maxillary 2 molar tooth anatomy and anomalies and endodontics management..

1. MAXILLARY II MOLAR SUBMITTED BY O.R.GANESAMURTHI 1 YEAR M.Sc.D ENDODONTICS

4. ENDODONTIC CORELATION

5. CASE REPORT

8. At least 2 buccal cusps

9. One or more lingual cusps

11. Average age of calcification : 14 to 16 years

14. Crown: Buccolingual > MesioDistal

16. Buccal cusps are of unequal size

18. Mesial aspect Less numerous Marginal ridge tubercles MB & Lingual roots are less divergent Distal aspect Smaller Distal cusps A greater portion of the occlusal aspect is visible

25. ROOT CANALS if 3 roots are present usually we can see 3 canals 1. mesiobuccal 2. distobuccal 3. palatal if 4 canal is present it is in mesiobuccal root but less frequently than in the 1 molar

26. ROOT CANAL ANATOMY

27. ROOTS AND ROOT CANALS 63 % straight PALATAL ROOT 37 % buccal curve 78 % distal curve MESIOBUCCAL ROOT 22 % straight 83 % straight DISTAL ROOT 17 % mesial curve

28. ROOT CANAL AND APICAL FORAMINA IN MAXILLARY 2 MOLAR MESIOBUCAL ROOT

29. ROOT ANOMALIES

33. ANATOMY RALATIONSHIPS IN SITU The maxillary 2 molar usually is more closely related to the maxillary sinus than the maxillary 1 molar This close relationship may produce Soreness In the maxillary teeth due to Maxillary sinusities

34. ENDODONTIC CORRELATION

35. Significance of average time of eruption, age of calcification, tooth length & root curvature: IT HELPS IN DIAGNOSIS AND TREATMENT PLAN TREATMENT IS DIFFERENT IN ADULT AND YOUNG NECROTIC PULP RCT ADULT Irreversible Pulpitis

36. YOUNG Irreversible Pulpit's Necrotic Pulp Reversible Pulpit's Pulp Capping or Pulpotomy Closed Apex Open Apex Apexification Obturation Apexogenesis RCT

37. ENDODONTIC CORELATION AN IMPORTANT AID FOR LOCATING ROOT CANAL IS THE DENTAL OPERATING MICROSCOPE (DOP). IT IS USED TO IDENTIFIED CANAL THE NUMBER OF 2 MESIOBUCCAL CANALS IDENTIFIED IN MAXILLARY 2 MOLAR INCREASED FROM 51 % NAKED EYE 82 % MICROSCOPE 93.7 %DOM

38. DENTAL OPERATING MICROSCOPE (DOP). The operating microscope is an indispensable tool for state-of-the-art endodontic treatment. The specialty practice should not be without a microscope; this instrument is useful in all phases of endodontic treatment from diagnosis to placement of the final restoration.

39. Loupes give excellent magnification and illumination An operating microscope.

40. ENDODONTIC CORELATION WITH PULP CHAMPER DIAGNOSTIC MEASURES ARE IMPORTANT AIDS IN THE LOCATION OF ROOT CANALS ORIFICES THESE MEASURES OBTAIN MULIPLE PRE TREATMENT RADIOGRAPHS EXAMINING THE CHAMBER WITH SHARP EXPLORER

41. 3. TROUGHING GROOVES WITH ULTRASONIC TIPS 4. STAINING THE CHAMBER WITH 1 % METHYLENE BLUE DYE CHAMPAGNE BUPPLE TEST 5. VISUALIZING CANAL BLEEDING POINT

42. PRE TREATMENT RADIOGRAPHS The palatal canal is centered between the mesiobuccal and distobuccal roots in maxillary molars. When a second mesiobuccal canal (MB 2 ) is suspected, a mesial radiograph is often required to identify it. However, as the horizontal angulation increases, the clarity of the radicular anatomy decreases. A 20 degree mesial shift is sufficient to separate the canals while limiting distortion.

43. Endo-Ray II film holder. the operator places the film parallel to the tooth and perpendicular to the central ray and as far apical as possible

44. digital radiography system

45. CONVEX PULP CHAMBER FLOOR OF PULP CHAMBER MARKEDLY CONVEX CANAL ORIFICES SLIGHT FUNNAL SHAPE IN THIS CASE REMOVAL OF A LIP OF DENTIN CANAL CAN BE ENTERED MORE IN A DIRECT LINE WITH THE AXIS

46. ROOT CROSS SECTION OF THE MAXILLARY 2 MOLAR

47. ROOT CROSS SECTION-ENDO CORRELATION PALATAL, MB 2 FLAT SHAPED CIRCULAR, FLAT MB 1 DISTOBUCCAL CANAL FLAT,RIBBON SHAPED NEAR APEX BALANCE FORCED INSTRUMENTATION METHOD ROTARY NiTi FILES ALLOWED CONTROLLED PREPARATION OF THE BUCCAL AND LINGUAL EXTENSIONS OF OVAL CANALS

