Management of maxillary first premolars with atypical anatomy, a new proposal for the approach of the cervical tooth region. Report of two cases and a literature review
DOI:
https://doi.org/10.24265/kiru.2025.v22n2.10Keywords:
Anatomic Variation; Retreatment; Root Canal Therapy; BicuspidAbstract
Anatomical variations of the root canal system are rare, however premolars are the ones that present the most variability compared to other teeth. The aim of this study was to describe the endodontic management of three-rooted first and second maxillary premolars with three independent root canals. The approach was performed under magnification, the instrumentation was hybrid and the obturation was performed with a calcium silicate-based sealant. Several cases of this anatomical variation have been reported, therefore a literature review was also carried out to evaluate the presentation and clinical management. Clinicians should be aware of anatomical aberrations that could become evident during the preoperative and intraoperative treatment. Magnification and cone beam computed tomography will play an important role in the long-term prognosis of these cases.
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References
Machtou P, Reit C. Non-surgical retreatment. In: Bergenholtz G, Textbook of Endodontology. 2ed. United Kingdom: Willey Blackwell, 2010. p. 335-346
Chandra A. Discuss the factors that affect the outcome of endodontic treatment. Aust Endod J. 2009;35(2):98-107.
Abbott PV. Recognition and prevention of failures in clinical dentistry. Endodontics. Ann. R. Australas Coll. Dent. Surg. 1991;11:150-166.
Patel S, Brown J, Pimentel T, Kelly RD, Abella F, Durack C. Cone beam computed tomography in Endodontics–a review of the literature. Int Endod J. 2019;52(8):1138-1152.
Gulabivala K, Ng YL. Factors that affect the outcomes of root canal treatment and retreatment—A reframing of the principles. Int Endod J. 2023;56(2):82-115.
Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J. 2011;44(7):583-609.
Fransson H, Dawson V. Tooth survival after endodontic treatment. Int Endod J. 2023;56(2):140–153.
Paik S, Sechrist C, Torabinejad M. Levels of evidence for the outcome of endodontic retreatment. J Endod. 2004;30(11):745-750.
Kang M, In Jung H, Song M, Kim SY, Kim HC, Kim E. Outcome of nonsurgical retreatment and endodontic microsurgery: a meta-analysis. Clinical oral investigations. 2015;19:569-582.
Ng YL, Mann V, Gulabivala K. Outcome of secondary root canal treatment: a systematic review of the literature. Int Endod J. 2008;41(12):1026-1046.
Baruwa AO, Martins JN, Meirinhos J, Pereira B, Gouveia J, Quaresma SA, et al. The influence of missed canals on the prevalence of periapical lesions in endodontically treated teeth: a cross-sectional study. J Endod. 2020;46(1):34-39.
Haxhia E, Ibrahim M, Bhagavatula P. Root-End surgery or nonsurgical retreatment: are there differences in long-term outcome? J Endod. 2021;47(8):1272-1277.
Ahmad IA, Alenezi MA. Root and root canal morphology of maxillary first premolars: a literature review and clinical considerations. J Endod. 2016;42(6):861-872.
Sieraski SM, Taylor GN, Kohn RA. Identification and endodontic management of three‑canalled maxillary premolars. J Endod. 1989;15(1):29-32.
Orstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol. 1986;2(1):20-34.
Zaatar EI, Al-Busairi MA, Behbehani MJ. Maxillary first premolars with three root canals. Quistessence Int. 1990;21(12):1007-1011.
Soares JA, Leonardo RT. Root canal treatment of three‐rooted maxillary first and second premolars–a case report. Int Endod J. 2003;36(10):705-710.
Evans M. Combined Endodontic And Surgical Treatment Of A Three‐rooted Maxillary First Premolar. Aust Endod J. 2004;30(2):53-55.
Evcil MS, Keles A. Endodontic treatment of three-rooted maxillary first premolar with pain: A case report, The Pain Clinic. 2005;17(3):339-342.
Evcil MS, Keleş A. Endodontic treatment of three-rooted maxillary first premolar with pain: A case report. The Pain Clinic. 2005;17(3):339-342.
Javidi, M, Zarei, M, Vatanpour M. Endodontic treatment of a radiculous maxillary premolar: a case report. J Oral Sci. 2008;50(1):99-102.
Arisu HD, Alacam T. Diagnosis and treatment of three-rooted maxillary premolars. Eur J Dent. 2009;3(1): 62-66.
Dadresanfar B, Khalilak Z, Shahmirzadi S. Endodontic treatment of a maxillary first premolar with type IV buccal root canal: A case report. Iran Endod J. 2009;4(1):35-36.
Martins JN. Primeiro pré-molar superior com três canais: diagnóstico e tratamento–quatro casos clínicos. Rev. Port. Estomatol. Med. Dent. Cir. Maxilofac. 2011;52(1):43-51.
