Sie sind auf Seite 1von 6

Case Report/Clinical Techniques

New Nomenclature for Extra Canals Based on Four Reported


Cases of Maxillary First Molars with Six Canals
Kittappa Karthikeyan, MDS, and Sekar Mahalaxmi, MDS

Abstract
This clinical article describes 4 different case reports of
maxillary first molars with unusual anatomy of 6 root
canals and their endodontic management. Treating
T he endodontic management of maxillary first molars presents a constant challenge.
There can be 3, 4 (more common), 5, 6, or more than 6 canals. The form, config-
uration, and number of root canals existing in maxillary first molars have been dis-
these additional canals in maxillary first molars might cussed by many authors. The occurrence of a fourth canal ranges from 50.4%–95%
be challenging. Inability to locate and properly treat (1–11), a fifth canal is 2.25% (2), and a few authors have also reported cases with
these extra canals might lead to failures. A thorough 6 canals (12, 13). The dentist must have a thorough knowledge of root canal
knowledge of root canal morphology and the proper morphology, and working under microscope increases the chances for successful
use of microscopes increase chances for successful clin- endodontic outcome.
ical results. Because presence of these extra canals is
not unusual and naming these canals still remains
elusive, a new nomenclature is suggested for ease of Case Reports
communication. (J Endod 2010;36:1073–1078) These are the case reports of 4 patients treated in the Department of Conservative
Dentistry and Endodontics, SRM Dental College, Chennai, India. A thorough history was
Key Words taken, and the cases were both clinically and radiographically evaluated. All 4 cases
Access modification, additional canals, magnification, were done by use of surgical operating microscope (Seiler Revelation Microscope,
nomenclature, root canal morphology St Louis, MO). The patients received local anesthesia with 2% lignocaine solution
with 1:80,000 epinephrine (Lignox 2% A; Indoco Remedies Ltd, Mumbai, India).
The entire procedure in each case was done by using rubber dam isolation. Frequent
irrigation with 3% sodium hypochlorite (Vensons India, Bangalore, India) was also
From the Department of Conservative Dentistry and carried out during cleaning and shaping. Radiographs were taken for each and every
Endodontics, SRM Dental College, Ramapuram, Chennai, India. step.
Address requests for reprints to Dr K. Karthikeyan, Senior
Lecturer, Department of Conservative Dentistry and Endodon-
tics, SRM Dental College, Ramapuram, Chennai-89, India. Case Report 1
E-mail address: dockarthicck@yahoo.com. A 38-year-old male patient reported to the department with pain in the upper left
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
region. On evaluation the diagnosis was confirmed as irreversible pulpitis with apical
doi:10.1016/j.joen.2009.12.001 periodontitis in tooth #14 (Fig. 1C). After conventional access cavity preparation, the
3 principal root canals were identified: mesiobuccal (MB), distobuccal (DB), and
palatal. After probing with a DG 16 (Hu-Friedy, Chicago, IL) endodontic explorer
and scraping calcifications with a spoon excavator, small hemorrhagic points were
noted approximately 3 mm from the MB orifice in the palatal direction and near the
orifice of the palatal and DB canals.
The conventional triangular access was modified to a trapezoidal shape to improve
access to the additional canals (Fig. 1A, B). The MB (Vertucci’s type IV), DB (Vertucci’s
type II), and palatal (Vertucci’s type II) roots had 2 canals each, fairly well-separated
and exiting from the floor of the pulp chamber.
Orifice shapers (size 25, .08 and .10 taper, RaCe; FKG Dentaire, La Chaux-de-
Fonds, Switzerland) with ethylenediaminetetraacetic acid (Glyde; Dentsply Maillefer,
Ballaigues, Switzerland) were used to preflare the coronal portion of the canals to
improve straight-line access. After working length determination, cleaning and shaping
were done by using K-files (Mani, Tochigi, Japan) and rotary files (RaCe) to size 25, .06
taper. The canals were dried with paper points (Dentsply Maillefer); a dry cotton pellet
was placed in the pulp chamber followed by a temporary seal with Cavit G (3M ESPE,
Seefeld, Germany).

