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Endodontic management of four rooted mandibular first premolar

Article  in  Journal of Conservative Dentistry · April 2013

DOI: 10.4103/0972-0707.105307 · Source: PubMed

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Dakshita Joy Sinha Ashish Amit Sinha

Kothiwal Dental College & Research Centre Kothiwal Dental College & Research Centre
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Case Report

Endodontic management of four rooted mandibular

first premolar
Dakshita Joy Vaghela, Ashish Amit Sinha1
Departments of Conservative Dentistry and Endodontics, 1Pedodontics, Kothiwal Dental College Research Centre and Hospital,
Moradabad, India

Abstract
Mandibular premolars have earned the reputation for having aberrant anatomy. The literature is replete with reports of extra
canals in mandibular first premolars, but reports about the incidence of extra roots in these teeth are quite rare. This paper
attempts at explaining a rare case of successful endodontic management of a four‑rooted mandibular first premolar with
diagnostic, interoperative and postoperative radiographic records along with a substantial data on the incidence of extra roots
in these teeth. The standard method of radiographic appraisal was maintained as the criteria for determining the presence of
extra roots.
Keywords: Anomalies, diagnosis, mandibular first premolar, root canal morphology

INTRODUCTION gives a two‑dimensional image of a three‑dimensional

A thorough understanding of root canal anatomy and
morphology is required for achieving high levels of success
in endodontic treatment. Failure to recognize variations in
root or root canal anatomy can result in the unsuccessful
endodontic treatment. Hence, it is imperative that the
clinician be well informed and alerted to the commonest
possible variations. Hoen and Pink in their analysis on
teeth requiring re‑treatment, found a 42% incidence of
missed roots or canals.[1]
Mandibular premolars have earned the reputation for
having the most aberrant anatomy. Numerous reports of
root canal variations in these teeth have been reported in
the literature.[2,3] Vertucci in his series of studies conducted
on extracted teeth, reported 2.5% incidence of a second
canal.[4] Zilich and Dawson reported 11.7% occurrence
of two canals and 0.4% of three canals.[5] In the case of
mandibular first premolars, it is normally a single‑rooted
tooth. The frequency of occurrence of two roots is 1.8%
while three roots are reported to be present in 0.2%of
cases. In single‑rooted mandibular first premolars, two or
more canals are found in 23.2% of cases.[6] These anatomic
abnormalities are additional challenges, which begin at the
case assessment and involve all operative stages, including
access cavity design, localization, cleaning, and shaping of
the root canal system. Although preoperative radiography
object, precise interpretation can reveal external and
anatomic details that suggest the presence of extra canals
or roots.
The purpose of this clinical report is to describe an
anatomic abnormality that was detected during routine
root canal treatment in a mandibular first premolar.
CASE REPORT
A 24‑year‑old male patient came to a private dental clinic
with pain in the left lower back tooth. On intraoral clinical
examination, there was a decayed 34. An intraoral periapical
radiograph was advised. On radiographic examination
preoperative radiograph revealed radiolucency involving
pulp with respect to 34 [Figure 1a]. Diagnosis of acute
irreversible pulpitis was made. Also IOPA revealed 34 having
four roots. To confirm the presence of four roots two more
radiographs one with distal angulation and the other with
mesial angulation were taken [Figure 1b, and c]. Access was
gained to the pulp chamber after administration of local
anesthesia (2% Lignocaine with 1:100000 epinephrine),
under rubber dam isolation. To gain sufficient access to
the canals, the conventional access opening was modified
into one that was wider. Orifice location was not easy as
the coronal pulp chamber was unusually long. After careful
inspection, four canal orifices were located and patency

Address for correspondence: Access this article online

Dr. Dakshita Joy Vaghela, Department of Conservative Dentistry Quick Response Code:
and Endodontics, Kothiwal Dental College Research Centre and Website:
www.jcd.org.in
Hospital, Moradabad ‑ 244 001, India.
E‑mail: djvaghela@yahoo.co.in
Date of submission : 11.02.2012 DOI:
Review completed : 28.02.2012 10.4103/0972-0707.105307
Date of acceptance : 10.05.2012

Journal of Conservative Dentistry | Jan-Feb 2013 | Vol 16 | Issue 1 87

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Dakshita and Ashish: Four rooted mandibular first premolar

