clinical caSE
Katarzyna Barczak
1, a, B, D, F, Jadwiga Buczkowska-Radlińska
1, a, D, ERoot Canal Treatment of a Mandibular First Molar
with Five Root Canals – Case Report
Leczenie endodontyczne pierwszego zęba trzonowego żuchwy
z pięcioma kanałami – opis przypadku
1 Department of conservative Dentistry, Pomeranian Medical University, Szczecin, Poland
A – concept, B – data collection, C – statistics, D – data interpretation, E – writing/editing the text, F – compiling the bibliography
Abstract
a thorough diagnosis of the anatomy of the root canal system is a prerequisite for successful root canal treatment. Observing the radiographs and examining of the pulp chamber floor help the location of root canal orifices. The endodontic treatment of mandibular molars with aberrant canal configurations can be diagnostically and techni-cally challenging. This case report presents the treatment of a mandibular first molar with five root canals, of which three were located in the mesial root. The morphological pattern of separate apical terminations of three mesial root canals with separate orifices as manifested in this case is very rare. Working-length of canals was measured using apical locator which was confirmed radiographically. all canals were mechanically cleared to size 35 Hedstroem files and irrigated with 2% hypochlorite solution. after drying with standard paper points canals were obturated with laterally condensed gutta-percha and aH-plus sealer. The Tooth were restored with composite resin Herculite. after two-years recall clinically and radiography indicated positive result of treatment (Dent. Med.
Probl. 2013, 50, 3, 373–376).
Key words: mandibular first molar, root canal treatment.
Streszczenie
Dokładne poznanie anatomii systemu kanałów korzeniowych jest warunkiem powodzenia leczenia endodontycz-nego. analiza zdjęć rentgenowskich oraz badanie dna komory pomagają zlokalizować ujścia kanałów korzenio-wych. leczenie endodontyczne zębów trzonowych żuchwy o nietypowej konfiguracji kanałów korzeniowych może być trudne zarówno diagnostycznie, jak i klinicznie. W pracy opisano leczenie endodontyczne pierwszego zęba trzonowego żuchwy z pięcioma kanałami, z których trzy były umiejscowione w korzeniach bliższych. Taki układ morfologiczny pierwszego zęba trzonowego żuchwy z trzema oddzielnymi kananałami i oddzielnymi wierzchołka-mi w korzeniu bliższym jest rzadko spotykany. Długość roboczą kanałów określono enometrycznie i potwierdzono radiologicznie. Kanały opracowano mechanicznie do rozmiaru narzędzia 35 i płukano 2% roztworem podchlory-nu sodu. Do ostatecznego płukania zastosowano 15% EDTa. Po osuszeniu sączkami papierowymi kanały zosta-ły wypełnione ćwiekami gutaperkowymi i uszczelniaczem aH plus metodą kondensacji bocznej. następnie ząb wypełniono materiałem Herculite. Badanie kontrolne kliniczne i radiologiczne po 2 latach potwierdziło pozytywny wynik leczenia (Dent. Med. Probl. 2013, 50, 3, 373–376).
Słowa kluczowe: pierwszy trzonowy ząb żuchwy, leczenie endodontyczne.
Dent. Med. Probl. 2013, 50, 3, 373–376
iSSn 1644-387X © copyright by Wroclaw Medical University and Polish Dental Society
Knowledge of the internal anatomy of teeth is very important in planning and performing endo-dontic treatments. normally, mandibular first mo-lars have two roots; a mesial and distal one. The
usual canal distribution is two canals in the mesi-al root, and one in the distmesi-al root. Severmesi-al case re-ports of patients with multiple canal systems in the mandibular first molar have been published [1, 2].
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The probability of a mandibular first molar hav-ing a fifth canal is 1–15% [3]. Three canals in the mesial and two in the distal root were found in 2.07% [4] and 3.4% [5], respectively.
additional third canals in the mesial root are situated centrally between the two main buc-cal and lingual root canals, and were described as a middle mesial canal [2]. The diameter of the third middle canals is smaller than that of the oth-er two [6]. The third middle mesial canal is defined as independent when a coronal orifice and apical foramen are observed, or confluent when the two main canals converge and terminate at a common apical foramen [1].
This case report presents the treatment of a mandibular first molar with five root canals, of which three were located in the mesial root and two in distal root. This tooth had three indepen-dent canals in the mesial root, a pattern that is sel-dom encountered.
