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Retrieval of swallowed endodontic file with gastro-scope


Tavargeri AK, Anegundi RT, Patil SB, Trasad V, Battepatti P. Saudi Endod J 2013;3:31-3.

Volume 3 / Issue 1 / January-April 2013

Review Article

Endodontic considerations on the variations of


the anatomy of the mandibular premolars
Panagiotis Gakis, EleftheriosTerry R. Farmakis1

Private Practice, 1Department of Endodontics, School of Dentistry, University of Athens, Athens, Greece
Key words:
Endodontic treatment, mandibular
premolars, multiple root canals, pulp
space anatomy

Address for correspondence:


Dr.EleftheriosTerry R. Farmakis,
27 D. Gedeon Str, Peania,
Athens 19002, Greece.
Email:elefarm@dent.uoa.gr

ABSTRACT
Objectives: This article investigates the internal and external morphological
variability of mandibular premolars along with clinical and radiographical signs
that leads to early identification of these cases. Materials andMethods: The
authors identified articles by searching the PubMed, Medline and Scopus
databases. Inclusion criteria were case reports of mandibular premolars
with aberrant internal and external anatomy, articles that describe the origin
of anatomy of mandibular premolars, the traits that may influence their
external and internal variability through species revolution and articles of new
technologies like cone beam computed tomography that help the diagnosis
of difficult cases. Results: In the majority of the cases, mandibular premolars
are reported to have one root canal running a single root. On the other hand,
anatomic irregularities in this group of teeth, such as the existence of more
than one root or more than one root canals or even a more complicated
root canal system cannot be considered infrequent as it appears in 1025%
of the cases. Conclusion:Successful endodontic treatment of mandibular
premolars is a challenge for the clinician as they often present morphological
and anatomical abnormalities.

INTRODUCTION

he most significant cause of failure of root


canal therapy is ineffective mechanical and
chemical debridement of the entire root canal
system.[1] Moreover, a lack of knowledge of pulp
space anatomy irregularities can adversely affect
the success of therapy.[2] These deficiencies lead to
insufficient treatment.[1,2]
Mandibular premolars present pulp space with
aberrant anatomy at a high rate.[3,4] According to
Nallapati,[3] these teeth pose many difficulties in
achieving successful endodontic treatment due to
variations in anatomy.
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DOI:
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Approximately, 98% of mandibular first premolars


are single rooted,[4] whereas 99.6% of mandibular
second premolars have a single root.[5] A single
root canal is present in 75.8% and 91%, of the
cases respectively.[4,5] In addition, Vertucci reported
that mandibular first premolar have one canal at
the apex in 74.0% of the teeth and mandibular
second premolar have one canal at the apex
in 97.5%. [6] As a result, the possibility of the
existence of aberrant anatomy in this group of
teeth cannot be ignored.

MATERIALS AND METHODS


In order to investigate the incidence of aberrant
anatomy in this group of teeth, the authors
identified articles by searching the PubMed,
Medline and Scopus databases. Keywords included
endodontic treatment, mandibular premolars, multiple
root canals, pulp space anatomy, anthropology and
species evolution. Inclusion criteria were case reports
of mandibular premolars with aberrant internal and
external anatomy(two or more root canals, two
Saudi Endodontic Journal Jan-Apr 2013 Vol 3 Issue 1

Gakis and Farmakis: Mandibular premolars morphology

or more roots and any of their combination), articles


that describe the origin of anatomy of mandibular
premolars, the traits that may influence their external
and internal variability through species revolution and
articles of new technologies such as cone beam computed
tomography (CBCT) that help the diagnosis of difficult
cases. In addition, acclaimed endodontic textbooks that
are currently been taught in most dental schools globally,
were used to draw more resources on the knowledge that
students are taught on this subject.
Interestingly enough, the complex pulp space system
of the mandibular premolars was addressed as early as
1925[7] and this complexity is the reason why especially
the mandibular first premolars are referred as an
endodontists enigma.[8,9]
External anatomy

