Endodontic Treatment of Mandibular Premolars With Complex Anatomy Case Series
Endodontic Treatment of Mandibular Premolars With Complex Anatomy Case Series
Endodontic Treatment of Mandibular Premolars With Complex Anatomy Case Series
ISSN No:-2456-2165
Abstract:- Mandibular premolars are usually thought to in these teeth as they pose a considerable clinical challenge
be easy to treat endodontically but variations in their for their management.
anatomic configuration make them a difficult task to
accomplish. The possibility of additional root canals Mandibular premolars may have vast diversity in canal
should always be kept in mind when performing morphology [3]. Mandibular second premolars usually have
endodontic treatment with such cases. Adequate one canal but two or more canals may exist [4], [5]. The
knowledge of pulp canal anatomy, proper radiographic incidence of these teeth with two and three canals is between
interpretation, incorporation of CBCT, and dental 0-0.4% and 2.5% respectively [3], [6].
operating microscope are prerequisites for the best
possible outcome in complex root canal treatment. This II. CASE REPORT 1
case series presents a relatively uncommon clinical case of
mandibular premolars with two and three canal A 50-year-old female reported to the Department of
configurations managed with the help of DOM. Conservative Dentistry and Endodontics with the complaint
of pain in the posterior right mandibular region for 3 weeks.
Keywords:- Complex Anatomy, Endodontic Enigma, The episode of pain was spontaneously induced,
Mandibular Premolar. sharpshooting, and necessitated intake of analgesics for relief.
She had no relevant medical history. On clinical examination
I. INTRODUCTION right mandibular first premolar (#44) was grossly carious.
Clinical examination, radiographic interpretation, and vitality
Thorough knowledge and understanding of normal test led to the diagnosis of symptomatic irreversible pulpitis
anatomy along with its common variation, good radiographs with right mandibular first premolar thus requiring
with correct interpretation, optimal access preparation, endodontic treatment.
treatment of almost all micro entries of the internal aspect of
the tooth are crucial for the success of root canal treatment. Radiographic examination of the affected tooth denoted
Failure to appreciate these anatomic variations may increase the unusual anatomy of tooth #44 (Fig- 1). Shadow of pulp
the chance of root canal failure. Root canals may be left chamber was discontinuing as the radicular pulp at 3mm
untreated because the clinician is unaware of their presence below the crestal bone. Such appearance is usually suggestive
[1]. Newer aids like CBCT and DOM play a major role in of the division of the main canal into two or more canal
finding canals [2]. A dental operating microscope opens a systems. Appearance, in this case, is suggestive of
new horizon for clinicians, especially when treating bifurcation. The tooth was anesthetized using 2% Lignocaine
endodontic enigma [2]. with 1:100000 adrenaline. Rubber dam isolation was done
and endodontic access opening using No. 2 round bur and
If one proceeds with a notion of finding a single safe end bur (Mani, Inc., Tochigi, Japan) in a high-speed
canal in this tooth, then the clinician is highly likely to miss a airoter handpiece. The procedures were done under a dental
significant canal which can cause the failure of the entire operating microscope (DOM; Carl Zeiss, Germany). Access
treatment plan. So, it is necessary to have an understanding opening and deroofing was done at 0.6x magnification. The
and contemplate the morphological pattern usually observed pulp chamber was flushed with 2.5% sodium hypochlorite. A
GG drills (Mani, Inc., Tochigi, Japan) were used for IV. DISCUSSION
coronal flaring up to the canal furcation, this allowed
fiberoptic of the microscope to illuminate the furcation area. Root canal anatomic variations are particularly common
Careful exploration of the pulp chamber floor revealed three with mandibular premolars thereby it is imperative for correct
canals orifices, two in buccal and one in lingual (Fig- 2). diagnosis, treatment planning, and careful handling of the
Canal patency was achieved using #10 K-file (Mani, Inc., endodontic procedure [7]. Table 1 shows anatomic variation
Tochigi, Japan). Working length was determined using a in mandibular first premolars while Table 2 shows anatomic
standard protocol (Fig- 3). Cleaning and shaping were variations in mandibular second premolars by various
performed using a crown-down technique at 1.4x authors. According to trope et al [8] found that Afro-
magnification using Protaper gold nickel-titanium rotary Americans have the highest incidence of mandibular
instruments (Maillefer, Dentsply, Ballaigues, Switzerland) premolars with extra canals than Caucasians. A study of 2000
under intermittent irrigation with 2.5% sodium hypochlorite mandibular premolars in Chennai (India) showed that one
and EDTA (AveuPrep, Vasai, India). The temporary canal was seen in 75.4% and two distinct canals in 20.8%
restoration was placed upon completion and the patient was while three separate canals in 0.4% of mandibular premolars
recalled after 2 days. [7].
