals, and apical foramen was observed between Caucasian, Indian, Mongoloid, and Middle Eastern ethnicities.The most common anatomic variation was C-shaped canals in mandibular first premolars with highest incidence in Mongoloid populations (upto 24%) while dens invaginatus was the most common developmental anomaly. Conclusions. A systematic review of mandibular premolars based on ethnicity and geographic clusters offered enhanced analysis of the prevalence of number of roots and canals, their canal configuration, and other related anatomy.

Extra roots and root canals in premolar and molar teeth: review of an endodontic challenge

The main goal of endodontic treatment is healing of the periapical tissues which are gained by elimination of bacteria and their byproducts from the canal and prevention from reinfection. Understanding of root canal anatomy is an essential part in endodontic treatment. Anatomic forms and variations in special teeth should be well known, one of them is extra roots/ canals. Although possible aberrations of canal anatomy should be considered for all teeth, some teeth should be highlighted. This review addresses the prevalence, diagnosis (clinical and radiographic), and endodontic management of teeth with extra roots/canals.

Endodontic management of three-rooted maxillary second premolar in a patient with bilateral occurrence of three roots in maxillary second premolars

The possibility of bilateral maxillary second premolars having three separate roots is quite low; however, it must be taken into account in clinical and radiographic evaluations during endodontic treatment. A correct clinical and radiographic diagnosis based on knowledge of root canal anatomy and critical interpretation of radiographs is necessary for a safer and successful endodontic treatment of these teeth. Failure of root canal treatment can occur due to missed roots/canals and often diagnosed when patient experiences continuous post-operative pain and discomfort. This case report describes the root canal treatment of a three-rooted maxillary second premolar in a patient with bilateral occurrence of three roots in maxillary second premolars.

Key words:Anatomic variations, maxillary second premolar, radiculous.

Endodontic management of two-rooted mandibular premolars using spiral computed tomography: a report of two cases

AIM

To present a unique case of mandibular first and second premolars with two roots and two root canals with the aid of spiral computed tomography (SCT).

BACKGROUND

Confirmation of morphology of mandibular first and second premolars with the aid of SCT.

CASE DESCRIPTION

Mandibular premolars usually have a single root and a single canal. The occurrence of two roots with two separate root canals is extremely rare. The use of SCT in this rare case greatly contributed toward making a confirmatory diagnosis and successful endodontic management.

CONCLUSION

Successful nonsurgical endodontic management of mandibular first and second premolars with two separate roots and root canals has been presented. In this case, exact root canal anatomy could not be confirmed by using radiographs alone. Hence, the use of SCT helped us in making a confirmatory diagnosis.

CLINICAL SIGNIFICANCE

Developmental anomalies can occur in any tooth and two rooted premolars are no exception. The complexity of such teeth has to be considered for planning endodontic treatment using latest diagnostic equipment to increase the chances of success.

Cone-beam computed tomography study of root and canal morphology of mandibular premolars in a western Chinese population

Background

Traditional radiography is limited in its ability to give reliable information on the number and morphology of root canals. The application of cone-beam computed tomography (CBCT) provides a non-invasive three-dimensional confirmatory diagnosis as a complement to conventional radiography. The aim of this study was to evaluate the root and canal morphology of mandibular premolars in a western Chinese population using CBCT scanning.

Methods

The sample included 149 CBCT images comprising 178 mandibular first premolars and 178 second premolars. The tooth position, number of roots and canals, and canal configuration according to Vertucci’s classification were recorded.

Results

The results showed that 98% of mandibular first premolars had one root and 2% had two roots; 87.1% had one canal, 11.2% had two canals and 0.6% had three canals. The prevalence of C-shaped canals was 1.1%. All mandibular second premolars had one root; 97.2% had one canal and 2.2% had two canals. The prevalence of C-shaped canals was 0.6%.

Conclusions

The prevalence of multiple canals in mandibular first premolars was mainly of Type V, and mandibular second premolars had a low rate of canal variation in this western Chinese population. Root canal bifurcation occurred at the middle or apical third in most bicanal mandibular premolars. CBCT scanning can be used in the management of mandibular premolars with complex canal morphology.

Deciduous Mandibular Second Molar with Supernumerary Roots and Root Canals Associated with Missing Mandibular Permanent Premolar

Morphological variations like additional roots and root canals in human deciduous dentition are rare. Knowledge of the morphology, variation of root and root canals of deciduous teeth are useful for successful endodontic treatment and exodontia. Presented here is a case report of the supernumerary roots and additional root canals of deciduous mandibular second molar (85) with congenitally bilateral missing of mandibular permanent second premolar (35 and 45) tooth bud.

Root canal re-treatment of a mandibular second premolar with three root canals: a case report

Accurate diagnosis of root canal morphology and anatomy is essential for thorough shaping and cleaning of the entire root canal system and consequent successful root canal treatment. Mandibular premolars show a wide variety of root canal anatomy. This paper describes a case of mandibular second premolar with three root canals that has previously received an incomplete root canal treatment.

A mandibular second premolar with three canals and atypical orifices

Mandibular second premolars with three canals (Type V, Vertucci) and separate foramina are very rare. The anatomy of the pulp chamber floor in these premolars usually reveals one lingual and two buccal orifices at the same level. This case report describes a second premolar with three canals and an unusual pulpal floor anatomy with one distobuccal and one distolingual orifice at the same level and an orifice on the mesiolingual wall. Very careful examination of the pulpal space, preferably with an optical device, is recommended to locate any unusual orifices.

Levels of Evidence for the Outcome of Nonsurgical Endodontic Treatment

The purpose of this systematic review was (a) to search for clinical articles pertaining to success and failure of nonsurgical root canal therapy, and (b) to assign levels of evidence to these studies. Electronic and manual searches were conducted to identify studies published between January 1966 and September 2004 with information on the success and failure of nonsurgical root canal therapy. Articles were reviewed and graded for strength of level of evidence (LOE) from one (highest level) to five (lowest level). This review resulted in the identification of 306 clinical studies related to this topic area. Six articles were randomized controlled trials (RCTs, LOE 1). This search also identified 12 low-quality RCTs (LOE 2), 14 cohort studies (LOE 2), five case-control and eight cross sectional studies (LOE 3), four low-quality cohort studies (LOE 4), and five low-quality case-control studies (LOE 4). The majority (73) of the often-quoted "success and failure" studies were case series (LOE 4). The rest of the articles were descriptive epidemiological studies (42), case reports (114), expert opinions (18), literature reviews (4), and one meta-analysis. Based on these findings, it appears that a few high-level studies have been published in the past four decades related to the success and failure of nonsurgical root canal therapy. The data generated by this search can be used in future studies to specifically answer questions and test hypotheses relevant to the outcome of nonsurgical root canal treatment.

Root Canal Treatment in a Mandibular Second Premolar with Three Root Canals

According to the endodontic literature, the possibility of three canals in mandibular second premolars is quite small. When three or more canals are present separation of the root canals has only been described at mid-root level. The present case describes root canal treatment of a root canal aberration at the level of the apical third (apical root canal separation starting at a length of 20 mm) where a combined use of the fiberoptic endoscope and the operating microscope was necessary to locate the canal orifices and to enter these orifices. The present report emphasizes the need of color contrast to enhance visualization.