‘Endodontic Treatment of Permanent Mandibular Molar

8/6/2019 Endodontic Treatment of Permanent Mandibular Molar

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ENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGYENDODONTOLOGY

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Endodontic Treatment of Permanent Mandibular Molar

with 3 distal canals

SURBHI KAKAR *

SACHIN GUPTA * *

* 3rd Year P.G. Student, * * Sr. Lecturer, Department of Conservative Dentistry & Endodontics, Subharti Dental Col lege, Meerut

INTRODUCTION

Over the years, there have been numerous

studies and several cases of multiple canal systems

in mandibular first molars teeth have been

investigated and discussed. Skidmore and Bjordal

(1971), Pomeranz et al. (1981), Weine (1981), Fabra

Campos (1985), Martinez Berna & Badanelli

(1985), Bond et al (1988), Jacobsen et al. (1994)

have reported the presence of the three root canals

in the mesial and the distal roots 1-7 Additionally,

Stroner et al and Batty & Interian 8, 9 have reported

a third canal that was located in the distal root.

Astonishingly, Reeh 10 has even reported a case with

seven canals, consisting of four canals in the mesial

root & three in the distal root.

It has been postulated that secondary dentine

apposition during tooth maturation would form

dentinal vertical partitions inside the root canal

cavity, thus creating the root canals. A third root

canal may also be created inside the root cavity of

mandibular molars by this process. Such third

canals are situated centrally between the two main

buccal and lingual root canals 11. The diameter of

those third canals is smaller than that of the other

two Martinez - Berna and Badanell i 1985 5 and is

age related because of apposition of dentine Fabra

- Campos 1985 4 with increasing reports of aberrant

canal morphology, the clinician needs to be aware

of its varied anatomy.

The purpose of this study is to discuss the

occurrence of three distal canals in a mandibular

first molar and its endodontic management.

CASE REPORT

A 30 year old North Indian female, presented

to the Department of Conservative and

Endodontics, Subharti Dental College, Meerut, with

the chief complaint of pain and swell ing in lower

left posterior region since two days. The pain was

spontaneous, acute and localised. It was partially

Case Report

ABSTRACT

The dynamic concept of the root canal system, describing a variable morphology of mul tiple root canals has been

established as the prevailing state in mandibular molars. The prognosis for endodontic treatment in these teeth is

unfavourable if clinician fails to recognize additional root canals. This case report presents the treatment of a

mandibular first molar with five root canals, of which three canals were located in the Distal root. Al l canals were

cleaned, shaped & obturated. Cleaning and Shaping of the three distal and two mesial canals was performed

using combination of Step Back (in Apical 1/3rd) and Crown Down (in Coronal & middle 1/3 rd ) technique and

obturated.

Key Words: Mandibular first molar, root canal treatment, morphological variations.


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relieved on taking medications and would recur

after few hours. Patient complained of thermal

sensitivity in the same region. The clinical

examination revealed deep occlusal caries

involving enamel and dentine of mandibular left

first molar.

An Intraoral periapical radiograph (IOPA) and

Electric pulp test was advised for the same tooth

(Fig.1). Radiograph revealed deep caries

approaching pulp chamber and periodontal

widening in relation to 36. The tooth was tender to

percussion and Electric Pulp Testing elucidated

response at a higher value then control tooth.

A diagnosis of acute irreversible pulpits with

apical periodontits was made. Endodontic treatment

was initiated for the same. Access cavity preparation

was accomplished using Endo access and Endo-Z

burs with high speed aerotar handpiece. Pulp

chamber was copiously irrigated with 5% NaOCl

while ensuring rubber dam isolation and high

volume evacuation.

Inspection of subpulpal floor using Endo-

explorer revealed two canal orifice in two mesial

and two distal root.

However careful exploration and inspection

using No. 6K file under magnifying loupes

revealed the presence of two more canal orifice,

one in mesial between mesiobuccal and

mesiolingual orifice, other in distal root between

distobuccal and distolingual orifice (Fig.2 & 3).

However patency was achieved only in five canals.

The middle mesial canal could not be negotiated

beyond 2-3mm which was estimated using RVG

(Gendex) and Apex locator (Ray Apex).

