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 REVIEW ARTICLE 7

Hany Mohamed Aly Ahmed, Gary Shun Pan Cheung

Accessory roots and root canals in maxillary

premolar teeth: a review of a critical endodontic
challenge
Hany Mohamed Aly
Ahmed
Department of Restora-
tive Dentistry, School of
Dental Sciences, Universiti
Sains Malaysia, Kelantan,
Malaysia
Key words accessory root, classication, maxillary premolar teeth, root canal
Gary Shun Pan
Cheung
Area of Endodontics,
Adequate knowledge of both external and internal radicular anatomy is a fundamental prerequisite Comprehensive Dental Care,
for successful endodontic therapy. Maxillary premolar teeth present an endodontic challenge due to Faculty of Dentistry, the
University of Hong Kong,
their increased prevalence for root and root canal aberrations. This review aims to discuss the occur- Hong Kong Special Adminis-
rence of accessory roots and root canals in maxillary premolar teeth and its relation to different ethnic trative Region, China

groups. A new classication is proposed to include all their accessory root and root canal congura- Correspondence to:
tions. In addition, the endodontic considerations, including their identication and management, are Dr Hany Mohamed Aly
Ahmed
discussed. Department of Restorative
Dentistry, School of Dental
Sciences,
Universiti Sains Malaysia,
Kubang Kerian, 16150,
Kelantan, Malaysia
Introduction root12-15. However, the presence of accessory roots Tel: 00-601-298-57937
Email: hany_endodontist@
and/or root canals can be rather common4,6,16. hotmail.com
The anatomical features of maxillary premolar teeth
show a lot of morphological variation. These vari-
ations comprise coronal anomalies such as dens in- Aetiology
vaginatus1, dens evaginatus2 and gemination3, and
radicular anomalies including accessory roots and root Accessory root formation
canals4, taurodontism5, buccal radicular longitudinal
sulcus6, abnormal curvatures, and dilacerations7,8. While the exact reason for accessory root forma-
Thorough knowledge of both normal and un- tion remains uncertain, different ethnic groups, lo-
usual dental morphology is essential for the practice cal traumatic injuries to Hertwigs epithelial root
of endodontics9. The problem of missed anatomy sheath during root formation, genetic factors
during root canal therapy is commonplace for teeth and some diseases are considered to be the main
requiring retreatment10,11. Maxillary premolars will causes17-21. Armitage22 suggested the occurrence
benet, as this tooth seems to show an increased of three-rooted maxillary and mandibular premolar
prevalence of root and root canal aberrations11. teeth as a rare recessive trait or a result of gene
Traditional beliefs and many morphological stud- mutation. Barros et al23 observed the presence of
ies are such that maxillary rst and second premolar three-rooted maxillary premolar teeth in two pa-
teeth are either single rooted, containing one or two tients of the same family and, hence, assumed the
root canals, or double rooted, with one canal in each possibility of inheritance.

ENDO (Lond Engl) 2012;6(1):718

8 Ahmed/Cheung Maxillary premolars: an endodontic challenge

Table 1 Percentage of three-canalled maxillary rst premolar teeth (*unpublished data).

Author/s Year Type of study Number Three

of teeth root canals (%)
Pineda and Kuttler32 1972 In vitro (radiographic analysis) 259 0.5
Green12 1973 In vitro (vertical ground sections) 50 0.0
Carns and Skidmore33 1973 In vitro (plastic casts) 100 6.0
Kerekes and Tronstad35 1977 In vitro (ground cross-sections) 20 10
Hession36 1977 In vitro (radiographic analysis) 12 8.3
Vertucci and Gegauff37 1979 In vitro (clearing method) 400 5.0
Bellizzi and Hartwell38 1985 In vivo (clinical survey) 514 3.3
Walker39 1987 In vitro (radiographic analysis and clearing method) 100 0.0
Pcora et al40 1991 In vitro (clearing method) 240 2.5
Sabala et al24 1994 In vivo (clinical survey) Not listed 0.8
alikan et al42 1995 In vitro (clearing method) 100 0.0
Zaatar et al44 1997 In vivo (clinical survey) 79 3.8
Loh13 1998 In vitro (visual and digital 957 0.0
radiographic analysis)
Kartal et al45 1998 In vitro (clearing method) 300 1.66
Chaparro et al46 1999 In vitro (transverse mid-root 150 3.3
and mesiodistal ground sections)
Nallapati47 2003 In vivo (clinical survey) Not listed >25
Sert and Bayirli48 2004 In vitro (clearing method) 200 3.0
Oginni50 2005 In vivo (clinical survey) 122 0.0
Lipski et al51 2005 In vitro (visual and radiographic analysis) 142 9.2
Atieh52 2008 In vitro (visual and 246 1.2
radiographic analysis, transverse sections)
Peiris53 2008 In vitro (clearing method) (Japanese) 81 1.2
Peiris53 2008 In vitro (clearing method) (Sri Lankan) 153 0.0
Ryo et al54 2008 In vitro (hand les) 55 9.0
Awawdeh et al55 2008 In vitro (clearing method) 600 1.5
Seif et al56 2008 In vitro (visual analysis of root number) 120 11.7
Weng et al14 2009 In vitro (modied clearing method) 95 0.0
Nganga et al57 2010 In vitro (clearing method) 155 6.5
Ahmed* 2011 In vivo (clinical survey) 30 6.7

