MaxillaryFirstMolarWithSevenRootCanalsDiagnosedWithCone-BeamComputedTo - PDF document

MaxillaryFirstMolarWithSevenRootCanalsDiagnosedWithCone-BeamComputedTomographyScanning:ACaseJojoKottoor,BDS,NatanasabapathyVelmurugan,MDS,RajmohanSudha,MDS,andSenthilkumarHemamalathi,MDSThepurposeofthisarticlewastoempha-sizetheimportanceofhavingathoroughknowledgeabouttherootcanalanatomy.Thiscasereportpresentstheendodonticmanagementofamaxil-laryÞrstmolarwiththreerootsandsevencanals.TheclinicaldetectionofthesevencanalswasmadeusingasurgicaloperatingmicroscopeandconÞrmedusingcone-beamcomputedtomography(CBCT)scanning.CBCTaxialimagesshowedthatboththe Fromthe*DepartmentofConservativeDentistryandEndodontics,MeenakshiAmmalDentalCollegeandHospital,TamilNadu,India. CaseReport/ClinicalTechniques,Number2010MaxillaryFirstMolarwithSevenRootCanalsDiagnosedwithCBCT ARTICLEINPRESS TABLE1.CaseReportsofMaxillaryFirstMolarswithUnusualCanalMorphologyRootconÞgurationNo.ofRootcanalsanatomyOtherkey1root1SinglecanalIndia,48-year-oldwomanGopikrishnaetal(2006)1root1SinglecanalTurkey,36-year-oldmanCobankaraetal(2008)1root1SinglecanalSpain;45yearoldCaucasianfemaledelaTorreetal(2008)2roots21C-shapedcanalUS,37-year-oldwhitemanNewtonandMcDonald(1984)2roots21C-shapedcanalBelgium,21-year-oldwhitewomanDeMoor(2002)2roots32C-shapedcanalBelgium,44-year-oldwhitewoman2roots32C-shapedcanal(bilateral)Israel,11-year-oldwhitefemaleDankneretal(1990)2roots4C-shapedcanal(trifurcateintheapicalone-third)Turkey,28-year-oldwhitewomanYilmazetal(2006)(22)2roots(1palatalandfusedbuccalroot)32NotidentiÞedMalagninoetal(1997)2roots(1palatalandfusedbuccalroot)32Brazil,23-year-oldwomanFava(2001)2roots(1palatalandfusedbuccalroot)21China,50-year-oldwomanMaetal(2009)(25)3roots(2palatalrootsandfusedbuccalroot)42India,25-year-oldwomanGopikrishnaetal(2008)3roots41Germany,36-year-oldwhitemanHulsmann(1997)3roots41US,38-year-oldwhitewomanChenandKarabucak(2006)3roots41India,45-and25-yearoldmenPoornietal(2008)(3cases)3roots41India,23-year-oldmanAggarwaletal(2009)4roots(MB,DB,MP,DP)4Mesiobuccal,distobuccal,mesiopalatal&distopalatalCanada,whiteChristieetal(1991)(2cases)4roots(MB,DB,MP,DP)4Mesiobuccal,distobuccal,mesiopalatal&distopalatalUS,31-year-oldmanDiFiore(1999)(31)4roots(MB,DB,MP,DP)4Mesiobuccal,distobuccal,mesiopalatal&distopalatalBrazil,38-year-oldanesewomanBaratto-Filhoetal(2002)Continued CaseReport/ClinicalTechniquesKottooretal.,Number ARTICLEINPRESS TABLE1.RootconÞgurationNo.ofRootcanalsanatomyOtherkeyinformationReference4roots(MB,DB,MP,DP)4Mesiobuccal,distobuccal,mesiopalatal&distopalatalBrazil,35-year-oldmanBarbizametal(2004)3roots52US,23-year-oldwhiteCecicetal(1982)3roots52Israel,22-year-oldwhiteHoltzman(1997)(34)3roots52Canada,42-year-oldJohal(2001)(35)3roots52Germany,21-year-oldHolderriethetal(2009)3roots53Brazil,15-year-oldwhiteFavierietal(2006)3roots53US,18-year-oldmanFergusonetal.