IEJ445.

fm Page 649 Tuesday, October 30, 2001 5:39 PM

CASE REPORT
Oxford,
International
IEJ
Blackwell
0143-2885
if
34
Root
445
2001
Fava
known
canal
UKScience,
in aEndodontic
maxillary
Ltd 2001
Ltd, first
Journal
molar

Root canal treatment in an unusual

Graphicraft Limited, Hong Kong
00

maxillary first molar: a case report

L. R. G. Fava*
São Paulo, Brazil

Abstract

Fava LRG. Root canal treatment in an unusual maxillary first molar: a case report. International
Endodontic Journal, 34, 649–653, 2001.

Aim The aim of this clinical article is to describe the unusual anatomy that was detected
in a maxillary first molar during routine endodontic treatment.
Summary Success in root canal treatment is achieved after thorough cleaning and shaping
followed by the complete obturation of the root canal system. Such treatment may be
performed in root canal systems that do not comply with the normal anatomical features
described in standard textbooks. The present case describes root canal treatment in a
maxillary first molar with two roots and a type IV canal configuration in the buccal root.
Key learning points
• Careful examination of radiographs and the internal anatomy of teeth is essential.
• Root canal treatment is likely to fail if the entire system is not debrided and filled.
• Anatomic variations can occur in any tooth.

Keywords: external anatomy, internal anatomy, root canal treatment.

Received 16 May 2000; accepted 30 January 2001

Introduction

A thorough knowledge of both the external and internal anatomy of teeth is an important
aspect of root canal treatment. However, in everyday endodontic practice, clinicians have
to treat teeth with atypical configurations. Extra roots or root canals if not detected are a
major reason for failure (Slowey 1974).
When a preoperative radiograph reveals an atypical tooth shape and an unusual contour,
further radiographs should be taken with a different angulation to confirm any unusual
anatomical features (Fava & Dummer 1997).
In vitro and in vivo studies have demonstrated substantial variation in human maxillary
molar anatomy regarding the number of roots and root canals or the presence of a

Correspondence: L. R. G. Fava, Av. Nove de Julho, 5483 9° andar cj. 91, 01407-200, São Paulo, Brazil
(fax: +551130790882; e-mail: luizrfava@hotmail.com).
*L.R.G. Fava is in private practice limited to endodontics, in São Paulo, Brazil.

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C-shaped root canal system (Cecic et al. 1982, Hartwell & Bellizzi 1982, Newton & McDonald
1984, Abdel-Aziz & Gomaa 1986, Bond et al. 1988, Dankner et al. 1990, Wong 1991, Fernandez
et al. 1994, Holtzman 1997, Hulsmann 1997). The purpose of this clinical report is to
describe an anatomic abnormality that was detected during routine root canal treatment
in a maxillary first molar.

Report

A 55-year-old female patient was referred for root canal treatment in her maxillary left first
molar. She complained of pain to cold and hot food and drinks for 7 days. Her family dentist
had performed emergency treatment consisting of caries removal and a provisional restora-
tion with a zinc oxide-eugenol based cement.
The following day the patient presented complaining of pain. The tooth was tender to
vertical percussion but not to palpation. A diagnosis of acute pulpitis was confirmed by heat
and cold sensitivity tests. The initial radiograph disclosed the presence of two roots and a
large coronal dressing (Fig. 1). The medical history was non-contributory.
The tooth was anaesthetized and isolated with rubber dam and access was gained to
the pulp chamber. The coronal pulp tissue was removed and the chamber irrigated with an
anionic detergent solution (Tergensol – Inodon Lab., Porto Alegre, RS, Brazil). Only two root
canal orifices were detected, one buccal and one palatal; however, the buccal orifice had
an unusual and large eliptical shape that occupied a large area of the pulp floor. The canals
were explored and the working length determined. Interestingly, the radiographic image
of the buccal root showed that the instrument was not well centred (Fig. 2), suggesting
the presence of another root canal.
During the initial cleaning and shaping there was continued bleeding from the mesial
aspect of the buccal root. A small precurved file (size .08 Flexofile; Dentsply Maillefer,

Figure 1 Preoperative radiograph of maxillary molar.