Midtb and Halse18 reported an association of Accessory root canal formation

three-rooted maxillary premolars with Turner syn-
drome, which is a sex chromosomal disorder associated
with a female phenotype. The interactions between
the mesenchyme and epithelium can be inuenced
by the reduced amount of X-chromosome material,
thereby modifying the sequence of events in tooth for-
mation, including the formation of accessory roots18.
Many reports indicated that three-rooted maxil-
lary premolar teeth are likely to occur bilaterally22-27.
In addition, the concurrent existence of three-rooted
rst and second maxillary premolar teeth has been
pointed out4,11,28,29.
The prevalence of accessory root canals is said to be
related to ethnic groups9,21. However, the literature
lacks enough documentation for such relationships
in single and double-rooted maxillary premolar teeth
with three canals, which may be due to their low
prevalence.
Age has been suggested to be a contributing
factor for root canal system aberration30,31. Between
the ages of 20 and 40 years, the continuous depo-
sition of secondary root dentine on the root canal
walls can be associated with the formation of re-

ENDO (Lond Engl) 2012;6(1):718

 Ahmed/Cheung Maxillary premolars: an endodontic challenge 9

Table 2 Percentage of three-canalled maxillary second premolar teeth (*unpublished data).

Author/s Year Type of study Number Three root

of teeth canals (%)
Pineda and Kuttler32 1972 In vitro (radiographic analysis) 282 0.0
Green12 1973 In vitro (vertical ground sections) 50 0.0
Vertucci et al34 1974 In vitro (clearing method) 200 1.0
Hession36 1977 In vitro (radiographic analysis) 24 0.0
Bellizzi and Hartwell38 1985 In vivo (clinical survey) 630 1.1
Pcora et al41 1992 In vitro (clearing method) 300 0.3
alikan et al42 1995 In vitro (clearing method) 100 0.0
Chima43 1997 In vivo (clinical survey) 46 0.0
Zaatar et al44 1997 In vivo (clinical survey) 103 1.0
Kartal et al45 1998 In vitro (clearing method) 300 0.66
Sert and Bayirli48 2004 In vitro (clearing method) 200 1.5
Velmurugan et al49 2005 In vivo (clinical survey) 220 1.36
Oginni50 2005 In vivo (clinical survey) 218 0.0
Peiris53 2008 In vitro (clearing method) (Japanese) 60 0.0
Peiris53 2008 In vitro (clearing method) (Sri Lankan) 114 0.0
Ryo et al54 2008 In vitro (hand les) 34 0.0
Seif et al56 2008 In vitro (visual analysis of root number) 80 5.0
Jayasimha Raj and Mylswamy15 2010 In vitro (clearing method) 200 0.0
Ahmed* 2011 In vivo (clinical survey) 40 5.0