(2005)3roots53US,14-year-oldwhiteBeatty(1984)(38)Presumablyfusionofthetooth#3and#453buccalIsrael,13-year-oldfemaleStabholzandFriedman(1983)3roots522(bifurcationatmiddleGermany,32-year-oldHolderriethetal(2009)3roots513(trifurcationintheapicalthird)USA,22-year-oldwomanWong(1991)3roots623(trifurcationintheapicalthird)US,19-year-oldblackMaggioreetal(2002)3roots63Spain,10-and17-year-oldmalesMartõnez-BernaandRuiz-Badanelli(1983)(3cases)3roots62US,27-year-oldblackwomanBondetal(1988)3roots62Brazil,26-year-oldmandeAlmeida-Gomesetal(2009)4roots(MB,MP,P,DB)6Mesiobuccal,mesiopalatal,mesial,palatal,distopalatal,distobuccalTurkey,31-year-oldwhitemanAdanir(2007)(12)MB,mesiobuccal;DB,distobuccal;MP,mesiopalatal;DP,distopalatal. CaseReport/ClinicalTechniques,Number2010MaxillaryFirstMolarwithSevenRootCanalsDiagnosedwithCBCT ARTICLEINPRESS Radiographicevaluationoftheinvolvedtoothdidnotindicateanyvariationinthecanalanatomy(Fig.1).Thetoothwasanesthetizedwith1.8mL(30mg)2%lignocainecontaining1:200,000epinephrine(Xylocaine;AstraZenecaPharmaIndLtd,Bangalore,India.)followedbyrubberdamisolation.Anendodonticaccesscavitywasestablished.ClinicalexaminationwithaDG-16endodonticexplorer(Hu-Friedy,Chicago,IL)revealedtwocanalopeningsineachofthedistobuccal,me-siobuccal,andpalatalroot.Duringexaminationwithasurgicaloper-atingmicroscope(SeilerRevelation,StLouis,MO),athirdcanalwaslocatedmidwaybetweenthemesiobuccalandpalataloriÞces.Coronalenlargementwasdonewithanickel-titaniumProTaperseriesoriÞceshaper(DentsplyMaillefer,Ballaigues,Switzerland)toimprovethestraight-lineaccess(Fig.1).Theworkinglengthwasdeterminedwiththehelpofanapexlocator(RootZX;Morita,Tokyo,Japan)andlaterconÞrmedusingaradiograph.Multipleworkinglengthradio-graphsweretakenatdifferentangulations(Fig.1).However,theradiographsdidnotclearlyrevealthenumberandmorphologyofrootcanalsystems.ToconÞrmthisunusualmorphology,itwasdecidedtoperformCBCTimagingofthetooth.AccesscavitywassealedwithIRMcement(DentsplyDeTreyGmbH,Konstanz,Germany).Aninformedconsentwasobtainedfromthepatient,andamultisliceCBCTscanofthemaxillawasperformed(SimulixEvolution;Nucletron,Chennai,IndiaPvtLtd)withatubevoltageof100KVandatubecurrentof8mA.Theinvolvedtoothwasfocused,andthemorphologywasobtainedintransverse,axial,andsagittalsectionsof0.5-mmthickness.CBCTscanslicesre-vealedsevencanals(threemesiobuccal,twopalatal,andtwodistobuc-cal)intherightmaxillaryÞrstmolar(Fig.2CBCTimagesprovidedvaluableinformationregardingthecanalconÞgurationandconÞrmedthesevencanalsthatwerenotclearlyseenintheconventionalradiograph.Atthesecondappointment,thepatientwasasymptomatic.Afteradministering1.8mL(36mg)2%lignocainewith1:200,000epinephrine(Xylocaine),cleaningandshapingwasperformedunderrubberdamisolationusingProTapernickel-titaniumrotaryinstruments(DentsplyMaillefer)withacrown-downtechnique.Irrigationwasperformedusingnormalsaline,2.5%sodiumhypochloritesolution,and17%EDTA;2%chlorhexidinedi-gluconatewasusedastheÞnalirrigant.Thecanalsweredriedwithabsorbentpoints(DentsplyMaillefer),andobturationwasperformedusingcoldlateralcompactionofgutta-percha(DentsplyMaillefer)andAHPlusresinsealer(Maillefer,Dentsply,Konstanz,Germany)Fig.1).Thetoothwasthenrestoredwithaposteriorcompositeresincore(P60;3MDentalProducts,StPaul,MN).Thepatientwasadvisedafull-coverageporcelaincrownandwasasymptomaticduringthefollow-upperiodof3months.Radiographicexaminationisanessentialcomponentofthemanagementofendodonticproblems.Theamountofinformationgainedfromconventionalradiographsanddigitallycapturedperiapicalradiographsislimitedbythefactthatthethree-dimensionalanatomyoftheareabeingradiographediscompressedintoatwo-dimensional.Newerdiagnosticmethodssuchascomputerizedaxialtomography(CT)scanninggreatlyfacilitateaccesstotheinternalrootcanalmorphology.OnedistinctadvantageofCTscanningovertheconventionalradiographisthatitallowstheoperatortolookatmultipleslicesoftoothrootsandtheirrootcanalsystems.Robin-sonetalreportedthatCTimagesidentiÞedagreaternumberofmorphologicvariationsthanpanoramicradiographs.Althoughconven-tionalCTscansproduceahighlevelofdetailintheaxialplane,itisessentialthattheradiationdoseiskeptaslowasreasonablyachievable(43,44)Theuseofspiralcomputerizedtomography(SCT)scansindentistryhasincreaseddramaticallyinthepast2decades(30,34, Figure1.)Preoperativeradiographof#3.()AccessopeningshowingsevenrootcanaloriÞces.()Workinglengthradiographof#3ineccentricangulation.)Postobturationradiograph. CaseReport/ClinicalTechniquesKottooretal.,Number ARTICLEINPRESS 45,46).SCTscansacquirerawprojectiondatawithaspiral-samplinglocusinarelativelyshortperiod.Withoutadditionalscanningtime,thesedatacanbeviewedasconventionaltransaxialimagessuchasmul-tiplanarreconstructionsorasthree-dimensionalreconstructions.WithSCTscans,itispossibletoreconstructoverlappingstructuresatarbi-traryintervals,and,thus,theabilitytoresolvesmallsubjectsisincreased.Theyhavedrasticallyreducedscantimeandeffectivedosages,buttheystillarenotasaccurateanddonotlimitthedosageaslowasreasonablyachievableCBCTscanningisarelativelynewerdiagnosticimagingmodalitythathasbeenusedinendodonticsfortheeffectiveevaluationoftherootcanalmorphology.Additionally,CBCTtechnologyaidsinthediagnosisofendodonticpathosis,assessingrootandalveolarfractures,analysisofresorptivelesions,identiÞcationofpathosisofnonendodonticorigin,andpresurgicalassessmentbeforeroot-end(48,50,51).MatherneetalinvestigatedtheuseofCBCTscanninginidentifyingrootcanalsystemsandcompareditwithimagesobtainedbyusingdigitalradiography.TheyconcludedthatCBCTimagesalwaysresultedintheidentiÞcationofgreaternumberofrootcanalsystemsthandigitalimages.BarattoFilhoetaluatedtheinternalmorphologyofmaxillaryÞrstmolarsbyexvivoandclinicalassessmentsusingoperatingmicroscopeandCBCTscanning.HeconcludedthatanoperatingmicroscopeandCBCTscanningwereimportantforlocatingandidentifyingrootcanals,andCBCTscanningcanbeusedasagoodmethodforinitialidentiÞcationofmaxillaryÞrstmolarinternalmorphology.ThemajoradvantagesofCBCTscanningovertheconventionalCTscansarex-raybeamlimitation,rapidscantime,andeffectivedosereduction;x-raybeamlimitationisachievedbyreducingthesizeoftheirradiatedareabycollimationoftheprimaryx-raybeamtotheareaofinterest.Itusesacone-shapedbeaminsteadofthefan-shapedoneusedinregularCTscanners.Rapidscantime(10-70seconds)isbecauseofitsabilitytoacquirethewholethree-dimensionalvolumeofdatainasinglerotationPublishedreportsindicatethattheeffectivedoseradiationissignif-icantlyreducedtoanaverageof36.9to50.3Sv,areportedradiationdoseequivalenttothatneededfor4to15panoramicradiographs.Pa-tientÕsradiationexposuretoaconventionalCTisapproximately100toSvformaxillaand200to500Svforthemandible,whereastheradiationexposure(forbothmaxillaandmandible)toCBCTscanningis34to102.PatientpositioningmodiÞcations(tiltingthechin)andtheuseofadditionalpersonalprotection(thyroidcollar)cansubstantiallyreducethedosagebyupto40%Althoughtherehasbeenenormousinterest,thecurrentCBCTtechnologyhaslimitationsrelatedtotheÔÔconebeamÕÕprojectiongeom-etry,detectorsensitivity,andcontrastresolution.TheseparameterscreateaninherentimageÔÔnoiseÕÕthatreducesimageclarityandmaylimitadequatevisualizationofstructuresinthedentoalveolarregion.EventhoughtheuseofCBCTscanninginvolveslessradiationthanconventionalCTscanning,theradiationdoseisstillhigherthanregularconventionalintraoralradiographs.Atthispointintime,CBCTscanningislimitedtomajormetropolitanareasandisveryexpensive.LimitationsalsoincludemedicolegalissuespertainingtotheacquisitionandinterpretationofCBCTdataInthepresentcase,CBCTscanningwasusedforabetterunder-standingofthecomplexrootcanalanatomy.CBCTaxialimagesconÞrmedthepresenceofthreerootsandsevenrootcanals,namelymesiobuccal),mesiobuccal),mesiobuccal),distobuccal),mesiopalatal(MP)anddisto-palatal(DP).Contralateraltoothappearedtohavenormalrootcanalanatomy(Fig.2).CBCTaxialimagesalsoshowedthatboth Figure2.)CBCTimagesof#3showingaxialsectionsatthe()cervicaland()apicallevel.()EnlargedaxialsectionCBCTimagesatthe(cervicaland()apicallevelshowingthreerootsandsevencanals. CaseReport/ClinicalTechniques,Number2010MaxillaryFirstMolarwithSevenRootCanalsDiagnosedwithCBCT ARTICLEINPRESS