The external dental morphology reflects the overall


morphology of the pulp chamberevery cusp hosts
a pulp horn and the external dimensions of the crown
are usually associated with the size and position of the
pulp chamber. Further, the variations in the mandibular
premolars external morphology should make the
clinician suspicious about possible variations in internal
dental anatomy, because in cases of mandibular
premolars with more than one root, the mesialdistal
or the buccallingual dimension is increased.[10,11]
Specifically, mandibular premolars are teeth that vary
in external morphology at high frequency along with
third molars and lateral maxillary incisors,[12] causing
difficulties in creating a proper opening access that
needs to be modified from the classical oval shape.
The crown of the mandibular first premolar has
two cusps namely one buccal and one lingual. The
mesialdistal dimension is smaller from all mandibular
posterior teeth. In contrast, the mandibular second
premolar can have two or three cusps.

crosssection, with rounded angles. Their apex also has


a distal deviation.[13]
Cases with two roots when located in the mesialdistal
axon, the conventional periapical(PA) radiograph masks
the true anatomy. If there are three or four roots, they
can be buccal and lingual. In the fortuitous event of a
90 rotation, the clinician is able to visualize most of
the complex anatomy[Figure1].
Internal anatomy

In general, the root canal of the mandibular first


premolar is conical and undifferentiated. At the coronal
portion, the root canal has an oval crosssection, an
oval or round section at the middle segment and
a round section at the apex. The pulp chamber is
connected to the root canal without a distinct limit,
which is typical of the bifurcation of the root canal at
the apex.[4,14]
With regard to anatomical aberrations, 24.2% of
mandibular first premolars have two or more root
canals. The rate of multiple foramina at the apex
is 20%. [15,16] There are reports on the treatment of
mandibular first premolars with three roots and three
root canals;[17] one root and three root canals;[18] two
root canals in one root;[18] two roots and three canals;[19]
and one root that has separated into three root canals
with distinct apex foramina. [3] In addition, another
irregularity reported is the Cshaped root canal space
anatomy, which is observed in 1018% of the cases.[20]
The root morphology of the mandibular second
premolar is similar to that of the first premolar, but its
dimensions are slightly wider. Bifurcation is present in

Externally, mandibular premolars have one root in


most cases; the rate of two or more roots in the first
premolar is 1.8% and 0.4% in the second premolar.[4,5]
In general, the root of the first mandibular premolars
present smaller mesialdistal and bigger buccallingual
dimensions and the apex usually presents a distal
deviation.[13]
In 99.6% of cases, second premolars have one root
that assumes a triangular formation in a transverse
Saudi Endodontic Journal Jan-Apr 2013 Vol 3 Issue 1

Figure1: Orthopantomogram of both mandibular premolars, each


with two roots
11

Gakis and Farmakis: Mandibular premolars morphology

these teeth, but at a lower rate compared with the first


premolars, approximately 8%.[4,12]

case of five root canals within one root has been


reported.[29]

Mandibular second premolars have variations in


morphology and the number of root canals. Specifically,
the rate of such teeth with one root is 99.6% and 90%
with one foramina.[12]

The rate of lateral root canals in first mandibular


premolars is 44.3% versus 48.3% in second premolars.
It is likely that lateral canals exist at the apical portion
of the root.[6]

Despite the greater variability in first premolars, the most


significant cases refer to the second premolar group.
There are case reports of second premolars with one
root and three root canals;[3] three roots and three root
canals;[2123] two roots and four root canals;[24,25] four root
canals in one root;[26,27] four roots and four canals.[11,28]

Mandibular premolars with two roots and/or two root


canals have not been reported, probably due to the fact
that they appear frequently in the clinical practice.

In Table1, the cases reported for both groups of


teeth are presented, along with the anatomical root
configurations and root canal locations.
A case report with four roots and four canals [28] is
documented in Figure2a and b. Furthermore, a single

Figure2:(a) Preoperative radiograph of tooth #35, showing irregular


root morphology.(b) Postoperative radiograph showing complete
obturation of the four root canals

Table1: The cases reported for both first and second mandibular premolars, along with the anatomical
root configurations and root canal locations
Reference
Cleghorn etal., 2008[17]

Tooth
number
#44

Root
number
3

Root
canalnumber
3

England etal., 1991[18]


England etal., 1991[18]
Poorni etal., 2010[19]

