Case Report/Clinical Techniques
Rare Root Canal Configuration of Bilateral Maxillary Second
Molar Using Cone-beam Computed Tomographic Scanning
Chang Zeng, PhD,* Ya Shen, PhD, Xiaoyue Guan, MS,* Xin Wang, Mingwen Fan,*
and Yuhong Li, PhD*
Abstract
The aim of this article was to present a right maxillary
second molar with an unusual root canal morphology
of 4 roots and 5 canals as confirmed by cone-beam
computed tomographic (CBCT) imaging. The tooth had
a C-shaped mesiobuccal root (CBCT imaging revealed
that the root was closer to the palate than the buccal
side) with 2 canals, 2 fused distobuccal roots with 2
separate canals, and 1 normal bulky palatal root with
1 canal. After thoroughly examining the rare anatomy,
root canal treatment was applied on the tooth. This
article shows the complexity of maxillary second molar
variation and shows the significance of CBCT imaging
in the confirmation of the 3-dimensional anatomy of
teeth and endodontic treatment. (J Endod 2016;-:15)
Key Words
Cone-beam computed tomography, maxillary
second molar, root anatomy
From the *Department of Operative Dentistry and End-
odontics, School and Hospital of Stomatology, Wuhan Univer-
sity, Wuhan, China; State Key Laboratory Breeding Base of
Basic Science of Stomatology (Hubei-MOST) and Key Labora-
tory of Oral Biomedicine Ministry of Education, School and Hos-
pital of Stomatology, Wuhan University, Wuhan, China;
Division of Endodontics, Department of Oral Biological and
Medical Sciences, Faculty of Dentistry, The University of British
Columbia, Vancouver, British Columbia, Canada; and School
of Stomatology, Wuhan University, Wuhan, China.
Address requests for reprints to Dr Yuhong Li or Dr Min-
gwen Fan, Department of Operative Dentistry and Endodontics,
School and Hospital of Stomatology, Wuhan University, Wuhan
430079, China. E-mail addresses: 1004809372@whu.edu.cn or
fmwmail@whu.edu.cn
0099-2399/$ - see front matter
Copyright 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.12.028
JOE Volume -, Number -, - 2016
R oot canal treatment is widely used for pulpitis and periapical disease, and root canal
treatment of the maxillary second molar (MSM) can be very difficult. Beside the
innermost position of the molar, the limitations of instruments and the high variation
of the MSM canal systems are the major reasons for the difficulties of root canal treat-
ment. The most common morphologies of MSM roots are the mesiobuccal (MB) root,
the distobuccal (DB) root, and the palatal root, with incidences varying between 73.6%
and 94.6% (14). A separate canal in each root usually exists. The most common
variation is the second MB (MB2) root canal; its incidence is different in studies,
varying between 13.87% and 78.9% (1, 3, 5, 6). An MB2 canal in the MSM is not as
common as in the maxillary first molar (MFM). Variation in the DB root is rare; the
reported occurrence is only 0.3% (4).
Some unusual anatomy of the MSM has been reported in the literature. Several
authors reported MSMs with 2 roots (ie, mesial and distal roots, which are similar to
mandibular molars) and 2 root canals in each root (7, 8). Zmener (9) and Ozcan
et al (10) reported MSMs with 3 canals in the MB root. Kottoor et al (11) showed
a case of 5 roots with 5 canals. Double palatal roots were also reported by several
authors (12, 13). Successful root canal treatment requires sufficient knowledge of
the morphology of the root canal systems. In the early 1960s through 1980s,
endodontists found variations of root canal systems by examining teeth without
relying on technology and by merely making use of their experience. At present,
with the help of microscopes and cone-beam computed tomographic (CBCT) imag-
ing, these unusual variations can be confirmed, and successful root canal treatment
can be performed. Radiography is necessary in root canal treatment. However, in
certain instances, radiography may not be enough, particularly when variations
are present. CBCT scanning is a new technology that is being used in dentistry.
Compared with radiography, CBCT imaging can show 3-dimensional (3D) scanning
images of all teeth, which can aid dentists in fully understanding the structure of teeth
and root canals.
The right MSM used in this study had 4 roots: 1 C-shaped MB root, 2 fused DB
roots, and 1 bulky palatal root. The MB root is a C-shaped root with 2 canals, and it
was closer to the palatal side. In addition, the DB roots are 2 fused roots; the upper
roots are fused together, and the lower segment clearly shows the 2 separate roots. End-
odontic treatment of this tooth was performed with the aid of CBCT imaging.
Case Report
A 26-year-old Chinese woman presented to Wuhan University Stomatological Hos-
pital, Wuhan, China. Her chief complaint was pain on her right maxillary molar that had
persisted for 3 days and radicular pain on the right side of her head. The pain was
extremely severe at night, preventing her from sleeping. According to the patient, she
did not have a systemic disease. Clinical examination showed caries on the buccal
side of her right MSM (tooth #2). The caries developed to the subgingiva, and the
root was exposed. The carious tooth was mobile of the first degree and showed severe
sensitivity to probe, percussion, and the thermal test. Vitality testing of the involved tooth
with heated gutta-percha and dry ice caused an intense lingering pain, whereas elec-
tronic pulp stimulation (SybronEndo, Orange, CA) caused a premature response.
