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					         I case report _ maxillary molars

maxillary molars
Author_ Dr Mark Dreyer, USA

                                                                        _Endodontic evaluation

                                                                            A 58-year-old female patient presented
                                                                        for endodontic evaluation and therapy
                                                                        in the upper left quadrant. Mild pain for
                                                                        several days was reported by the patient
                                                                        prior to the appointment. Medical history
                                                                        was non-contributory, and dental history
                                                                        was remarkable for multiple existing large
                                                                        amalgam restorations (Figs. 1–3). Clinical
                                                                        examination and diagnostic evaluation
                                                                        were performed for all posterior teeth on
                                                                        the right side, including cold testing,
                                                                        percussion, palpation, periodontal probing
                                                                        and bite challenge. Findings led to a pre-
                                                                        operative diagnosis of irreversible pulpitis
                                                                        in tooth #3 with normal peri-radicular

                                                                           After anaesthesia and isolation with the
Fig. 1
                                                                                    rubber dam, entry was made
                                                                                    into a calcified pulp chamber.
                               _Maxillary first molars are                          Use of the dental operating
                            notable for their complex root-                         microscope (OM) greatly en-
                            canal system morphology. The                            hances lighting and visibility,
                            mesio-buccal (MB) roots are                             allowing for careful and de-
                            characterised by an irregular                           liberate clearing of reparative
                            ovoid morphology, resulting in                          dentine, pulp stones and other
                            an isthmus or fin of pulpal tis-                        potential impediments to canal
                                                               Fig. 2
                            sue extending palatally to the                          orifices. It is important to stress
                            principle MB canal. This case                           that the files must not be taken
                            report presents steps taken to                          into the canals prior to develop-
                            address this anatomy in order                           ing proper access form. In such
                            to maximise the disinfection                            cases, ledging and blockages
                            and debridement of the root-                            can easily occur, needlessly
                            canal system. Failure to address                        compromising and complicat-
                            this anatomic complexity may                            ing treatment. The palatal pulp
                            lead to persistence or recur-                           tissue was calcified and extir-
                                                               Fig. 3
                            rence of endodontic disease.                            pated in toto (Fig. 4).

28 I roots    1_ 2010
                                                                                                        case report _ maxillary molars             I

                                                      Fig. 4                                                        Fig. 5

                                                      Fig. 6                                                        Fig. 7

_Ultrasonic tips

    Ultrasonic tips were used to plane the pulpal floor
and increase visibility. These instruments are available
from many manufacturers in a variety of sizes and
shapes designed to address specific case needs. The ori-
fice of the MB2 canal was located towards the palatal
orifice in an unusual presentation (Figs. 5 & 6). This
stresses the importance of continuing to examine the
                                                                                                                    Fig. 8
pulpal floor with the OM throughout the procedure,
as irrigants and instrumentation constantly alter the
presentation of subtle cues and clues to orifice location.
                                                               _A complex system
   Once the orifice location had been determined,
canal negotiation and instrumentation were com-                    This case report has demonstrated the complex
pleted. Warm vertical compaction of gutta-percha               root-canal system anatomy present in maxillary mo-
and ZOE sealer was used in this case, demonstrating            lars. Use of the OM throughout a carefully executed
the treated canal morphology (Figs. 7 & 8). The MB2            coronal and radicular access procedure maximises
canal was addressed as a completely separate canal.            the ability to disinfect and debride these teeth.

   A study that examined more than 1,700 teeth,                   Ultrasonic instrumentation allows for the judi-
which included more than 1,000 first molars, demon-            cious removal of dentine required to prevent iatro-            _contact             roots
strated the presence of the MB2 canal in 93% of                genic mishaps and unnecessary weakening of the
these teeth.1 These findings are not surprising, given         tooth. Meticulous root-canal therapy lays the                  Dr Mark Dreyer is a 1986
the morphology of the MB root in maxillary molars.             foundation for successful long-term retention and              graduate of the University of
                                                               restorative care for patients who present with                 Florida College of Dentistry.
    In order to better acquaint oneself with this              endodontic disease._                                           He practices as a general
anatomy, examine extracted teeth or consult Brown                                                                             dentist limited to endodontics
and Herbranson’s Tooth Atlas, a rich source of 3-D im-         _Reference                                                     in Orlando and Kissimmee,
agery. The final radiographs demonstrate placement                                                                            Florida, and can be contacted
of an orifice barrier, subsequent to temporisation and         1. Stropko J. Canal morphology of maxillary molars: Clinical   at
referral back to the restorative dentist.                         observations of canal configurations. JOE, June 1999.

                                                                                                                                      1   _ 2010   I 29

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