ENDODONTOLOGY

Case Report

Endodontic Treatment of Permanent Mandibular Molar with 3 distal canals

SURBHI KAKAR * SACHIN GUPTA **

ABSTRACT
The dynamic concept of the root canal system, describing a variable morphology of multiple root canals has been established as the prevailing state in mandibular molars. The prognosis for endodontic treatment in these teeth is unfavourable if clinician fails to recognize additional root canals. This case report presents the treatment of a mandibular first molar with five root canals, of which three canals were located in the Distal root. All canals were cleaned, shaped & obturated. Cleaning and Shaping of the three distal and two mesial canals was performed using combination of Step Back (in Apical 1/3rd) and Crown Down (in Coronal & middle 1/3rd ) technique and obturated. Key Words: Mandibular first molar, root canal treatment, morphological variations.

INTRODUCTION
Over the years, there have been numerous studies and several cases of multiple canal systems in mandibular first molars teeth have been investigated and discussed. Skidmore and Bjordal (1971), Pomeranz et al. (1981), Weine (1981), Fabra Campos (1985), Martinez Berna & Badanelli (1985), Bond et al (1988), Jacobsen et al. (1994) have reported the presence of the three root canals in the mesial and the distal roots
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mandibular molars by this process. Such third canals are situated centrally between the two main buccal and lingual root canals 11. The diameter of those third canals is smaller than that of the other two Martinez - Berna and Badanelli 1985 5 and is age related because of apposition of dentine Fabra - Campos 1985 4 with increasing reports of aberrant canal morphology, the clinician needs to be aware of its varied anatomy. The purpose of this study is to discuss the occurrence of three distal canals in a mandibular first molar and its endodontic management.

Additionally,

Stroner et al and Batty & Interian 8, 9 have reported a third canal that was located in the distal root. Astonishingly, Reeh 10 has even reported a case with seven canals, consisting of four canals in the mesial root & three in the distal root. It has been postulated that secondary dentine apposition during tooth maturation would form dentinal vertical partitions inside the root canal cavity, thus creating the root canals. A third root canal may also be created inside the root cavity of

CASE REPORT
A 30 year old North Indian female, presented to the Department of Conservative and Endodontics, Subharti Dental College, Meerut, with the chief complaint of pain and swelling in lower left posterior region since two days. The pain was spontaneous, acute and localised. It was partially

.G. * 3rd Year P Student, ** Sr. Lecturer, Department of Conservative Dentistry & Endodontics, Subharti Dental College, Meerut

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ENDODONTOLOGY
relieved on taking medications and would recur after few hours. Patient complained of thermal sensitivity in the same region. The clinical examination revealed deep occlusal caries involving enamel and dentine of mandibular left first molar. An Intraoral periapical radiograph (IOPA) and Electric pulp test was advised for the same tooth (Fig.1). Radiograph revealed deep caries approaching pulp chamber and periodontal widening in relation to 36. The tooth was tender to percussion and Electric Pulp Testing elucidated response at a higher value then control tooth. A diagnosis of acute irreversible pulpits with apical periodontits was made. Endodontic treatment was initiated for the same. Access cavity preparation was accomplished using Endo access and Endo-Z burs with high speed aerotar handpiece. Pulp chamber was copiously irrigated with 5% NaOCl while ensuring rubber dam isolation and high volume evacuation. Inspection of subpulpal floor using Endoexplorer revealed two canal orifice in two mesial and two distal root. However careful exploration and inspection using No. 6K file under magnifying loupes revealed the presence of two more canal orifice, one in mesial between mesiobuccal and mesiolingual orifice, other in distal root between distobuccal and distolingual orifice (Fig.2 & 3). However patency was achieved only in five canals. The middle mesial canal could not be negotiated beyond 2-3mm which was estimated using RVG (Gendex) and Apex locator (Ray Apex). Intermittent irrigation with 5% NaOCl along
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SURBHI KAKAR, SACHIN GUPTA

with EDTA as lubricant was continued throughout the procedure. Finally all canals were enlarged upto size F2 Protaper Rotary. Pre obturation master cone was verified using Intraoral Periapical Radiograph (IOPA) (Fig.4). Obturation was done using size F2 Protaper cones and AH Plus sealer. Access cavity was sealed using IRM (Fig.5 & 6). An appointment was scheduled with the Department of Radiology for Dentascan of the concerned tooth to ascertain the root morphology. The Dentascan confirmed the presence of two roots (one mesial and one distal) with three orifices in the distal canal (Fig.7).

