Aust Endod J 2010; 36: 39–41

C A S E R E P O RT

Endodontic treatment of a mandibular first molar with three

mesial canals and broken instrument removal aej_162 39..41

Farhad Faramarzi, DDS, MSD1; Hamidreza Fakri, DDS2; Homan H Javaheri, DDS2
1 Department of Endodontics, Dental School, Shaheed Behesti University of Medical Sciences, Tehran, Iran
2 Private Practice, Tehran, Iran

Keywords Abstract
broken instrument removal, endodontic
treatment, mandibular first molar with three To succeed in any dental procedure, the clinician’s awareness of the patient’s
mesial canals. dental anatomy and its variations is crucial. In endodontic therapy, obtaining
full information about the root canals’ variations can affect the outcome
Correspondence
substantially. This case report presents the endodontic treatment of a man-
Dr Homan Javaheri, Private Practice, #1
dibular first molar exhibiting three mesial root canals with 4 mm of a separated
Arghavan Street, Dibaji Jonoubi Avenue,
Tehran 1951694953, Islamic Republic of Iran. K-file in the coronal third of the mesiolingual canal on an 18-year-old female
Email: [Link]@[Link] patient. This case demonstrates the importance of locating additional canals in
any roots undergoing endodontic treatment and how the clinician’s awareness
doi:10.1111/j.1747-4477.2009.00162.x of aberrant internal anatomy may change the treatment results.

ture and the location of the fragment than the specific

Introduction
technique used (16). In this case, we demonstrate the
The mandibular first molar, as the earliest permanent endodontic treatment of a mandibular first molar with
posterior tooth to erupt, is considered to be frequently three mesial root canals and the removal of a K-file in the
involved in endodontic procedures (1) and clinicians coronal third of ML canal fractured in previous treatment.
may be confronted by aberrant internal anatomy of the
mandibular first molars. A middle mesial (MM) canal
Case report
sometimes is present in the developmental groove
between the mesiobuccal (MB) and mesiolingual (ML) An 18-year-old female patient was referred to the
canals. The incidence of an MM canal ranges from 1% to Department of Endodontics in order to have endodontic
15% (1). treatment in her right first mandibular molar tooth. Her
Numerous in vitro and in vivo studies on the morphol- medical history was non-contributory and clinical exami-
ogy of mandibular first molars have provided new data nation did not reveal any pain to palpation or percussion.
relating to the presence of extra roots, additional root The preoperative radiograph showed radio-opaque mate-
canals, lateral canals or transverse canal anastomoses rial at the apices, lesions at both the mesial and distal
between the two or three canals in the mesial root (2–6). apices and a fracture K-file in ML (Fig. 1).
These studies have pointed out the need for careful After achieving anaesthesia, the tooth was isolated
inspection for the existence of possible additional canals. with a rubber dam and the access cavity preparation was
Several clinical reports have described more than two performed using Endo access and Endo-z burs (Dentsply,
canals in the mesial root of mandibular first molars Maillefer, Baillaigues, Switzerland). Investigation of the
(7–15). It is of prime importance for the clinicians to root canal system was initially performed with the aid of
clearly identify the topographic location of any additional an endodontic explorer and then with size 10 K-files
canals orifices. This could be best achieved with the aid of (Dentsply). Three root canals were initially detected (two
a dental operating microscope. in the mesial root, one in the distal root).
The removal of fractured instruments is more influ- Creation of a straight-line access was essential first step
enced by anatomy of tooth, degree of root canal curva- to allow maximum visibility of the broken files (17). The

© 2009 The Authors 39

Journal compilation © 2009 Australian Society of Endodontology
Endodontic treatment of a molar F. Faramarzi et al.

Figure 1 Pre-operative radiograph of tooth #30.

Figure 3 Post-operative radiograph.

irrigation with 2.5% sodium hypochlorite and MTAD

(BioPure, Dentsply, TulsaDental, OK, USA). The canals
were filled by the cold lateral condensation technique,
using gutta-percha (Maillefer) and AH-26 as a root canal
sealer (Dentsply, De Trey, GmbH, Germany).
A temporary filling (Cavit G, 3M ESPE) was placed
and a postoperative radiograph was taken to assess the
quality of obturation in all canals (Fig. 3). At the
follow-up appointment, the patient was symptom-free
and was sent back to her dentist for restoration.

Discussion

Figure 2 Working length radiograph demonstrated three mesial canals.

Morphological variations in root canal system anatomy
should always be considered at the beginning of treat-
ment. Each case, independently of the type of tooth,
Gates–Glidden and LN burs (Dentsply) were used to should be examined carefully, clinically and radiographi-
prepare a platform at the coronal end of the fragment. cally in order to detect possible anatomical aberrations.
The two-phase removal technique (18) (using hand Once endodontic treatment has been initiated, proper
instruments to bypass the fragment and applying ultra- access cavity preparation is a basic prerequisite for the
sonic device to loosen it) was used. investigation and successful detection of all root canal
After bypassing the fractured instrument, coronal orifices (19). An operating microscope can help the clini-
flaring of the root canal orifices was carried out with GT cian to identify morphological deviations and to under-
Accessories files No. 35 12% taper (Dentsply) in order to stand thoroughly the topographic anatomy of the pulp
enhance access and visualisation. A MM canal orifice, chamber floor and the exact location of canal orifices. It is
equidistant between ML and MB canal orifices, was evident from many studies and clinical practices in endo-
found. Observation of the pulp chamber with the aid of dontics that the use of magnification is considered helpful
an operating microscope under 12.8¥ magnification for the successful completion of endodontic treatment
revealed an additional third canal in the mesial root. (20,21). According to endodontic literature, the MM
An apex locator (Root ZX, Morita, Tokyo, Japan) was canal can be found in 1–15% of the cases (1). In most of
used to verify the working length in all root canals. An the cases, this canal is hidden by a dentinal projection of
operative radiograph was taken to confirm the indepen- the mesial aspect of pulp chamber walls. In all cases
dent presence of the third canal in the mesial root of mandibular molars, this dentinal growth is usually
(Fig. 2). The bypassed fragment was removed by applying located between the two main canals and should be
ultrasonic device. All the canals were shaped with the removed carefully in order to detect the additional canal
basic series of M-two instruments (VDW, Germany) after or canals. Ultrasound technology is a very useful tool for
preparation up to a No. 15 manual K-file under copious the clinician to clean such an area efficiently.

40 © 2009 The Authors

Journal compilation © 2009 Australian Society of Endodontology
F. Faramarzi et al. Endodontic treatment of a molar

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Journal compilation © 2009 Australian Society of Endodontology