Case Report/Clinical Techniques
New Nomenclature for Extra Canals Based on Four Reported
Cases of Maxillary First Molars with Six Canals
Kittappa Karthikeyan, MDS, and Sekar Mahalaxmi, MDS
Abstract
This clinical article describes 4 different case reports of
maxillary first molars with unusual anatomy of 6 root
canals and their endodontic management. Treating
these additional canals in maxillary first molars might
be challenging. Inability to locate and properly treat
these extra canals might lead to failures. A thorough
knowledge of root canal morphology and the proper
use of microscopes increase chances for successful clin-
ical results. Because presence of these extra canals is
not unusual and naming these canals still remains
elusive, a new nomenclature is suggested for ease of
communication. (J Endod 2010;36:1073–1078)
Key Words
Access modification, additional canals, magnification,
nomenclature, root canal morphology
From the Department of Conservative Dentistry and
Endodontics, SRM Dental College, Ramapuram, Chennai, India.
Address requests for reprints to Dr K. Karthikeyan, Senior
Lecturer, Department of Conservative Dentistry and Endodon-
tics, SRM Dental College, Ramapuram, Chennai-89, India.
E-mail address: dockarthicck@yahoo.com.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2009.12.001
JOE — Volume 36, Number 6, June 2010
T he endodontic management of maxillary first molars presents a constant challenge.
There can be 3, 4 (more common), 5, 6, or more than 6 canals. The form, config-
uration, and number of root canals existing in maxillary first molars have been dis-
cussed by many authors. The occurrence of a fourth canal ranges from 50.4%–95%
(1–11), a fifth canal is 2.25% (2), and a few authors have also reported cases with
6 canals (12, 13). The dentist must have a thorough knowledge of root canal
morphology, and working under microscope increases the chances for successful
endodontic outcome.
Case Reports
These are the case reports of 4 patients treated in the Department of Conservative
Dentistry and Endodontics, SRM Dental College, Chennai, India. A thorough history was
taken, and the cases were both clinically and radiographically evaluated. All 4 cases
were done by use of surgical operating microscope (Seiler Revelation Microscope,
St Louis, MO). The patients received local anesthesia with 2% lignocaine solution
with 1:80,000 epinephrine (Lignox 2% A; Indoco Remedies Ltd, Mumbai, India).
The entire procedure in each case was done by using rubber dam isolation. Frequent
irrigation with 3% sodium hypochlorite (Vensons India, Bangalore, India) was also
carried out during cleaning and shaping. Radiographs were taken for each and every
step.
Case Report 1
A 38-year-old male patient reported to the department with pain in the upper left
region. On evaluation the diagnosis was confirmed as irreversible pulpitis with apical
periodontitis in tooth #14 (Fig. 1C). After conventional access cavity preparation, the
3 principal root canals were identified: mesiobuccal (MB), distobuccal (DB), and
palatal. After probing with a DG 16 (Hu-Friedy, Chicago, IL) endodontic explorer
and scraping calcifications with a spoon excavator, small hemorrhagic points were
noted approximately 3 mm from the MB orifice in the palatal direction and near the
orifice of the palatal and DB canals.
The conventional triangular access was modified to a trapezoidal shape to improve
access to the additional canals (Fig. 1A, B). The MB (Vertucci’s type IV), DB (Vertucci’s
type II), and palatal (Vertucci’s type II) roots had 2 canals each, fairly well-separated
and exiting from the floor of the pulp chamber.
Orifice shapers (size 25, .08 and .10 taper, RaCe; FKG Dentaire, La Chaux-de-
Fonds, Switzerland) with ethylenediaminetetraacetic acid (Glyde; Dentsply Maillefer,
Ballaigues, Switzerland) were used to preflare the coronal portion of the canals to
improve straight-line access. After working length determination, cleaning and shaping
were done by using K-files (Mani, Tochigi, Japan) and rotary files (RaCe) to size 25, .06
taper. The canals were dried with paper points (Dentsply Maillefer); a dry cotton pellet
was placed in the pulp chamber followed by a temporary seal with Cavit G (3M ESPE,
Seefeld, Germany).
Case Report 2
A 21-year-old male patient reported to the department complaining of pain in the
left upper back tooth region for 1 month. On evaluation it was diagnosed as irreversible
pulpitis with apical periodontitis in tooth #14 (Fig. 2C). A conventional endodontic
access opening was made; the 3 principal root canal systems were identified (MB,
Nomenclature of Maxillary Molars 1073
Case Report/Clinical Techniques

