CASE REPORT

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Filippo Cardinali, Francesca Cerutti, Eugenio Tosco, Antonio Cerutti

Preoperative diagnosis of a third root canal in first and second maxillary premolars: a challenge for the clinician
Filippo Cardinali
Private practice, Ancona, Italy

Francesca Cerutti
Department of Restorative Dentistry University of Brescia Brescia, Italy

Key words

anatomical variants, maxillary premolars, radicular anatomy, three-canal maxillary premolars

Eugenio Tosco
Department of Restorative Dentistry Polytechnic University of Marche Ancona, Italy

Aim: The aim of this report was to describe the steps of a diagnostic protocol used to recognise the presence of a third root canal in first and second maxillary premolars at an early stage. Materials and methods: A total of 43 maxillary first premolars and 51 maxillary second premolars were endodontically treated in a private practice between 1999 and 2004 after having been examined clinically and radiographically. Results: A third root canal was present in 4 out of the 43 first maxillary premolars (9.3%) and in 1 out of the 51 (1.9%) second maxillary premolars that were endodontically treated. All of the five cases were diagnosed preoperatively. The early interception of an anatomical variant allows the clinician to choose the best operative strategy for a specific tooth in terms of access cavity design, canal shaping and cleaning, filling and post-endodontic restoration. Conclusions: Radiographic and clinical examinations of maxillary premolars are essential for early diagnosis of the presence of a third root canal. A careful examination of the pulp chamber floor can help to find the orifice of a third root canal intra-operatively.

Antonio Cerutti
Department of Restorative Dentistry University of Brescia Brescia, Italy Correspondence to: Dr Filippo Cardinali Via Cesare Battisti, 24 Ancona, Italy 60123 Email: filocardinali@libero.it

Introduction
The most difficult aspects for a clinician performing orthograde root canal treatment are generally related to the anatomy of the teeth1. Anomalous root and root canal morphology, even if present with different degrees of incidence, can occur in every tooth; several studies have investigated the presence of anatomical anomalies of maxillary premolars.

First and second maxillary premolars generally present with one or two roots, and with one or two root canals, but in a few cases, three roots or three canals have been reported in the literature2-17. Concerning first maxillary premolars with three roots, three anatomic variants exist: three separated roots, interfused buccal roots, and three interfused roots. The presence of a third root or a total of three canals is reported in the literature with percentages ranging

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Table 1 The percentage of the number of roots of the first maxillary premolar, as reported by nine different studies. Reference (number of teeth examined) Pucci and Reig2, 1945 (n.d.) De Deus3, 1973 (n.d.) Carns and Skidmore4,1973 (100) Vertucci and Gegauff5, 1979 (400) Pecora et al6, 1991 (240) Loh7, 1998 (957) Kartal et al8, 1998 (300) Chaparro et al , 1999 (159)
9

1 root 43 35.5 22 26 55.8 49.4 37.3 40 15.5

2 roots 52.6 61 72 70 41.7 50.6 61.3 56.7 75.4

3 roots 2.4 3.5 6 4 2.5 0 1.3 3.3 9.2

Lipski et al10, 2003 (142)

n.d., number of teeth not disclosed in the study

Table 2 The percentage of the number of canals characteristic of the first maxillary premolar, as reported by 13 studies. Reference (number of teeth examined) Hess , 1925 (269) Pineda and Kuttler12,1972 (259) Green13,1973 (50) Carns and Skidmore , 1973(100) Vertucci and Gegauff , 1979 (400) Della Serra and Ferreira14, 1981 (260) Walker15, 1987 (n.d.) Pecora et al , 1991 (240) De Deus , 1992 (108) Caliskan et al17, 1995 (n.d.) Kartal et al8, 1998 (300) Chaparro et al , 1999 (159) Lipski et al , 2003 (142)
10 9 3 6 5 4 11

