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Braz Dent J 20(5) 2009

424 L.R. Soares et al.

IntroductIon

The aatomy of the rot caal system determiesthe parameters uder which the edodotic treatmetwill be accomplished ad directly affects the therapysuccess. Madibular premolars have reat variability o

their iteral morpholoy due to the possible preseceof more tha oe root caal (1-6). Tzaetakis et al. (7)

reported that the icidece of two or more caals i themadibular secod premolar ca rae from 1.2 to 34%.The occurrece of three caals i madibular secod premolars has bee reported as 0.0% (8) ad 0.4% (9),ad is characterized by the presece of a wide caal i

Diagnosis and Root Canal Treatment in aMandibular Premolar with Three Canals

Lauce Rosa SOARES1

Marcos ARRUDA1

Marcos Pôrto de ARRUDA2,3

Adréa Leão RAngEL1

Edso TAKAnO1

Jacy Ribeiro de CARVALHO JÚnIOR 1

Paulo Cesar SAQUY4

1 Dental School, Federal University of Goiás, Goiania, GO, Brazil 2 Dental School, Catholic University of Brasília, Brasilia, DF, Brazil

3

Dental School, University of Ribeirão Preto, Ribeirão Preto, SP, Brazil 4 Ribeirão Preto Dental School, University of São Paulo, Ribeirão Preto, SP, Brazil

This paper presets a case report of a left madibular secod premolar with three caals ad three differet apical foramia. A 39-year-old male patiet preseted to our cliic with pai i the madibular left secod premolar. Iitially, pai was caused by cold stimulus adlater was spotaeously. The itraoral cliical examiatio revealed a fractured amalam restoratio with occlusal caries. Percussioad cold (Edo-Frost) tests were positive. The radioraphic examiatio showed the presece of two roots. The probable diaosiswas a acute pulpitis. After access cavity, it was observed remaii roof of the pulp chamber ad mild bleedi i the tooth liualarea, idicati the possible presece of a third caal. The edodotic treatmet was completed i a sile sessio usi Root ZXapex locator ad K3 niTi rotary system with surical diameter correspodi to a .02/45 file i the three caals ad irriatio with 1%sodium hypochlorite. The caals were obtured with utta-percha coes ad Sealer 26 usi the lateral codesatio techique. After 1 year of follow-up, the tooth was asymptomatic ad periapical repair was observed radioraphically. Iteral alteratios should becosidered duri the edodotic treatmet of madibular secod premolars. The correct diaosis of these alteratios by the aalysis

of preoperative radioraphs ca help the locatio of two or more caals, thereby avoidi root therapy failure.

Key Words: detal pulp cavity, detal pulp diseases, edodotic, root caal therapy.

the liual face ad two small caals i the buccal face(mesiobuccal ad distobuccal).

There have bee reports of madibular secod premolar with 3, 4 ad eve 5 root caals (5,10,11). Thesereports demostrate that such aatomic variatio mihtoccur i cliical practice, i spite of its low icidece.

Morpholoic variatios of the pulp cavity have beedocumeted ad diaosed by computed tomoraphy(12) ad optical microscopy (13), but most variatiosi tooth aatomy ca be idetified radioraphically.

This paper presets ad discusses, by the aaly-sis of radioraphic imaes, the case of a edodotictreatmet performed i a madibular secod premolar

Correspodece: Prof. Dr. Paulo César Saquy, Departameto de Odotoloia Restauradora, Faculdade de Odotologia de Ribeirão Preto, USP, Aveida

do Café, S/n, 14040-904 Ribeirão Preto, SP, Brasil. Tel: +55-16-3602-3982. Fax: +55-16-3633-0999.

ISSn 0103-6440 Braz Dent J (2009) 20(5): 424-427

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Mandibular premolar with three canals 425

with three caals ad three differet apical foramia.

case report

A 39-year-old male patiet preseted to our cliicwith pai i the left madibular secod premolar. Theitraoral cliical examiatio revealed a fractured amal-am restoratio with occlusal caries i this tooth. The patiet reported that the pai was iitially caused by coldstimulus that ceased few miutes after its removal. After a short period, the pai ceased oly with aalesics adafterwards, it became spotaeous, itese ad pulsed.

The preoperative periapical radioraph showedthe presece of two caals ad two roots, oe mesial adoe distal (Fi 1A). The probable diaosis was a acute pulpitis ad the edodotic treatmet was idicated. The

patiet received local aesthesia (3% lidocaie with 1:100 000 adrealie) ad a rubber dam was placed addisifected with 1% sodium hypochlorite. The accesscavity was prepared with roud diamod burs (Kg So-rese, Barueri, SP, Brazil) mouted i a water-cooledhih-speed hadpiece. After reachi the pulp chamber,the roof was removed ad the lateral walls were preparedwith a safe-ed tapered bur (Edo-Z; Detsply/Maillefer,Ballaiues, Switzerlad) positioed parallel to the loaxis of the tooth. The diverece of the cavity walls was provided by the coicity of the Edo Z drill.

Mesial ad distal caals were located with#08 ad #10 K-files (Detsply/Maillefer). Duri thestadard caal preparatio, it was oticed that the iitialistrumets crossed whe placed ito mesial ad distalcaals. Therefore, the access cavity was wideed i thetooth liual face, reveali residual pulp chamber roof ad mild bleedi i this area, suesti the presece of a liual caal. Exploratio cofirmed the presece of three root caals: mesiobuccal, distobuccal ad liual.

The caals were irriated with 1% sodiumhypochlorite ad the worki leth was determiedusi the Root ZX apex locator (J. Morita, Tokyo,Japa) (Fi.1B). Biomechaical preparatio was ac-complished with the K3 ickel-titaium rotary system(SybroEdo, Orae, CA, USA). The roots cervicalthird were prepared with .06/30 ad .06/25 istrumetsfollowed by the apical preparatio with .04/20, .02/20,04./25, 02/25, .02/30, .02/35, .02/40 ad .02/45, beithis last oe the apical master file of the three caals.

The caals were irriated with 1% sodium hypo-chlorite ad were filled by lateral codesatio of utta-

percha coes ad Sealer26 edodotic sealer (DetsplyId. e Com. Ltda., Petrópolis, RJ, Brazil) (Fi 1 C-E).

dIscussIon

Madibular secod premolar is oe of the mostdifficult teeth for the edodotic treatmet (14). This ca be attributed to variatios i the iteral morpholoy of their pulp cavity, cosideri the umber of root caals,apical deltas ad lateral caals (13,15). I additio, theaccess cavities i these teeth are relatively small, hecereduci the visualizatio of the area. A wider edodoticaccess is ecessary to locate extra root caals (7).

Preoperative radioraphs are used to idetify aa-tomical alteratios of the root caal system. The aalysisof the aatomical aspects of pulp chamber roof ca also

help idetifyi these iteral variatios thus, facilitatithe properly locatio of all root caals (13,16).

During radiographic examination, a careful

interpretation of the periodontal ligament space (Fig

1A) could suggest the presence of an extra root or

canal. Indeed, in the present case, it can be noticed a

sudden change of the radiopacity of the canal space

(Fig 1A). The radiolucent space uniformly disappears

from the pulp chamber, suggesting a possible presence

of an additional canal (10,13,17). In these cases, in

order to better visualize the pulp chamber, the access

cavity should have divergent walls to the oclusal face.In the present case, this procedure was done with the

Endo Z drill (Dentsply/Maillefer) positioned parallel

to the teeth long axis. The divergence of the cavity

walls was provided by the conicity of the active part

of the drill.

I the case reported i this paper, some opeiresistace was felt duri the iitial eotiatio of caalswith #08 ad #10 istrumets, idicati the preseceof more root caals. At this momet, it is importat touse tactile sesibility ad also observe the directio of the edodotic istrumet duri its itroductio itothe caal. After localizatio of the caals, the cervicalthird was wideed with the #25.10 ni-Ti istrumet of K3 system (SybroEdo). Preflari of the root cervi-cal portio allows a correct determiatio of the iitialistrumet ad, cosequetly, a better cleai of theapical third ad filli of the root caals (18-20).

Althouh in vitro ad in vivo studies (5,10,11)report low icidece of madibular secod premolar with three caals, each case should be aalyzed idividu-

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426 L.R. Soares et al.

ally by a careful radioraphic ad cliical examiatio, aimi to fid other root caals.

Fi. 1. Pael of periapical radioraphs documeti teh case. A = Preoperative radioraph; B = Worki leth determiatio; C =Selectio of the mai utta-percha coes; D = Testi of the caal filli; E = Fial obturatio; F = 1-year follow-up.

