Case Report/Clinical Techniques

Endodontic Management of a Maxillary First Molar with

Eight Root Canal Systems Evaluated Using Cone-beam
Computed Tomography Scanning: A Case Report
Jojo Kottoor, MDS, Natanasabapathy Velmurugan, MDS, and Smitha Surendran, MDS
Abstract
Introduction: Root canal treatment of maxillary molars
presenting with complex root canal configurations can
be diagnostically and technically challenging. Methods:
Nonsurgical endodontic therapy of a left maxillary first
molar with three roots and eight root canals was
successfully performed. This unusual morphology was
diagnosed using a dental operating microscope (DOM)
and confirmed with the help of cone-beam computed
tomography (CBCT) images. Results: CBCT axial images
showed that both the mesiobuccal and distobuccal root
contained a Sert and Bayirli type XV canal, whereas the
palatal root showed a Vertucci type II canal configuration. Conclusions: The use of a DOM and CBCT imaging
in endodontically challenging cases can facilitate a better
understanding of the complex root canal anatomy,
which ultimately enables the clinician to explore the
root canal system and clean, shape, and obturate it
more efficiently. (J Endod 2011;37:715719)

Key Words
Cone-beam computed tomography scanning, maxillary
first molar, root canal anatomy, root canals

From the Department of Conservative Dentistry and

Endodontics, Meenakshi Ammal Dental College and Hospital,
Chennai Tamil Nadu, India.
Address reqeusts for reprints to Dr Jojo Kottoor, Department of Conservative Dentistry and Endodontics, Meenakshi
Ammal Dental College and Hospital, Alapakkam Main Road,
Maduravoyal, Chennai Tamil Nadu, India 600 095. E-mail
address: drkottooran@gmail.com
0099-2399/$ - see front matter
Copyright 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.01.008

JOE Volume 37, Number 5, May 2011

he main objective of root canal treatment is thorough cleaning and shaping of all
pulp spaces and its complete filling with an inert filling material (1). A major cause
of post-treatment disease is the inability to locate, debride, or adequately fill all canals of
the root canal system (2). Together with diagnosis and treatment planning, a better
knowledge of the root canal system and its frequent variations is an absolute necessity
for successful root canal treatment (3). The form, configuration, and number of root
canals in maxillary first molars have been discussed for more than half a century (4).
Maxillary first molars commonly present with three roots and three canals, with
a second mesiobuccal canal (MB2) canal seen in 56.8% and 96.1% of the cases
(57). Apart from these presentations, a wide variation of root and canal
configurations of the maxillary first molars has been documented in the dental
literature. This includes a single root canal in a single root (8), two root canals (9),
five root canals (10), six root canals (11), C-shaped canals (12), and an additional
palatal root (13). Recently, Kottoor et al (14) reported the endodontic management
of a maxillary first molar with seven root canals. Case reports of maxillary first molars
presenting with six or more root canals are summarized in Table 1. This case report
presents a maxillary first molar with an unusual morphology of three roots and eight
root canals, which has neither been reported in any clinical or laboratory studies
nor clinical case reports so far. This unusual morphology was confirmed with the
aid of cone-beam computed tomography (CBCT) scanning.