1 canal 19.5 50.1 8 9 26 19.5 36 17.1 8.3 9.8 8.7 40 2.1

2 canals 79.3 49.4 92 85 69 79.3 64 80.4 84.2 90.2 89.7 56.7 88.6

3 canals 1.2 0.5 0 6 5 1.2 0 2.5 7.5 0 1.6 3.3 9.2

from 0 to 9.2%2-15,17 (see Tables 1 and 2). The archetype of the second maxillary premolar can be identified in a single root; Pecora et al16 examined 435 second maxillary premolars, reporting the presence of a single root in 90.3% of the cases, two roots in 9.7% of cases and no case of three roots. The presence of a third root canal in second maxillary premolars has been shown in the literature, but in extremely low percentages, ranging from 0 to 1%8,12,16-18 (Table 3). An accurate literature analysis stressed that the presence or absence of a third root canal is influenced by genetic factors, since three-rooted premolars are more frequent in Caucasian populations and practically non-existent in Asian populations15,19-21. In order to predict all situations that may arise while performing root canal therapy, the clinician should know all of the possible anatomical variations, and recognise them in the diagnostic phase of the treatment based on his or her anatomical knowledge and on a correct interpretation of preoperative radiographs22. In the case of maxillary premolars, in fact, an early detection of the presence of a third root canal will change the operative strategy of the orthograde treatment in terms of access cavity, root canal orifice localisation, canal shaping, obturation and restorative techniques. The aim of this paper is to focus on the signs that can reveal to the operator the presence of a third root canal in maxillary premolars. Incorrect interpretation of the clinical and radiographic data regarding canal and root morphology of the tooth can result in incomplete shaping, cleaning and filling of the endodontic system, with a high expectancy of clinical failure23.

Report
The present study encompassed 43 first maxillary premolars and 51 second maxillary premolars that underwent root canal treatment over a period of 5 years (from 1999 to 2004) in a private practice. All teeth included in the study were clinically and radiographically examined before root canal treatment; in all cases one or more intra-operative radiographs were taken. Once root canal treatment was completed, teeth were monitored both clinically and radiographically in recalls that took place every year. All cases presented in this article are characterised by a follow-up of at least 3 years.

n.d., number of teeth not disclosed in the study Table 3 The percentage of the number of canals of the second maxillary premolar, as reported in 5 studies. Reference (number of teeth examined) Pineda and Kuttler , 1972 (259) Vertucci18, 1984 (200) Pecora et al6, 1992 (435) Caliskan et al17, 1995 (n.d.) Kartal et al , 1998 (300)
8 12

1 canal 81.8 75 67.3 72 48.66

2 canals 18.2 24 32.4 28 50.64

3 canals 0 1 0.3 0 0.66

n.d., number of teeth not disclosed in the study

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Diagnostic phase
Clinical examination
A careful clinical examination can furnish the clinician with signs that are typical of the presence of a third root. In the buccal aspect, the gingiva has a flat appearance and its convexity is not in harmony with the adjacent elements. Sulcular probing can disclose the presence of a buccal furcation; sometimes a small depression can be present, starting from the buccal roots furcation and proceeding in a coronal direction for a few millimetres, remaining mainly localised in the cervical third of the tooth crown.

Operative strategies
The execution of a correct coronal access cavity is the basis of a rational and predictable orthograde root canal treatment: if the access is inadequate in terms of extension, position or depth, the treatment outcome will not be optimal24. If in the diagnostic phase the presence of a third canal is suspected, the access cavity will present a mesiodistal extension in the buccal portion. Consequently, the cavity will be T-shaped, because this is the only morphology that represents the coronal projection of the pulp chamber floor, allowing straight-line access to the canals25. If, on the contrary, the diagnostic phase does not address the search for a third canal, only an accurate observation of the pulp chamber floor and a correct interpretation of the canal entrance shape will be helpful. The canal orifices of multi-rooted teeth are often linked by slightly marked sulci; this can also occur in three-canal maxillary premolars when the bifurcation of the buccal canals is located in the pulp chamber. It is then advisable to completely remove the pulp tissue from the chamber and to exploit the action of the irrigants (generally sodium hypochlorite), by activating them with ultrasonic instruments, to have a clearer vision of the pulp chamber floor. Sometimes the bifurcation of the two buccal canals can be found in the middle third of the root; in these cases the canal entrance shape can be of use, since it will not be circular, but probably oval and flattened in the bucco-palatal direction. In this case, the behaviour of manual instruments in the initial negotiation of the canal can suggest the presence of a third canal. Upon probing the buccal canal, the instrument may deviate mesially or distally before proceeding in the apical direction24. In this phase, the canal orifices have not yet been transported and, for this reason, when the instrument is in the mesiobuccal canal, the handle deviates distally. Vice versa, when the file is in the distobuccal canal, the handle is displaced mesially. The presence of a third root canal should also be considered when, in the working-length radiograph, the instrument is totally displaced mesially or distally respective to the root profile26. Once the presence of two buccal root canals is defined, the canal entrances will be transported in opposite directions from each other using Gates-Glidden burs (SybronEndo, Orange, CA, USA) or Orifice Openers (Dentsply, York, PA,