48. The Balanced Force action. This instrumentation technique uses clockwise/ anticlockwise rotational motion to remove dentine with flexible stainless steel files or nickel-titanium files. It is useful for rapidly removing dentine in curved canals whilst maintaining curvature (files are not precurved)

49. ROOT CANAL ORIFICES 1 CANAL SEPARATE IN TO 2 CANALS RELATIONSHIP OF THE 2 CANAL ORIFICES DIVISION IS BUCCAL AND PALATAL CLOSER 2 CANAL ORIFICES PALATAL CANAL SPLITS FROM THE MAIN CANAL AT SHARP ANGLE IT IS VISUAL CONFIGURATION AS LOWER CASE LETTER h GREATER CHANCE OF 2 CANALS JOIN AT SOME POINT IN THE BODY OF THE ROOT BUCCAL CANAL IS STRAIGHT PORTION OF THE h

50. Examination of pulp chamber floor can reveal clues to the location of orifices and to the type of canal system present Rotary NiTi files must be used cautiously with the type of anatomy because instrument separation can occur as the files traverses the sharp curvature in to the common part of canal

52. ROOT CANAL WITH ENDODONTIC CORRELATION TEETH WITH FUSED ROOTS THESE PARALLEL ROOT CANALS ARE FREQUENTLY SUPERIMPOSED RADIOGRAPHLY BUT THEY CAN IMAGED BY EXPOSING RADIOGRAPH FROM DISTAL ANGLE OCCASINALLY 2 CANALS 1 BUCCAL AND 1 PALATAL BOTH EQUAL LENGTH AND DIAMETER

53. 3 CANAL ORIFICES 2 CANAL ORIFICES

54. ACCESS CAVITY PREPARATION IN DIFFERENT CANAL ACCESS OUTLINE FORM 2 CANALS 4 CANALS 3 CANALS RHOMBOID SHAP ROUND TRIANGLE WITH BASE TO BUCCAL OVAL AND WIDEST IN BUCCO LINGUAL

55. WORKING LENGTH DETERMINATION Modern electronic apex locators are reliable instruments that can help the clinician determine the working length Successful treatment depends on the anatomy of the root canal system the dimension of the canal walls and the final size of enlarging instruments

56. J. Morita Root ZX electronic apex locator.

57. Analytic Endo Analyzer electronic apex locator and electronic pulp tester

58. WORKING LENGTH SIZE OF ROOT CANAL INSTRUMENTATION CANAL CLEANLINESS DISADVANTAGES INCREASED RISK OF PROCEDURAL ERRORS ROOT FRACTURES IRRIGANT VOLUME NUMBER OF INSTRUMENT CHANGES DEPTH OF PENERATION OF IRRIGANT NEEDLES LESS IMPORTANT FACTOR

59. ACCESSORY CANALS AND ENDODONTICS CORRELATION ACCESSORY CANALS FILLED THERMOPLASTIC GUTTAPURCHA ACCESSORY CANALS REMOVED SURGICAL PROCDURES APEX SHOULD BE RESECTED 2 TO 3 mm REMOVES MOST OF THE UNPREPARED UNFILLED ACCESSORY CANAL ELIMINATING A POTENTIAL RESERVOIR OF PATHOGENS

60. ROOT RESECTION FOR REMOVAL OF ACCESSORY CANAL Root end resection a bevel perpendicular to the long axis of a root exposes a small number of microtubules

61. root resection with 45-degree bevel exposes significantly grater number of tubules increasing the chance of leakage into and out of the root canal to prevent this root end cavity preparations should extend coronally to the height of the bevel

62. ACCESSORY CANAL ELIMINATION

64. Fracture under heavily occlusal force

66. TEETH WITH MINIMAL,NO CLINICAL CROWN Depth of penetration bur to reach the pulp canal is measured on a Preoperative radiograph clinician reaches this depth without locating the canal 2 radiograph Should be taken before procedure Straight radiograph Angled radiograph Preparation deviating in a Mesial or distal side Preparation deviating in a Buccal or lingual side The clinician redirect the penetration angle if necessary

68. Medications

69. Occlusal trauma

72. The Analytic ultrasonic gold nitride tips are available in sizes #2 through #5, and NiTi tips are available in sizes #6 through #8. Pictured left to right are #2, #3, #6, #7, and #8. Many other configurations are available

73. The Spartan ultrasonic handpiece has been specifically "tuned" to work the CPR tips.

74. ULTRASONICS The CPR tips are available in nitride (gold-yellow) and NiTi (green, blue, and purple). The extremely fine tips coupled with the small handpiece allow unprecedented visibility Ultrasonic tips can be used to remove pulp stones and to cut dentin while locating additional canals.