Figure 1. Case 1. (A, B) Modified (trapezoidal) access cavity of case 1 showing 6 orifices (2 palatal, 2 MB, and 2 DB canals). (C) Preoperative radiograph. (D)
Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modified access, and black line is for
canal orifice outline and external outline of modified access.

DB, and palatal). The pulp chamber floor was then explored with DG 16
explorer mesial to the line joining MB and the palatal canals to locate the
MB2 canal. Hemorrhagic points were noted approximately 1 mm mesial
to the orifice of the palatal and 2 mm from the MB and DB canals toward
the palatal direction. The conventional triangular access was modified
to a rectangular shape to improve access to the additional canals
(Fig. 2A, B). The MB (Vertucci’s type IV), DB (Vertucci’s type II),
and palatal (Vertucci’s type II) roots had 2 orifices each, well-
separated and exiting from the floor of the pulp chamber.
Coronal flaring was done with ProTaper SX rotary file (Dentsply
Maillefer) to improve straight-line access, and the working length
was calculated. Cleaning and shaping were done by using K-files
(Mani) and ProTaper rotary files (Dentsply Maillefer) up to F2 size
and palatal canals to F3 size. The canals were then dried with paper
points; a dry cotton pellet was placed in the pulp chamber followed
by a temporary seal with Cavit G.
Case Report 3
A 25-yearold-female patient reported to the department complain-
ing of intermittent pain in the right upper back tooth region. On evalu-
ation a diagnosis of irreversible pulpitis with apical periodontitis
associated with tooth #3 was made (Fig. 3C). A conventional
endodontic access opening was made, and the MB, DB, and palatal
canal orifices were identified. After troughing; the pulp chamber floor
was explored with a DG 16 explorer, which indicated the presence of 2
MB and 2 DB canals. The conventional access was modified to improve
access to the additional canals (Fig. 3A, B). The DB2 and MB2 were
approximately 3 mm and 2 mm, respectively, from the DB1 and MB1
orifices in the palatal direction. During verifying the patency of DB1
canal with 10 size K-file, it was noted that the file could be oriented
in 2 different angulations. A radiograph was taken with files in all the
canals (2 files in DB1 canal with different angulations) to confirm
that the files were within the root canal system, which revealed 3 canals
in DB root (Gulabivala’s supplemental canal configuration type III)
(Fig. 4). MB and palatal roots had Vertucci’s type IV and type I config-
urations, respectively.
After coronal flaring with ProTaper SX rotary file and working
length determination, cleaning and shaping were accomplished with
K-files up to size #25 and ProTaper rotary files to size F3 for palatal
canal and F2 for the other canals. It was observed that DB1 and DB2
joined together after cleaning and shaping. The canals were then dried

Figure 2. Case 2. (A, B) Modified (rectangular) access cavity of case 2 showing 6 orifices (2 palatal, 2 MB, and 2 DB canals). (C) Preoperative radiograph. (D)
Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modified access, and black line is for
canal orifice outline and external outline of modified access.

