MAXILLARY I,II MOLAR

MAXILLARY II MOLAR SUBMITTED BY

O.R.GANESAMURTHI1 YEAR M.Sc.D ENDODONTICS

INDEX EXTERNAL ANATOMY OF TOOTH MORPHOLOGY OF TOOTH

INTERNAL ANATOMY OF TOOTH PULP CHAMPER ROOT CANAL SYSTEM

ANOMALIES OF TOOTH

ENDODONTIC CORELATION

CASE REPORT

REFERENCE

INTRODUCTIONThe maxillary second molar is the tooth located distally from both the maxillary first molars of the mouth but mesial from both maxillary third molars. This is true only in permanent teeth. In deciduous teeth, the maxillary second molar is the last tooth in the mouth and does not have a third molar behind it. The function of this molar is similar to that of all molars in regard to grinding being the principle action during mastication. There are usually four cusps on maxillary molars, two on the buccal and two palatal

MAXILLARY II MOLAR

Class traits

3 or more cusps At least 2 buccal cusps One or more lingual cusps In general 2 or 3 roots

Average time of eruption : 11 to 13 years

Average age of calcification : 14 to 16 years

Average length : 20.0 mmCHRONOLOGY OF SECOND MOLAR

CHRONOLOGY OF SECOND MOLAR

Arch traits 3 roots: 2 Buccal & 1 Palatal Crown: Buccolingual > MesioDistal Cusps 3 major cusps MP, MB & DB Arranged in a tricuspid-triangular pattern Lesser-sized DL cusp & sometimes missingOblique ridge: MP to DB cuspBuccal cusps are of unequal sizeMP cusp is larger than DP

Buccal aspect Smaller crown size Less prominent DB cusp & narrower MD Distally inclined BUCCAL roots

Lingual aspect DL cusp is smaller in width & height LINGUAL root is narrower MD & slightly Distally inclined No cusp of Carabelli

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

Occlusal aspect

MB & DL angles are more acute ML & DB angles are more obtuse More variable pit/groove pattern More numerous supplementary groove Crown is more constricted MD

INTERNAL ANATOMYPulpMesioDistal section 2 horns, MB is higher Pulp chamber, roof & floor Canals, narrow Canal orifice

BuccoLingual section Pulp chamber is wider 2 horns of equal height

Cross -section 3 canals

INTERNAL ANATOMY PULP CHAMBER

THE PULP CHAMBER OF MAXILLARY 2 MOLAR IS SIMILAR TO THAT OF THE MAXILLARY 1 MOLAR EXCEPT IT IS NARROWER MESIODISTALLY PULP HORNS- 4 1.MESIOBUCCAL 2.DISTOBUCCAL 3.MESIOPALATAL 4.DISTOPALATALROOF MORE RHOMBOIDAL IN CROSS SECTIONFLOOR- OBTUSE TRIANGLE IN CROSS SECTION

PULP CHAMBER ANATOMY

ROOT CANALSif 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

ROOT CANAL ANATOMY

ROOTS AND ROOT CANALSPALATAL ROOTMESIOBUCCAL ROOTDISTAL ROOT63 % straight37 % buccal curve78 % distal curve22 % straight83 % straight17 % mesial curve

YEARTEETHSAMPLE1 CANAL 1 FORAMEN1 CANAL 2 FORAMINE2 CANAL 1 FORAMINE2 CANAL 2 FORAMINE197229464.6 %14.4 %8.2 %12.8 %19742962.1 %_13.8 %24.1 %198510071 %_17 %12 %

ROOT CANAL AND APICAL FORAMINA IN MAXILLARY 2 MOLAR MESIOBUCAL ROOT

ROOT ANOMALIESNUMBERS OF STUDIESNUMBERS OF TEETHONE ROOTTWO ROOTSTHREE ROOTSFOUR ROOTS312722.8 %7.8 %88.6 %0.4 %

ANATOMY RALATIONSHIPS IN SITU

The maxillary 2 molar usually is more closely related to the maxillary sinus than the maxillary 1 molarThis close relationship may produce Soreness In the maxillary teeth due to Maxillary sinusities

ENDODONTIC CORRELATION

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 YOUNGADULT NECROTIC PULPIrreversible Pulpitis

RCT

YOUNGReversible Pulpit'sIrreversible Pulpit's Necrotic PulpApexogenesisPulp Capping or PulpotomyClosed ApexOpen ApexRCTApexification Obturation

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

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.