Fig. 1. Diagnostic IOPA radiograph revealing deep caries and periodontal widening in relation to 36

Fig. 2. Working length radiograph depicting patency in five canals out of six (The middle mesial canal could not be negotiated beyond 2-3 mm)

Fig. 3. Clinical View of the 6 orifices. Note - The small middle mesial orifices right behind the mesio buccal orifices.

ENDODONTOLOGY

ENDODONTIC TREATMENT OF PERMANENT MANDIBULAR MOLAR WITH 3 DISTAL CANALS

than in the mesial root Martinez Berna and Badanelli (1985). The larger mesiodistal dimension of the distal root, compared to mesial root, may account for the rare incidence of third canal created by dentine apposition in distal roots.
Fig. 4. Master Cone IOPA radiograph.

In this case report there was confluence of the third middle distal canal with Distobuccal and Distolingual canals and having common apical termination. Instrumentation is one of the key factors in the success of endodontic therapy and the clinician should be aware of the varied anatomy. An avid clinician should be always keen to explore the possibility of additional canals whenever in doubt, with the assistance of technologies such as the those of magnification and illumination. In this case report the hybrid technique was followed to prevent strip perforation.
REFERENCES:
1. Skidmore AE, Bjorndal AM (1971) Root canal morphology of the Human mandibular first molar. Oral Surgery. Oral Medicine, Oral Pathology, 32, 778-84. 2. Pomerantz HH, Eidelman Dl, Goldberg MG (1981) Treatment considerations of the middle mesial canal of mandibular first and second molar. Journal of Endodontics 7, 565-8. 3. Weine FS (1981) Case report: Three canals in the mesial root of mandibular first molar. Journal of Endodontics 8. 51720. 4. Fabra Campos H (1985) Unusual root anatomy of mandibular first molars. Journal of Endodontics 11, 312-14. 5. Martinez-Berna A. Badanelli P 91985) Mandibular first molar with six root canals. Journal of Endodontics 8, 348-52.

Fig. 5. IOPA radiograph of Obturation with F2 ProTaper cones and AHPlus sealer

Fig. 6. Clinical view before sealing the access cavity with IRM

Fig. 7. Dentascan Confirming the presence of two roots (one mesial and one distal) with three orifices in distal canal.

6. Bond JL, Hartwell, GR, Donnelly JC, Portell FR (1988) Clinical management of middle mesial root canals in mandibular molars. Journal of Endodontics 14, 312-14. 7. Jacobsen E. Dick K. Bodell R. Mandibular first molars with, multiple mesial canals. J. Endodon 1994. 20:610-3. 8. Stroner W, Remeikis N. Carr G. Mandibular first molar with three distal canals. Oral Surg 1984:54:554-7. 9. Beatty R, Interian C.A. Mandibular first molar with five canals: reported a case. JADA; 111:769-71. 10. Reeh E. Seven canals in a lower first molar. J. Endodon 1998;24:497-9. 11. L. Holtzman. Root Canal treatment of a mandibular first molar with the mesial root canals. IEJ 1997; 30: 422-423. 93

DISCUSSION
It has already been discussed and demonstrated in literatures that mandibular molars may manifest variations of root canal morphology. According to the literature the incidence of third distal canals is 0.6% (Fabra - Campos 1985). The incidence of third canal in the distal root of mandibular molars was found to be much lower