1074 Karthikeyan and Mahalaxmi JOE — Volume 36, Number 6, June 2010

Figure 3. Case 3. (A, B) Modified (rhomboidal) access cavity of case 3 showing 5 orifices (1 palatal, 2 MB, and 3 DB canals; DB and SDB had same orifice). (C)
Preoperative radiograph. (D) Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modi-
fied access, and black line is for canal orifice outline and external outline of modified access.
with paper points, and a dry cotton pellet was placed in the pulp
chamber followed by a temporary seal with Cavit G.
Case Report 4
A 49-year-old male patient reported to the department complain-
ing of pain in tooth #14 with previously attempted root canal (the proce-
dure was done in a private clinic). On evaluation a diagnosis of pulp
necrosis associated with tooth #14 was made (Fig. 5C). A conventional
endodontic access opening was already present without any coronal
restoration. After isolation, carious tooth structure was removed, and
the 3 principal root canal systems were identified (MB, DB, and
palatal). The orifice of the palatal canal was large and dumbbell-
shaped. By using a DG 16 endodontic explorer, catch points were noted
approximately 2 mm and 1 mm from the MB and DB orifices, respec-
tively, in the palatal direction and another canal orifice 2 mm approx-
imately mesial to the orifice of the palatal.
The access cavity was then modified to a trapezoidal shape
(Fig. 5A, B) to improve access to the additional canals. The pulp
chamber floor revealed entry to 6 canals. The MB (Vertucci’s type
Figure 4. Case 3. Radiograph showing the presence of 1 palatal, 2 MB, and 3
DB canals.
JOE — Volume 36, Number 6, June 2010
Case Report/Clinical Techniques
IV), DB (Vertucci’s type II), and palatal (Vertucci’s type II) roots had
2 orifices each, fairly well-separated and exiting from the floor of the
pulp chamber.
Coronal flaring was done with ProTaper SX rotary file to improve
straight-line access, and the working length was calculated. Cleaning
and shaping were done by using K-files and ProTaper rotary files up
to F2 size and palatal canals to F3 size. The canals were then dried
with paper points, and a dry cotton pellet was placed in the pulp
chamber followed by a temporary seal with Cavit G.
At the next appointment, the root canals of all 4 cases were irri-
gated with 3% sodium hypochlorite (Vensons India) followed by
normal saline and dried with paper points. The canals were obturated
(Figs. 1D, 2D, 3D, 5D) by using resin sealer (RC Seal; Prime Dental
Products, Mumbai, India) and laterally condensed gutta-percha
(Dentsply Maillefer). All cases were postendodontically restored with
full veneer crowns, and they were asymptomatic thereafter at 6-month
follow-up.
Discussion
The variation of root canal morphology especially in multi-rooted
teeth is a constant challenge for successful endodontic therapy (14).
These case reports emphasize the importance of use of magnification
for exploring canals and modification of the access cavity to ensure
proper endodontic treatment.
Endodontic access should be designed to provide direct access to
the apical third of the root canal system (15). The dentist should be able
to visualize all aspects of the coronal third of the root canal system, and
all tooth structure or restorative material that interferes with straight-
line access should be removed (15). To achieve a straight-line access,
the conventional triangular access cavity can be modified into many
shapes such as clover leaf–like (shamrock) (16), heart (17), trape-
zoidal (11, 15, 18, 19), rectangular (20), rhomboidal (3, 21), and
ovoid (22) shapes, depending on the particular clinical situation. In
these presented cases the conventional triangular access was prepared
first, and then it was modified Figs. 1(A, B), 2(A, B), 3(A, B), and
5(A, B) during exploration of extra canals.
According to the literature, the occurrence of fourth canal in
maxillary first molar ranges greatly: 53% (Hess 1925) (9), 56.2%
(Okumara 1927) (10), 51.5% (Weine et al 1969) (1), 64.3% (Pineda
and Kuttler 1972) (5), 62% (Seidberg et al 1973) (7), 50.4% (Slowey
1974) (8), 69% (Pomeranz and Fishelberg 1974) (6), 72% (more
Nomenclature of Maxillary Molars 1075
Case Report/Clinical Techniques

Figure 5. Case 4. (A, B) Modified (trapezoidal) access cavity of case 4 showing 6 orifices (2 palatal, 2 MB, and 2 DB canals). (C) Preoperative radiograph. (D)
Obturation radiograph. In (B) blue line indicates internal outline of conventional access, red line indicates internal outline of modified access, and black line is for
canal orifice outline and external outline of modified access.