parative dentine stimulated from external insults like Epidemiology

caries, trauma and restorative procedures. When the
dentine from opposing canal walls meet at a nar-
row point, two root canals are then formed30. After
the age of 40, continuous dentine deposition would
reduce the complexity of the root canal system30.
Matuella et al6 observed the relation between the
external and internal radicular anatomy of double-
rooted maxillary rst premolar teeth with external
radicular buccal longitudinal sulci. Interestingly, this
buccal sulcus was accompanied by total and apical
bifurcation in 42.9% and 34.3% of the buccal root
canals, respectively. That is a total of about four-
fths of such roots with a bifurcated canal inside.
Furthermore, more than two apical foramina were
observed in 30.8% of these buccal roots.
The bilateral occurrence of root canal aberrations
is common, and it has been noted that the rarer the
aberration, the more likely it is to occur bilaterally24.
Accordingly, root canal treatment of such maxillary
premolar teeth with complex internal root anatomy
may serve as a suitable reference for the correspond-
ing contralateral teeth currently being considered for
endodontic therapy.
A review of the literature was undertaken in PubMed
and Google Scholar search engines to identify the
available articles discussing the prevalence of three-
canalled maxillary premolar teeth from 1972. The re-
sults show that the prevalence of maxillary premolar
teeth with three roots or root canals varied widely,
from 0 to above 25%12-15,24,32-57 (Tables 1 and 2).
Maxillary premolars with four canals have also been
reported35,58. These variations in the maxillary pre-
molar teeth require special attention to prevent the
undesirable event of leaving a root canal untreated.
Comparing studies from various populations al-
lows the identication of the correlation between
the occurrence of accessory roots or root canals in
posterior teeth and ethnicity9,21,59,60. Accordingly,
it is recommended that ethnicity should be consid-
ered during the preoperative evaluation prior to root
canal therapy. It seems that the prevalence of a third
canal, usually presented in a third root in maxillary
premolars, is different for people of different ethnic
origin (Table 3). Nallapati47 reported a prevalence
of three-canalled maxillary premolar teeth in over

ENDO (Lond Engl) 2012;6(1):718

10 Ahmed/Cheung Maxillary premolars: an endodontic challenge

Table 3 Percentage of maxillary premolar teeth with accessory roots and root canals in different populations
(AR: three-rooted maxillary premolars; *three-canalled maxillary premolars presented with undened root number).

Population Maxillary rst Maxillary second Author/s

premolars premolars
Jamaican (African descents and >25%* Nallapati47
others)
Saudi Arabian 1.211.7% (AR) 5.0% (AR) Atieh52
Seif et al 56

Pomeranian and Polish of 9.0*9.2% (AR) 0.0% Lipski51

Caucasian origin Ryo et al54
Kenyans with African descents 6.5%* Nganga et al57
Andalusian (Seville, Andalusia, 3.3% (AR) Chaparro et al46
southern Spain)
Turkish 0.03.0%* 1.5%* alikan et al42
Sert and Bayirli48
Jordanian 1.5% Awawdeh et al55
(0.8% (AR))
Japanese 1.2% (AR) 0.0% Peiris53
Chinese 0.00.63%* Walker39
Weng et al14
Singaporeans 0.0% Loh13
Nigerian 0.0% 0.0% Chima43
Oginni50
Sri Lankan 0.0% 0.0% Peiris53
Indian 0.0% Jayasimha Raj and Mylswamy15

25% of the Jamaican population, which is made up Classication

of people from mostly African descent. The Saudi
Arabian population, as well as Caucasians and Ken-
yans with African descents, also appeared to have a
fairly high incidence, up to 11.2%46,51,52,54,56,57. On
the other hand, other populations, like the Turkish,
Jordanian, Japanese and Chinese, show a low ten-
dency of having three-canalled maxillary premolar
teeth14,48,53,55.
Sex predilection
Sert and Bayirli48 classied the root canal congur-
ations of 2,800 teeth by gender in a Turkish popu-
lation, and showed a higher prevalence of three-
canalled maxillary rst premolar teeth in females
(4%) than males (2%). Maxillary second premolar
teeth showed higher prevalence in males (2%) than
females (1%)48. However, a recent survey of the
Kenyan population of African descent indicated that
the said conguration was more prevalent in males
(11.7%) than females (1.3%)57.
Bellizzi and Hartwell16 and Carlsen61 classied the
external morphological features of three-rooted
maxillary premolar teeth (also named as radiculous
premolars, small molars, mini-molars and miniature
three-canalled maxillary molars4,6,23) into three cat-
egories (Table 4).
The internal anatomy of three-rooted maxillary
premolar teeth has been examined by using high-res-
olution computed tomography (CT), and a percepti-
ble heterogeneity in their root canal systems was iden-
tied62. While the circular and ovoid cross sections are
often seen in the cervical, middle and apical thirds, a
comma-shaped cross section could be observed in the
cervical third of the mesiobuccal root canal62.
While there are many reported cases, in vitro
and in vivo studies have presented three-canalled
maxillary premolars with three separate or fused
roots16,23,27-29,33,46,49,63-70, their occurrence in
double- and single-rooted anatomy can also ex-
ist4,6,37,71,72. Vertucci and Gegauff37 found 1% of
maxillary rst premolar teeth existed as three canals

ENDO (Lond Engl) 2012;6(1):718

 Ahmed/Cheung Maxillary premolars: an endodontic challenge 11

Table 4 Previous classications of three-rooted maxillary premolar teeth.