Case Report 2
A 21-year-old male patient reported to the department complaining of pain in the
left upper back tooth region for 1 month. On evaluation it was diagnosed as irreversible
pulpitis with apical periodontitis in tooth #14 (Fig. 2C). A conventional endodontic
access opening was made; the 3 principal root canal systems were identified (MB,

JOE — Volume 36, Number 6, June 2010 Nomenclature of Maxillary Molars 1073
Case Report/Clinical Techniques

Figure 1. Case 1. (A, B) Modified (trapezoidal) access cavity of case 1 showing 6 orifices (2 palatal, 2 MB, and 2 DB canals). (C) Preoperative radiograph. (D)
Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modified access, and black line is for
canal orifice outline and external outline of modified access.

DB, and palatal). The pulp chamber floor was then explored with DG 16 ation a diagnosis of irreversible pulpitis with apical periodontitis
explorer mesial to the line joining MB and the palatal canals to locate the associated with tooth #3 was made (Fig. 3C). A conventional
MB2 canal. Hemorrhagic points were noted approximately 1 mm mesial endodontic access opening was made, and the MB, DB, and palatal
to the orifice of the palatal and 2 mm from the MB and DB canals toward canal orifices were identified. After troughing; the pulp chamber floor
the palatal direction. The conventional triangular access was modified was explored with a DG 16 explorer, which indicated the presence of 2
to a rectangular shape to improve access to the additional canals MB and 2 DB canals. The conventional access was modified to improve
(Fig. 2A, B). The MB (Vertucci’s type IV), DB (Vertucci’s type II), access to the additional canals (Fig. 3A, B). The DB2 and MB2 were
and palatal (Vertucci’s type II) roots had 2 orifices each, well- approximately 3 mm and 2 mm, respectively, from the DB1 and MB1
separated and exiting from the floor of the pulp chamber. orifices in the palatal direction. During verifying the patency of DB1
Coronal flaring was done with ProTaper SX rotary file (Dentsply canal with 10 size K-file, it was noted that the file could be oriented
Maillefer) to improve straight-line access, and the working length in 2 different angulations. A radiograph was taken with files in all the
was calculated. Cleaning and shaping were done by using K-files canals (2 files in DB1 canal with different angulations) to confirm
(Mani) and ProTaper rotary files (Dentsply Maillefer) up to F2 size that the files were within the root canal system, which revealed 3 canals
and palatal canals to F3 size. The canals were then dried with paper in DB root (Gulabivala’s supplemental canal configuration type III)
points; a dry cotton pellet was placed in the pulp chamber followed (Fig. 4). MB and palatal roots had Vertucci’s type IV and type I config-
by a temporary seal with Cavit G. urations, respectively.
After coronal flaring with ProTaper SX rotary file and working
length determination, cleaning and shaping were accomplished with
Case Report 3 K-files up to size #25 and ProTaper rotary files to size F3 for palatal
A 25-yearold-female patient reported to the department complain- canal and F2 for the other canals. It was observed that DB1 and DB2
ing of intermittent pain in the right upper back tooth region. On evalu- joined together after cleaning and shaping. The canals were then dried

Figure 2. Case 2. (A, B) Modified (rectangular) access cavity of case 2 showing 6 orifices (2 palatal, 2 MB, and 2 DB canals). (C) Preoperative radiograph. (D)
Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modified access, and black line is for
canal orifice outline and external outline of modified access.

1074 Karthikeyan and Mahalaxmi JOE — Volume 36, Number 6, June 2010
Case Report/Clinical Techniques

Figure 3. Case 3. (A, B) Modified (rhomboidal) access cavity of case 3 showing 5 orifices (1 palatal, 2 MB, and 3 DB canals; DB and SDB had same orifice). (C)
Preoperative radiograph. (D) Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modi-
fied access, and black line is for canal orifice outline and external outline of modified access.