Figure 2 Radiograph taken during working length determination.

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CASE REPORT
Figure 3 Postoperative radiograph showing obturation of the root canal system.

Figure 4 Radiograph taken 13 months after root canal obturation.

Ballaigues, Switzerland) was inserted in that region; it became lodged in the wall. With
clockwise and counterclockwise rotational movements, the instrument was advanced
until working length was achieved. Both mesial and distal aspects of the buccal root and
also the palatal canal were then cleaned and shaped using hand files (Flexofile – Dentsply
Maillefer) coupled with constant irrigation with an anionic detergent solution (Tergensol –
Inodon Lab.).
After cleaning and shaping, the canals were dried and obturated by cold lateral con-
densation of gutta-percha with a calcium hydroxide-based sealer (Sealapex, Sybron/Kerr,
Romulus, MI, USA) (Fig. 3). A sterilized cotton pellet was placed in the pulp chamber, the
access cavity sealed with Cavit (ESPE, Seefeld, Germany) and the patient dismissed. The
tooth was restored subsequently by the family dentist and 13 months later the tooth was
clinically asymptomatic and radiographically sound (Fig. 4).

Discussion

This report highlights two important issues. The first is the presence of only two roots, one
buccal and one palatal, and the second is the presence of a type IV configuration (Weine
1989) in the buccal root.
Most endodontic and dental anatomy texts describe the human maxillary first molar with
three roots and three or four root canals (Serra & Ferreira 1976, Weine 1989, Ingle et al.
1994, Leonardo 1998, Walker 1998, Roldi et al. 1999). In this case the initial radiograph
suggested only two roots, one buccal and one palatal. When a radiograph shows only one
buccal root, it is possible that the tooth has indeed only one buccal root or that the two
buccal roots have fused.
Maxillary first molars with a single buccal root have not been described in the literature.
However, cases of fused buccal roots have been described in textbooks (Serra & Ferreira

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1976), clinical cases (Sabala et al. 1994, Malagnino et al. 1997) and in in vitro studies (Pécora
et al. 1991). Pécora et al. (1991) found fused buccal roots in only 7.9% of human maxillary
first molars, whilst Sabala et al. (1994) reported only 0.4% with the same abnormality. As
the description of one buccal root has never been described before, it is possible that the
buccal root in this case represented a fusion.
The presence of two root canals in the maxillary first molar is rare, for example, Hartwell
& Bellizzi (1982) found only three cases (0.5%) out of 538 teeth treated in their in vivo study.
On the other hand, every individual root has a unique canal system. It may have one root
canal exiting in one apical foramen (type I), two root canals that join short of the apex
ending in one foramen (type II), two distinct canals emerging on the root surface through
two distinct foramina (type III) or one root canal that bifurcates inside the root ending in
two foramina (type IV) (Weine 1989). A type II configuration was described in a maxillary
first molar with fused buccal roots by Malagnino et al. (1997).
When the maxillary first molar has three distinct roots, the type IV canal configuration is
the least common and is usually described in the mesiobuccal root (Weine et al. 1969,
Pineda 1973, Gilles & Reader 1990, Kulild & Peters 1990) or in the palatal root (Holtzman
1997). Until now no clinical reports have described a two-rooted maxillary first molar in
which the buccal root presented a type IV configuration.
From a clinical standpoint, radiographic or other images provide clinicians with the most
appropriate method to detect variations in both root and canal anatomy. Only by correct
examination and interpretation of these images can the clinician detect such variations and
be aware of them before and during endodontic procedures.

Conclusion

When root canal treatment is to be performed the clinician should be aware that both external
and internal anatomy may be abnormal. Fortunately all procedures in this case were per-
formed uneventfully. However, in cases where the radiographic images are not clear or the
direct visualization of the internal anatomy is impaired, it is recommended that magnification
devices are used.

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