ENDODONTOLOGY

Case Report

Endodontic Management of Mandibular First Molar

With Three Distal Root Canals
Manoj Agarwal * #
H.P. Trivedi ** #
Manju Gupta *** #
Sankalp Mittal **** #

ABSTRACT
A mandibular first molar tooth requiring root canal treatment was found to have one mesial and one distal root and
a total of five canals. The mesial root had two separate canals; the distal root had three canals. This case demonstrates
a rare anatomical configuration and supplements previous reports of the existence of such configurations in
mandibular first molars.
Keywords: aberrant anatomy, five root canals, mandibular first molar, middle distal canal

Introduction

A mandibular first molar with three distal

The main objective of root canal treatment is

canals was first reported by Berthiaume (1983)3;

the thorough mechanical and chemical cleansing

however, the three distal canals ended in two apical

of the entire pulp space followed by complete

foramina. Examples of mandibular first molars with

obturation with an inert filling matrial 1. The two

three distal canals, all ending in separate apical

most frequent causes of failure in root canal

foramina, have also been described 4,5,6. In addition,

treatment are imperfect instrumentation and

Quackenbush (1986) reported the existence of three

incomplete lling. Thus, a thorough knowledge of

separate distal canals in two extracted mandibular

pulp space morphology will help to reduce

first molars 7. The present report describes root canal

endodontic failures caused by incomplete

treatment in a right mandibular first molar with five

debridement and obturation. Therefore, it is

canals, two in mesial root and three of which are

imperative aberrant anatomy is identified prior to

located in distal.

and during root canal treatment of such teeth.

Case report

Unusual canal anatomy associated with the

A 29 year old male patient was reported with

mandibular first molar has been reported in several

very acute pain in right lower back tooth,

studies. In a radiographic study of extracted teeth

particularly at night and while drinking anything

mandibular first molars had three mesial canals in

cold. On clinical examination, mandibular right

13.3% of specimens, four mesial canals in 3.3% of

permanent first molar (tooth 46) was tender on

specimens, and three distal canals in 1.7% of

percussion. The tooth was restorated with the silver

specimens 2.

amalgam before two and half year and margins of

* Senior Demonstrator, ** Professor & Head, *** Associate Professor, **** Assistant Professor, # Department of Conservative Dentistry & Endodontics, Government
Dental College & Hospital, Jaipur, INDIA

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MANOJ AGARWAL, H.P. TRIVEDI, MANJU GUPTA, SANKALP MITTAL

restoration was broken. The preoperative diagnostic

Following local anesthesia with 2% lignocaine

intra-oral radiograph revealed radiolucency beneath

containing 1:200000 adrenaline (Xylocaine;

the restoration in close proximity to the pulp

AstraZeneca Pharma Ind Ltd, Bangalore, India), old

(secondary carious lesion) and widening of

silver amalgam restoration removed with the help

periodontal ligament space (Fig-1). The diagnosis

of round carbide bur with continuous air water

acute irreversible pulpitis established. Endodontic

spray. Caries completely removed with the help of

treatment was planned.

round diamond bur. Distal wall constructed with

the help of glass inomer cement. An endodontic
access cavity was made with the help of endo
access burs (Dentsply Tulsa Dental Specialties). On
examination with a DG-16 endodontic explorer
(Hu-Friedy, Chicago, IL, USA), the pulp chamber
disclosed five canal orifice, two in mesial root and
three in distal root (mesiobuccal, mesiolingual,
distobuccal, middle distal and distolingual) (Fig 2).
After enlarging the orices with a Gates Glidden

Fig.1 - Pre operative Radiograph

drill (Mani Inc., Takanezawa, Japan), Working

lengths of each canals were determined using apex
locater and confirmed radiographically. The root

Fig.2-Clinical view of the 5 separate canal orice in the chamber.

MB, mesiobuccal; ML, mesiolingual; DB,distobuccal; MD, middle
distal; DL, distolingual.
Fig.4 - Master Cone placement

Fig.3 - Three files placed in distal root

Fig.5 - Obturated 5 canal orifices

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ENDODONTOLOGY

ROOT CANAL OBTURATION BY ULTRASONIC CONDENSATION OF GUTTA PERCHA

AND AN IN VITRO INVESTIGATION ON THE QUALITY OF OBTURATION

Discussion
A thorough understanding of tooth
morphology, careful interpretation of angled
radiographs, proper access preparation, and a
detailed exploration of the interior of the tooth are
essential prerequisites for a successful treatment
outcome 9. Morphologic variations and aberrations
in root canal anatomy should always be considered
at the beginning of treatment 9. To minimize the
Fig.6 - Post operative radiograph

risk of endodontic treatment failure, a precise

knowledge of the root canal morphology is vital.
This case report highlights the rare incidence of 3
canals in the distal root of a permanent mandibular
first molar. There have been numerous studies
describing the morphology of mandibular first
molars. Skidmore and Bjorndal 10 , Pineda and
Kuttler