Karumaran CS, Gunaseelan R, Krithikadatta J. Microscope-aided endodontic treatment of maxillary first premolars with three roots: A case series. Indian J Dent Res. 2011;22(5):706-708.
Nimigean V, Nimigean VR, Sălăvăstru DI, Buţincu L. A rare morphological variant of the first maxillary premolar: A case report. Rom J Morphol Embryol. 2013;54(4):1173-5.
Sulaiman AO, Dosumu OO, Amedari M. Maxillary first premolar with three root canals: a case report. Ann Ib Postgrad Med. 2013;11(2):105-108.
Relvas JB, De Carvalho FM, Marques AA, Sponchiado Jr EC, Garcia LD. Endodontic treatment of maxillary premolar with three root canals using optical microscope and NiTi rotatory files system. Case Rep Dent. 2013(1):710408.
Oporto VGH, Saavedra R, Soto PCC, Fuentes R. Variaciones Anatómicas de Raíces Dobles en un solo Paciente: Tratamiento Endodóntico y Rehabilitación de un Primer Premolar Trirradicular. Reporte de Caso. Int J Morphol. 2013;31(1):45-49.
Kexian X, Xiao W, Yuangao L, Ping Z. Root canal treatment of two-rooted three-canal maxillary first premolar: a case report. West China J Stomatol. 2013;31(6):641-643.
Theruvil R, Ganesh C, George AC. Endodontic management of a maxillary first and second premolar with three canals. J Conserv Dent. 2014;17(1):88-91.
Gopal S, John G, Pavan Kumar K, Latha S, Latha S, Kallepalli S. Endodontic treatment of bilateral maxillary first premolars with three roots using CBCT: a case report. Cas Rep. Dent. 2014(1):505676
Küçükkaya S. Root-canal treatment of premolar teeth with complex anatomy. J Dent Sci. 2014;9(1):96-97.
Praveen R, Thakur S, Kirthiga M, Shankar S, Nair VS, Manghani P. The radiculous premolars: Case reports of a maxillary and mandibular premolar with three canals. J Nat Sci Biol Med. 2015;6(2):442-5.
Mathew J, Devadathan A, Syriac G, Shamini S. Root canal treatment of a maxillary first premolar with three roots. J Pharm Bioallied Sci. 2015;7(2):S746-8.
Srinivasan R, Dabra T, Ravishanker P, Bhagabati N. Endodontic management of small molars. Med J Armed Forces India. 2015;71(2):S542-S545.
Agwan AS, Sheikh Z. Identification and endodontic treatment of three-canalled maxillary first premolar. J Ayub Med Coll Abbottabad. 2016;28(3):627-629.
Sathyanarayanan K, Srinivasan MR, Balagopal S & Poornima L. Report of occurrence and endodontic management of three-rooted maxillary first and second premolars in the same individual. Indian J Dent Res. 2017;28(3):337-340.
Uğur Z, Akpinar KE, Altunbaş D. Maxillary first premolars with three root canals: Two case reports. J Istanb Univ Fac Dent. 2017;51(3):50-54.
Agarwal PM, Taneja S. Root Canal Treatment of Three Rooted Maxillary First and Second Premolar using CBCT: A Case Report. J Clin. Diagnostic Res. 2018;12(4):6-8.
AlRahabi MK, Ghabbani HM. Endodontic management of a three-rooted maxillary premolar: A case report. J. Taibah Univ Medical Sci. 2019;14(3):312-316.
Bafaqeeh MS, Alqedairi A. Maxillary first premolar with three root canals: Four case reports. Saudi Endod J. 2019;9(3):216-221.
Balthazard R, Corne P, Vincent M, Mortier E. Methodological Approach to the Endodontic Treatment of First Premolars with Three Root Canals: Two Case Reports. J. Contemp. Dent. Pract. 2019;20(2):263-269.
Beyraghshamshir R, Karimian E, Sekandari S. Maxillary Premolars with three root canals: A Case Report. Iran Endod J. 2020;15(4):252-262.
Hamedi A, Jafarzadeh H, Navabi S. Endodontic Management of a Maxillary Premolar with a Rare Configuration (Three Buccolingually Positioned Canals in a Single Root) as Confirmed by Cone Beam Computed Tomography: a Case Report. J Dent (Shiraz). 2022;23(4):506-510.
Huang W, Yang J & Li Y. Cone-beam computed tomography three-dimensional reconstruction aids treatment of three root canals with severe curvature in maxillary first premolar: a case report. J. Int. Med. Res. 2022;50(6):1-6.
Molina JJ. Recognition and endodontic management of maxillary first premolars with two roots and three canals. bilaterality case report. Rev Cient Odontol. 2023;11(2):e157.