76. Management of calcified tooth Coated with a chelating agent should be introduced In to the canal to determine patency This file should be removed until canal enlargement It should be used in short up and down movement and In a selective circumferential filling motion with most of the Lateral pressure directed away from the furcation This safely enlarge the coronal canal and moves it laterally To avoid the furcation

77. LIMITATIONS Stop excavating dentin if a canal orifices cannot be found to avoid Weakening the tooth structure Serious error can arise from inappropriate attempt canals Root wall or furcation perforations can occur

79. Initial outline form occasionally can be created without dental dam

81. CASE REPORTS

82. Endodontic Miscellany : Maxillary 2 molar with two canals in the palatal root During pre-clinical Endodontic on extracted teeth, a maxillary second molar was found to have a palatal root with two canals. While locating the canals, because of eccentric location of the instrument in the palatal canal, a second canal was suspected. Placement of another instrument easily verified the presence of the second canal..

83. The palatal root canal system was characterized by two canal orifices and two canals that appeared to unite in the apical third of the root. which constitute type II canal configuration according to Vertucci's classification 8 Most of the clinical literature on the fourth canal in maxillary molars reports an additional mesiobuccal canal (MB2)3,4,5. But an anomalous root morphology that occurs Infrequently

84. Table 1: Canal Configurations of Maxillary second Molar Year Author Canal configuration P MB DB 1979 Slowey 2 1 1 1979 Thews 2 1 1 1982 Cecic 2 2 1 1983 Martinez- 1 3 2 Berna 1984 Beatty 1 3 1 1988 Bond 2 2 2 1991 Wong 3 1 1 1994 Jacobsen 2 1 1 1997 Hulsmann 1 1 2

85. Two canals in a single palatal root may present in one of the following types a. Two separate orifices, two separate canals and two separate foramina. b. Two separate palatal roots, each with one orifice, one canal and one foramen. c. One palatal root, one orifice, a bifurcated canal and two foramina

86. To investigate properly the possibility of additional canals, the dentist should: # understand the complexity of the morphology of the tooth involved # take additional off-angle radiographs # ensure adequate “straight-line” access to improve visibility

87. # examine the pulpal floor for “lines” to areas where additional canals may be located # remove a small amount of tooth structure that often may occlude a canal orifice. The dentist should be suspicious of additional canals if endodontic files are not well centred in the canal on the radiograph or if endodontic files are not well centred in the canal clinically.

88. Discussion Having the information observed from the radiographs and knowing what combinations of internal anatomy are possible, the dentist should be able to determine what type of canal configuration is present. An examination of the floor of the pulp chamber offers clues to the type of canal configuration present.

89. A Five-canal Maxillary Second Molar* May 2007, Volume 4, No.5 Journal of US -China Medical Science , ISSN1548-6648 USA CASE REPORT The patient was a 35 years old male who presented with a severe spontaneous pain in the maxillary right area which had been constant for one day. The medical status was unremarkable. Clinical examinations revealed that tooth-2 had deep mesio-occlusal caries without pulp exposure and was very sensitive to cold test.

90. Radiographic examination disclosed an unusual anatomical configuration of the roots, suggesting that four roots might be present. A diagnosis of acute pulpitis was made for tooth-Following local anaesthesia an endodontic access opening was made and the pulp chamber was exposed clearly.

91. Preoperative radiograph of tooth

92. Examination of the chamber floor with an endodontic explorer (DG-16) revealed five canal orifices 1.mesiobuccal canal (MB1), 2.mesiobuccal 2nd canal (MB2), 3.mesiopalatal canal (MP), 4.distopalatal canal (DP) 5.distobuccal canal (DB)

93. The orifice of the mesiopalatal canal was large, well formed, and located at the mesiopalatal corner of the pulp chamber. The distopalatal canal was also large and well developed and more distal to the chamber than a single palatal root would be expected. The MB2 orifice was found nearly on the imaginary line between the MBl and MP orifice, and about 1.5mm palatal to the MBl orifice

94. Occlusal view of seating of master point, displaying five root canal orifices Occlusal view of the access opening showing MB1, MB2, DB, and MP canal orifices

95. All canals were easily negotiated, and the working length was determined by using electronic apex locator Root ZX The root canals were cleaned and shaped using K-type files and Gates Glidden drills #2, #3, and #4 with passive step-back technique. Apical preparations in the buccal canals were enlarged to a master file size of 30, and in the palatal canal to size of 45.