Loupes give excellent magnification and illuminationAn operating microscope.

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

3. TROUGHING GROOVES WITH ULTRASONIC TIPS

4. STAINING THE CHAMBER WITH 1 % METHYLENE BLUE DYE CHAMPAGNE BUPPLE TEST

5. VISUALIZING CANAL BLEEDING POINT

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 thehorizontal angulation increases, the clarity of the radicular anatomy decreases. A 20 degree mesial shift is sufficient to separate the canals while limiting distortion.

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

digital radiography system

FLOOR OF PULP CHAMBERMARKEDLY CONVEXCANAL ORIFICES SLIGHT FUNNAL SHAPEIN THIS CASEREMOVAL OF A LIP OF DENTINCANAL CAN BE ENTERED MORE INA DIRECT LINE WITH THE AXISCONVEX PULP CHAMBER

ROOT CROSS SECTION OF THE MAXILLARY 2 MOLAR

ROOT CROSS SECTION-ENDO CORRELATION

PALATAL, MB 2 FLAT SHAPEDMB 1CIRCULAR, FLATDISTOBUCCAL CANALFLAT,RIBBON SHAPEDNEAR APEX BALANCE FORCED INSTRUMENTATION METHOD

ROTARY NiTi FILES ALLOWED CONTROLLED PREPARATION OF THE BUCCAL AND LINGUALEXTENSIONS OF OVAL CANALS

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)

RELATIONSHIP OF THE 2 CANAL ORIFICESCLOSER 2 CANAL ORIFICESGREATER CHANCE OF 2 CANALS JOIN AT SOME POINT IN THE BODY OF THE ROOT1 CANAL SEPARATE IN TO 2 CANALSDIVISION IS BUCCAL AND PALATALPALATAL CANAL SPLITSFROM THE MAIN CANALAT SHARP ANGLE IT IS VISUAL CONFIGURATION AS LOWER CASE LETTER hBUCCAL CANAL IS STRAIGHTPORTION OF THE h

ROOT CANAL ORIFICES

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

ROOT CANAL WITH ENDODONTIC CORRELATIONTEETH WITH FUSED ROOTSOCCASINALLY 2 CANALS1 BUCCAL AND 1 PALATALBOTH EQUAL LENGTH AND DIAMETERTHESE PARALLEL ROOT CANALS ARE FREQUENTLY SUPERIMPOSEDRADIOGRAPHLY BUT THEY CAN IMAGED BY EXPOSING RADIOGRAPHFROM DISTAL ANGLE

3 CANAL ORIFICES2 CANAL ORIFICES

ACCESS CAVITY PREPARATION IN DIFFERENT CANAL4 CANALS RHOMBOID SHAP

3 CANALSROUND TRIANGLE WITH BASE TO BUCCAL2 CANALSACCESS OUTLINE FORMOVAL AND WIDESTIN BUCCOLINGUAL

WORKING LENGTH DETERMINATIONModern 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

J. Morita Root ZX electronic apex locator.

Analytic Endo Analyzer electronic apex locator and electronic pulp tester

SIZE OF ROOT CANAL INSTRUMENTATIONWORKING LENGTH CANAL CLEANLINESSIRRIGANT VOLUMENUMBER OF INSTRUMENT CHANGESDEPTH OF PENERATION OF IRRIGANTNEEDLES LESS IMPORTANT FACTORDISADVANTAGES

INCREASED RISK OF PROCEDURAL ERRORSROOT FRACTURES

ACCESSORY CANALS AND ENDODONTICS CORRELATIONAPEX SHOULD BE RESECTED 2 TO 3 mm REMOVES MOST OF THE UNPREPAREDUNFILLED ACCESSORY CANALELIMINATING A POTENTIAL RESERVOIR OF PATHOGENS

ACCESSORY CANALS FILLEDTHERMOPLASTIC GUTTAPURCHA ACCESSORY CANALS REMOVEDSURGICAL PROCDURES

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

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

ACCESSORY CANAL ELIMINATIONROOT RESECTIONSAPICAL RAMIFICATIONSACCESSORY CANALS1 mm OF ROOT RESECTION52 %40 %2 mm OF ROOT RESECTION78 %40 %3 mm OF ROOT RESECTION98 %93 %