Bellizzi and Hartwells classication16

Category 1 Fusion of all three roots or only the two buccal ones, and a semi-fused or free palatal root.
Category 2 Normal separation of the buccal roots at the mid-root or apical third level, with either a
semi-fused or free palatal root.
Category 3 Normal separation of the buccal roots up to the cervical level, with a free palatal root and
the classic tripod appearance.
Carlsens classication61
Class A One-rooted variant: the three-root cones are non-separated.
Class B Two-rooted variant: the mesiofacial and the distofacial root cones are non-separated. The
lingual cone is separated. Under these conditions, the facial root cones may be considered
as one root component.
Class C Three-rooted variant: the three-root cones are separated.

in a double- and single-rooted form. Sieraski et al4
presented maxillary rst premolar teeth with the
buccal root enclosing two root canals (conguration
types 1-2 and 2-1). Weine71 and Dadresanfar et al72
commented that these two buccal root canals usually
have a common orice. Mattuella et al6 noted a high
incidence of two separate root canals in a maxillary rst
premolar with its buccal root exhibiting a longitudinal
sulcus. Kerekes and Tronstad35 reported the presence
of four canals in a maxillary second premolar 5 mm
from the apex, which then joined to one root canal.
Sert and Bayirli48 observed that 2% of maxillary pre-
molar teeth with a 1-2-3-2 canal conguration were
in males. Awawdeh et al55 reported 0.5% of double-
rooted maxillary rst premolar teeth with 3 canals,
while 0.2% showed an additional canal conguration
(2-3-2-3).
As a result of these wide anatomical variations,
either in the number of roots or root canals, a gen-
eralised classication is required to describe these
morphological aberrations in maxillary premolar
teeth. Although Vertuccis classication for root
canal morphology73 and its subsequent supplemen-
tal congurations48,74 are benecial in recognising
most root canal congurations, the number of roots
present in premolar teeth and the root canals con-
tained therein were not addressed. For instance,
Class VIII represents three separate, distinct root
canals extending from the pulp chamber to the
apex73, but with no information on whether these
canals are encased in single, double or three-rooted
premolars. From an anatomical perspective, the root
canal system will vary in maxillary premolar teeth
with class VIII in single, double and three-rooted
variants, especially for the presence of canal inter-
communications, such as isthmuses. From a clinical
perspective, the radiographic interpretation, clinical
diagnostic landmarks and some endodontic proce-
dures will also vary when these root canals are pre-
sented in different root numbers. A new, proposed
classication (Table 5) is given here, hoping to in-
clude all possible accessory root and root canal con-
gurations in relation to maxillary premolar teeth.
Endodontic implications
Preoperative assessment
a) Clinical
The clinical examination of three-rooted maxillary
premolar teeth commonly reveals a relatively large
sized crown, especially in the mesiodistal diameter,
resembling a small molar23. However, this should
not be taken as a general rule as it is subjective, and
usually the coronal structure of the tooth requiring
root canal treatment may have been destroyed ex-
tensively. Other crown anomalies like gemination
might also indicate a complex root canal system58.
The presence of periodontal pockets and/or gin-
gival recession can facilitate the identication of the
external root anatomy, such as root bifurcation. How-
ever, in three-rooted premolar teeth, the furcation is
commonly located between the apical and middle
third of the root length75, which complicates its detec-
tion70. In double-rooted maxillary premolar teeth, the
buccal longitudinal sulcus can be probed, indicating
an increased possibility for root canal aberrations6.