with paper points, and a dry cotton pellet was placed in the pulp IV), DB (Vertucci’s type II), and palatal (Vertucci’s type II) roots had
chamber followed by a temporary seal with Cavit G. 2 orifices each, fairly well-separated and exiting from the floor of the
pulp chamber.
Coronal flaring was done with ProTaper SX rotary file to improve
Case Report 4 straight-line access, and the working length was calculated. Cleaning
A 49-year-old male patient reported to the department complain- and shaping were done by using K-files and ProTaper rotary files up
ing of pain in tooth #14 with previously attempted root canal (the proce- to F2 size and palatal canals to F3 size. The canals were then dried
dure was done in a private clinic). On evaluation a diagnosis of pulp with paper points, and a dry cotton pellet was placed in the pulp
necrosis associated with tooth #14 was made (Fig. 5C). A conventional chamber followed by a temporary seal with Cavit G.
endodontic access opening was already present without any coronal At the next appointment, the root canals of all 4 cases were irri-
restoration. After isolation, carious tooth structure was removed, and gated with 3% sodium hypochlorite (Vensons India) followed by
the 3 principal root canal systems were identified (MB, DB, and normal saline and dried with paper points. The canals were obturated
palatal). The orifice of the palatal canal was large and dumbbell- (Figs. 1D, 2D, 3D, 5D) by using resin sealer (RC Seal; Prime Dental
shaped. By using a DG 16 endodontic explorer, catch points were noted Products, Mumbai, India) and laterally condensed gutta-percha
approximately 2 mm and 1 mm from the MB and DB orifices, respec- (Dentsply Maillefer). All cases were postendodontically restored with
tively, in the palatal direction and another canal orifice 2 mm approx- full veneer crowns, and they were asymptomatic thereafter at 6-month
imately mesial to the orifice of the palatal. follow-up.
The access cavity was then modified to a trapezoidal shape
(Fig. 5A, B) to improve access to the additional canals. The pulp
chamber floor revealed entry to 6 canals. The MB (Vertucci’s type Discussion
The variation of root canal morphology especially in multi-rooted
teeth is a constant challenge for successful endodontic therapy (14).
These case reports emphasize the importance of use of magnification
for exploring canals and modification of the access cavity to ensure
proper endodontic treatment.
Endodontic access should be designed to provide direct access to
the apical third of the root canal system (15). The dentist should be able
to visualize all aspects of the coronal third of the root canal system, and
all tooth structure or restorative material that interferes with straight-
line access should be removed (15). To achieve a straight-line access,
the conventional triangular access cavity can be modified into many
shapes such as clover leaf–like (shamrock) (16), heart (17), trape-
zoidal (11, 15, 18, 19), rectangular (20), rhomboidal (3, 21), and
ovoid (22) shapes, depending on the particular clinical situation. In
these presented cases the conventional triangular access was prepared
first, and then it was modified Figs. 1(A, B), 2(A, B), 3(A, B), and
5(A, B) during exploration of extra canals.
According to the literature, the occurrence of fourth canal in
maxillary first molar ranges greatly: 53% (Hess 1925) (9), 56.2%
(Okumara 1927) (10), 51.5% (Weine et al 1969) (1), 64.3% (Pineda
Figure 4. Case 3. Radiograph showing the presence of 1 palatal, 2 MB, and 3 and Kuttler 1972) (5), 62% (Seidberg et al 1973) (7), 50.4% (Slowey
DB canals. 1974) (8), 69% (Pomeranz and Fishelberg 1974) (6), 72% (more

JOE — Volume 36, Number 6, June 2010 Nomenclature of Maxillary Molars 1075
Case Report/Clinical Techniques

Figure 5. Case 4. (A, B) Modified (trapezoidal) access cavity of case 4 showing 6 orifices (2 palatal, 2 MB, and 2 DB canals). (C) Preoperative radiograph. (D)
Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modified access, and black line is for
canal orifice outline and external outline of modified access.