Radiographic examination showed that this tooth had low density on the middle distal
area of the crown and no obvious periapical lesion (Fig. 1A); the examination also
showed no obvious root canal abnormity of tooth #2. Based on the findings, the
Rare Root Canal Configuration of MSM 1
Case Report/Clinical Techniques
Figure 1. (A) Preoperative radiograph of tooth #2. (B) Working length determination. Radiograph with K-files showing 5 separate root canals. (C) After root canal
treatment. (D) One-month follow-up. No obvious abnormities were observed. Restoration was suggested to the patient.
diagnosis of her right MSM was acute pulpitis. Root canal treatment was
suggested, and the patient consented.
Local anesthesia with 4% articaine containing 1:100,000 epineph-
rine (Primacaine; Acteon Group, Merignac Cedex, France) was admin-
istered to the tooth. After a rubber dam was placed, an access opening
was created. The palatal orifice was easy to find. With the help of the
DG16 endodontic explorer (Hu Friedy, Chicago, IL), 2 DB orifices
were also found. During examination using a surgical operating micro-
scope (Carl Zeiss, Oberkochen, Germany), the fourth canal was located
on the mesial side (ie, between the buccal and palatal pulp floor). This
unusual morphology aroused our suspicion that other canals existed.
To ascertain the variations in the root and canal, a CBCT scan was
performed. The access cavity was sealed with glass ionomer cement
(Medical Equipment Factory of Shanghai Medical Instruments,
Shanghai, China). Informed consent was obtained from the patient,
and a multislice CBCT (NewTom VG; QR Srl, Verona, Italy) was per-
formed with a tube voltage of 110 kV and a tube current of
4.05 mA. All protective measures were undertaken to protect the pa-
tient from scattered radiation. CBCT scanning images (Fig. 2) and 3D
reconstruction images (Fig. 3) were obtained. They showed the pres-
ence of 4 roots and 5 canals: 1 MB root, 2 DB roots, and 1 palatal root.
The MB root was a C-shaped root with 2 canals. The DB roots had 2
canals in each of the roots, and the palatal root had 1 canal (Figs.
2AD and 3AD, F, G, I, and J).
With the assistance of CBCT images, the ET 20 Ultrasonic core
(Acteon Group) was used under a microscope to discover another
orifice of the MB root. Five canals were found (Fig. 2EG). Coronal
enlargement was performed using nickel-titanium ProTaper S1 and
SX files (Dentsply Maillefer, Ballaigues, Switzerland) to obtain a
2 Zeng et al.
straight-line access. The working length was measured with an elec-
tronic apex locator (SybronEndo) and confirmed using a radiograph
with K-files (Dentsply Maillefer) (Fig. 1B). Then, the root canals were
cleaned and shaped with PathFile (Dentsply Maillefer) and ProTaper
nickel-titanium rotary instruments (Dentsply Maillefer) using a
crown-down technique. During preparation, EDTA gel (Longly, Wu-
han, China) was used as the lubricant. Irrigation was performed
with 2.5% sodium hypochlorite. Ultrasonic irrigation with normal sa-
line was used for the final irrigation. The tooth was intracanal medi-
cated with calcium hydroxide and sealed with Caviton White (GC
Corp, Tokyo, Japan). After 1 week, the patient came back and reported
that she did not feel pain on the tooth when the tooth was palpated. Un-
der a rubber dam, final rinsing of the canals was performed by using
normal saline coupled with ultrasonic agitation. The canals were dried
with absorbent paper points (Gapadent, Tianjin, China). The tooth was
obturated using the warm gutta-percha condensation technique with
the Elements Obturation Unit (SybroEndo, Glendora, CA). AH Plus
(Dentsply DeTrey GmbH, Konstanz, Germany) was used as the sealer.
The obturating results are shown in Figures 1C and D and 2HK.
Discussion
With the development of endodontics, radiography has been an
essential part in handling endodontic problems. Conventional radio-
graphs such as X-rays and panoramic radiography helped dentists bet-
ter understand the problem of teeth, periodontal tissue, the jaw, and so
on. These radiographs have been applied for many years because of
their low price, easy operation, relatively low radiation dose, and imme-
diate results. However, these radiographs can provide only 2-
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Figure 2. Microscope images and CBCT scanning images of tooth #2. (AC) The different CBCT scanning levels of tooth #2 before obturation. (D) An enlarged
picture of tooth #2 before obturation, which revealed 2 MB canals, 2 DB canals, and 1 palatal canal. (EG) Microscope images of the 5 root canals: MB1, MB2,
DB1, DB2, and palatal (P). (HJ) The different CBCT scanning levels of tooth #2 after obturation. (K) An enlarged picture of tooth #2 after obturation, which
revealed the 5 obturated canals.
dimensional images, and higher success rates are needed. These con-
ventional radiographies sometimes do not meet our requirements.