than 3 canals) (Acosta Vigouroux and Trugeda Bosaans 1978) (2),
74% (Thomas et al 1993) (11), 72% (Fogel et al 1994) (3), and
95% (Kulid and Peters 1990) (4). The occurrence of a fifth canal
was 2.25% (Acosta Vigouroux and Trugeda Bosaans) (2).
Some authors have reported a few cases with 6 canals (Martinez-
Berna and Ruiz-Badanelli (3 MB, 2 DB, and 1 palatal) (12) and Bond
et al (2 MB, 2 DB, and 2 palatal) (13). The review of previously reported
cases that had more than 4 canals in maxillary molars is tabulated in
Table 1.
Of the 4 presented case reports, 3 cases had 2 palatal, 2 MB, and 2
DB canals; the fourth one had 1 palatal canal, 2 MB canals, and 3 DB
canals (DB1and DB2 shared same orifice, and DB3 had separate
orifice). In all the cases, routine extension of the pulp chamber floor
with troughing along the line angles was carried out without penetrating
deeper or extending into the coronal dentin.
Slowey (23) stated that root canal anatomy of each tooth dictates
the location of the initial entry of access and size of the first file to be
used and contributes to a rational approach to solve the problems
that arise during therapy. Among the root canal anomalies of maxillary
molars, the least frequent appears to be that of the palatal root (23, 24).
The incidence of more than 1 palatal canal has been reported to be less
than 2% (25). In the presented 4 case reports, 3 cases had 2 palatal
canals.
Magnification aids such as loupes and dental operating micro-
scopes enable the clinician to easily identify the extra canals (21).
The endodontic procedures were performed under dental operating
microscopes in the presented cases.
Nomenclature of Root Canals in Maxillary Molars
In cases in which there are more than 3 canals in a tooth, the
terminology of the additional canals is not clear and unique; MB2
(21, 26) and P1 (20) (in case of 2 palatal canals) were both called me-
siopalatal canals by different authors. Some authors refer to MB2 as

TABLE 1. Previously Reported Cases with >4 Canals in Maxillary Molars

Author name Year Type of study No of cases / extracted teeth No. of canals
Vigouroux et al (2) 1978 Extracted teeth 3 5
Cecic et al (33) 1982 Clinical case 1 5
Martinez-Berna et al (12) 1983 Clinical case 1 6
Beatty (34) 1984 Clinical case 1 5
Bond et al (13) 1988 Clinical case 1 6
Wong (35) 1991 Clinical case 1 5
Hulsmann (36) 1997 Clinical case 1 5
Holtzman (37) 1997 Clinical case 2 5
Johal (38) 2001 Clinical case 1 5
Maggiore et al (39) 2002 Clinical case 1 6
Barbizam et al (40) 2004 Extracted tooth 1 5
Ferguson et al (41) 2005 Clinical case 1 5
Ghoddusi (20) 2006 Clinical case 2 5
Chen et al (29) 2006 Clinical case 1 5
Filho et al (28) 2009 Ex vivo 1 7
Clinical 1 5
1 6
CBCT 1
Aggarwal et al (18) 2009 Clinical case 1 5
Weng et al (24) 2009 Ex vivo 2 (first molar) 5
1 (second molar) 5
Holderrieth et al (32) 2009 Clinical case 3 5

CBCT, cone beam computed tomography.