Case Report
A 30-year-old Indian male patient reported to the postgraduate clinic of the
Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental
College, Chennai, India, with the chief complaint of spontaneous pain in the upper
left posterior for the past 5 days. He revealed a history of intermittent pain for the
last 2 months, which had increased in intensity in the preceding 5 days. The patient reported subjective symptoms of prolonged sensitivity to hot and cold and the recent
heightened intensity of pain, which awakened the patient throughout the night. Clinically, the left maxillary first molar (tooth #14) had a deep mesio-occlusal carious
lesion. The patients medical history was unremarkable. Palpation of the buccal and
palatal aspects of the tooth did not reveal any tenderness; however, the tooth was tender
to vertical percussion. Periodontal probing around the tooth and mobility were within
physiological limits. Thermal testing (heated gutta-percha and dry ice) caused an
intense lingering pain, whereas electric pulp testing (Parkel Electronics Division, Farmingdale, NY) showed pulpal vitality on tooth #14. Preoperative radiographs revealed
a mesio-occlusal radiolucency approaching the pulp space with a widened periodontal
ligament adjacent to the mesiobuccal root. From the clinical and radiographic examination, a diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis was made, and nonsurgical endodontic treatment was recommended.
Radiographic evaluation of the involved tooth did not indicate any variation in the
root canal anatomy (Fig. 1A). The mesial surface of the tooth was restored with
composite resin (Z100; 3M Dental Products, St Paul, MN) after caries excavation to
enable optimal isolation. Local anesthesia was induced using 1.8 mL 2% lidocaine
with 1:200,000 epinephrine (Xylocaine; AstraZeneca Pharma Ind Ltd, Bangalore,
India). A rubber dam was placed, and a conventional endodontic access opening

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TABLE 1. Summary of Case Reports of Maxillary First Molars Presenting with Six or More Root Canals
Root
configuration

Root canal anatomy

No. of canals

Mesiobuccal

Distobuccal

Palatal

Reference

3 roots

3 roots
3 roots

6
6

2
2

2
1

2
3 (apical third
trifurcation)

and
Mart
nez-Berna
Ruiz-Badanelli (1983)
(3 cases) (15)
Bond et al (1988) (16)
Maggiore et al (2002) (17)

4 roots
(MB, MP, P, DB)
3 roots

MB, MP, M, P, DP, DB

3 roots

3 roots
3 roots

6
6

2
2

3
2

1
2

3 roots
3 roots

7
8

3
3

2
3

2
2

was established with an Endo Access bur and an Endo Z bur (Dentsply
Tulsa, Tulsa, OK). Initially, the mesiobuccal (MB1), the distobuccal
(DB1), and the two palatal canals (mesiopalatal [MP] and the distopalatal [DP]) were located. While viewing the floor of the pulp chamber
under a dental operating microscope (DOM) (Seiler Revelation, St
Louis, MO), two additional root canal orifices were located palatally
to the MB1 and DB1. However, several attempts to introduce a file
into these orifices were unsuccessful. On troughing away the dentin
occluding the orifices using ET 18D ultrasonic tips (Satelec/Acteon,
Merignac, France), the second and third mesiobuccal (MB2 and
MB3) and distobuccal (DB2 and DB3) root canal orifices were located.
The conventional triangular access was modified to a trapezoidal shape
to improve access to the additional canals. Coronal enlargement was
performed with a nickel-titanium ProTaper SX rotary file (Dentsply
Maillefer, Ballaigues, Switzerland) to improve the straight-line access
(Fig. 1B). Root canals were explored with ISO #10 K-files. CBCT scanning was used to confirm and ascertain the unusual root canal
morphology. All the root canals were dried and no medicament placed.
A sterile cotton pellet was placed in the pulp chamber and Cavit G (3M
ESPE Dental Products, St Paul, MN) was used to seal the access cavity.
Informed consent was obtained from the patient, and a computed
tomography scan was performed with a CBCT scanner (Kodak 9500 Cone
Beam 3D, Chennai, India) at a tube voltage of 60 kVp and tube current of
5 mA. All protective measures were taken to protect the patient from radiation according to As Low As Reasonably Achievable guidelines. Axial
images were transmitted to a commercially available dental program (Kodak Dental Imaging Software 3D module v 2.4) to reformat panoramic
and cross-sectional images in all three planes. Axial slices of the maxilla
of 200-mm thickness were obtained at different levels to determine the
root canal morphology (Fig. 2AC). CBCT scan slices revealed eight
root canals (three mesiobuccal, three distobuccal, and two palatal) in
the left maxillary first molar (Fig. 2AG).
CBCT images provided valuable information regarding the canal
configuration and confirmed the eight canals that were not clearly
seen in the conventional radiograph. At the next appointment after 2
weeks, the patient was asymptomatic. After administering 1.8 mL 2%
lidocaine with 1:200,000 epinephrine, the working lengths were determined with the help of an apex locator (Root ZX; Morita, Tokyo, Japan)
under rubber dam isolation. Individual intraoral periapical radiographs for the mesiobuccal (Fig. 1C), distobuccal (Fig. 1D), and palatal
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Kottoor et al.