CBCT imaging is essential in identifying morphology variations. In our
study, with the assistance of X-rays and a microscope, only 4 canals
(ie, 2 DB canals, 1 MB canal, and 1 palatal canal) were found; the fifth
canal was discovered with the assistance of CBCT scanning. CBCT scan-
ning showed that the tooth had 4 roots and 5 canals: a C-shaped MB root
with 2 canals, 2 fused DB roots with 2 canals, and a bulky palatal root
with 1 canal. The 3D reconstruction of tooth #2 is shown in Figure 3.
The reconstruction shows that CBCT imaging is helpful for clinical diag-
nosis and treatment. Rigolone et al (14) suggested that although irra-
diation doses and cost are not negligible, the cost-benefit ratio could
sway in favor of making this technology more acceptable. Matherne
et al (15) researched the benefit of CBCT imaging in endodontic treat-
ment; they concluded that CBCT images always resulted in the identifi-
cation of a greater number of root canal systems compared with digital
images. However, not all patients need CBCT imaging. By relying on
experience and using a microscope, most teeth could be treated suc-
cessfully. When we have doubts about a tooth, CBCT imaging is used
to solve our problem.
Maxillary molars, particularly second molars, have the most
complicated root canal systems (16). Kim et al (1) reported that in
MSMs 4.63% had 1 root, 10.72% had 2 roots, 82.7% had 3 roots,
and 5.6% had 4 roots. Many studies reported that 3 separate roots
were the most common morphologies in MSMs; the incidence varies
from 73.6%94.6%, which is lower than that in MFMs (1, 2, 3, 17,
18). Fusion could be observed in maxillary molars (3), but the defini-
JOE Volume -, Number -, - 2016
Case Report/Clinical Techniques
tion of fusion is still not unified. Some researchers considered fusion as
full roots fusing together, whereas some defined fusion as one third or
less of the roots fusing together; other researchers did not even mention
the meaning of fusion (1). Currently, fusion more frequently occurs in
MSMs compared with MFMs, which may be the reason for the higher
variation of MSMs. CBCT scanning and 3D reconstruction implied
that the DB roots of tooth #2 in our study were 2 roots that fused
together (Fig. 3AD). The MB root was closer to the palatal side rather
than the buccal side. The CBCT scanning images showed that the other
side of the maxillary second tooth (ie, tooth #15 of the patient) was also
unusual. Tooth #15 had 3 roots with 4 canals: 1 oval-shaped MB root, 1
DB root, and 1 palatal root; the MB root with 2 canals was similar to the
mesial root in the mandibular molars, and the DB and palatals had one
canal each in the distal surface (Fig. 3E and H).
In the MSM with 3 roots, the most common canal variation is the
second canal in the MB root; this incidence varies between 34.4% and
78.9% (1, 3, 5, 17). The variation rate of MB2 canals is lower than in
MFMs. As reported in the literature, 97.58% of teeth have 1 canal in DB
and palatal roots (1). Peikoff et al (2) reported a retrospective study of
520 completed endodontic treatments of MSM teeth; in their work, they
classified the variation of the root canal system into 6 categories:
1. 3 separate roots and 3 separate canals (56.9%)
2. 3 separate roots and 4 canals (2 in the MB root) (22.7%)
3. 3 roots and canals, of which MB and DB canals combine to form a
common buccal root with a separate palatal root (9%)
4. 2 separate roots, with a single canal in each root (6.9%)
Rare Root Canal Configuration of MSM 3
Case Report/Clinical Techniques

Figure 3. (AD) The 3D reconstruction of tooth #2. It had 4 roots: 1 MB root, 2 DB roots, and 1 palatal root. (E) The 3D reconstruction of tooth #15. (F) The apical
view of tooth #2. (G) The CBCT scanning image of tooth #2. (H) The CBCT scanning image of tooth #15. (I and J) The root canal 3D reconstruction of tooth #2.

4 Zeng et al. JOE Volume -, Number -, - 2016


5. 1 main root and canal (3.1%)
6. 4 separate roots and 4 separate canals including 2 palatal roots
(1.4%)
In our case, the MSM with 4 roots and 5 canals, as shown in the 3D
reconstruction of the root canal system in Figure 3I and J, is yet to be
classified. No similar case has been reported in the literature. Only 2
types of the 5 canals in MSMs have been reported. One of these 2 kinds,
which consists of 3 canals in the MB root, 1 canal in the DB root, and 1
canal in the palatal root, has been reported by Osvaldo Zmener (9) and
Ozcan et al (10); the other kind consists of 2 canals in the MB root, 1
canal in the DB root, and 2 canals in the palatal root. The present case
shows that MSMs may have an unusual root distribution, and the num-
ber of canals may be greater than 3 or 4.
Conclusion
This case report has discussed the endodontic management of an
unusual MSM with 4 roots and 5 canals and has emphasized the impor-
tance of the microscope and CBCT imaging in endodontic treatment.
Acknowledgments
The authors thank Prof Bin Fan and Dr Ting Xu for their
contribution and comments.
Supported by grants from the National Natural Science Foun-
dations of China (no. 81271190 and no. 81371130).
The authors deny any conflicts related to this study.
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Rare Root Canal Configuration of MSM 5