11

, and Vertucci1 have all reported on the

morphology of the mandibular first molar. Their

reports have shown that mandibular first molars
have three or four canals. Baugh and Wallace12

Fig.7 - Radiograph after coronal restoration

reported that the prevalence of a middle mesial

canals were prepared in a crown-down method

canal in mandibular rst molars is 1%-15%. A

using Profile Ni-Ti rotary instrumentation (Dentsply

comprehensive survey of the endodontic literature

Maillefer, Switzerland). Irrigation between each

reveals that the mandibular first molar presenting

instrument was performed using saline, 5.25%

with 3 canals in the distal root is a rare

sodium hypochlorite and 17% EDTA (Smear Clear,

phenomenon. Mandibular first molar with 3 distal

SybronEndo). The canals were dried with absorbent

canals was first reported by Berthiaume in 19833 ;

points (Dentsply Tulsa, Tulsa, OK,USA). All canals

however, the 3 distal canals ended in 2 apical

were instrumented up to no. 25 and 4% taper

foramina. Reuben et al.13 using SCT, examined 125

Profile. Master cone for each canals were selected

mandibular first molars of the same ethnicity as the

(Fig- 4 ) after shaping, all canals were obturated

present patient, and none of the teeth presented

with no.25 4% taper gutta-percha points (Dentsply

with 3 distal canals. In the present case, 5 distinct

Maillefer, Switzerland) and sealer Tubliseal EWT

orifices were identified in the floor of the pulp

(SybronEndo, Glendora, CA) (Fig-5 and6). Coronal

chamber, two were in mesial root and three were

restoration was done with silver amalgam (Fig-7)

in distal root, all three canal had a common apical

and after seven days cast metal crown was given.

opening.

At the six month follow-up examination, the tooth

was completely asymptomatic.
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MANOJ AGARWAL, H.P. TRIVEDI, MANJU GUPTA, SANKALP MITTAL

Conclusion

5. Beatty RG, Interian CM (1985) A mandibular rst molar

with ve canals: report of case. Journal of American Dental
Association 111, 76971.

The present case report describes the

endodontic management of a mandibular first

6. Friedman S, Moshonov J, Stabholz A (1986) Five root canals

in a mandibular rst molar. Endodontics and
DentalTraumatology 2, 2268.

molar with five canals, three in the distal and two

in the mesial. It is mandatory that the clinician

7. Quackenbush LE (1986) Mandibular molar with three distal

root canals. Endodontics and Dental Traumatology 2, 489.

should possess a thorough knowledge of not only

the normal anatomy of the root canal system, but

8. Reddy PY, Karpagavinayagam K, Subarao CV. Management

of dens invagitanus diagnosed by spiral computed
tomography: a case report. J Endod 2008;34:1138-42.

also aberrations. Thus, multiple angulated

radiograph and close clinical inspection of the

9. Vertucci FJ. Root canal morphology and its relationship to

endodontic procedures. Endod Top 2005;10:3-29.

chamber floor at higher magnification is essential

whilst treating teeth that have a high incidence of

10. Skidmore AE, Bjorndal AM. Root canal morphology of

human mandibular rst molar. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1971;32:778-84.

extra canals.
References :

11. Pineda F, Kuttler Y. Mesiodistal and buccolingual

roentgenographic investigation of 7,275 root canals. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1972;33:101-10.

1. Vertucci FJ. Root canal anatomy of the human permanent

teeth. Oral Surg Oral Med Oral Pathol. 1984 Nov;58(5):589-99.
2. Goel NK, Gill KS, Taneja JR. Study of root canals
configuration in mandibular first permanent molar. J Indian
Soc Pedod Prev Dent. 1991 Mar;8(1):12-4.

12. Baugh D, Wallace J. Middle mesial canal of the mandibular

rst molar: a case report and literature review. J Endod
2004;30:185-6.

3. Berthiaume JT (1983) Five canals in a lower rst molar.

Journal of Michigan Dental Association 65, 2134.

13. Reuben J, Velmurugan N, Kandaswamy D. The evaluation

of root canal morphology of the mandibular rst molar in an
India population using spiral computed tomography scan: an
in-vitro study . J Endod 2008;34:212-5.

4. Stroner WF, Remeikis NA, Carr GB (1984) Mandibular rst

molar with three distal canals. Oral Surgery 57, 5547.

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