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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 mm
CHRONOLOGY 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 missing
Oblique ridge: MP to DB cusp
Buccal cusps are of unequal size
MP cusp is larger than DP
Buccal aspectSmaller crown size
Less prominent DB cusp & narrower MD
Distally inclined BUCCAL roots
Lingual aspectDL 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 ANATOMY
PulpMesioDistal section2 horns, MB is higher
Pulp chamber, roof & floor
Canals, narrow
Canal orifice
BuccoLingual sectionPulp chamber is wider
2 horns of equal height
Cross -section3 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.DISTOPALATAL
ROOF – MORE RHOMBOIDAL IN CROSS SECTION
FLOOR- OBTUSE TRIANGLE IN CROSS SECTION
PULP CHAMBER ANATOMY
ROOT CANALS
if 3 roots are present usually we can see
3 canals
1. mesiobuccal
2. distobuccal
3. palatal
if 4 canal is presentit is in mesiobuccal root but less frequently than in
the 1 molar
ROOT CANAL ANATOMY
ROOTS AND ROOT CANALS
PALATAL ROOT
MESIOBUCCAL
ROOT
DISTAL ROOT
63 % straight
37 % buccal curve
78 % distal curve
22 % straight
83 % straight
17 % mesial curve
YEAR TEETH
SAMPLE
1 CANAL 1
FORAMEN
1 CANAL 2
FORAMINE
2 CANAL 1
FORAMINE
2 CANAL 2
FORAMINE
1972 294 64.6 % 14.4 % 8.2 % 12.8 %
1974 29 62.1 % _ 13.8 % 24.1 %
1985 100 71 % _ 17 % 12 %
ROOT CANAL AND APICAL FORAMINA IN MAXILLARY 2 MOLAR MESIOBUCAL ROOT
ROOT ANOMALIES
NUMBER
S OF
STUDIES
NUMBERS
OF TEETH
ONE
ROOT
TWO
ROOTS
THREE
ROOTS
FOUR
ROOTS
3 1272 2.8 % 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 molar
This close relationship may produce
Soreness In the maxillary teeth due to
Maxillary sinusities
ENDODONTICCORRELATION
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 YOUNG
ADULT
NECROTIC PULP
Irreversible Pulpitis
RCT
YOUNG
Reversible Pulpit'sIrreversible Pulpit's
Necrotic Pulp
Apexogenesis
Pulp Capping or
PulpotomyClosed Apex Open Apex
RCT Apexification
Obturation
ENDODONTIC CORELATIONAN 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
illumination
An operating microscope.
ENDODONTIC CORELATION WITHPULP CHAMPER
DIAGNOSTIC MEASURES ARE IMPORTANT
AIDS IN THE LOCATION OF ROOT
CANALS ORIFICES
THESE MEASURES
1. OBTAIN MULIPLE PRE TREATMENT
RADIOGRAPHS
2. 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 the
horizontal 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 to
the central ray and as far apical as
possible
digital radiography system
FLOOR OF PULP CHAMBER
MARKEDLY CONVEX
CANAL ORIFICES SLIGHT FUNNAL SHAPE
IN THIS CASE
REMOVAL OF A LIP OF DENTIN
CANAL CAN BE ENTERED MORE IN
A DIRECT LINE WITH THE AXIS
CONVEX PULP CHAMBER
ROOT CROSS SECTION OF THE MAXILLARY 2 MOLAR
ROOT CROSS SECTION-ENDO CORRELATION
PALATAL, MB 2 FLAT SHAPED
MB 1 CIRCULAR, FLAT
DISTOBUCCAL
CANAL
FLAT,RIBBON SHAPED
NEAR APEX
BALANCE FORCED INSTRUMENTATION METHOD
ROTARY NiTi FILES ALLOWED CONTROLLED
PREPARATION OF THE BUCCAL AND LINGUAL
EXTENSIONS 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 ORIFICES
CLOSER 2 CANAL ORIFICES
GREATER CHANCE OF 2 CANALS
JOIN AT SOME POINT IN
THE BODY OF THE ROOT
1 CANAL SEPARATE IN TO 2 CANALS
DIVISION IS BUCCAL
AND PALATAL
PALATAL CANAL SPLITS
FROM THE MAIN CANAL
AT SHARP ANGLE IT IS
VISUAL CONFIGURATION
AS LOWER CASE LETTER h
BUCCAL CANAL IS STRAIGHT
PORTION 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 CORRELATION
TEETH WITH FUSED ROOTS
OCCASINALLY 2 CANALS
1 BUCCAL AND 1 PALATAL
BOTH EQUAL LENGTH AND DIAMETER
THESE PARALLEL
ROOT CANALS
ARE FREQUENTLY
SUPERIMPOSED
RADIOGRAPHLY
BUT THEY CAN
IMAGED BY
EXPOSING
RADIOGRAPH
FROM DISTAL
ANGLE
3 CANAL ORIFICES 2 CANAL ORIFICES
ACCESS CAVITY PREPARATION IN DIFFERENT CANAL
4 CANALS
RHOMBOID
SHAP
3 CANALS
ROUND
TRIANGLE WITH
BASE TO
BUCCAL
2 CANALS
ACCESS OUTLINE FORM
OVAL AND