Intermittent irrigation with 5% NaOCl along

with EDTA as lubricant was continued throughout

the procedure.

Finally all canals were enlarged upto size F2

Protaper Rotary. Pre obturation master cone was

verified using Intraoral Periapical Radiograph

(IOPA) (Fig.4).

Obturation was done using size F2 Protaper

cones and AH Plus sealer. Access cavity was sealed

using IRM (Fig.5 & 6).

An appointment was scheduled with the

Department of Radiology for Dentascan of the

concerned tooth to ascertain the root morphology.

The Dentascan confirmed the presence of two

roots (one mesial and one distal) wi th three orifices

in the distal canal (Fig.7).

Fig. 1. Diagnostic IOPA radiograph revealing deep caries and

periodontal w idening in relation to 36

Fig. 2. Working length radiograph depicting patency in five canals

out of six (The middl e mesial canal could not be negotiated

beyond 2-3 mm)

Fig. 3. Clinical View of the 6 orifices. Note - The small middle

mesial orifi ces right behind the mesio buccal orif ices.

SURBHI KAKAR, SACHIN GUPTA


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Fig. 4. Master Cone IOPA radiograph.

Fig. 5. IOPA radiograph of Obturation with F2 ProTaper cones

and AHPlus sealer

Fig. 6. Clini cal view before sealing the access cavity wi th IRM

Fig. 7. Dentascan Confirming the presence of two roots

(one mesial and one di stal) wi th three ori fices in distal canal.

DISCUSSIONIt has already been discussed and

demonstrated in l iteratures that mandibular molars

may manifest variations of root canal morphology.

According to the literature the incidence of

third distal canals is 0.6% (Fabra - Campos 1985).

The incidence of third canal in the distal root of

mandibular molars was found to be much lower

than in the mesial root Martinez Berna and

Badanelli (1985). The larger mesiodistal dimension

of the distal root, compared to mesial root, may

account for the rare incidence of thi rd canal createdby dentine apposition in distal roots.

In this case report there was confluence of the

third middle distal canal with Distobuccal and

Distolingual canals and having common apical

termination.

Instrumentation is one of the key factors in

the success of endodontic therapy and the clinician

should be aware of the varied anatomy. An avid

clinician should be always keen to explore the

possibility of additional canals whenever in doubt,with the assistance of technologies such as the those

of magnification and il lumination.

In this case report the hybrid technique was

followed to prevent strip perforation.

REFERENCES:1. Skidmore AE, Bjorndal AM (1971) Root canal morphology

of the Human mandibular first molar. Oral Surgery. OralMedicine, Oral Pathology, 32, 778-84.

2. Pomerantz HH, Eidelman Dl, Goldberg MG (1981)

Treatment considerations of the middle mesial canal of

mandibular first and second molar. Journal of Endodonti cs7,565-8.

3. Weine FS (1981) Case report: Three canals in the mesialroot of mandibular fi rst molar. Journal of Endodonti cs8. 517-

20.

4. Fabra Campos H (1985) Unusual root anatomy of

mandibular first molars. Journal of Endodontics11, 312-14.

5. Martinez-Berna A. Badanelli P 91985) Mandibular firstmolar with six root canals. Journal of Endodontics8, 348-52.

6. Bond JL, Hartwell , GR, Donnelly JC, Portell FR (1988)

Clinical management of middle mesial root canals in

mandibular molars. Journal of Endodonti cs14, 312-14.

7. Jacobsen E. Dick K. Bodell R. Mandibular first molars wi th,multiple mesial canals. J. Endodon 1994. 20:610-3.

8. Stroner W, Remeikis N. Carr G. Mandibular first molarwith three distal canals. Oral Surg 1984:54:554-7.

9. Beatty R, Interian C.A. Mandibular first molar with fivecanals: reported a case. JADA; 111:769-71.

10. Reeh E. Seven canals in a lower first molar. J. Endodon

1998;24:497-9.

11. L. Holtzman. Root Canal treatment of a mandibular firstmolar with the mesial root canals. IEJ1997; 30: 422-423.

ENDOD ONTIC TREATMENT O F PERMANENT MAND IBULAR MOLAR W ITH 3 D ISTAL CANALS

‘Endodontic Treatment of Permanent Mandibular Molar

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