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REVIEW ARTICLE 7
groups. A new classication is proposed to include all their accessory root and root canal congura- Correspondence to:
tions. In addition, the endodontic considerations, including their identication and management, are Dr Hany Mohamed Aly
Ahmed
discussed. Department of Restorative
Dentistry, School of Dental
Sciences,
Universiti Sains Malaysia,
Kubang Kerian, 16150,
Kelantan, Malaysia
Introduction root12-15. However, the presence of accessory roots Tel: 00-601-298-57937
Email: hany_endodontist@
and/or root canals can be rather common4,6,16. hotmail.com
The anatomical features of maxillary premolar teeth
show a lot of morphological variation. These vari-
ations comprise coronal anomalies such as dens in- Aetiology
vaginatus1, dens evaginatus2 and gemination3, and
radicular anomalies including accessory roots and root Accessory root formation
canals4, taurodontism5, buccal radicular longitudinal
sulcus6, abnormal curvatures, and dilacerations7,8. While the exact reason for accessory root forma-
Thorough knowledge of both normal and un- tion remains uncertain, different ethnic groups, lo-
usual dental morphology is essential for the practice cal traumatic injuries to Hertwigs epithelial root
of endodontics9. The problem of missed anatomy sheath during root formation, genetic factors
during root canal therapy is commonplace for teeth and some diseases are considered to be the main
requiring retreatment10,11. Maxillary premolars will causes17-21. Armitage22 suggested the occurrence
benet, as this tooth seems to show an increased of three-rooted maxillary and mandibular premolar
prevalence of root and root canal aberrations11. teeth as a rare recessive trait or a result of gene
Traditional beliefs and many morphological stud- mutation. Barros et al23 observed the presence of
ies are such that maxillary rst and second premolar three-rooted maxillary premolar teeth in two pa-
teeth are either single rooted, containing one or two tients of the same family and, hence, assumed the
root canals, or double rooted, with one canal in each possibility of inheritance.
Table 3 Percentage of maxillary premolar teeth with accessory roots and root canals in different populations
(AR: three-rooted maxillary premolars; *three-canalled maxillary premolars presented with undened root number).
in a double- and single-rooted form. Sieraski et al4 variants, especially for the presence of canal inter-
presented maxillary rst premolar teeth with the communications, such as isthmuses. From a clinical
buccal root enclosing two root canals (conguration perspective, the radiographic interpretation, clinical
types 1-2 and 2-1). Weine71 and Dadresanfar et al72 diagnostic landmarks and some endodontic proce-
commented that these two buccal root canals usually dures will also vary when these root canals are pre-
have a common orice. Mattuella et al6 noted a high sented in different root numbers. A new, proposed
incidence of two separate root canals in a maxillary rst classication (Table 5) is given here, hoping to in-
premolar with its buccal root exhibiting a longitudinal clude all possible accessory root and root canal con-
sulcus. Kerekes and Tronstad35 reported the presence gurations in relation to maxillary premolar teeth.
of four canals in a maxillary second premolar 5 mm
from the apex, which then joined to one root canal.
Sert and Bayirli48 observed that 2% of maxillary pre- Endodontic implications
molar teeth with a 1-2-3-2 canal conguration were
in males. Awawdeh et al55 reported 0.5% of double- Preoperative assessment
rooted maxillary rst premolar teeth with 3 canals,
while 0.2% showed an additional canal conguration a) Clinical
(2-3-2-3). The clinical examination of three-rooted maxillary
As a result of these wide anatomical variations, premolar teeth commonly reveals a relatively large
either in the number of roots or root canals, a gen- sized crown, especially in the mesiodistal diameter,
eralised classication is required to describe these resembling a small molar23. However, this should
morphological aberrations in maxillary premolar not be taken as a general rule as it is subjective, and
teeth. Although Vertuccis classication for root usually the coronal structure of the tooth requiring
canal morphology73 and its subsequent supplemen- root canal treatment may have been destroyed ex-
tal congurations48,74 are benecial in recognising tensively. Other crown anomalies like gemination
most root canal congurations, the number of roots might also indicate a complex root canal system58.