ENDO (Lond Engl) 2012;6(1):718

12 Ahmed/Cheung Maxillary premolars: an endodontic challenge
Table 5 Proposed classication of maxillary premolar teeth with accessory roots
and/or root canals. BR: buccal root. PR: palatal root.
Three-rooted maxillary premolar teeth
Class 1 The maxillary premolar teeth exhibit three
roots with three root canals (either two
buccal roots and one palatal root or one
buccal root and two palatal roots).
Double-rooted maxillary premolar teeth with 2 buccal and 1 palatal root canals
Class 2 The buccal root exhibits two root canals
coronally and joining to form one canal
with one apical foramen. The palatal root
has one root canal.
BR PR
Class 3 The buccal root exhibits two separate root
canals extending coronally to the apex.
The palatal root has one root canal.
BR PR
Class 4 The buccal root exhibits one root canal
coronally which bifurcates into two separ-
ate root canals with two apical foramina.
The palatal root has one root canal.
BR PR
Single-rooted maxillary premolar teeth with 3 root canals
Class 5 The single root exhibits three separate root
canals with three apical foramina.
Maxillary premolar teeth with supplemental congurations
Class 6 Three-canalled maxillary premolar teeth with additional canal con-
gurations
(like 1-2-3-2 and 2-3-2-3) are included.
Four-canalled maxillary premolar teeth are described under this class.
ENDO (Lond Engl) 2012;6(1):718
b) Radiographic
Although the conventional radiographic views pro-
vide only two-dimensional images, they are funda-
mental and valuable examination tools in the detec-
tion of accessory roots and root canals. Radiographic
analysis should essentially be performed using prop-
erly exposed and processed radiographs to pave
the way for optimal interpretation of external and
internal root anatomy76. The use of magnication
and other supportive viewing aids are benecial77,78.
Digital radiography provides real-time image dis-
play, reduced radiation exposure, enhanced image
processing and ease of archiving79,80. Even though
the image quality and precision remain limited with
earlier machines79,81, the use of digital radiography
nowadays has gained more popularity.
The radiographic appearance of three-rooted
maxillary premolars can be identied on straight-
on preoperative radiographs, in which the mesio-
distal width of the mid-root image is equal or
greater than the mesiodistal width of the coronal
image4. Tracing the periodontal ligament space
of each individual root is essential. Although the
radiographic interpretation would become more
difcult when the three roots lie close to each
other or are fused, altering the horizontal angle
can facilitate their detection11,23,82. Bifurcation of
the root canal can be detected with meticulous
observation for the dimensional regularity of the
pulpal space. Abrupt diminishing or the appear-
ance of a break point in the root canal usually
indicates a bifurcation (Fig 1).
Recent advances in diagnostic radiographic
techniques have provided promise in the detec-
tion and interpretation of root canal anatomy83-86.
Cone beam computed tomography (CBCT) is able
to provide three-dimensional imaging with a low
radiation dose and reasonably high resolution, pro-
ducing images resembling that of modied canal
staining and clearing techniques in identifying root
canal anatomy85,86. However, CBCT should be only
considered when the conventional periapical radio-
graphs fail to provide adequate information and
details of the structures to be identied87, as CBCT
views can also show some misleading ndings88. To
sum up, two- and three-dimensional radiographic
images are valuable tools in providing useful infor-
 Ahmed/Cheung
mation regarding the root and root canal anatomy;
however, they should be correlated with the clinical
picture in order to achieve proper morphological
assessment11,88.
Access cavity preparation
Access cavity preparation is a critical step during
which accessory roots and/or root canals are de-
tected. Complete removal of the roof of the pulp
chamber and all interferences to the root canal ori-
ces should then give an indication of the internal
morphological features of the root11. Better pre-
cision and enhanced visibility of the internal root
anatomy can be achieved by utilising some form of
assisted vision, such as magnication and co-axial
illumination11,89.
In three-rooted maxillary premolar teeth,
the access cavity should be wide buccally, in a
mesiodistal direction, forming a T or a triangular
conguration4,23,47, resembling that of maxillary
molar teeth, but smaller in size. The buccal canal
orices are located at the same horizontal line, and
can often be clearly identied when the two canals
open into the pulp chamber separately (Figs 2a
to c). The two orice openings are shifted mesially
and distally, respectively, relative to the palatal
orice (Fig 2b). This shift becomes more difcult to
recognise when the buccal canals bifurcate below
the cervix and share a common orice; however,
the relatively wider mesiodistal dimension of
this common buccal orice should be noticeable
(Fig 2c).
a b
Fig 2 Schematic diagram showing (a) normal location of the buccal and palatal orices at the same vertical intersecting
line. (b) The buccal orices are located mesially and distally to the vertical intersecting line extended from the palatal orice.
(c) The common orice of the two buccal canals is usually wider mesiodistally than the palatal orice, even though they are
located at the same vertical intersecting line.
Maxillary premolars: an endodontic challenge 13
The pulp chamber volume of the three-rooted
variant is variable, and a distance of less than 1 mm
between the most cervical region of the pulp cham-
ber roof and the canal bifurcation can exist62. This
requires great caution by using suitably sized access
burs to prevent accidental perforation of the pulp
chamber furcation.
Root canal exploration
There may be times when the identication of the
Fig 1 Root canal
usual root canal conguration is missed during clin- bifurcation related to
ical and radiographic examinations or during access maxillary rst premolar
tooth (white arrow:
cavity preparation. This may become discernible break point; yellow
during canal exploration and working length de- arrows: bifurcated root
canals).
termination.
Tactile examination, which can be precisely per-
formed after removal of the coronal resistance, is
via the use of a small pre-curved le along the root
canal walls. A catch on the way towards the apical
foramen might indicate the presence of an accessory
canal orice76. During working length determin-
ation, the clinician should observe the le directions