thepalatalanddistobuccalrootpresentwithaVertuccitypeIIcanal(ie,twocanaloriÞcesjointogetherandexitasoneapicalforamen),whereasthemesiobuccalrootshowedaSertandBayirlitypeXVcanalconÞguration(ie,MBandMBjoinedatthemiddlethirdoftherootandexitinoneapicalforamen,whereasMBhasaseparatecanaloriÞceandexitingforamen)(Fig.2).TheMBisusuallylocatedpalatallyandmesiallytotheMB,butinthisparticularcasewaslocatedbetweenMBandDBFig.1)andthispeculiarloca-tionwasconÞrmedintheCBCTaxialimages(Fig.2).Thus,CBCTscanningwaspivotalinthediagnosisofthisunusualrootcanalsystemandtowardsitssuccessfulendodonticmanagement.ThepresentcasereportdiscussestheendodonticmanagementofanunusualcaseofamaxillaryÞrstmolarwiththreerootsandsevencanalsandalsohighlightstheroleofsurgicaloperatingmicroscopeandCBCTscanningasanobjectiveanalytictooltoascertainrootcanalReferences1.KulildJC,PetersDD.IncidenceandconÞgurationofcanalsystemsinthemesiobuc-calrootofmaxillaryÞrstandsecondmolars.JEndod1990;16:311Ð7.2.BuhrleyLJ,BarrowsMJ,BeGoleEA,etal.EffectofmagniÞcationonlocatingtheMB2canalinmaxillarymolars.JEndod2002;28:324Ð7.3.GopikrishnaV,BhargaviN,KandaswamyD.EndodonticmanagementofamaxillaryÞrstmolarwithasinglerootandasinglecanaldiagnosedwiththeaidofspiralCT:acasereport.JEndod2006;32:687Ð91.4.ChristieWH,PeikoffMD,FogelHM.Maxillarymolarswithtwopalatalroots:aretro-spectiveclinicalstudy.JEndod1991;17:80Ð4.5.BarbizamJV,RibeiroRG,TanomaruFilhoM.Unusualanatomyofpermanentmaxil-larymolars.JEndod2004;30:668Ð71.6.FergusonDB,KjarKS,HartwellGR.Threecanalsinthemesiobuccalrootofamaxil-laryÞrstmolar:acasereport.JEndod2005;31:400Ð2.7.deAlmeida-GomesF,Maniglia-FerreiraC,CarvalhodeSousaB,etal.SixrootcanalsinmaxillaryÞrstmolar.OralSurgOralMedOralPatholOralRadiolEndod2009;108:e157Ð9.8.DanknerE,FriedmanS,StabholzA.BilateralCshapeconÞgurationinmaxillaryÞrstmolars.JEndod1990;16:601Ð3.9.MartõA,Ruiz-BadanelliP.MaxillaryÞrstmolarswithsixcanals.JEndod1983;9:375Ð8.10.BondJL,HartwellG,PortellFR.MaxillaryÞrstmolarwithsixcanals.JEndod1988;11.MaggioreF,JouYT,KimS.Asix-canalmaxillaryÞrstmolar:casereport.IntEndodJ2002;35:486Ð91.12.AdanirN.AnunusualmaxillaryÞrstmolarwithfourrootsandsixcanals:acasereport.AustDentJ2007;52:333Ð5.13.AlaviAM,OpasanonA,NgYL,etal.RootandcanalmorphologyofThaimaxillarymolars.IntEndodJ2002;35:478Ð85.14.ThomasRP,MouleAJ,BryantR.RootcanalmorphologyofmaxillarypermanentÞrstmolarteethatvariousages.IntEndodJ1993;26:257Ð67.15.HulsmannM.AmaxillaryÞrstmolarwithtwodisto-buccalrootcanals.JEndod16.StoneLH,StronerWF.Maxillarymolarsdemonstratingmorethanonepalatalrootcanal.OralSurgOralMedOralPathol1981;51:649Ð52.17.BarattoFilhoF,ZaitterS,HaragushikuGA,etal.AnalysisoftheinternalanatomyofmaxillaryÞrstmolarsbyusingdifferentmethods.JEndod2009;35:337Ð42.18.CobankaraFK,TerlemezA,OrucogluH.MaxillaryÞrstmolarwithanunusualmorphology:reportofararecase.OralSurgOralMedOralPatholOralRadiolEn-dod2008;106:e62Ð5.19.delaTorreF,Cisneros-CabelloR,ArangurenJL,etal.Single-rootedmaxillaryÞrstmolarwithasinglecanal:endodonticretreatment.OralSurgOralMedOralPatholOralRadiolEndod2008;106:e66Ð8.20.NewtonCW,McDonaldSA.C-shapedcanalconÞgurationinamaxillaryÞrstmolar.JEndod1984