TEETH WITH MINIMAL OR NO CLINICAL CROWN Short crown may be developmental defect Caries left untreated

Fracture under heavily occlusal force

External trauma

Before starting the procedure clinician should study their root angulations on Preoperative radiograph

Examine the cervical crown anatomy with an explorer

Pulp chamber located at the center of the crown at the level Of the CEJ

TEETH WITH MINIMAL,NO CLINICAL CROWNDepth 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 radiographPreparation deviating in a Mesial or distal sideAngled radiographPreparation deviating in a Buccal or lingual side The clinician redirect the penetration angle if necessary

Teeth with calcified canal Endodontic correlation

Causes of calcified tooth

Caries

Medications

Occlusal trauma

aging

Use of magnification and transillumination

Search canal orifices after completely preparing the pulp chamber

And cleaning and drying its floor ( 70 % denature ethanol )

Chamber floor is DARKER in color than its wallManagement of calcified tooth

Developmental grooves connecting orifices are LIGHTER in color Than the chamber floor Staining the pulp chamber floor with1 % methylene blue dye Performing the sodium hypochlorite CHAMPAGNE BUPPLE test

Searching for canal bleeding point

Dentin must slowly be removed down the root

Use long thin ultrasonic tips under high magnification of a DOM to avoid removing too much tooth structureManagement of calcified tooth

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

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

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.

As the search moves apically Two Radiographs must be taken 1. straight on direction 2. angled directions

Very small pieces of lead foil placed at the apical extent of the penetration Can provide a radiograph references

Use first a small file K FILE ( #6, #8, or #10 ) coated with a chelating agent

Coated with a chelating agent should be introduced In to the canal to determine patencyThis 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 furcationThis safely enlarge the coronal canal and moves it laterally To avoid the furcationManagement of calcified tooth

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 occurLIMITATIONS

Rotated teeth This case altered crown root relationship Management of rotated teeth Radiograph examination is crucial

Initial outline form occasionally can be created without dental dam

Positioning of bur with long axis of the tooth

Bur penetration for both depth and angulations should be confirmed Frequently with radiographs

CASE REPORTS

Endodontic Miscellany : Maxillary 2 molarwith two canals in the palatal rootDuring 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..

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

Table 1: Canal Configurations ofMaxillary second MolarYear Author Canal configuration P MB DB1979 Slowey 2 1 1 1979 Thews 2 1 1 1982 Cecic 2 2 1 1983 Martinez- 1 3 2 Berna1984 Beatty 1 3 1 1988 Bond 2 2 2 1991 Wong 3 1 1 1994 Jacobsen 2 1 1 1997 Hulsmann 1 1 2

Two canals in a single palatal root maypresent 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

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

# 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.

Discussion

Having the information observed from theradiographs 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 thetype of canal configuration present.

A Five-canal Maxillary Second Molar*May 2007, Volume 4, No.5 Journal of US -China Medical Science , ISSN1548-6648 USACASE 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.

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.

Preoperative radiograph of tooth

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)

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

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

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.

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

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

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)

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.

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.

A maxillary second molar with 6 canals: A case reportQUINTESSENCE INTERNATIONAL VOLUME 39 NUMBER JANUARY 2008A 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 patients 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

One month later, the patient returned, reporting prolonged pain to cold on the restored maxillary right second molar, and root canal treatment was indicatedBefore 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.

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

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

Preoperative radiograph

All 6 canal orifices in viewTwo mesiobuccal canals.

2 distobuccal canals

1 mesiopalatal canal

1 distopalatal canalWorking length determination of all canals.

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

DISCUSSIONThe 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.

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.

With sufficient knowledge of tooth anatomy and an awareness of possible root canal variations, careful inspection of preoperative radiographsand 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

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

REFERENCES

2. ENDODONTICS Fifth Edition JOHN I. INGLE, DDS, MSD LEIF K. BAKLAND, DDS3. ROOT CANAL MORPHOLOGY 4. May 2007, Volume 4, No.5 Journal of US -China Medical Science , ISSN1548-6648, USA5. QUINTESSENCE INTERNATIONAL VOLUME 39 NUMBER 1 JANUARY 20086. Journal of Endodontic 11, 308-10.1

EndodonticsProblem-Solving in Clinical PracticeTR Pitt Ford, BDS, PhD, FDS RCPSJS Rhodes, BDS, MSc, MRD RCS, 7.

THANK YOU ALL