Non-surgical Root Canal Treatment Case VII:
Maxillary Molar/Four Canals (MB1, MB2, DB, P)
Khaled Seifelnasr
Chief Complaint
“I have severe pain in the left side of my face, I feel it throbbing sometimes. I’m not sure where the pain is coming from.”
Medical History
The patient (Pt) was a 37-year-old white female. Her vital signs were as follows: blood pressure (BP) 118/72 mmHg; pulse, 74 beats per minute and regular; respiratory rate, 18 breaths per minute. A complete review of systems was conducted. No significant findings were noted. There were no contraindications to dental treatment (Tx).
The Pt was American Society of Anesthesiologists Physical Status Scale (ASA) Class I.
Dental History
The Pt had extensive restorative Tx. Teeth #12, #14, and #15 were observed to have large restorations.She was referred by her general dentist for evaluation of symptoms and Tx.
Clinical Evaluation (Diagnostic Procedures)
Examinations
Extra-oral Examination (EOE)
EOE revealed no significant findings, and no lymphaneopathy or extra-oral swellings were noted. The temporomandibular joint (TMJ) demonstrated no discomfort to opening or closing, no popping, clicking, or deviation to either side upon opening.
Intra-oral Examination (IOE)
IOE revealed multiple extensive restorations.
Diagnostic Tests
| Tooth | #13 | #14 | #15 |
| Percussion | – | + | – |
| Palpation | – | – | – |
| Thermal | Normal vital | Non–vital | Normal vital |
+: Pain/response; –: No pain/no response
Radiographic Findings
Periapical (PA) radiographic findings revealed large restorations invloving multiple surfaces of teeth #12, #14, and #15 (Figure 13.1). Tooth #14 showed a large composite restoration in close proximity to the pulp. The palatal root of tooth #14 showed apical resorption with a well defined radiolucent lesion involving the apex of that root.
Figure 13.1 Preoperative radiograph, first visit (Day 1).
Pretreatment Diagnosis
Pulpal
Necrotic Pulp, tooth #14
Apical
Symptomatic Apical Periodontitis, tooth #14
Treatment Plan
Emergency:NoneDefinitive:Non-surgical Root Canal Treatment (NSRCT) of tooth #14
Alternative
Extraction or no treatment
Restorative
Core build-up and full coverage restoration
Prognosis
| Favorable | Questionable | Unfavorable |
| X |
Clinical Procedures: Treatment Record
First visit (Day 1): A review of medical history (RMHX) of Pt was conducted. Informed consent, written and verbal, was obtained. A local infiltration was performed with 72 mg of 2% Xylocaine® with 1:100,000 epinephrine (epi). A rubber dam (RD) was placed and an access was made through the occlusal surface of the tooth. The pulp chamber was irrigated with 2.5% sodium hypochlorite (NaOCI); four canal orifices were located. A necrotic pulp was noted upon access. Working-length measurements were taken radiographically and verified via an electronic apex locator (Root ZX® II, J. Morita, Kyoto, Japan)(Figures 13.2 and 13.3). All canals were instrumented using .04 taper Vortex® Nickel Titanium (NiTi) rotary files (Dentsply Sirona, Johnson City, TN, USA). 2.5% NaOCl, 17% ethylenediaminetetraacetic acid (EDTA), and RC-Prep® were utilized throughout the procedure. Mesio-Buccal (MB) 1 and MB 2 canals were enlarged to a size #30, .04 taper, the Disto-Buccal (DB) canal was enlarged to a size #35, 0.04 taper, and the Palatal canal was enlarged to a size #60, .04 taper. The irrigants were then introduced to the canals after cleaning and shaping, followed by activation via ultrasonic activation files. All canals were dried with sterile paper points and medicated with calcium hydroxide (Ca(OH)2) powder freshly mixed with sterile saline. The Ca(OH)2 paste was packed and distributed throughout the canals. The access was closed with a sterile dry cotton pellet and Cavit™ (3M, Two Harbors, MN, USA). Occlusion was verified. Oral and written postoperative instructions were given.
Figure 13.2 MB1 and DB length-estimation radiograph (Day 1).
Figure 13.3 MB2 and P length-estimation radiograph (Day 1).
Second visit (Day 2): Pt was contacted for postoperative follow-up; the Pt reported that the dull pain had subsided and that she was feeling well.
Third visit (Day 14): RMHX; no changes were noted. Local infiltration with 72 mg of 2% Xylocaine with 1:100,000 epi was administered. A RD was placed and access was made through the CavitTM. The pulp chamber was irrigated with 2.5% NaOCl and 17% EDTA. Ultrasonic files were utilized to remove the Ca(OH)2 and the final rotary instruments were reintroduced in the canals to the previous diameters and working distances. All canals were dried with sterile paper points and obturated with gutta-percha (GP) and AH Plus® Root Canal Sealer (Dentsply Sirona, Konstanz, Germany) utilizing the warm vertical condensation technique. A radiograph was taken (Figure 13.4).
Figure 13.4 Postoperative radiograph, second visit (Day 14).
Working length, apical size, and obturation technique
| Canal | Working Length | Apical Size, Taper | Obturation Material and Techniques |
| MB1 | 19.5 mm | 30, .04 | GP, AH Plus® sealer Warm vertical condensation |
| MB2 | 19.0 mm | 30, .04 | GP, AH Plus® sealer Warm vertical condensation |
| DB | 19.5 mm | 35, .04 | GP, AH Plus® sealer Warm vertical condensation |
| P | 20.0 mm | 60, .04 | GP, AH Plus® sealer Warm vertical condensation |
Postoperative Evaluation
Fourth visit (15-month follow-up): Pt reported she had been asymptomatic. Soft tissues appeared to be normal and tooth had no apical tenderness or percussion sensitivity. PA radiograph demonstrated a healed tooth #14 with intact lamina dura (Figure 13.5). Figure 13.6 illustrates the location of MB2 intra-orally for the case. Figures 13.7–13.11 illustrate the prevalence of MB2 in maxillary molars. Figures 13.12 and 13.13 illustrate the unusual anatomy of maxillary molars.
Figure 13.5 One-year follow-up radiograph showing healed lesion.
Figure 13.6 Intra-oral picture showing location of MB2 (Day 14).
Figure 13.7 Maxillary 1st molar tooth #3 showing presence of MB2.
Figure 13.8 Maxillary 2nd molar tooth #15 showing presence of MB2.
Figure 13.9 Maxillary 1st molar tooth #3 showing presence of MB2.
Figure 13.10 Maxillary 1st molar tooth #14 showing presence of MB2.
Figure 13.11 Maxillary 2nd molar tooth #2 showing presence of MB2.
Figure 13.12 Unusual Maxillary 1st molar, tooth #3, showing presence of MB1, MB2 and MB3.
Figure 13.13 Maxillary molar tooth #14 with the second palatal canal and MB2.
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