WIDEST
IN BUCCO
LINGUAL
WORKING LENGTH DETERMINATION
Modern 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 INSTRUMENTATION
WORKING LENGTH
CANAL CLEANLINESS
IRRIGANT VOLUME
NUMBER OF INSTRUMENT CHANGES
DEPTH OF PENERATION OF IRRIGANT
NEEDLES
LESS
IMPORTANT
FACTOR
DISADVANTAGES
INCREASED RISK OF PROCEDURAL ERRORS
ROOT FRACTURES
ACCESSORY CANALS AND ENDODONTICS CORRELATION
APEX SHOULD BE RESECTED 2 TO 3 mm
REMOVES MOST OF THE UNPREPARED
UNFILLED ACCESSORY CANAL
ELIMINATING A POTENTIAL RESERVOIR OF PATHOGENS
ACCESSORY CANALS
FILLED
THERMOPLASTIC
GUTTAPURCHA
ACCESSORY CANALS
REMOVEDSURGICAL
PROCDURES
ROOT RESECTION FOR REMOVALOF ACCESSORY CANAL
Root 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 ELIMINATION
ROOT
RESECTIONS
APICAL
RAMIFICATIONSACCESSORY
CANALS
1 mm OF ROOT
RESECTION52 % 40 %
2 mm OF ROOT
RESECTION78 % 40 %
3 mm OF ROOT
RESECTION98 % 93 %
TEETH WITH MINIMAL ORNO 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 CROWN
Depth 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 radiograph
Preparation deviating in a
Mesial or distal side
Angled radiograph
Preparation 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 wall
Management 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
structure
Management 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
patency
This 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
furcation
This safely enlarge the coronal canal and
moves it laterally To avoid the furcation
Management 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 occur
LIMITATIONS
Rotated teethThis 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 root
During 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 of
Maxillary second Molar
Year Author Canal configuration
P MB DB
1979 Slowey 2 1 1
1979 Thews 2 1 1
1982 Cecic 2 2 1
1983 Martinez- 1 3 2
Berna
1984 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 the
radiographs 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 the
type of canal configuration present.
A Five-canal Maxillary Second Molar*
May 2007, Volume 4, No.5 Journal of US -China
Medical Science , ISSN1548-6648 USA
CASE 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 orifices
Occlusal 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 orifices
Postobturation radiograph
(RVG) displaying five root canals
DISCUSSION
Peikoff classified the anatomical root
and canal variations into six
categories:
(1) Three separate roots and three
separate canals;
(2) three separate roots and four
canals (two in the mesiobuccal root)
(3) three roots and canals whose
mesiobuccal and distobuccal canals
combine to form a common
buccal with a separate palatal
(4) two separate roots with a single
canal in each
(5)one main root and canal
(6) 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 report
QUINTESSENCE INTERNATIONAL VOLUME 39 • NUMBER JANUARY 2008
A 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 patient’s 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 indicated
Before 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 compaction
using 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 view Two 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.
a b
c d
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 radiographs
and 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 chance
of 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, DDS
3. ROOT CANAL MORPHOLOGY
4. May 2007, Volume 4, No.5 Journal of
US -China Medical Science ,
ISSN1548-6648, USA
5. QUINTESSENCE INTERNATIONAL
VOLUME 39 • NUMBER 1 •
JANUARY 2008
6. Journal of Endodontic 11, 308-10.
1
Endodontics
Problem-Solving in Clinical Practice
TR Pitt Ford, BDS, PhD, FDS RCPS
JS Rhodes, BDS, MSc, MRD RCS,
7.
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