inside the root canal, as well as the location within
the root on the radiograph. Eccentric le position, in
a mesial or distal direction, indicates the probability
of root canal bifurcation (Fig 3).
Working length determination
Vier-Pelisser et al62 observed the variability in the
apical foramina position for three-rooted maxillary
premolar teeth; the foramina tended to lie in the
c
ENDO (Lond Engl) 2012;6(1):718
14 Ahmed/Cheung Maxillary premolars: an endodontic challenge
a b
Fig 3 (a and b) The mesiodistal shift of the le direction was observed in the buccal root of tooth 25 (white arrows: (a)
distal location, (b) mesial location). (c) The two root canals were concurrently identied in the buccal root.
palatal and distal aspects of the buccal and palatal
roots. This nding indicates the necessity of using
electronic apex locators for locating the apical for-
amen, in addition to the periapical radiographic
views, in order to maintain high levels of accuracy
during working length determination90.
Root canal preparation
Three-rooted maxillary premolar teeth
Before initiating the mechanical instrumentation, the
dentine thickness of the buccal roots should be ac-
curately evaluated. Even though three-rooted max-
illary premolar teeth can accept many different in-
strumentation techniques23,27,28,91, their buccal root
canals are signicantly smaller in diameter than in
double- or single-rooted forms35. Attention should
be paid to this, especially when they are encased in
thin needle-like buccal roots4. Using some enlarg-
ing instruments, like the Gates-Glidden burs (sizes 3
and 4), is not recommended92. It is advisable to ex-
ploit the use of hand les and nickel titanium rotary
les of a suitable taper (not more than 0.06)4,93.
Meticulous care should be taken for the curvature
of these roots and for the abrupt curve at the bi-
furcation entrance, to prevent le separation. Once
broken, the separated segment can be extremely
difcult to retrieve and its removal often would carry
a high risk of root perforation94,95. The use of an
ENDO (Lond Engl) 2012;6(1):718
c
irrigation needle with a small diameter is favourable
for more effective ow of the root canal irrigants96.
The treatment procedure becomes increasingly com-
plicated when either of the buccal canals becomes
calcied64,67.
In cases where the two buccal roots exhibit a nar-
row single orice, the mesiobuccal and distobuccal
root canals should be enlarged towards the mesial
and distal walls respectively, in order to provide an
adequate space for subsequent mechanical prepar-
ation and obturation4,71.
Double-rooted maxillary premolar teeth
with three canals
Double-rooted maxillary premolar teeth are basic-
ally presented with particular external morphologi-
cal landmarks. In 62% to 100% of cases, the buccal
root exhibits a palatal groove, sometimes called a
buccal furcation groove (also described as devel-
opmental depression or furcation concavity), which
extends from a point just apical to the bifurcation,
and disappears towards the apex97. Occasionally,
the buccal root is complicated by a buccal groove or
a longitudinal sulcus6,97, which usually indicates the
presence of two buccal canals6. As a result of these
external root morphological features, many authors
recommended avoiding unnecessary enlargement
of these roots, as this can increase the risk of per-
foration and vertical root fracture97,98. Particular
 Ahmed/Cheung
Fig 4 Broken le (ar-
row) in the apical third
of a curved distobuccal
canal in a double-rooted
maxillary rst premolar
tooth.
consideration should also be taken when the ac-
cessory buccal canal is curved to prevent separation
of les (Fig 4).
Obturation
Maxillary premolars with buccal root/root
canal bifurcations in the cervical third
Different obturation techniques have been success-
fully employed for three-canalled maxillary pre-
molar teeth with coronally separated buccal roots/
root canals28 (Fig 5). While using small-sized heat
carriers, pluggers and narrow backll needles used
during the warm compaction technique are suit-
able for most canal types99; the lateral compaction
method using a spreader with minimum taper is rec-
ommended when the buccal roots in three-rooted
premolars are obviously thin. This will conserve the
amount of dentine required for removal, to enable
the proper accommodation of the warm compacted
armamentarium. Furthermore, the amount of heat
transferred through thin dentine walls from the root
canal to the external root surface can reach high
levels, causing undesirable thermal damage to the
supporting peri-radicular tissues100-102.
Maxillary premolars with buccal root/root
canal bifurcations in the middle third
In the case of root/root canal bifurcations occur-
ring at the mid-root region, adequate aring of the
canal coronal to the bifurcation is important for the
Maxillary premolars: an endodontic challenge 15
a b
Fig 5 (a and b) Obturation of three-canalled maxillary rst premolars using the lateral
compaction technique.
introduction of gutta-percha cones into each branch
of the bifurcated canal. If the coronal space is not
enough to accept two master cones at once, the
larger master cone can be cut by a scalpel at the
level of bifurcation; this segment of gutta-percha is
pierced at the end by a spreader or a le (Fig 6), and
then introduced and compacted into the canal103.
Subsequently, the second master cone can be guided
into the second canal and the obturation technique
continued. That is, obturation is done by the down
packing of each buccal canal separately, followed by
backlling of the common canal47. It is advisable to
take a conrmatory periapical radiograph after ll-
ing the canals to the level of bifurcation and before
backlling the common coronal portion. Magnica-
tion and illumination will afford a controlled obtur-
ation of the buccal canals during the warm vertical
compaction technique.
Maxillary premolars with buccal root/root
canal bifurcations in the apical third
The obturation of canals exhibiting apical bifurcation
is the most challenging. Magnication and illumin-
ation are important in controlling the obturation
procedure, which can be adequately lled using the
squirt technique. In this technique, both ends of
the root canals are obturated simultaneously by in-
jection of thermoplasticised gutta-percha, followed
by backlling103. Practicing this technique requires
experienced hands and an optimal apical stop.
An alternative method may be to adjust the mas-
ter gutta-percha cone (preferably, using one with
ENDO (Lond Engl) 2012;6(1):718
16 Ahmed/Cheung Maxillary premolars: an endodontic challenge