Pawar R, Bansod A, Samuel RM, Zinge P. The Endodontic Treatment of Three-Rooted Maxillary Premolar Resembling a Small Molar: A Case Report. Cureus. 2024;16(11):e73634.
Jiannan C, Yangpeng Z, Huanhuan S, Qiang Z. Endodontic Treatment of Maxillary Premolar With Three Roots: A Case Report. Case Rep Dent. 2024;2024:5525349
Makati D, Shah NC, Brave D, Singh Rathore VP, Bhadra D, Dedania MS. Evaluation of remaining dentin thickness and fracture resistance of conventional and conservative access and biomechanical preparation in molars using cone-beam computed tomography: An in vitro study. J Conserv Dent. 2018;21(3):324-327.
Krishan R, Paqué F, Ossareh A, Kishen A, Dao T, Friedman S. Impacts of conservative endodontic cavity on root canal instrumentation efficacy and resistance to fracture assessed in incisors, premolars, and molars. J Endod. 2014;40(8):1160-6.
Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor. J Endod. 2004;30(1):5-16.
Beltes P, Kalaitzoglou ME, Kantilieraki E, Beltes C, Angelopoulos C. 3-Rooted Maxillary First Premolars: An Ex Vivo Study of External and Internal Morphologies. J Endod. 2017;43(8):1267-1272.
Costa FFNP, Pacheco-Yanes J, Siqueira JF Jr, Oliveira ACS, Gazzaneo I, Amorim CA et al. Association between missed canals and apical periodontitis. Int Endod J. 2019; 52(4):400-406.
Perrin P, Neuhaus KW, Lussi A. The impact of loupes and microscopes on vision in endodontics. Int Endod J. 2014;47(5):425-429.
Perrin P, Neuhaus KW, Eichenberger M, Lussi A. Influence of different loupe systems and their light source on the vision in endodontics. Swiss Dent J. 2019;129(11):922-928.
Sunildath SM, Mathew J, George L, Vineet RV. Cone-Beam Computed Tomography and Microscope-Assisted Endodontic Management of Maxillary First Premolar with Three Roots. Indian J Dent Sci. 2020;12(4):240-243.
Borghesi A, Michelini S, Zigliani A, Tonni I, Maroldi R. Three-rooted maxillary first premolars incidentally detected on cone beam CT: an in vivo study. Surg Radiol Anat. 2019;41: 461–468.
Johnsen GF, Dara S, Asjad S, Sunde PT, Haugen HJ. Anatomic comparison of contralateral premolars. J Endod. 2017;43(6):956-963.
Mashyakhy M, Abu-Melha AS. Analysis of bilateral symmetry of root canal anatomy in permanent dentition: An in vivo CBCT study in a Saudi Arabian population. J. Contemp. Dent. Pract. 2021;22(8):867-875.
Chybowski EA, Glickman GN, Patel Y, Fleury A, Solomon E, He J. Clinical outcome of non-surgical root canal treatment using a single-cone technique with endosequence bioceramic sealer: a retrospective analysis. J Endod. 2018;44(6):941-945.
Tian YY, Guo B, Zhang R, Yu X, Wang H, Hu T et al. Root and canal morphology of maxillary first premolars in a Chinese subpopulation evaluated using cone‐beam computed tomography. Int Endod J. 2012;45(11):996-1003.
Saber SE, Ahmed MH, Obeid M, Ahmed HM. Root and canal morphology of maxillary premolar teeth in an Egyptian subpopulation using two classification systems: a cone beam computed tomography study. Int Endod J. 2019;52(3):267-278.
Bürklein, S, Heck R, Schäfer E. Evaluation of the root canal anatomy of maxillary and mandibular premolars in a selected German population using cone-beam computed tomographic data. J Endod. 2017;43(9):1448-1452.
De Lima CO, De Souza LC, Devito KL, Do Prado M, Campos CN. Evaluation of root canal morphology of maxillary premolars: a cone‐beam computed tomography study. Aust Endod J. 2019;45(2):196-201.
Al Zubaidi SM, Almansour MI, Al Mansour NN, Alshammari AS, Alshammari AF, Altamimi YS, et al. Assessment of root morphology and canal configuration of maxillary premolars in a Saudi subpopulation: a cone-beam computed tomographic study. BMC Oral Health. 2021;21:1-11.
Olczak K, Pawlicka H & Szymański W. Root form and canal anatomy of maxillary first premolars: a cone-beam computed tomography study. Odontology. 2022;110:365-375.
Abella F, Teixidó LM, Patel S, Sosa F, Duran-Sindreu F, Roig M. Cone-beam computed tomography analysis of the root canal morphology of maxillary first and second premolars in a Spanish population. J Endod. 2015;41(8):1241-1247.
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