than 3 canals) (Acosta Vigouroux and Trugeda Bosaans 1978) (2), used and contributes to a rational approach to solve the problems
74% (Thomas et al 1993) (11), 72% (Fogel et al 1994) (3), and that arise during therapy. Among the root canal anomalies of maxillary
95% (Kulid and Peters 1990) (4). The occurrence of a fifth canal molars, the least frequent appears to be that of the palatal root (23, 24).
was 2.25% (Acosta Vigouroux and Trugeda Bosaans) (2). The incidence of more than 1 palatal canal has been reported to be less
Some authors have reported a few cases with 6 canals (Martinez- than 2% (25). In the presented 4 case reports, 3 cases had 2 palatal
Berna and Ruiz-Badanelli (3 MB, 2 DB, and 1 palatal) (12) and Bond canals.
et al (2 MB, 2 DB, and 2 palatal) (13). The review of previously reported Magnification aids such as loupes and dental operating micro-
cases that had more than 4 canals in maxillary molars is tabulated in scopes enable the clinician to easily identify the extra canals (21).
Table 1. The endodontic procedures were performed under dental operating
Of the 4 presented case reports, 3 cases had 2 palatal, 2 MB, and 2 microscopes in the presented cases.
DB canals; the fourth one had 1 palatal canal, 2 MB canals, and 3 DB
canals (DB1and DB2 shared same orifice, and DB3 had separate
orifice). In all the cases, routine extension of the pulp chamber floor Nomenclature of Root Canals in Maxillary Molars
with troughing along the line angles was carried out without penetrating In cases in which there are more than 3 canals in a tooth, the
deeper or extending into the coronal dentin. terminology of the additional canals is not clear and unique; MB2
Slowey (23) stated that root canal anatomy of each tooth dictates (21, 26) and P1 (20) (in case of 2 palatal canals) were both called me-
the location of the initial entry of access and size of the first file to be siopalatal canals by different authors. Some authors refer to MB2 as

TABLE 1. Previously Reported Cases with >4 Canals in Maxillary Molars


Author name Year Type of study No of cases / extracted teeth No. of canals
Vigouroux et al (2) 1978 Extracted teeth 3 5
Cecic et al (33) 1982 Clinical case 1 5
Martinez-Berna et al (12) 1983 Clinical case 1 6
Beatty (34) 1984 Clinical case 1 5
Bond et al (13) 1988 Clinical case 1 6
Wong (35) 1991 Clinical case 1 5
Hulsmann (36) 1997 Clinical case 1 5
Holtzman (37) 1997 Clinical case 2 5
Johal (38) 2001 Clinical case 1 5
Maggiore et al (39) 2002 Clinical case 1 6
Barbizam et al (40) 2004 Extracted tooth 1 5
Ferguson et al (41) 2005 Clinical case 1 5
Ghoddusi (20) 2006 Clinical case 2 5
Chen et al (29) 2006 Clinical case 1 5
Filho et al (28) 2009 Ex vivo 1 7
Clinical 1 5
1 6
CBCT 1
Aggarwal et al (18) 2009 Clinical case 1 5
Weng et al (24) 2009 Ex vivo 2 (first molar) 5
1 (second molar) 5
Holderrieth et al (32) 2009 Clinical case 3 5

CBCT, cone beam computed tomography.