96. The root canals were copiously irrigated with 3% H2O2 solution. Then the canals were obturated with AH-Plus sealer and gutta-percha using a lateral compaction technique. A temporary restoration with IRM was placed and a permanent restoration was advised. At the 3 month recall examination, the tooth was asymptomatic with normal periapical

97. Post obturation occlusal view of the pulp chamber floor showing all five root canal orifices Postobturation radiograph (RVG) displaying five root canals

98. DISCUSSION Peikoff classified the anatomical root and canal variations into six categories: Three separate roots and three separate canals; (2) three separate roots and four canals (two in the mesiobuccal root)

99. three roots and canals whose mesiobuccal and distobuccal canals combine to form a common buccal with a separate palatal two separate roots with a single canal in each one main root and canal four separate roots and four separate canals including two palatal.

100. This study also revealed that occurrence of ‘standard' configuration, 3 roots with 3 or 4 canals, was the most frequent (88.6%). In addition to Yang et al. result found that the maxillary second molars had a C-shaped root in 4.5% and C-shaped in Chinese population.

101. QUINTESSENCE INTERNATIONAL VOLUME 39 • NUMBER JANUARY 2008 A maxillary second molar with 6 canals: A case report A 31-year-old man presented to the dental clinic with a chief complaint of a fractured amalgam restoration on the maxillary right second molar. The patient’s medical history was non contributory. A preoperative radiograph taken after removing the fractured amalgam. Although the cavity was deep, there were no clinical symptoms. Therefore, the tooth was restored with a gold crown

102. One month later, the patient returned, reporting prolonged pain to cold on the restored maxillary right second molar, and root canal treatment was indicated Before the access opening was prepared, we assumed from the preoperative radiograph that it had two divergent palatal roots. Immediately after obtaining access, two mesiobuccal canals were apparent. When we located one distobuccal canal, its isthmus suggested the presence of a second canal.

103. We established the root canal anatomy to be as follows: 2 canals in the mesiobuccal root with one apical foramen, 2 separate canals in the distobuccal root, 1 canal in the mesiopalatal root, and 1 canal in the distopalatal root On the first visit,we determined the working lengths from the radiograph using a Root Zx . On the second visit, the six root canals were instrumented with a Profile Ni-Ti rotary file and irrigated with 1mL of 2.5% sodium hypochlorite after each change of file size

104. At the third visit, all of the canals were obturated by a combination of lateral and vertical compaction compaction using gutta-percha and Sealapex.The final radio-graphs and photograph srevealed the unusual anatomy of six canals filled with gutta-percha Preoperative radiograph

105. All 6 canal orifices in view Two mesiobuccal canals. 2 distobuccal canals 1 mesiopalatal canal

106. 1 distopalatal canal Working length determination of all canals.

107. a b c d Post treatment radiographs (a, b) and photographs (c, d) of the maxillary right second molar with 6 canals.

108. DISCUSSION The use of microscopes during endodontic treatments in dental clinics has become more widespread, and this practice has made the detection of hidden accessory canals easier, especially for mesiolingual canals of the maxillary molars. it is not necessary to use a microscope to detect every hidden root canal orifice in the pulp chamber. There are many studies of the configurations of apical canals that help practioners to predict the anatomy and positions of the pulp chamber and root canals before access preparation.

109. However, the average number of canals in a tooth is merely an indication when dealing with an individual case. Based on a study involving 500 pulp chambers of extracted teeth, Krasner and Rankow recently proposed new rules for locating root canal orifices. The rules state that the orifices of root canals are always located at the junction of the walls and the floor, at the angles in the floor-wall junction, and at the termini of the root developmental fusion lines.

110. With sufficient knowledge of tooth anatomy and an awareness of possible root canal variations, careful inspection of preoperative radiographs and the dentinal map of pulpal floor should decrease the possibility of missing canals, even without using microscopes, and therefore result in lower failure rates of endodontic treatment

111. CONCLUSION For successful endodontic treatment, it is helpful to keep in mind that there is a chance of encountering a maxillary second molar with more than 3 or 4 canals, or even 6, as this case.

112. REFERENCES 1 2. ENDODONTICS Fifth Edition JOHN I. INGLE, DDS, MSD LEIF K. BAKLAND, DDS 3. ROOT CANAL MORPHOLOGY 4. May 2007, Volume 4, No.5 Journal of US -China Medical Science , ISSN1548-6648, USA 5. QUINTESSENCE INTERNATIONAL VOLUME 39 • NUMBER 1 • JANUARY 2008 6. Journal of Endodontic 11, 308-10. Endodontics Problem-Solving in Clinical Practice TR Pitt Ford, BDS, PhD, FDS RCPS JS Rhodes, BDS, MSc, MRD RCS, 7.

113. THANK YOU ALL