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Mandibular premolar with three canals 427

resuMo

O presete artio teve como objetivo a apresetação de um casoclíico de um seudo pré-molar iferior esquerdo com trêscaais com três forames distitos. Paciete de 39 aos de idade,

leucoderma, relatava dor iicialmete estimulada ao frio e poste-riormete dor espotâea o referido dete. no exame itraoralfoi costatada restauração de amálama fraturada e cárie oclusal.Os testes de sesibilidade à percussão e ao frio (Edo-Frost)foram positivos. O exame radioráfico evideciou a preseça deduas raízes. O diaóstico provável foi de pulpite auda. Apóso preparo de acesso à câmara pulpar otou-se a preseça de tetoremaescete e um leve sarameto, sedo possível localizar um terceiro caal a reião liual. O tratameto edodôticofoi realizado em uma úica sessão, com auxílio do localizador apical Root ZX, e o preparo biomecâico com sistema rotatóriocom limas de niTi K3 com diâmetro cirúrico correspodete aoistrumeto .02/45 os três caais, e a solução química auxiliar hipoclorito de sódio 1%. A obturação foi realizada por codesa-ção lateral de uta-percha e cimeto Sealer26. Durate o períodode proservação de 1 ao, o dete apresetou-se cliicameteassitomático com reparação dos tecidos periapicais observadaradioraficamete. Alterações iteras devem ser cosideradasdurate tratameto edodôtico em seudos pré-molares iferi-ores. O correto diaóstico destas alterações por meio da aálisede radiorafias pré-operatórias podem auxiliar a localizaçãode dois ou mais caais, evitado dessa maeira o isucesso dotratameto a ser realizado.

acKnoWLedGeMents

The authors are rateful to the Professors Edso Takao ad JacyRibeiro de Carvalho Júior from the Edodotics Specializatio

Course of the Federal Uiversity of goiás for their support.

reFerences

1. Barrett MT. The iteral aatomy of teeth with special refereceto the pulp ad its braches. Detal Cosmos 1925;67:581-592.

2. Amos ER. Icidece of bifurcated root caals i madibular bi-cuspids. J Am Det Assoc 1955;50:70-71.

3. Elad MC Jr, Hartwell gR, Lace JR. Detectio ad treatmetof multiple caals i madibular premolars. J Edod 1991;17:174-178.

4. Baisde MF, Kulild JC, Weller Rn. Root caal cofiuratio of the madibular first premolar. J Edod 1992;18:505-508.

5. Macri E, Zmeer O. Five caals i a madibular secod premolar.J Edod 2000;26:304-305.

6. Almeida-gomes F, Sousa BC, Satos RA. Uusual aatomy of madibular premolars. Aust Edod J 2006;32:43-45.

7. Tzaetakis gn, Laoudakos TA, Kotakiotis Eg. Edodotictreatmet of a madibular secod premolar with four caals usioperati microscope. J Edod. 2007;33:318-321.

8. Vertucci FJ. Root caal aatomy of the huma permaet teeth.Oral Surery 1984;58:589-599.

9. Zillich R, Dowso J. Root caal morpholoy of madibular first ad secod premolars. Oral Sur Oral Med Oral Pathol1973;36:738-744.

10. Clehor BM, Christie WH, Do CC. Aomalous madibular premolars: a madibular first premolar with three roots ad amadibular secod premolar with a C-shaped caal system. ItEdod J 2008;41:1005-1014.

11. Al-Fouza KS. The microscopic diaosis ad treatmet of a madibular secod premolar with four caals. It Edod J2001;34:406-410.

12. Clehor BM, Christie WH, Do CC. The root ad root caalmorpholoy of the huma madibular first premolar: a literaturereview. J Edod 2007;33:509-516.

13. De Moor RJg, Calberso FLg. Root caal treatmet i a madibu-lar secod premolar with three root caals. J Edod 2005;31:310-313.

14. Awawdeh LA, Al-Qudah AA. Root form ad caal morpholoyof madibular premolars i a Jordaia populatio. It Edod J2008;41:240-248.

15. nallapati S. Three Caal Madibular First ad Secod Premolars:A Treatmet Approach. A Case Report. J Edod 2005;31:474-476.

16. Clehor BM, Christie WH, Do CC. The root ad root caalmorpholoy of the huma madibular secod premolar: a litera-ture review. J Edod 2007;33:1031-1037.

17. Vertucci FJ. Root caal morpholoy of madibular premolars. J

Am Det Assoc 1978;97: 47-50.18. Wu MK, Barkis D, Roris A, Wesselik PR. Does the first file to

bid correspod to the diameter of the caal i the apical reio?It Edod J 2002;35:264-267.

19. Vai JR, Satos R, Limoi O, guerisoli DM, Capelli A, PecoraJD. Ifluece of cervical preflari o determiatio of apical filesize i maxillary molars: SEM aalysis. Braz Det J 2005;16:181-186.

20. Khademi A, Yazdizadeh M, Feiziafard M. Determiatio of themiimum istrumetatio size for peetratio of irriats to theapical third of root caal systems. J Edod 2006;32:417-420.

Accepted August 15, 2009

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