1076 Karthikeyan and Mahalaxmi JOE — Volume 36, Number 6, June 2010

mesiolingual canal (3). To avoid confusion, considering that every root
might contain 3 canals at the most, the following nomenclature of addi-
tional canals in maxillary molars is suggested:
Canals of MB root
MB1: mesiobuccal (MB)
MB2: second mesiobuccal (SMB)
MB3: mesiobuccopalatal (MBP)
Canals of DB root
DB1: distobuccal (DB)
DB2: second distobuccal (SDB)
DB3: distobuccopalatal (DBP)
Canals of palatal root
Palatal (P)
Mesiopalatal (MP)
Distopalatal (DP)
In MB and DB roots the canals are named starting from most
buccal canal, and subsequent canals are named heading toward the
palatal direction. But in the palatal root the main canal is palatal (P);
the extra canals are termed mesiopalatal (MP) or distopalatal (DP), de-
pending on the location (mesial or distal) of the canal in relation to the
main palatal. The use of term lingual (eg, mesiolingual) in case of
maxillary molars should be avoided.
Methods of Detecting Additional Canals
Different methods of locating extra canals have been discussed by
many authors (15, 27–32):
1. Additional off-angle radiographs (at least 3 radiographs at varying
horizontal angles).
2. Use of computed tomography.
3. Use of magnification (loupes and dental operating microscopes).
4. Examine dentinal map minutely and use DG 16 to explore the floor
of the pulp chamber.
5. Look for hemorrhagic spots (indicate the presence of extra
canals).
6. Perform champagne or bubble test with sodium hypochlorite.
7. Staining the pulp chamber with dye (eg, 1% methylene blue).
8. Use of ultrasonic tips, special round burs, and thin tapering fin-
ishing burs to remove a small amount of tooth structure or
calcification and trough the line angles of the pulp chamber
will help.
9. Modify the conventional outline form to include the extra canals.
10. Ensure adequate straight-line access to improve visibility.
Before considering all these methods, having a thorough knowl-
edge of complexity of the root canal system, increased operator expe-
rience, and increased time per appointment help in identification and
treatment of these extra canals. All 4 cases presented here had varied
root canal morphology. Hence it is very clear that the presence of these
extra canals could be potentially missed if a thorough exploration is
forgone.
Conclusion
These case reports contribute to our understanding of the
complexity of the root canal morphology found in maxillary first molars.
The presented nomenclature gives unique names for root canals in the
maxillary molars. Many authors consider such cases to occur infre-
quently, but it is not (>2% of more than 4 canals), so dentists should
be aware of them when considering endodontic treatment of maxillary
molars.
JOE — Volume 36, Number 6, June 2010
Case Report/Clinical Techniques
Acknowledgments
We thank Prof Dr Kavitha, Dr Jones Mathias, Dr Gingu Koshi
George, and Dr S. Chandrasekar, SRM Dental College for their
support in preparation of this manuscript.
References
1. Weine FS, Healey HJ, Gerstein H, Evanson L. Canal configuration in the mesiobuccal
root of the maxillary first molar and its endodontic significance. Oral Surg Oral Med
Oral Pathol 1969;28:419–25.
2. Acosta Vigouroux SA, Trugeda Bosaans SA. Anatomy of the pulp chamber floor of
the permanent maxillary first molars. J Endod 1978;4:214–9.
3. Fogel HM, Peikoff MD, Christie WH. Canal configuration in the mesiobuccal root of
the maxillary first molar: a clinical study. J Endod 1994;20:135–7.
4. Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuc-
cal root of maxillary first and second molars. J Endod 1990;16:311–7.
5. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of
7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101–10.
6. Pomeranz H, Fishelberg G. The secondary mesiobuccal canal of maxillary molars. J
Am Dent Assoc 1974;88:119–24.
7. Seidberg BH, Altman M, Guttuso J, Suson M. Frequency of two mesiobuccal root
canals in maxillary permanent first molars. J Am Dent Assoc 1973;87:852–6.
8. Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg 1974;
37:762–72.
9. Hess W. The anatomy of the root canals of the teeth of the permanent dentition. Lon-
don: John Bale Sons and Danielsen; 1925. part I:32–5.
10. Okumara T. Anatomy of the root canals. J Am Dent Assoc 1927;14:632–6.
11. Thomas RP, Moule AJ, Bryant R. Root canal morphology of maxillary permanent first
