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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 128-130

Endodontic management of maxillary second molar with two separated palatal roots: A report of two cases


1 Abha Dental Center, Abha, Saudi Arabia
2 General Dentistry, King Khalid University, Abha, Saudi Arabia
3 Dental Department, Division of Endodontics, King Abdulaziz University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission13-Nov-2021
Date of Decision17-Nov-2021
Date of Acceptance18-Nov-2021
Date of Web Publication31-Aug-2022

Correspondence Address:
Dr. Abdulrahman Abdullah AlDhbaan
Department of Endodontics, Abha Dental Center, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoralsci.sjoralsci_60_21

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  Abstract 


Awareness of root canal morphology and variations is a crucial factor in successful root canal therapy. The prevalence of two palatal roots in a maxillary second molar is very rare. This study aimed to describe a case report of root canals treatment of a maxillary second molar with two palatal roots. Careful digital radiograph also cone-beam computed tomography examination seems necessary for the detection of variations.

Keywords: Maxillary molar, tooth morphology, two palatal root


How to cite this article:
AlDhbaan AA, Aldhaban OA, Al-Hawwas A. Endodontic management of maxillary second molar with two separated palatal roots: A report of two cases. Saudi J Oral Sci 2022;9:128-30

How to cite this URL:
AlDhbaan AA, Aldhaban OA, Al-Hawwas A. Endodontic management of maxillary second molar with two separated palatal roots: A report of two cases. Saudi J Oral Sci [serial online] 2022 [cited 2022 Oct 5];9:128-30. Available from: https://www.saudijos.org/text.asp?2022/9/2/128/355224




  Introduction Top


The main ultimate goals of root canal therapy are the thorough mechanical and chemical debridement of the entire pulp space, followed by complete obturation with an inert filling material. It is very important that the anatomical details of the root canal be observed before and during root canal procedures. This is because deviations from the norm can occur during root canal treatment.

Although it is rare to find two palatal roots in the second maxillary molars, in respective studies,[1],[2],[3] the authors did not find any upper second molars with duple palatal root canals. Libfeld and Rotstein[4] reported a 0.4% incidence of four-rooted maxillary second molars among 1200 teeth studied. This article describes two cases of unusual root and canal morphology involving the four-rooted second molar and their endodontic management.


  Case Reports Top


Case 1

A 51-year-old Saudi female was referred for endodontic evaluation after obtaining informed consent. The patient's chief complaint was mild pain to biting on her maxillary right side.

Based on the clinical and radiographic examinations for the right maxillary second molar, the tooth was diagnosed with having a previously treated pulp with symptomatic apical periodontitis. A treatment plan is a nonsurgical root canal retreatment.

Local anesthesia was administered and the bridge was removed by suction then the tooth was isolated using a rubber dam. Following the removal of the coronal restoration, three canal orifices (mesiobuccal, distobuccal, and distopalatal [DP]) filled with silver cones were identified. After examination of the pulpal floor under dental operating microscope (Global Dental Microscopes, Global Surgical Corporation,USA) a fourth opening in the pulpal floor was discovered. The access cavity outline was modified to establish straight-line access for all canals. The silver cone was removed using Stieglitz pliers forceps (Henry Schein) and application of indirect ultrasonic energy to a silver point by placing the ultrasonic tip against forceps that are holding the silver point.

The working length was determined using an apex locator (Root ZX II, J. Morita, Tokyo, Japan) and confirmed radiographically. All root canals were biomechanically prepared using single-length technique with ProTaper Next NiTi rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland). The canals were irrigated with 2.5% sodium hypochlorite between each file; during instrumentation, the canals were dried with paper points and obturated using gutta-percha cones and AH-plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). Finally, the access cavity was filled with a resin-modified glass ionomer filling, and the patient was referred to prosthodontic clinic to fabricate a full-coverage crown [Figure 1].
Figure 1: Preoperative, Postoperative and 3 months follow-up radiographs of case 1

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Case 2

A 47-year-old Saudi female with a noncontributory medical history was referred with a complaint of severe discomfort with his right maxillary teeth. The clinical and radiographic examinations revealed a maxillary right second molar with deep occlusal caries with tenderness on percussion. The clinical findings, radiographic findings, and pulp sensibility test led to a diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis with maxillary right second molar, necessitating root canals therapy.

Radiographic examination revealed four separate roots. The tooth was anesthetized. The tooth was anesthetized and rubber dam isolation was performed. The square shape access cavity was prepared with Cavity Access Set (Dentsply Maillefer, Ballaigues, Switzerland). Examination of the pulp chamber confirmed the presence of four orifices: Two on the buccal aspect and two on the palatal aspect.