Adanir (2007) (18)

de Almeida-Gomes et al
(2009) (19)
Karthikeyan and
Mahalaxmi (2010)
(4 cases) (20)
Albuquerque et al (2010)
(3 cases) (11)
Kottoor et al (2010) (14)
Present case

root (Fig. 1E) were taken to confirm the working lengths. Cleaning and
shaping were performed using ProTaper nickel-titanium rotary instruments (Dentsply Maillefer) with a crown-down technique. The MB1,
DB1, MP, and DP canals were enlarged to ProTaper F3; whereas the
MB2, MB3, DB2, and DB3 canals were enlarged until ProTaper F2.
During root canal preparation, irrigation was performed using normal
saline, 2.5% sodium hypochlorite solution, and 17% EDTA. Final
rinsing of the canals was performed using 2% chlorhexidine digluconate coupled with ultrasonic agitation. The canals were dried with
absorbent points (Dentsply Maillefer), and obturation was performed
using cold lateral compaction of gutta-percha (Dentsply Maillefer)
and AH Plus resin sealer (Maillefer Dentsply, Konstanz, Germany). A
final radiograph was taken to establish the quality of the obturation.
After completion of root canal treatment, the tooth was restored with
a posterior composite filling (Z100; 3M ESPE Dental Products, St
Paul, MN) (Fig. 1F). The patient experienced no post-treatment discomfort and was subsequently referred for appropriate coronal restoration.

Discussion
The anatomy of teeth is not always predictable. A great number of
variations could occur in formation in both the roots and their shape.
Hess (21) reported the wide variation and complexity of root canal
systems establishing that a root with a tapering canal and a single
foramen was the exception rather than the rule. Weine et al (22) divided
the position of one or two canals within a root into four basic types. Vertucci (2) described a much more detailed canal system and identified
eight pulp space configurations. Recently, 14 new additional canal types
were reported by Sert and Bayirli highlighting the complexity of root
canal systems (23).
Of the various comprehensive maxillary first molar ex vivo studies
in the dental literature, only Baratto Filho et al (24) reported a maxillary
first molar with three roots and seven root canals. Of the 140 extracted
maxillary first molars evaluated, only one tooth showed seven root
canals, which contained three mesiobuccal, three distobuccal, and
one palatal canal. The frequency of MB2 canals in the mesiobuccal
root was reported to be 92.85% (based on ex vivo results), 95.63%
(based on clinical results), and 95.45% (based on CBCT results),
whereas the corresponding figures for the distobuccal root (DB2)
were 1.15% (ex vivo) and 3.75% (clinical) and those for the palatal
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Figure 1. (A) A preoperative radiograph of tooth #14. (B) Access opening showing the eight root canal orifices. (CE) Eccentrically angulated radiographs of
tooth #14 to confirm the working length in the (C) mesiobuccal, (D) distobuccal, and (E) palatal roots. (F) A postobturation radiograph of tooth #14 in eccentric
angulation showing the root canal system of the tooth.