#34
#34
#34

1
1
3

3
2
3

Nallapati, 2005[3]
Nallapati, 2005[3]
Rodig and Hulsmann,
2003[21]
Shokouhinejad, 2009[22]

#44
#45
#35

1
1
3

3
3
3

#35

AlFouazan, 2001[24]

#35

Rhodes, 2001[25]
Tzanetakis etal., 2007[26]
Holtzman, 1998[27]
Farmakis, 2008[28]
Sachdeva etal., 2007[11]

#35
#35
#45
#35
#35

2
1
1
4
4

4
4
4
4
4

Macri and Zmener, 2000[29]

#45

De Moor and
Calberson, 2005[23]

#45

12

Root configuration

Root canal location

Mesiobuccal,
distobuccal, lingual

One mesial
2 Two distal

Mesial buccal, distal


buccal, lingual
Mesiobuccal
Distobuccal
Lingual
Mesial, distal

Mesiobuccal, distobuccal, lingual

Mesial, distal

Mesial, distal, two lingual


Mesiobuccal, distobuccal
Mesial, distal lingual

Distal
Mesial
Mesiobuccal

Two buccal, one lingual


Buccal, lingual
One mesial
Two distal
Lingual, mesial buccal, distobuccal
Mesial buccal, distal buccal, lingual
Mesial buccal, distal buccal, lingual
Mesiobuccal
Distobuccal
Lingual
Mesial buccal, lingual
Distal buccallingual
Mesial, distal, buccal, lingual
Two buccal, two lingual
Two buccal, two lingual
Mesial, distal, two lingual
Mesiobuccal, distobuccal
Mesial, distal lingual
Mesiobuccal
Distobuccal
Near to distal buccal
Lingual
Mesial lingual
Distal
Mesial
Mesiobuccal

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Gakis and Farmakis: Mandibular premolars morphology

Ethnic and genetic differences

The morphological and anatomic abnormalities of


the first lower premolars are associated with ethnic
differences and genetic disorders, [30] a finding that
has not been observed with second premolars. For
example, first mandibular premolars are three times
more likely to present with over numbered root canals
in AfricanAmericans compared with Caucasians.[30] In
addition, a more number of root canals in these teeth
has been observed in Chinese, Turkish and Kuwaiti
persons.[4] The genetic syndrome Turner(45X) is linked
to over numbered roots compared with females with
normal genotypes.[31]
The pulp chamber in second premolars is often longer
in 45X females and 45X/46XX females compared with
healthy women.[32]

DISCUSSION
A complicated root canal system poses a challenge
in every phase of endodontic therapy; thus, if not
accomplished correctly, the success rate is expected to
be lower a tenet that applies to premolars.[33]
The complex internal anatomy of first premolars and
the high rate of congenital absence and variations in
the external anatomy of second premolars[34] can be
attributed in part to genetic traits and evolutionary
patterns.
Modern people belong to the developed species
Homo sapiens. Early humans, such as early Homo,
were dentally similar to African apes. [35] Specifically,
mandibular premolars had crown outlines that
approximated molars, with more cusps, wider
mesialdistal and buccallingual dimensions and multiple
roots that were wider. [36] Further, these teeth had a
broad occlusal polygon surface and an asymmetrical
outline.[37,38]
According to the tritubercular theory of dental
evolution, proposed by Cope and then Osborn in the
late 19thcentury, multicusped teeth, such as molars
and premolars in mammals, developed through cusp
budding of simple conical teeth.[39,40]
As humans evolved, the dimensions of mandibular
premolars decreased due to selective pressures.[36] It is
unclear when the unique, prolonged human pattern of
growth and development originated.[35]
Saudi Endodontic Journal Jan-Apr 2013 Vol 3 Issue 1