Rubber dam isolation was performed and temporary The clinician should visualize radiographically and have
restoration was removed. A master cone radiograph was adequate knowledge of internal anatomy before undergoing
taken which confirmed three separate root canals (Fig-4). endodontic treatment. When performing endodontic treatment
Sonic activator (Endoactivator, Maillefer, Dentsply, examination of pulp chamber floor may offer clues for the
Ballaigues, Switzerland) was used for activation of the location of orifices. Krasner and Rankow [9] demonstrated a
sodium hypochlorite, root canals were dried using paper definite pattern of pulp chamber floor and canal wall anatomy
points (Maillefer, Dentsply, Ballaigues, Switzerland). Canal exists. They proposed six laws for identifying canal orifices
obturation was carried out in two segments along with a resin which were found in 95% of the examined tooth.
sealer. (AH Plus, Maillefer, Dentsply, Ballaigues,
Switzerland). Individual tributaries of the main canal beyond The introduction of the microscope in Endodontics has
furcation were obturated using single cone technique and the revolutionized the everyday practice of specialty, enabling the
cones were seared off at the level of furcal orifices using practitioner to deliver an exceptionally high level of care in
touch n heat system (Sybron Endo, California, USA), and cases that previously may have been untreatable or resulted in
pluggers were used to vertically compact the gutta-percha. a compromised prognosis. Microscopes are very helpful in
Radicular pulp space was obturated using thermoplasticized treating complex anatomy such as endodontic enigma. D G
injectable gutta-percha (Kerr, California, USA). A hand 16 probe is particularly useful as a pathfinder on dentinal
plugger was used for the compaction of thermoplasticized maps for finding canals. Evaluation of two or more
gutta-percha. (Fig- 5) shows post obturation radiograph. radiographs is of utmost importance before an endodontic
procedure. According to Martinez-Lozano et al [10] by
III. CASE REPORT 2 changing the horizontal angulation by 20° and 40° showed
the actual number of canals in premolars. CBCT is also a
A 30 years old male reported to the Department of valuable tool for determining the number and position of root
Conservative Dentistry and Endodontics with the complaint canals before an endodontic treatment, which was used in one
of pain in the posterior right mandibular region for the last 1 of the cases.
week. He gave a history of intermittent pain and food
lodgment for the past 1 month in the same region. There was Also, abrupt disappearance of main canal indicate that
no relevant medical history. On clinical examination right there is a trifurcation or bifurcation which are the guidelines
mandibular second premolar (#45) had amalgam restoration suggested by Nattress and Martin. [11]
having secondary caries. Clinical examination, radiographic
interpretation, and vitality test led to the diagnosis of V. CONCLUSION
symptomatic irreversible pulpitis with right mandibular
second premolar thus requiring endodontic treatment. Owing to anatomic variations which are relatively
common with mandibular premolars which significantly
Radiographic interpretation of the affected tooth increases the difficulty for endodontic treatment. Thus dental
denoted the unusual anatomy of tooth #45 (Fig- 6). To study operating microscopes should be incorporated are in our
anatomic variation in detail CBCT was taken which showed practice as it is a valuable tool to increase the visualization
root bifurcation mesiodistally (Fig- 7 and 8) Prior to CBCT and illumination at the same time.
previous amalgam restoration with #45 was removed to
decrease the artifacts. As guided by the CBCT main canal
was clinically found at the middle one-third of the root (Fig-
9). After careful exploration of both the canals standard
protocol for working length determination (Fig- 10) cleaning
Fig. 8. Case 2. (CBCT showing axial section) Fig 12. Case 2. (Post obturation radiograph)
ACKNOWLEDGMENT
This case series did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
REFERENCES