present in premolar teeth and the root canals con- The presence of periodontal pockets and/or gin-
tained therein were not addressed. For instance, gival recession can facilitate the identication of the
Class VIII represents three separate, distinct root external root anatomy, such as root bifurcation. How-
canals extending from the pulp chamber to the ever, in three-rooted premolar teeth, the furcation is
apex73, but with no information on whether these commonly located between the apical and middle
canals are encased in single, double or three-rooted third of the root length75, which complicates its detec-
premolars. From an anatomical perspective, the root tion70. In double-rooted maxillary premolar teeth, the
canal system will vary in maxillary premolar teeth buccal longitudinal sulcus can be probed, indicating
with class VIII in single, double and three-rooted an increased possibility for root canal aberrations6.
Table 5 Proposed classication of maxillary premolar teeth with accessory roots b) Radiographic
and/or root canals. BR: buccal root. PR: palatal root.
Three-rooted maxillary premolar teeth Although the conventional radiographic views pro-
Class 1 The maxillary premolar teeth exhibit three vide only two-dimensional images, they are funda-
roots with three root canals (either two mental and valuable examination tools in the detec-
buccal roots and one palatal root or one
buccal root and two palatal roots). tion of accessory roots and root canals. Radiographic
analysis should essentially be performed using prop-
erly exposed and processed radiographs to pave
the way for optimal interpretation of external and
internal root anatomy76. The use of magnication
and other supportive viewing aids are benecial77,78.
Double-rooted maxillary premolar teeth with 2 buccal and 1 palatal root canals Digital radiography provides real-time image dis-
Class 2 The buccal root exhibits two root canals play, reduced radiation exposure, enhanced image
coronally and joining to form one canal
with one apical foramen. The palatal root processing and ease of archiving79,80. Even though
has one root canal. the image quality and precision remain limited with
earlier machines79,81, the use of digital radiography
nowadays has gained more popularity.
The radiographic appearance of three-rooted
BR PR
maxillary premolars can be identied on straight-
on preoperative radiographs, in which the mesio-
Class 3 The buccal root exhibits two separate root
canals extending coronally to the apex. distal width of the mid-root image is equal or
The palatal root has one root canal. greater than the mesiodistal width of the coronal
image4. Tracing the periodontal ligament space
of each individual root is essential. Although the
radiographic interpretation would become more
difcult when the three roots lie close to each
BR PR other or are fused, altering the horizontal angle
Class 4 The buccal root exhibits one root canal can facilitate their detection11,23,82. Bifurcation of
coronally which bifurcates into two separ- the root canal can be detected with meticulous
ate root canals with two apical foramina.
The palatal root has one root canal.
observation for the dimensional regularity of the
pulpal space. Abrupt diminishing or the appear-
ance of a break point in the root canal usually
indicates a bifurcation (Fig 1).
Recent advances in diagnostic radiographic
BR PR techniques have provided promise in the detec-
Single-rooted maxillary premolar teeth with 3 root canals tion and interpretation of root canal anatomy83-86.
Class 5 The single root exhibits three separate root Cone beam computed tomography (CBCT) is able
canals with three apical foramina.
to provide three-dimensional imaging with a low
radiation dose and reasonably high resolution, pro-
ducing images resembling that of modied canal
staining and clearing techniques in identifying root
canal anatomy85,86. However, CBCT should be only
considered when the conventional periapical radio-
graphs fail to provide adequate information and
Maxillary premolar teeth with supplemental congurations
details of the structures to be identied87, as CBCT
Class 6 Three-canalled maxillary premolar teeth with additional canal con-
gurations
views can also show some misleading ndings88. To
(like 1-2-3-2 and 2-3-2-3) are included. sum up, two- and three-dimensional radiographic
Four-canalled maxillary premolar teeth are described under this class. images are valuable tools in providing useful infor-
mation regarding the root and root canal anatomy; The pulp chamber volume of the three-rooted
however, they should be correlated with the clinical variant is variable, and a distance of less than 1 mm
picture in order to achieve proper morphological between the most cervical region of the pulp cham-
assessment11,88. ber roof and the canal bifurcation can exist62. This
requires great caution by using suitably sized access
burs to prevent accidental perforation of the pulp
Access cavity preparation
chamber furcation.