Radiographic examination
The limit of a radiographic examination is the production of a two-dimensional image of a threedimensional root canal system; to achieve a better evaluation of the three-dimensional structure of the tooth, three preoperative radiographs often have to be taken at different angles. Nevertheless, a good quality radiograph, taken according to the parallel technique, can provide enough evidence of internal and external anatomy of the root to suggest the presence of a third canal1. By analysing the external anatomical details, the presence of a third root canal can be suspected whenever the radicular anatomy is not clearly visible or distinct. If the buccal roots are separated, it is sometimes possible to distinguish the furcation cortical bone. Another external aspect of anatomy to be considered is that a premolar tooth with three roots has a small taper; when the mesiodistal diameter of the middle third of the root is equal or greater than the mesiodistal diameter of the crown, a third root canal is likely to be present6. Considering the internal root anatomy, the analysis has to be conducted following the run of the canal proceeding from the pulp chamber toward the apex. If the root canal suddenly seems to broaden and straighten, or if it loses its radiolucency such that its course cannot be followed anymore, it should be suspected that there is the presence of a second canal in the same root or of a canal in another root superposed on the first one because of the radiographic projection.

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Fig 1 Clinical case 1.

d Fig 1a Fig 1b Fig 1c Fig 1d Fig 1e Fig 1f Fig 1g

Preoperative radiograph of tooth 15. The accurate analysis of the external radicular anatomy shows the scarce conicity of the root: the mesiodistal diameter of the radicular middle third is almost equal to the crown mesiodistal diameter, as indicated by the arrows. The observation of the internal radicular anatomy details indicates several discontinuous canal lumens. The intra-operative radiograph with the root canal instruments (K-files) inserted into the canals confirms the presence of three root canals. Post-operative radiograph, after root canal filling. Control radiograph taken after coronal restoration. Control radiograph taken at the 6-year follow-up recall.

USA) to obtain a straight-line access to both canals. Straight-line access reduces the stress on the root canal instruments and decreases the fracture risk and the extent of canal transportation27. Finally, the clinician should know that the presence of three root canals is associated with a reduced radicular diameter: in maxillary premolars with separated roots the dentine wall around the canal lumen varies from 1.8 mm in the coronal third of the root to 1 mm in the apical third28.

Two clinical cases out of the 94 examined in this study, both performed by Dr Filippo Cardinali, will be reported as examples.

Clinical case 1
A 45-year-old patient complained of diffuse pain in the maxillary right posterior quadrant. Clinical and radiographic examination showed the presence of an amalgam restoration of tooth 15 with a secondary car-

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Fig 2 Clinical case 2.

d Fig 2a Fig 2b

Fig 2c Fig 2d Fig 2e Fig 2f

Preoperative radiograph of tooth 24, showing the massive loss of mineralised tissue due to caries. Preoperative radiograph of tooth 24. Neither the external radicular anatomy nor the course of the root canals is clearly discernible. The mesiodistal diameter at the middle third is larger than the coronal mesiodistal diameter, as indicated by the red arrows. The intra-oral picture illustrates that the buccal canal orifice is not as circular as the palatine one, but rather oval and flattened in the buccal-palatal direction. After the shaping and transportation of the canal orifices, the presence of two buccal canals is evident, as shown by the intra-oral photograph. Intra-operative radiograph with the master cones inserted into the root canals. Post-operative radiograph, taken to check the canal obturation.

ious lesion. The diagnosis was acute pulpitis of tooth 15; the therapy included an orthograde root canal treatment, followed by prosthetic restoration. In the radiograph, the root presented a small taper: the mesiodistal root diameter at the middle third was equal to the crown mesiodistal diameter. Moreover, the canal course did not appear linear while proceeding from the crown towards the apex (Figs 1a to 1c). The working length radiograph confirmed the presence of three root canals (Fig 1d). After root canal shaping, the

canals were obturated (Fig 1e) and the tooth was restored (Fig 1f). The recall radiograph taken 6 years (Fig 1g) after the endodontic treatment confirmed the success of the treatment.