Case Report
A 26-year-old female was referred for endo-dontic therapy of her left mandibular first molar. Partial pulp extirpation had been performed pre-viously by another dentist, and a temporary fill-ing placed. Radiographs showed no changes in the apical region and no anatomical abnormality was observed (one mesial and one distal root) (Fig. 1). Adequate anesthesia was applied and, after rubber dam placement, the temporary filling material was removed. The canals were explored with size 15 H-files and K-files and five distinct orifices were found; three mesially and two distally. Three inde-pendent canals with separate apical terminations of the mesial root canals could be distinguished as type VIII Vertucci’s classification [7]. In the dis-tal root, there were two independent distobuccal
and distolingual canals (type II Vertucci’s classi-fication). An apical locator (Root ZX®, J. Morita,
Tokyo, Japan) and a no. 15 file were used to estab-lish the length of the canal, which was confirmed radiographically (Fig. 2).
all five canals were cleared with Hedstroem files (Maillefer) to size 35 and irrigated with 2% sodium hypochlorite solution. The final rinse for each canal was performed with 2 ml of 15% ED-Ta. The canals were then dried with standard pa-per points and obturated with cold laterally con-densed gutta-percha and aH plus sealer (DeTrey, Dentsply, Switzerland) using size a and B spread-ers (Maillefer®) (Fig. 3). a radiographic control
showed correctly obturated canals (Fig. 4–6). The tooth was restored with light-cured composite res-in Herculite® (Kerr, Scafati, italy).
Fig. 1. Preoperative radiographs of the left mandibular
first molar
Ryc.1. Zdjęcie radiologiczne pierwszego zęba
trzono-wego żuchwy (36) przed leczeniem endodontycznym
Fig. 2.Working-length radiograph. Five endodontic
instruments are inserted into the canals
Ryc. 2. Zdjęcie radiologiczne z pięcioma narzędziami
umieszczonymi w kanałach zęba
Fig. 3. Postoperative radiograph. The distal root canals
converge to a common apical termination
Ryc. 3. Zdjęcie radiologiczne wykonane po
Root canal Treatment of a Mandibular First Molar with Five Root canals
375
Discussion
General studies investigating the anatomy of root canal systems and the anatomical variations found in different types of teeth have provided in-formation that might improve the outcome of end-odontic treatments. an evaluation of the number of roots and their morphology revealed that in Thailand 87% of mandibular first molars had two separate roots [5]. The frequency of two separate roots in the Sudanese population was 78% [8].
in a study of 760 mandibular molars, Fabra-campos [4] found that 2.6% had three canals in the mesial root. The third canal ended as an inde-pendent canal in only one tooth (0.13%). in a sam-ple of 118 first mandibular molars, Gulabivala et al. [5] found two (1.9%) teeth with type Viii mesial roots and five (4.8%) with type ii distal roots.
cli-nicians have shown a small number of treatments of mandibular first molars with five canals [1, 9].
The search for an extra orifice is aided by the use of magnifying loupes and operating micro-scopes, which help to provide enhanced visualiza-tion of the root canal intricacies and to locate the canals, and help with cleaning and shaping. The present case report shows that each case warrant-ing root canal treatment should be carefully eval-uated radiographically and clinically. Treating ex-tra canals may be challenging, but the inability to find and properly treat root canals may cause fail-ures. it is important to report cases with unusu-al morphologicunusu-al canunusu-al configurations. This draws the attention of the profession to their existence so that similar cases may be better recognized and successfully managed in the future.
Fig. 4–6. Two-years recall radiograph indicating healthy periapical bone structure
Ryc. 4–6. Kontrolne RTG wykonane po 2 latach ukazuje prawidłową strukturę kości w okolicy wierzchołkowej
References
[1] Holtzmann l.: Root canal treatment of a mandibular first molar with three mesial root canals. int. Endod. J. 1997, 30, 422–423.
[2] Baugh D., Wallace J.: Middle mesial canal of the mandibular first molar: a case report and literature review. J. En-dod. 2004, 30, 185–186.
[3] navarro l.F., luzi a., Garcia a.a., Garcia a.H.: Third canal in the mesial root of permanent mandibular first molars: Review of literature and presentation of 3 clinical reports and 2 in vitro studies. Med. Oral Patol. Oral cir. Bucal 2007, 12, 605–609.
[4] Fabra-campos H.: Unusual root anatomy of mandibular first molars. J. Endod. 1985, 11, 568–572.
[5] Gulabivala K., Opasanon a., nG Y.-l, & alavi a.: Root and canal morphology of Thai mandibular molars. int. Endod. J. 2002, 35, 56–62.
[6] Martinez-Berna a., Badanelli P.: Mandibular first molar with six root canals. J. Endod. 1981, 8, 348–352. [7] Vertucci F.J.: Root canal anatomy of the human permanent teeth. Oral Surg. Oral Med. Oral Pathol. 1984, 58,
589–599.
[8] ahmed H.a., abu-Bakr n.H., Yahia n.a., ibrahim Y.E.: canal morphology of Sudanese molar. int. Endod. J. 2007, 40, 766–771.
[9] Barletta F.B., Dotto S.R., Reis M. de R., Forreira R., coelho Travasso R.M.: Mandibular molar with five ca-nals. aust. Endod. J. 2008, 34, 129–132.
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Address for correspondence:
Katarzyna Barczak
Department of conservative Dentistry Pomeranian Medical University Powstańców Wlkp. 72 70-111 Szczecin Poland Tel.: 91 466 16 48 E-mail: kasiabarczak@vp.pl Received: 25.07.2013 Revised: 2.09.2013 accepted: 16.09.2013
Praca wpłynęła do Redakcji: 25.07.2013 r. Po recenzji: 2.09.2013 r.