Access cavity preparation is a critical step during
which accessory roots and/or root canals are de-
Root canal exploration
tected. Complete removal of the roof of the pulp
chamber and all interferences to the root canal ori- There may be times when the identication of the
Fig 1 Root canal
ces should then give an indication of the internal usual root canal conguration is missed during clin- bifurcation related to
morphological features of the root11. Better pre- ical and radiographic examinations or during access maxillary rst premolar
tooth (white arrow:
cision and enhanced visibility of the internal root cavity preparation. This may become discernible break point; yellow
anatomy can be achieved by utilising some form of during canal exploration and working length de- arrows: bifurcated root
canals).
assisted vision, such as magnication and co-axial termination.
illumination11,89. Tactile examination, which can be precisely per-
In three-rooted maxillary premolar teeth, formed after removal of the coronal resistance, is
the access cavity should be wide buccally, in a via the use of a small pre-curved le along the root
mesiodistal direction, forming a T or a triangular canal walls. A catch on the way towards the apical
conguration4,23,47, resembling that of maxillary foramen might indicate the presence of an accessory
molar teeth, but smaller in size. The buccal canal canal orice76. During working length determin-
orices are located at the same horizontal line, and ation, the clinician should observe the le directions
can often be clearly identied when the two canals inside the root canal, as well as the location within
open into the pulp chamber separately (Figs 2a the root on the radiograph. Eccentric le position, in
to c). The two orice openings are shifted mesially a mesial or distal direction, indicates the probability
and distally, respectively, relative to the palatal of root canal bifurcation (Fig 3).
orice (Fig 2b). This shift becomes more difcult to
recognise when the buccal canals bifurcate below
Working length determination
the cervix and share a common orice; however,
the relatively wider mesiodistal dimension of Vier-Pelisser et al62 observed the variability in the
this common buccal orice should be noticeable apical foramina position for three-rooted maxillary
(Fig 2c). premolar teeth; the foramina tended to lie in the
a b c
Fig 2 Schematic diagram showing (a) normal location of the buccal and palatal orices at the same vertical intersecting
line. (b) The buccal orices are located mesially and distally to the vertical intersecting line extended from the palatal orice.
(c) The common orice of the two buccal canals is usually wider mesiodistally than the palatal orice, even though they are
located at the same vertical intersecting line.
a b c
Fig 3 (a and b) The mesiodistal shift of the le direction was observed in the buccal root of tooth 25 (white arrows: (a)
distal location, (b) mesial location). (c) The two root canals were concurrently identied in the buccal root.
palatal and distal aspects of the buccal and palatal irrigation needle with a small diameter is favourable
roots. This nding indicates the necessity of using for more effective ow of the root canal irrigants96.
electronic apex locators for locating the apical for- The treatment procedure becomes increasingly com-
amen, in addition to the periapical radiographic plicated when either of the buccal canals becomes
views, in order to maintain high levels of accuracy calcied64,67.
during working length determination90. In cases where the two buccal roots exhibit a nar-
row single orice, the mesiobuccal and distobuccal
root canals should be enlarged towards the mesial
Root canal preparation
and distal walls respectively, in order to provide an
Three-rooted maxillary premolar teeth adequate space for subsequent mechanical prepar-
ation and obturation4,71.