;10:397Ð9.21.DeMoorRJ.C-shapedrootcanalconÞgurationinmaxillaryÞrstmolars.IntEndodJ22.YilmazZ,TuncelB,SerperA,etal.C-ShapedrootcanalinamaxillaryÞrstmolar:acasereport.IntEndodJ2006;39:162Ð6.23.MalagninoV,GallottiniL,PassarielloP.Someunusualclinicalcasesonrootanatomyofpermanentmaxillarymolars.JEndod1997;23:127Ð8.24.FavaLR.RootcanaltreatmentinanunusualmaxillaryÞrstmolar:acasereport.IntEndodJ2001;34:649Ð53.25.MaL,ChenJ,WangH.RootcanaltreatmentinanunusualmaxillaryÞrstmolardiag-nosedwiththeaidofspiralcomputerizedtomographyandinvitrosectioning:acasereport.OralSurgOralMedOralPatholOralRadiolEndod2009;107:e68Ð73.26.GopikrishnaV,ReubenJ,KandaswamyD.EndodonticmanagementofamaxillaryÞrstmolarwithtwopalatalrootsandasinglefusedbuccalrootdiagnosedwithspiralcomputedtomography-acasereport.OralSurgOralMedOralPatholOralRadiolEndod2008;105:74Ð8.27.ChenIP,KarabucakB.Conventionalandsurgicalendodonticretreatmentofamaxil-laryÞrstmolar:unusualanatomy.JEndod2006;32:228Ð30.28.PoorniS,KumarA,IndiraR.MaxillaryÞrstmolarwithaberrantcanalconÞguration:areportof3cases.OralSurgOralMedOralPatholOralRadiolEndod2008;106:29.AggarwalV,SinglaM,LoganiA,etal.EndodonticmanagementofamaxillaryÞrstmolarwithtwopalatalcanalswiththeaidofspiralcomputedtomography:acasereport.JEndod2009;35:137Ð9.30.ChristieWH,PeikoffMD,FogelHM.Maxillarymolarswithtwopalatalroots:aretro-spectiveclinicalstudy.JEndod1991;17:80Ð4.31.DiFiorePM.Afour-rootedquadrangularmaxillarymolar.JEndod1999;25:695Ð7.32.Baratto-FilhoF,FariniukLF,FerreiraEL,etal.Clinicalandmacroscopicstudyofmaxillarymolarswithtwopalatalroots.IntEndodJ2002;35:796Ð801.33.CecicP,HartwellG,BellizziR.ThemultiplerootcanalsysteminthemaxillaryÞrstmolar:acasereport.JEndod1982;8:113Ð5.34.HoltzmanL.MultiplecanalmorphologyinthemaxillaryÞrstmolar:casereports.QuintessenceInt1997;28:453Ð5.35.JohalS.UnusualmaxillaryÞrstmolarwith2palatalcanalswithinasingleroot:acasereport.JCanDentAss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CaseReport/ClinicalTechniquesKottooretal.,Number ARTICLEINPRESS 56.LudlowJB,Davies-LudlowLE,BrooksSL,etal.Dosimetryof3CBCTdevicesfororalandmaxillofacialradiology:CBMercuray,NewTom3Gandi-CAT.DentomaxillofacRadiol2006;35:219Ð26.57.BrooksSL.EffectiveDoseofTwoCone-BeamCTScanners:I-CATandNewTom3G.QuarterlyPublicationoftheAmericanAssociationofDentalMaxillofacialRadio-graphicTechnicians.Winter2005.58.PatelS.Newdimensionsinendodonticimaging:part2.Conebeamcomputedtomography.IntEndodJ2009;42:463Ð75.59.VertucciFJ.Rootcanalanatomyofthehumanpermanentteeth.OralSurgOralMedOralPatholOralRadiolEndod1984;58:589Ð99.60.SertS,BayirliGS.EvaluationofrootcanalconÞgurationsofthemandibularandmaxil-larypermanentteethbygenderintheTurkishpopulation.JEndod2004;30:391Ð8. CaseReport/ClinicalTechniques,Number2010MaxillaryFirstMolarwithSevenRootCanalsDiagnosedwithCBCT ARTICLEINPRESS