Fig 6 A photograph
showing pierced gutta-
percha after cut off.

a 1 2 3 4 b

Fig 7 (a) Schematic diagram showing the obturation procedure of a buccal root with apical bifurcation. 1) Prepared canals
before obturation. 2) Master cone adjustment in one root canal. 3) Half of the master cone length is removed and the
remaining gutta-percha above the bifurcation is softened. A pre-sized plugger is used for apical compaction (a snugly t-
ting master cone in a well-prepared apical stop is required to prevent the accidental pushing of the cone out of the apex).
4) Another master cone is adjusted on the new working length, followed by lateral compaction technique. (b) A periapical
radiograph showing a buccal canal with apical bifurcation. The apical third was obturated by the above technique.

a 0.04 taper) in the larger canal. Then, half of the References

cone is cut off using a pre-sized heat carrier or a
scalpel. Heat is applied to soften some distance of
the remaining gutta-percha above the bifurcation
area. This softened portion can be compacted using
a pre-sized hand plugger into the other canal (Figs
7a and b). Re-softening and further compaction is
performed until the apical area is adequately lled;
a periapical radiograph can conrm this. If injectable
gutta-percha is not available for backlling, another
master cone can be adjusted to the canal length
above the bifurcation and the remainder of the canal
space lled by warm lateral compaction technique.
Conclusion
The occurrence of three-canalled maxillary pre-
molar teeth with variable morphological features
reects their extreme anatomical complexity. This
necessitates sufcient awareness for their identi-
cation and management to prevent any undesirable
consequences, if they are missed during root canal
therapy.
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