Before initiating the mechanical instrumentation, the
dentine thickness of the buccal roots should be ac-
Double-rooted maxillary premolar teeth
curately evaluated. Even though three-rooted max-
with three canals
illary premolar teeth can accept many different in-
strumentation techniques23,27,28,91, their buccal root Double-rooted maxillary premolar teeth are basic-
canals are signicantly smaller in diameter than in ally presented with particular external morphologi-
double- or single-rooted forms35. Attention should cal landmarks. In 62% to 100% of cases, the buccal
be paid to this, especially when they are encased in root exhibits a palatal groove, sometimes called a
thin needle-like buccal roots4. Using some enlarg- buccal furcation groove (also described as devel-
ing instruments, like the Gates-Glidden burs (sizes 3 opmental depression or furcation concavity), which
and 4), is not recommended92. It is advisable to ex- extends from a point just apical to the bifurcation,
ploit the use of hand les and nickel titanium rotary and disappears towards the apex97. Occasionally,
les of a suitable taper (not more than 0.06)4,93. the buccal root is complicated by a buccal groove or
Meticulous care should be taken for the curvature a longitudinal sulcus6,97, which usually indicates the
of these roots and for the abrupt curve at the bi- presence of two buccal canals6. As a result of these
furcation entrance, to prevent le separation. Once external root morphological features, many authors
broken, the separated segment can be extremely recommended avoiding unnecessary enlargement
difcult to retrieve and its removal often would carry of these roots, as this can increase the risk of per-
a high risk of root perforation94,95. The use of an foration and vertical root fracture97,98. Particular
consideration should also be taken when the ac- introduction of gutta-percha cones into each branch
cessory buccal canal is curved to prevent separation of the bifurcated canal. If the coronal space is not
of les (Fig 4). enough to accept two master cones at once, the
larger master cone can be cut by a scalpel at the
level of bifurcation; this segment of gutta-percha is
Obturation
pierced at the end by a spreader or a le (Fig 6), and
Maxillary premolars with buccal root/root then introduced and compacted into the canal103.
canal bifurcations in the cervical third Subsequently, the second master cone can be guided
into the second canal and the obturation technique
Different obturation techniques have been success- continued. That is, obturation is done by the down
fully employed for three-canalled maxillary pre- packing of each buccal canal separately, followed by
molar teeth with coronally separated buccal roots/ backlling of the common canal47. It is advisable to
root canals28 (Fig 5). While using small-sized heat take a conrmatory periapical radiograph after ll-
carriers, pluggers and narrow backll needles used ing the canals to the level of bifurcation and before
during the warm compaction technique are suit- backlling the common coronal portion. Magnica-
able for most canal types99; the lateral compaction tion and illumination will afford a controlled obtur-
method using a spreader with minimum taper is rec- ation of the buccal canals during the warm vertical
ommended when the buccal roots in three-rooted compaction technique.
premolars are obviously thin. This will conserve the
amount of dentine required for removal, to enable
Maxillary premolars with buccal root/root
the proper accommodation of the warm compacted
canal bifurcations in the apical third
armamentarium. Furthermore, the amount of heat
transferred through thin dentine walls from the root The obturation of canals exhibiting apical bifurcation
canal to the external root surface can reach high is the most challenging. Magnication and illumin-
levels, causing undesirable thermal damage to the ation are important in controlling the obturation
supporting peri-radicular tissues100-102. procedure, which can be adequately lled using the
squirt technique. In this technique, both ends of
the root canals are obturated simultaneously by in-
Maxillary premolars with buccal root/root
jection of thermoplasticised gutta-percha, followed
canal bifurcations in the middle third
by backlling103. Practicing this technique requires
In the case of root/root canal bifurcations occur- experienced hands and an optimal apical stop.
ring at the mid-root region, adequate aring of the An alternative method may be to adjust the mas-
canal coronal to the bifurcation is important for the ter gutta-percha cone (preferably, using one with
Fig 6 A photograph
showing pierced gutta-
percha after cut off.
a 1 2 3 4 b
Fig 7 (a) Schematic diagram showing the obturation procedure of a buccal root with apical bifurcation. 1) Prepared canals
before obturation. 2) Master cone adjustment in one root canal. 3) Half of the master cone length is removed and the
remaining gutta-percha above the bifurcation is softened. A pre-sized plugger is used for apical compaction (a snugly t-
ting master cone in a well-prepared apical stop is required to prevent the accidental pushing of the cone out of the apex).
4) Another master cone is adjusted on the new working length, followed by lateral compaction technique. (b) A periapical
radiograph showing a buccal canal with apical bifurcation. The apical third was obturated by the above technique.
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