1076 Karthikeyan and Mahalaxmi JOE — Volume 36, Number 6, June 2010
Case Report/Clinical Techniques
mesiolingual canal (3). To avoid confusion, considering that every root Acknowledgments
might contain 3 canals at the most, the following nomenclature of addi-
tional canals in maxillary molars is suggested: We thank Prof Dr Kavitha, Dr Jones Mathias, Dr Gingu Koshi
George, and Dr S. Chandrasekar, SRM Dental College for their
Canals of MB root support in preparation of this manuscript.
MB1: mesiobuccal (MB)
MB2: second mesiobuccal (SMB) References
MB3: mesiobuccopalatal (MBP)
1. Weine FS, Healey HJ, Gerstein H, Evanson L. Canal configuration in the mesiobuccal
Canals of DB root root of the maxillary first molar and its endodontic significance. Oral Surg Oral Med
DB1: distobuccal (DB) Oral Pathol 1969;28:419–25.
DB2: second distobuccal (SDB) 2. Acosta Vigouroux SA, Trugeda Bosaans SA. Anatomy of the pulp chamber floor of
DB3: distobuccopalatal (DBP) the permanent maxillary first molars. J Endod 1978;4:214–9.
3. Fogel HM, Peikoff MD, Christie WH. Canal configuration in the mesiobuccal root of
Canals of palatal root the maxillary first molar: a clinical study. J Endod 1994;20:135–7.
Palatal (P) 4. Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuc-
Mesiopalatal (MP) cal root of maxillary first and second molars. J Endod 1990;16:311–7.
Distopalatal (DP) 5. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of
7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101–10.
In MB and DB roots the canals are named starting from most 6. Pomeranz H, Fishelberg G. The secondary mesiobuccal canal of maxillary molars. J
buccal canal, and subsequent canals are named heading toward the Am Dent Assoc 1974;88:119–24.
7. Seidberg BH, Altman M, Guttuso J, Suson M. Frequency of two mesiobuccal root
palatal direction. But in the palatal root the main canal is palatal (P); canals in maxillary permanent first molars. J Am Dent Assoc 1973;87:852–6.
the extra canals are termed mesiopalatal (MP) or distopalatal (DP), de- 8. Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg 1974;
pending on the location (mesial or distal) of the canal in relation to the 37:762–72.
main palatal. The use of term lingual (eg, mesiolingual) in case of 9. Hess W. The anatomy of the root canals of the teeth of the permanent dentition. Lon-
maxillary molars should be avoided. don: John Bale Sons and Danielsen; 1925. part I:32–5.
10. Okumara T. Anatomy of the root canals. J Am Dent Assoc 1927;14:632–6.
11. Thomas RP, Moule AJ, Bryant R. Root canal morphology of maxillary permanent first
molar teeth at various ages. Int Endod J 1993;26:257–67.
Methods of Detecting Additional Canals 12. Martinez-Berna A, Ruiz-Badanelli P. Maxillary first molars with six canals. J Endod
Different methods of locating extra canals have been discussed by 1983;9:375–81.
many authors (15, 27–32): 13. Bond JL, Hartwell G, Portell FR. Maxillary first molar with six canals. J Endod 1988;
14:258–60.
1. Additional off-angle radiographs (at least 3 radiographs at varying 14. Malagnino V, Gallotini L, Passariello P. Some unusual clinical cases on root anatomy
of permanent maxillary molars. J Endod 1997;23:127–8.
horizontal angles). 15. Johal S. Unusual maxillary first molar with 2 palatal canals within a single root:
2. Use of computed tomography. a case report. J Can Dent Assoc 2001;67:211–4.
3. Use of magnification (loupes and dental operating microscopes). 16. Ingle JI, Backland LK, Peters DD, Buchanan S, Mullaney TP. Endodontic cavity prep-
4. Examine dentinal map minutely and use DG 16 to explore the floor aration. In: Ingle JI, Backland LK, eds. Endodontics. 4th ed. Baltimore, MD: Williams
of the pulp chamber. and Wilkins; 1994:96–8.
17. Neaverth EJ, Kotler LM, Kattenback RF. Clinical investigation of endodontically
5. Look for hemorrhagic spots (indicate the presence of extra treated maxillary molars. J Endod 1997;13:506–12.
canals). 18. Aggarwal V, Singla M, Logani A, Shah N. Endodontic management of a maxillary first
6. Perform champagne or bubble test with sodium hypochlorite. molar with two palatal canals with the aid of spiral computed tomography: a case
7. Staining the pulp chamber with dye (eg, 1% methylene blue). report. J Endod 2009;35:137–9.
19. Iqbal M, Fillmore E. Preoperative predictors of number of root canals clinically de-
8. Use of ultrasonic tips, special round burs, and thin tapering fin- tected in maxillary molars: a PennEndo database study. J Endod 2008;34:413–6.
ishing burs to remove a small amount of tooth structure or 20. Ghoddusi J, Mesgarani A, Gharagozloo S. Endodontic re-treatment of maxillary
calcification and trough the line angles of the pulp chamber second molar with two separate palatal roots: a case report. Iranian Endodontic
will help. Journal 2008;3:83–5.
9. Modify the conventional outline form to include the extra canals. 21. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal
configurations. J Endod 1999;25:446–50.
10. Ensure adequate straight-line access to improve visibility. 22. Christie WH, Thompson GK. The importance of endodontic access in locating maxil-
lary and mandibular molar canals. J Can Dent Assoc 1994;60:527–32, 535–6.
Before considering all these methods, having a thorough knowl- 23. Slowey RR. Root canal anatomy road map to successful endodontics. Dent Clin
edge of complexity of the root canal system, increased operator expe- North Am 1979;23:555–73.
rience, and increased time per appointment help in identification and 24. Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al. Root canal morphology of
treatment of these extra canals. All 4 cases presented here had varied permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: a new
root canal morphology. Hence it is very clear that the presence of these modified root canal staining technique. J Endod 2009;35:651–6.
25. Stone LH, Stroner WF. Maxillary molars demonstrating more than one palatal root
extra canals could be potentially missed if a thorough exploration is canal. Oral Surg 1981;51:649–52.
forgone. 26. Hartwell G, Applelstein CM, William W, Lyons, Guzek ME. The incidence of four
canals in maxillary first molars: a clinical determination. J Am Dent Assoc 2007;
138:1344–6.
Conclusion 27. Smadi L, Khraisat A. Detection of a second mesiobuccal canal in the mesiobuccal
roots of maxillary first molar teeth. Oral Surg Oral Med Oral Pathol Oral Radiol
These case reports contribute to our understanding of the Endod 2007;103:77–81.
complexity of the root canal morphology found in maxillary first molars. 28. Filho FB, Zaitter S, Haragushiku GA, de Campos EA, Abuabara A, Correr GM. Analysis
The presented nomenclature gives unique names for root canals in the of the internal anatomy of maxillary first molars by using different methods. J Endod
maxillary molars. Many authors consider such cases to occur infre- 2009;35:337–42.
29. Chen IP, Karabucak B. Conventional and surgical endodontic retreatment of a maxil-
quently, but it is not (>2% of more than 4 canals), so dentists should lary first molar: unusual anatomy. J Endod 2006;32:228–30.
be aware of them when considering endodontic treatment of maxillary 30. Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of cone-beam computed
molars. tomography to identify root canal systems in vitro. J Endod 2008;34:87–9.

