International Journal of Oral Care and Research

CASE REPORT
Year
: 2022  |  Volume : 10  |  Issue : 2  |  Page : 45--47

Endodontic management of unusual anatomy of mandibular premolar: A case report


Padigala Ravi Sekhar Babu1, Janavathi2, Mithun J Kaslekar3, Kishore S Kumar4, Vikram Shetty2, Basavaraj Halli5,  
1 CKS Teja Dental College, Tirupathi, Andhra Pradesh, India
2 Department of Conservative Dentistry and Endodontics, Albadar Rural Dental College and Hospital, Kalaburgi, Karnataka, India
3 Department of Conservative Dentistry and Enodontics, SJM Dental College and Hospital, Chitradurga, Karnataka, India
4 Department of Conservative Dentistry and Enodontics, Aditya Dental College and Hospital, Beed, Maharashtra, India
5 Department of Conservative Dentistry and Endodontics, AME Dental College and Hospital, Raichur, Karnataka, India

Correspondence Address:
Janavathi
Department of Conservative Dentistry and Endodontics, Albadar Rural Dental College and Hospital, Kalaburgi, Karnataka
India

Abstract

Mandibular second premolars with three canals (Type V, Vertucci) and separate foramina are very infrequent. The incidence of three canals in mandibular second premolar has been reported to be 0.46–0.5%. The present report describes non-surgical endodontic treatment of mandibular second premolar with three canals. In this case, three orifices were located in mesiobuccal, distobuccal, and lingual. The clinicians must be aware of such anatomical variations and be able to use a variety of tools for adequate diagnosis and management.



How to cite this article:
Sekhar Babu PR, Janavathi, Kaslekar MJ, Kumar KS, Shetty V, Halli B. Endodontic management of unusual anatomy of mandibular premolar: A case report.Int J Oral Care Res 2022;10:45-47


How to cite this URL:
Sekhar Babu PR, Janavathi, Kaslekar MJ, Kumar KS, Shetty V, Halli B. Endodontic management of unusual anatomy of mandibular premolar: A case report. Int J Oral Care Res [serial online] 2022 [cited 2022 Sep 30 ];10:45-47
Available from: https://www.ijocr.org/text.asp?2022/10/2/45/348775


Full Text



 Introduction



Root canal treatment requires a thorough knowledge and understanding of root canal system and its varying morphology, which in turn will increase the long-term success of the treatment.[1] One of the reasons for acute flare-up could be attributed to the failure in locating the presence of additional canals[2]; familiarity with the variations in morphology helps in location and negotiation of canals and their subsequent intervention.

Mandibular premolars have shown greater variabilities in their morphology, with the presence of more than one canal.[3] Vertucci et al.[4] reported that the mandibular second premolar had one root canal at the apex in 97.5% and two canals in only 2.5% of the teeth; however, three root canals were scarce.

Zillich and Dowson found the incidence of three canals in mandibular second premolars to be 0.4%, which emphasizes the occurrence as being scarce. Mandibular premolars with three canals have been investigated before, but three orifices on the floor of the pulp chamber is rare.

The endodontic treatment of mandibular premolars with aberrant root canal morphology is challenging.[5] Adequate use of armamentarium and adapting proper techniques resulted in successful completion of endodontic treatment in the present case. The anatomy of the pulp chamber floor in this premolar reveals three root canals, two buccal and one lingual, in which the main canal is trifurcated from the midroot to the apex. This case report describes a second premolar with three canals and roots and an unusual pulpal floor anatomy.

 Case Report



A 55-year-old female with a non-contributing medical history was reported to the Department of Dental Surgery, Government General Hospital, Kurnool, for non-surgical endodontic treatment of mandibular right first premolar. The chief complaint was painful sensation on the lower right side on biting. The extraoral examination did not reveal any significant changes. Clinical examination revealed caries in the right second premolar and first molar.

Periodontal, endodontic, and occlusal evaluation of tooth 45 and adjacent teeth were done. There was slight tenderness to percussion and palpation, and the mobility of tooth was in normal physiological limits for tooth 45, whereas 46 is mobile (grade II-Wein’s). The intraoral periapical radiograph revealed a slight widening of periodontal ligament space with respect to tooth #45 and furcation involvement with widening of periodontal ligament for 46. Pulp sensibility tests were done using an electric pulp tester and the tooth showed a negative response.

All treatment options were explained to the patient for rehabilitating 45, as 46 had poor prognosis (according to) so it is advised to extract and the patient gave consent to restore the tooth.