Clinical case 2
A 53-year-old patient complained of diffused pain in the maxillary left posterior quadrant. Clinical and radiographic examination showed the presence of a deep

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Fig 2 Clinical case 2 (continued).

g Fig 2g Fig 2h Fig 2i Fig 2j

Post-operative radiograph, taken in a different projection, to provide a complete view of the root canal system and a more precise control of the filling. The prosthetic preparation shows, close to the gingival sulk, the presence of a furcation between the two buccal roots. This image shows the radiograph taken at the 1-year follow-up visit. Radiograph taken at the 3-years follow-up visit showing the complete filling of the canal system and the absence of any radiological signs of failure of the therapy.

carious lesion on tooth number 24, while tooth 25 was missing (Fig 2a). In the radiograph, the radicular external anatomy was not defined and the canal course did not appear to be linear proceeding from the crown towards the apex. The mesiodistal diameter of the root in the middle third was greater than the mesiodistal crown diameter (Fig 2b). The diagnosis was acute pulpitis of tooth 24; the therapy included an orthograde root canal treatment and a prosthetic restoration. After complete removal of the carious lesion, the pulp chamber was opened: the buccal canal orifice was oval and flattened in the buccal-palatine direction (Fig 2c). The canal entrances were transported, and the canals were then shaped (Fig 2d). Consequently, three master cones were fit to the working length, and a radiograph was taken (Fig 2e). After obturation, the access cavity was sealed with composite and two radiographs were taken from different angles (Figs 2f and 2g). Six months later, the tooth was prepared for a gold ceramic crown: the crown preparation showed the presence of a furcation between the two buccal roots (Fig 2i). Clinical and radiographic recalls 3 years after the treatment revealed the success of the therapy (Figs 2i and 2j).

Discussion
In the 43 first maxillary premolars examined in this study, 4 presented with a third root canal (9.3%), while a third canal was present in only 1 out of 51 second maxillary premolars (1.9%). All of these five teeth belonged to males and all cases presented clinical and/or radiographic signs that, carefully evaluated, allowed a preoperative determination of a third root canal. The presence of a third root canal in first maxillary premolars is a clinical reality that cannot be disregarded, since the literature reports the occurence of its presence2-15,17. Second maxillary premolars, on the contrary, present a third root canal in a few cases only8,12,16-18. It is widely accepted that the success of root canal treatment depends essentially on a correct and complete shaping, cleaning and obturation of the root canal system28. According to Hoen and Pink23, 42% of teeth that need root canal retreatment presented at least one root canal that was not correctly shaped, cleaned and filled. To discover the anatomical difficulties to be faced, the true challenge for the clinician is to consider each case on its own merit during the diagnostic phase through an accurate clinical examination and a correct interpretation of the preoperative radiograph(s).

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Thus, he/she will be able to plan the most suitable operative strategy on how to treat the tooth. In a premolar with three separated roots, shaping of canals located in roots with small diameters, especially the buccal ones, is a clinical challenge. Consequently, the root canal preparation must respect the anatomy, avoiding excessive removal of the root canal dentine to avoid weakening the tooth structure. For the same reason, obturation techniques using thermoplasticised gutta-percha are preferred to lateral condensation, in consideration, of the major stress produced on the radicular dentine when using the latter technique29,30. This means that the operator needs to know the anatomical variants of the tooth in question and has to apply his or her knowledge in the preoperative interpretation of the clinical and radiographic data.

6.

7. 8. 9.

10.

11. 12.

13. 14.

15.

Conclusion
In the case of the first and second maxillary premolars, this study focused on the signs that, if correctly read, allow for the identification of the presence of a third root canal. In the absence of obvious clinical and radiographic signs, the clinician who approaches root canal treatment of a first maxillary premolar should always consider the possibility of the presence of a third canal. In these cases, the factors that should be carefully evaluated are the position of the manual instruments used in the initial negotiation of the canal and also their position shown by the radiographic images.

16.

17.

18. 19. 20.

21.

22. 23.

24.

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