was ascertained using a small size K‑file (Kerr, Orange,
California). Mesiobuccal, distobuccal, mesiolingual, and
distolingual canals were identified. Working length was
established with the use of apex locator (Root ZX, J. Morita
Inc.) Then the working length radiograph was taken and
measured [Figure 2a].
The canals were cleaned and shaped with hand K‑files and
nickel titanium rotary ProTaper files (Dentsply Maillefer,
Switzerland). The canals were sequentially irrigated
using 5.25% Sodium hypochlorite and 17% EDTA during
the cleaning and shaping procedure. The canals were
thoroughly dried and obturation was done using F2 Pro
Taper Gutta‑percha and AH Plus sealer (Dentsply, Maillefer,
Switzerland) .
The post‑endodontic permanent restoration was completed
with composite (3M ESPE Dental Products, St Paul, MN)
[Figure 2b]. The patient was reviewed after a month and
was found to be asymptomatic. A 1‑year recall radiograph
showed satisfactory healing and was advised to get this
tooth crowned [Figure 2c].
DISCUSSION
The presence of extra roots or canals in mandibular premolars
is undoubtedly an endodontic challenge. Clearly, these
findings are clinically important as in a study at the University
of Washington assessing the results of endodontic therapy,
the mandibular first and second premolars showed failure
rates of 11.45% and 4.54%, respectively.[7] Conceivably, these
findings could be due to the complex root canal anatomy
of a large number of these teeth. A wide range of opinions
are reported in the literature regarding the number of root
canals, but there are very few reports on the variations in
the numbers of roots that occur in mandibular premolars.[8,9]
Accurate preoperative radiographs, straight and angled,
using parallel technique are essential in providing clues
as to the number of roots that exist.[10] Optimum opening
of the access cavity is absolutely necessary. Despite the
existence of complicated dental anatomy, shaping outcomes
with nickel–titanium instruments are mostly predictable.[11]
Cautious use of rotary or hand nickel–titanium files prepares
the canals to a predetermined shape.
There are many reports regarding four root canals
in mandibular second premolar[12‑14] and five‑canaled
mandibular second premolar[15] but four canals in mandibular
first premolar is hard to find in the published literature.
These discussions also validate an important consideration
that must not be overlooked, that is, the anatomic position
of the mental foramen and the neurovascular structures
that pass through it, in close proximity to the apices of the
mandibular first and second premolars. There are reports
in the literature, of flare‑ups in mandibular first and second
premolars with associated paresthesia of the inferior
alveolar and mental nerves.[16,17] The failure to recognize
the presence of extra root or canals can often lead to
acute flare‑ups during treatment and subsequent failure of
endodontic therapy.

a b c
Figure 1: (a) Preoperative intraoral periapical radiograph (straight angulation) (b) Preoperative intraoral periapical radiograph
(mesial angulation) (c) Preoperative intraoral periapical radiograph (distal angulation)

a b c
Figure 2: (a) Working length radiograph (b) Postobturation radiograph (c) Recall radiograph 1-year postoperatively

88 Journal of Conservative Dentistry | Jan-Feb 2013 | Vol 16 | Issue 1

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Dakshita and Ashish: Four rooted mandibular first premolar

CONCLUSION 7. Ingle JI, Simon JH, Machatou P, Bogaerts P. Outcome of endodontic

Successful and predictable endodontic treatment requires
knowledge of biology, physiology, and root canal anatomy.
The clinician should be astute enough to identify the
presence of unusual numbers of roots and their morphology.
Teeth with extra roots and/or canals pose a particular
challenge. A thorough knowledge of root canal anatomy
and its variations, careful interpretation of the radiograph,
close clinical inspection of the floor of the chamber, and
proper modification of access opening are essential for a
successful treatment outcome.
REFERENCES
1. Hoen MM, Pink FE. Contemporary endodontic retreatments: An analysis
based on clinical treatment findings. J Endod 2002;28:834‑6.
2. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral
Surg Oral Med Oral Pathol 1984;58:589‑99.
3. Kerekes K, Tronstad L. Morphometric observations on root canals of
human premolars. J Endod 1977;3:74‑9.
4. Vertucci FJ. Root canal morphology of mandibular premolars. J Am Dent
Assoc 1978;97:47‑50.
5. Zilich R, Dowson J. Root canal morphology of mandibular first and
second premolars. Oral Surg Oral Med Oral Pathol 1973;36:738‑44.
6. Ingle JI, Simon JH, Machatou P, Bogaerts P. Outcome of endodontic
treatment and re‑treatment. Textbook of Endodontics. BC Deker Inc;
Hamilton Ontario, Canada. 5th ed. Chapter 13; 2002. p. 751.
treatment and re‑treatment. Textbook of Endodontics. BC Deker Inc;
Ontario, 5th ed. Canada; Chapter 13; 2002. p. 748‑50.
8. Goswami M, Chandra S, Chandra S, Singh S. Mandibular premolar with
two roots. J Endod 1997;23:187.
9. Shapira Y, Delivanis P. Multiple‑rooted mandibular second premolars.
J Endod 1982;8:231‑2.
10. Silha RE. Paralleling long cone techic. Dent Radiogr Photogr
1968;41:3‑19.
11. Peters OA. Current challenges and concepts in the preparation of root
canal systems: A review. J Endod 2004;30:559‑67.
12. Farmakis ET. Four‑rooted mandibular second premolar. Aust Endod J
2008;34:126‑8.
13. Holtzman L. Root canal treatment of mandibular second premolar with
four root canals: A case report. Int Endod J 1998;31:364‑6.
14. Sachdeva GS, Ballal S, Gopikrishna V, Kandaswamy D. Endodontic
management of a mandibular second premolar with four roots and four
root canals with the aid of spiral computed tomography: A case report.
J Endod 2008;34:104‑7.
15. Macri E, Zmener O. Five canals in a mandibular second premolar.
J Endod 2000;26:304‑5.
16. Glassman GD. Flare‑up with associated parasthesia of a
mandibularsecond premolar with three root canals. Oral Surg Oral Med
Oral Pathol 1987;64:110‑3.
17. Prakash R, Nandini S, Ballal S, Kumar SN, Kandaswamy D. Two‑rooted
mandibular second premolars: Case report and survey Indian. J Dent
Res 2008;19:70‑3.
How to cite this article: Vaghela DJ, Sinha AA. Endodontic
management of four rooted mandibular first premolar. J Conserv
Dent 2013;16:87-9.
Source of Support: Nil, Conflict of Interest: None declared.

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