Access cavity was done for tooth 45 using local anesthetic agent (2% lidocaine with 1: 100,000 epinephrine) under rubber dam isolation and tooth #45 was accessed. The pulp chamber was initially entered using number 2 round diamond bur (Dentsply Maillefer, Ballaigues, Switzerland), and the dentin that covers the pulp chamber was unroofed with Endo Z burs (SybronEndo, Orange, CA, USA). The pulp chamber was located in the distal half of the tooth. Careful inspection of the pulpal floor and walls revealed a black spot in the mesiolingual wall; ultrasonics were used to remove dentin shelves which covered the buccal orifices and negotiated with a 0.08 K file (Maillefere). Careful examination of the pulpal floor revealed three canal orifices, two buccal and one lingual, and they were located with a DG-16 endodontic explorer. In order to obtain a glide path, No. 10 K file (Dentsply Maillefer) was lubricated and used in watch winding motion and three separate canals were located [Figure 1]. Working lengths of all the three canals were initially determined radiographically and later confirmed with an apex locator (J. Morita) [Figure 2]. All the three canals were initially hand filed with 20 size K file (Flexofiles, Dentsply Maillefer) until the working length. Canals were shaped with nickel titanium rotary instruments (ProTaper Gold-Dentsply Malliefer) up to a size of 25 and taper 6% along with frequent irrigation using 5.25% sodium hypochlorite and 2% chlorhexidine solutions. The canals were lubricated with Glyde (Dentsply) during instrumentation. Calcium hydroxide-containing iodoform was placed inside the canal as an intracanal medicament during the interappointment period, and access cavity was sealed using Cavit (3M ESPE).{Figure 1} {Figure 2}

The patient was asymptomatic during the interappointment period. After 3 weeks, tooth 45 was reopened, the intracanal medicament was removed, and the length of the master cone was checked with a radiograph [Figure 3]. All the three canals were finally obturated with 6% gutta-percha (Dentsply Maillefer) using AH Plus as a sealer, and the coronal access was sealed with Cavit [Figure 4].{Figure 3} {Figure 4}

 Discussion



Mandibular premolars have been reported with complex morphology, making them one of the most difficult teeth to manage endodontically. Therefore, the familiarity of both basic and possible variations in root canals is essential for successful non-surgical root canal treatment.[6]

In the pre-access analysis, prior to the access preparation, the operators need to evaluate the orientation and location of root canal orifices thoroughly based on both clinical and radiographic findings.

The root shape, root position, and relative root outline should be carefully determined from the radiograph. A high-quality pre-operative radiograph with straight and angled views provides insight into the existing root canals.[7]

Generally, in mandibular premolars with three canals, the cervical half of the root is wider than usual, with little or no taper. Root canals may not be evident in radiographs and may look unusual. A sudden change in radiographic density and sudden narrowing of the root canal space usually indicate an additional canal. Therefore, careful interpretation of the periodontal ligament space and angled views may suggest the presence of an extra root or canal. In the presented cases, unusual root shape was observed in pre-treatment radiographs, which recommended the possibility of extra roots and canals.[6]

Detecting orifices, especially of the third canal, is a great challenge for the dentists. Many practitioners recommended using Gates-Glidden drills to pre-flare the canal. Access preparation was modified with pre-flaring of coronal portion for thorough visualization of the root canal as well as ease of placement of initial apical file and shaping and cleaning of the apical third of the root canal system.

In this case, after the regular design of access cavity was prepared, another unusual orifice was observed, the pulpal floor is with one distobuccal orifice and one distolingual orifice at the same level and one orifice on the mesiolingual wall.

The cervical pre-flaring after access preparation helps in easy negotiation of hidden canals, as it removes dentin precisely and conservatively. Pre-flaring can be done using hand, rotary, and recently ultrasonic tips.

Hoen and Pink reported 42% of missed canals or roots in teeth requiring retreatment.

Although in-vitro and in-vivo studies[8],[9],[10] report low incidence of mandibular second premolars with three canals, each case should be analyzed individually through precise radiographic and clinical examination in order to find all root canals.

 Conclusion



This case report has demonstrated a morphofunctional rehabilitation. Successful and predictable endodontic treatment requires knowledge of normal anatomy and variations. In the case in which radiographic images are not helpful to clarify root canal anatomy and aberrations, magnification devices are recommended. Also enhancement of color contrast by means of dye may be helpful to visualize deeply situated orifice and aberrations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Nallapati S Three canal mandibular first and second premolars: A treatment approach. J Endod 2005;31:474-6.
2Rossman LE, Hasselgren G, Wolcott JF Oral facial dental pain and emergencies: Endodontic diagnosis and management. In: Cohen S, Hargreaves KM, editors. Pathways of Pulp. 9th ed. St. Louis, MO: Mosby; 2006.
3Slowey RR Root canal anatomy. Road map to successful endodontics. Dent Clin North Am 1979;23:555-73.
4Vertucci F, Seelig A, Gillis R Root canal morphology of the human maxillary second premolar. Oral Surg Oral Med Oral Pathol 1974;38:456-64.
5Ash MM Jr. Wheeler’s Dental Anatomy, Physiology and Occlusion. 8th ed. Philadelphia: W. B. Saunders; 2003. p. 151-6.
6England MC Jr, Hartwell GR, Lance JR Detection and treatment of multiple canals in mandibular premolars. J Endod 1991;17:174-8.
7Kupczik K, Delezene LK, Skinner MM Mandibular molar root and pulp cavity morphology in Homo naledi and other Plio-Pleistocene hominins. J Human Evolut 2019;130:83-95.
8Al-Fouzan KS The microscopic diagnosis and treatment of a mandibular second premolar with four canals. Int Endod J 2001;34:406-10.
9Macri E, Zmener O Five canals in a mandibular second premolar. J Endod 2000;26:304-5.
10Cleghorn BM, Christie WH, Dong CC Anomalous mandibular premolars: A mandibular first premolar with three roots and a mandibular second premolar with a C-shaped canal system. Int Endod J 2008;41:1005-14.