The pulp tissue was removed, and working lengths were determined using an apex locator (Root ZX II, J. Morita Corp., Tokyo, Japan) and confirmed with a periapical radiograph. The four root canals were biomechanically prepared using single-length technique with ProTaper Next NiTi rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland). The canals were irrigated with 2.5% sodium hypochlorite between each file during instrumentation. The canals were dried with paper points and filled with nonsetting calcium hydroxide (Meta Biomed Co. Ltd., Chungcheongbuk-do, South Korea). Finally, the tooth was filled with temporary filling (ESPE, Seefeld, Germany). Moreover, take cone-beam computed tomography (CBCT) to confirm the morphology [Figure 2].
Figure 2: Preoperative, working length determination and postoperative radiographs along with CBCT axial views at apical, middle and occlusal root sections

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At the second appointment (1 week later), the root canals were obturated by gutta-percha cones and AH-plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). Finally, the access cavity was filled with a resin-modified glass ionomer filling and the patient was referred to prosthodontic clinic to fabricate a full-coverage crown.


  Discussion Top


Successful root canal treatment involves biomechanical instrumentation, three-dimensional obturation, and good coronal seal. Missing or undetected canals are often the main reasons for the failure of root canal treatment.[5],[6] This case highlighted the importance of detecting the morphological tooth during the treatment. Thus, thorough knowledge of the root canal system will help to reduce endodontic failures caused by incomplete debridement and obturation.

The two palatal roots are usually referred to as mesiopalatal and DP roots.[7],[8] Other studies used different terminology including first and second palatal roots,[9],[10] mesiolingual and distolingual roots,[7] or radix mesiolingual and radix distolingual.[11]

In the published studies, the prevalence of two palatal roots in maxillary second molars is very rare. Alavi et al.[12] examined 268 maxillary molars and they did not find any four-rooted maxillary molars. Peikoff et al.[13] observed that 1.4% of maxillary molars had duple palatal root. Hartwell and Bellizzi[14] found that 9.6% of the 176 maxillary second molars had four canals in an in vivo study. The presence of two palatal roots, on the other hand, has gone rare.

The extra palatal root could be seen in the digital radiograph in this case report. It can be concluded that, although the radiographs have limitations in giving information, careful examination of the radiographs with multiple angles also the use of CBCT are necessary. Because of its posterior placement, the anatomy of the maxillary second molar is difficult to diagnose. The superposition of anatomical components such as the zygomatic arch on this region's radiographs may make it difficult to diagnose a morphologic of second maxillary molar. We were able to overcome the superimpositions by taking numerous radiographs from various angles and using CBCT.


  Conclusion Top


Finally, while treating maxillary second molars, the likelihood of palatal roots with one or more canals, as well as the existence of two palatal roots, should be noted. It is critical to examine clean radiographs taken from two different angulations as well as the internal architecture of the teeth. If more roots or root canals are not discovered, root canal therapy is likely to fail.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the patient's images and other clinical information to be reported in the journal. The patient's parents understand that the patient's 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 Top

1.
Al Shalabi RM, Omer OE, Glennon J, Jennings M, Claffey NM. Root canal anatomy of maxillary first and second permanent molars. Int Endod J 2000;33:405-14.  Back to cited text no. 1
    
2.
Green D. Morphology of the pulp cavity of the permanent teeth. Oral Surg Oral Med Oral Pathol 1955;8:743-59.  Back to cited text no. 2
    
3.
Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589-99.  Back to cited text no. 3
    
4.
Libfeld H, Rotstein I. Incidence of four-rooted maxillary second molars: Literature review and radiographic survey of 1,200 teeth. J Endod 1989;15:129-31.  Back to cited text no. 4
    
5.
Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Top 2005;10:3-29.  Back to cited text no. 5
    
6.
Cantatore G, Berutti E, Castellucci A. Missed anatomy: Frequency and clinical impact. Endod Top 2006;15:3-31.  Back to cited text no. 6
    
7.
Friedman S, Stabholz A, Rotstein I. Endodontic management of molars with developmental anomalies. Int Endod J 1986;19:267-76.  Back to cited text no. 7
    
8.
Patel S, Patel P. Endodontic management of maxillary second molar with two palatal roots: A report of two cases. Case Rep Dent 2012;2012:590406.  Back to cited text no. 8
    
9.
Barker BC, Parsons KC, Mills PR, Williams GL. Anatomy of root canals. II. Permanent maxillary molars. Aust Dent J 1974;19:46-50.  Back to cited text no. 9
    
10.
Qun L, Longing N, Qing Y, Yuan L, Jun W, Qingyue D. A case of asymmetric maxillary second molar with double palatal roots. Quintessence Int 2009;40:275-6.  Back to cited text no. 10
    
11.
Carlsen O, Alexandersen V. Radix mesiolingualis and radix distolingualis in a collection of permanent maxillary molars. Acta Odontol Scand 2000;58:229-36.  Back to cited text no. 11
    
12.
Alavi AM, Opasanon A, Ng YL, Gulabivala K. Root and canal morphology of Thai maxillary molars. Int Endod J 2002;35:478-85.  Back to cited text no. 12
    
13.
Peikoff MD, Christie WH, Fogel HM. The maxillary second molar: Variations in the number of roots and canals. Int Endod J 1996;29:365-9.  Back to cited text no. 13
    
14.
Hartwell G, Bellizzi R. Clinical investigation of in vivo endodontically treated mandibular and maxillary molars. J Endod 1982;8:555-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]



 

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