molar teeth at various ages. Int Endod J 1993;26:257–67.
12. Martinez-Berna A, Ruiz-Badanelli P. Maxillary first molars with six canals. J Endod
1983;9:375–81.
13. Bond JL, Hartwell G, Portell FR. Maxillary first molar with six canals. J Endod 1988;
14:258–60.
14. Malagnino V, Gallotini L, Passariello P. Some unusual clinical cases on root anatomy
of permanent maxillary molars. J Endod 1997;23:127–8.
15. Johal S. Unusual maxillary first molar with 2 palatal canals within a single root:
a case report. J Can Dent Assoc 2001;67:211–4.
16. Ingle JI, Backland LK, Peters DD, Buchanan S, Mullaney TP. Endodontic cavity prep-
aration. In: Ingle JI, Backland LK, eds. Endodontics. 4th ed. Baltimore, MD: Williams
and Wilkins; 1994:96–8.
17. Neaverth EJ, Kotler LM, Kattenback RF. Clinical investigation of endodontically
treated maxillary molars. J Endod 1997;13:506–12.
18. Aggarwal V, Singla M, Logani A, Shah N. Endodontic management of a maxillary first
molar with two palatal canals with the aid of spiral computed tomography: a case
report. J Endod 2009;35:137–9.
19. Iqbal M, Fillmore E. Preoperative predictors of number of root canals clinically de-
tected in maxillary molars: a PennEndo database study. J Endod 2008;34:413–6.
20. Ghoddusi J, Mesgarani A, Gharagozloo S. Endodontic re-treatment of maxillary
second molar with two separate palatal roots: a case report. Iranian Endodontic
Journal 2008;3:83–5.
21. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal
configurations. J Endod 1999;25:446–50.
22. Christie WH, Thompson GK. The importance of endodontic access in locating maxil-
lary and mandibular molar canals. J Can Dent Assoc 1994;60:527–32, 535–6.
23. Slowey RR. Root canal anatomy road map to successful endodontics. Dent Clin
North Am 1979;23:555–73.
24. Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al. Root canal morphology of
permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: a new
modified root canal staining technique. J Endod 2009;35:651–6.
25. Stone LH, Stroner WF. Maxillary molars demonstrating more than one palatal root
canal. Oral Surg 1981;51:649–52.
26. Hartwell G, Applelstein CM, William W, Lyons, Guzek ME. The incidence of four
canals in maxillary first molars: a clinical determination. J Am Dent Assoc 2007;
138:1344–6.
27. Smadi L, Khraisat A. Detection of a second mesiobuccal canal in the mesiobuccal
roots of maxillary first molar teeth. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2007;103:77–81.
28. Filho FB, Zaitter S, Haragushiku GA, de Campos EA, Abuabara A, Correr GM. Analysis
of the internal anatomy of maxillary first molars by using different methods. J Endod
2009;35:337–42.
29. Chen IP, Karabucak B. Conventional and surgical endodontic retreatment of a maxil-
lary first molar: unusual anatomy. J Endod 2006;32:228–30.
30. Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of cone-beam computed
tomography to identify root canal systems in vitro. J Endod 2008;34:87–9.
Nomenclature of Maxillary Molars 1077
Case Report/Clinical Techniques
31. Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human
permanent maxillary first molar: a literature review. J Endod 2006;32:813–21.
32. Holderrieth S, Gernhardt CR. Maxillary molars with morphologic variations of the
palatal root canals: a report of four cases. J Endod 2009;35:1060–5.
33. Cecic P, Hartwell G, Bellizzi R. The multiple root canal system in the maxillary first
molar: a case report. J Endod 1982;8:113–5.
34. Beatty RG. A five-canal maxillary first molar. J Endod 1984;10:156–7.
35. Wong M. Maxillary first molar with three palatal canals. J Endodon 1991;17:298–9.
36. Hulsmann M. A maxillary first molar with two disto-buccal root canals. J Endod
1997;23:707–8.
1078 Karthikeyan and Mahalaxmi
37. Holtzman L. Multiple canal morphology in the maxillary first molar: case reports.
Quintessence Int 1997;28:453–5.
38. Johal S. Unusual maxillary first molar with 2 palatal canals within a single root:
a case report. J Can Dent Assoc 2001;67:211–4.
39. Maggiore F, Jou YT, Kim S. A six-canal maxillary first molar: case report. Int Endod J
2002;35:486–91.
40. Barbizam JV, Ribeiro RG, Filho MT. Unusual anatomy of permanent maxillary
molars. J Endod 2004;30:668–71.
41. Ferguson DB, Kjar KS, Hartwell GR. Three canals in the mesiobuccal root of a maxil-
lary first molar: a case report. J Endod 2005;31:156–7.
JOE — Volume 36, Number 6, June 2010