Case report 1
A 16-year-old female presented to an emergency endodontic appointment with a chief complaint of spontaneous pain, and increasing pain to temperature variations in the maxillary right side. The medical history was non-contributory. A clinical and radiographic examination revealed a carious lesion on the mesial buccal side of the maxillary right first molar (tooth 16) (Fig. 1, Fig. 2). The reaction to the ice sensibility test was an intense pain that remained present for more than one minute. The adjacent teeth had a normal response to this test. The diagnosis was an irreversible pulpitis on tooth 16. The endodontic therapy was proposed and accepted.
After proper anaesthesia and rubber dam isolation, the access cavity was prepared. During the exploration of the pulp chamber floor with a dental operating microscope (Opmi Pico, Carl Zeiss Surgical, Germany) it was possible to identify five canal orifices: two in the mesiobuccal root (MB and MP canals), two in the distobuccal root (DB and DP canals) and one in the palatal root (Fig. 3). During the root canal negotiation it became apparent that both canals in the mesiobuccal root were joining together in the apical third of the root. The same was happening in the distobuccal root. After measuring the working length, the rotary instrumentation was finished to an F2 Protaper in the buccal canals and with an F3 file in the palatal. After bio-mechanical preparation, the canals were dried and filled with a calcium hydroxide paste. The access cavity was provisionally restored. At the second visit, two weeks later, the root canal obturation was performed (Fig. 4,Fig. 5).Case report 2
A 28-year-old male was referred to endodontic treatment from a primary dentist. The patient did not have any complaint. The clinical and radiographic examination was able to detect a large carious lesion on the mesial surface of the maxillary first left molar (tooth 26) (Fig. 6). The response to the ice sensibility test was normal. The clinical diagnosis was a normal pulp on tooth 26, but because the extensive decay was impossible to excavate without pulp exposure the endodontic therapy was proposed and accepted by the patient.
After proper anaesthesia and rubber dam isolation, the decay was excavated and the access opening was prepared. With the help of a dental operating microscope the pulp chamber was examined. An anatomic configuration similar to the previous case report (Fig. 7) was noted. The endodontic treatment process was similar to previous case (Fig. 8, Fig. 9).Case report 3
A 63-year-old female was presented for endodontic evaluation of the maxillary first right molar (tooth 16). The patient had no complaint on that specific tooth upon clinical examination and it was possible to detect a large amalgam filling without decay (Fig. 10). The diagnosis was a normal pulp on tooth 16. The primary doctor requested endodontic therapy on tooth 16 for oclusal correction as part of the overall treatment plan.
The tooth was anaesthetized and the rubber dam was placed. The amalgam filling was removed and the access preparation was performed. The examination of the pulp chamber floor utilizing a dental operating microscope was able to detect three orifice openings (MB, DB and PT canals) that were negotiated and bio-mechanical prepared to an F2 Protaper file. Two grooves were noted emerging from both buccal canals in the direction to palatal canal. Time limitation did not allow the exploration of the grooves at the first visit. The canals were dried and then dressed with a paste of calcium hydroxide. The access opening was provisionally closed with Cavit filling. At the second visit the two grooves were opened with #2 ProUltra ultrasonic tip (ProUltra, Dentspy Maillefer, USA) troughing and two extra canals were detected, one in each buccal root (MP and DP canals) (Fig. 11). The Cone Beam Computer Tomography (CBCT) scan obtained during the implant treatment planning was analysed to confirm the tooth anatomy (Fig. 12). Upon exploration of the two extra root canals, two independent root canals were noted on the mesiobuccal root and two merging canals were noted in the distobuccal root. The bio-mechanical preparation to an F2 Protaper rotary file was accomplished. The obturation procedures were accomplished at this appointment (Fig. 13, Fig. 14).
Fig. 13. Obturation of the five root canals of tooth 16.