root (second palatal canal) were 2.05% (ex vivo), 0.62% (clinical),
and 4.55% (CBCT).
Traditionally, the mesiobuccal root of the maxillary first molar has
generated more research and clinical investigation than the other roots
(25). Most of the in vitro studies of the mesiobuccal root canal anatomy
(2630) have not reported the presence of a third canal in the
mesiobuccal root. Two such studies have reported their incidence to
be between 1.1% and 10% (31, 32). However, its presence has been
documented in a few case reports (10, 14). The third canal in the
distobuccal root of maxillary first molars is rare, with only two
documented reports in the dental literature (20, 24). These reports
presented a Gulabivala type III (33) and a Sert and Bayirli type XVIII
root canal configuration (23) in the distobuccal root of maxillary first
molars.
The maxillary first molar is predominantly a three-rooted tooth
with a buccolingually broad mesiobuccal root and a rounded or ovoid
distobuccal root in the cross-section (5). This anatomic difference
could possibly explain for the higher incidence of multiple canals in
the mesiobuccal root (25). In the present case, CBCT axial images
clearly depicted that the distobuccal root was broad buccolingually,
similar to the mesiobuccal root (Fig. 2B). The contralateral distobuccal
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root also presented with a similar anatomy (Fig. 2B and C). This variation in the external root morphology may perhaps explain for the rare
internal anatomy of three root canals within the distobuccal.
Conventional intraoral periapical radiographs are an important
diagnostic tool in endodontics for assessing the root canal configuration. Nevertheless, it is not completely reliable because of its inherent
limitation (34). The application of further analytic diagnostic tools
such as CBCT scanning for the assessment of unusual root canal
morphology has been highlighted, aiding the correct endodontic
management of complicated and challenging cases (14, 35). CBCT
images are reconstructed using significantly lower radiation doses
compared with alternative conventional computed tomography
scanning. This is because with CBCT scanning the raw data are
acquired in the course of a single sweep of a cone-shaped x-ray source
and reciprocal detector around the patients head. The efficient use of
the radiation beam and the elimination of the need for a conventional
image intensification system used in conventional computed tomography scanners result in a huge reduction in radiation exposure.
CBCT data were particularly useful in assessing the root and canal
morphology in the present case. CBCT axial images confirmed the presence of three roots and eight root canals, namely the MB1, MB2, MB3,

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Figure 2. (AC) CBCT images of the maxillary arch showing axial sections at the (A) cervical, (B) middle, and (C) apical level. (DF) Enlarged axial-section CBCT
images of tooth #14 at the (D) cervical, (E) middle, and (F) apical level showing three roots and eight root canals.

DB1, DB2, DB3, MP, and DP (Fig. 2AF). The contralateral tooth
appeared to have a normal root canal anatomy (Fig. 2AC).
CBCT axial images also showed that both the mesiobuccal and the
distobuccal root had a Sert and Bayirli type XV canal configuration
(23) (ie, the first and second canals of both roots joined at the
middle third and exited through one apical foramen, whereas the
third canal had a separate canal orifice and exiting foramen).
The palatal root presented with a Vertucci type II canal pattern
(2) (ie, two canal orifices joining together and exiting into one
apical foramen) (Fig. 2B and C).
The removal of vital and necrotic remnants of pulp tissues, microorganisms, and microbial toxins from the root canal system is essential
for endodontic success (36). Extensive isthmuses, anastomosis, fins,
cul-de-sacs, and other parts of the canal system that are difficult to
debride via mechanical instrumentation have been found to be present
in all multirooted teeth (37). Therefore, chemical irrigation using
sonics and ultrasonics should be an essential part of root canal debridement because it allows for cleaning beyond what might be achieved by
root canal instrumentation alone (38).
The role of microscopy in endodontics should not be underestimated. Buhrley et al (7) had preformed an in vivo study to determine
the practitioners ability to locate the MB2 canal in maxillary molars
using the DOM and/or dental loupes. They concluded that when the
maxillary first molars were considered separately, the frequency of
MB2 canal detection for the microscope, dental loupes, and no magnification groups were 71.1%, 62.5%, and 17.2%, respectively. In the
present case, success was largely dependent on the use of magnification,
which allowed for the identification of the eight distinct root canal
orifices with ease. Hence, clinicians should familiarize themselves
with dental microscopy and new imaging technology, such as CBCT
scanning, to get additional anatomic information in endodontic practice.

Conclusion
The clinical significance of the present case is that this is the first
report of a case with three roots and eight root canals in a maxillary first
molar. The routine use of DOM while performing endodontic treatment
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Kottoor et al.

is suggested because it will definitely be helpful in identifying and treating all root canals successfully.

Acknowledgments
The authors deny any conflicts of interest related to this study.

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