Over eons, the four multirooted premolar teeth of


hominids fused their roots and declined in volume
and number,[36] resulting in todays two singlerooted
premolars, of which the second is more frequently
singlerooted with a single canal, impacted or
absent.[41,42]
Despite their complex original form, endodontic
treatment of these teeth remains a challenge. Diagnostic
information directly influences clinical decisions and
accurate data effect better treatmentplanning decisions
and potentially more predictable outcomes.[43]
To overcome these challenges, an initial PA radiograph
should be performed. Although PAs are 2D images
of 3D anatomical structures, they contain most of the
necessary initial information.[18]
If the root anatomy(external and/or internal) is
elusive (e.g., the tooth appears to have one welldefined
canal in the cervical third of the root that disappears or
narrows suddenly as it travels apically), additional PAs
at various horizontal angulations(Clarks technique) can
facilitate the diagnosis. If a radiolucent line is present
mesial or distal to the main canal, an additional canal
should be suspected[44][Figure3].
During clinical examination, if gingival recession is
present and a furcal external morphology is present in
these teeth, may hint the presence of two buccal roots.[3]
The working lengthestablishing PA or the fitting cone
PA can also reveal a second canal, if the file (or the
guttapercha cone) is positioned offcenter from the
axis of the root.
These irregularities have clinical significance as untreated
canal space can lead a root canal treatment to failure.
According to Hoen and Pink, missed root canals are
noted in 42% of teeth that have been retreated.[45] If
the irrigation protocol is meticulously applied, sealer
and/or warm Guttapercha can reveal the presence of
lateral root canals[Figure4].
If there are doubts with regard to the internal structure
of the tooth that is receiving endodontic treatment, a
CBCT is advised[17][Figure5]. CBCT imaging is gaining
rapid acceptance in dentistry and endodontics, based
on its ability to generate undistorted 3D images of the
maxillofacial skeleton, the teeth and their surrounding
structures.[46]
13

Gakis and Farmakis: Mandibular premolars morphology

However, CBCT imaging should not be performed


for every mandibular premolar that is treated
endodontically, due to high costs and difficulty in
accessing this system and to protect patient from
unnecessary exposure to radiation. Alternatively,
conventional PA is an accessible, costeffective,
highresolution imaging modality. [48] Furthermore,
CBCT imaging creates distortions with regard to
materials, such as metal posts and endodontic filling
materials, due to differential absorptionknown as
cupping artifactswhich create starshaped streak
artifacts, mimicking crack lines on CBCT images
and complicating the interpretation of the acquired
images.[49]
Figure3: Preoperative radiograph demonstrating aberrant internal
anatomy of the mandibular premolars

Figure4: Periapical(PA) radiograph revealing the presence of a lateral


root canal filled by sealer that is associated with a lateral PA lesion
on tooth #44

Magnification also aids the clinician throughout


endodontic treatment. Examination of the pulp
chamber with magnification, by microscope[3,6,2426,28,29]
or magnifying loops [19,21] or fiberoptic endoscope [23]
is invaluable in treating complex cases. With
magnification, the pulp chamber can be examined
more properly and by following its landmarks, all of
the root canal systems orifices can be located. The
cost of an optical microscope might be high for
the general dentist. Nevertheless, magnifying loops are
affordable and effect results that are comparable with
microscopy.[50]
Finally, if a patient complains of insistent pain of a
mandibular premolar and sensitivity to cold and hot and
has received endodontic therapy, the clinician should
determine whether the root canals have been detected
and instrumented.[6]

CONCLUSION
Endodontic therapy of mandibular premolars, because
of their frequent morphological and anatomical
abnormalities, is a challenge for the clinician. On each
given case, robust knowledge of the literature(both
statistical data and case reports equally), a thorough
study and analysis of the external and internal
morphology and careful interpretation of the
radiographic imaging, is needed, in order to achieve a
high degree of success in their treatment.
Figure5: Cone beam computed tomography imaging revealing both
right mandibular premolars with three root canals

ACKNOWLEDGMENT

Furthermore, in failing cases without any obvious cause,


CBCT can aid in locating missed canals better than
PAs.[47]

The authors would like to thank Associate Professor


E.G.Kontakiotis(School of Dentistry, University of Athens,
Greece) for his valuable comments on the review.

14

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Gakis and Farmakis: Mandibular premolars morphology

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How to cite this article: Gakis P, Farmakis ER. Endodontic consider
ations on the variations of the anatomy of the mandibular premolars.
Saudi Endod J 2013;3:10-6.
Source of Support: Nil. Conflict of Interest: None declared.

Saudi Endodontic Journal Jan-Apr 2013 Vol 3 Issue 1

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