JOE — Volume 36, Number 6, June 2010 Nomenclature of Maxillary Molars 1077
Case Report/Clinical Techniques
31. Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human 37. Holtzman L. Multiple canal morphology in the maxillary first molar: case reports.
permanent maxillary first molar: a literature review. J Endod 2006;32:813–21. Quintessence Int 1997;28:453–5.
32. Holderrieth S, Gernhardt CR. Maxillary molars with morphologic variations of the 38. Johal S. Unusual maxillary first molar with 2 palatal canals within a single root:
palatal root canals: a report of four cases. J Endod 2009;35:1060–5. a case report. J Can Dent Assoc 2001;67:211–4.
33. Cecic P, Hartwell G, Bellizzi R. The multiple root canal system in the maxillary first 39. Maggiore F, Jou YT, Kim S. A six-canal maxillary first molar: case report. Int Endod J
molar: a case report. J Endod 1982;8:113–5. 2002;35:486–91.
34. Beatty RG. A five-canal maxillary first molar. J Endod 1984;10:156–7. 40. Barbizam JV, Ribeiro RG, Filho MT. Unusual anatomy of permanent maxillary
35. Wong M. Maxillary first molar with three palatal canals. J Endodon 1991;17:298–9. molars. J Endod 2004;30:668–71.
36. Hulsmann M. A maxillary first molar with two disto-buccal root canals. J Endod 41. Ferguson DB, Kjar KS, Hartwell GR. Three canals in the mesiobuccal root of a maxil-
1997;23:707–8. lary first molar: a case report. J Endod 2005;31:156–7.

1078 Karthikeyan and Mahalaxmi JOE — Volume 36, Number 6, June 2010