Hindawi

Case Reports in Dentistry

Volume 2020, Article ID 8096539, 6 pages
https://doi.org/10.1155/2020/8096539

Case Report
A Rare Case of Single-Rooted Mandibular Second Molar with
Single Canal

Abdulmohsen Alfadley ,1,2 Ahmad Alquraishi,3 Yaser Almazrou,4 and Fahd Aljarbou5
1
Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, King Saud bin Abdulaziz University for
Health Sciences, Riyadh, Saudi Arabia
2
King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
3
Internship Unit, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard
Health Affairs, Riyadh, Saudi Arabia
4
Presidency of State Security, Department of Medical Services, Riyadh, Saudi Arabia
5
Department of Restorative Dental Sciences, Division of Endodontics, College of Dentistry, King Saud University,
Riyadh, Saudi Arabia

Correspondence should be addressed to Abdulmohsen Alfadley; [email protected]

Received 4 January 2020; Revised 22 April 2020; Accepted 12 May 2020; Published 16 June 2020

Academic Editor: Gavriel Chaushu

Copyright © 2020 Abdulmohsen Alfadley et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

The root canal anatomy of mandibular second molar teeth is known to be highly variable. Whilst the most frequently seen
configuration is two mesial canals and one distal canal, other variations such as four canals, two canals, and C-shaped canal
system do also exist. This case report describes the diagnosis and management of unusual root canal configuration of a
mandibular second molar, with one canal in a single conical root, using the contemporary advancements in endodontics.
Following clinical and radiographic examinations of the case, a diagnosis of symptomatic irreversible pulpitis with symptomatic
apical periodontitis of tooth #47 was established, and root canal treatment followed by composite buildup and crown were
planned. Clinicians should be aware of the different anatomic variants each tooth may exhibit. Furthermore, clinicians need to
possess the proper knowledge and skills that allow them to utilize the diagnostic and therapeutic tools available at their disposal
in order to optimize the quality of care provided to their patients.

1. Introduction to overlook part of this anatomy during the debridement

phase [6] resulting in the emergence or persistence of
The principal objective of endodontic treatment is to prevent endodontic disease [7].
and, when needed, to treat endodontic disease, apical peri- The root canal morphology of mandibular second molars
odontitis [1]. In order to accomplish this objective, high- has been elegantly evaluated in landmark studies by Vertucci
quality chemomechanical cleaning and shaping of the intri- and Weine et al. using clearing and radiographic techniques,
cate root canal system are required in order to eradicate respectively [8, 9]. Similar to the mandibular first molar, this
intracanal microorganisms [2, 3]. This task requires elaborate tooth most commonly has two roots; mesial and distal, with
knowledge of pulp space anatomy, including expected and two mesial canals (mesiobuccal and mesiolingual) and one
less usual canal morphology. Variations such as additional distal canal [8–10]. Nevertheless, other configurations have
canals, bi/trifurcations, lateral and furcal canals, apical deltas, been reported in mandibular second molar teeth such as four
and canal ramifications are frequently encountered during canals, two canals, C-shaped canal, taurodontism, and one
root canal treatment, and their incidence and clinical signif- canal in a single root [8–12]. Previously published articles
icance have been reported before [4, 5]. Due to the complex agree on the rare occurrence of one canal in a single-rooted
and highly variable pulp space anatomy, it is not uncommon (Vertucci Type I) mandibular second molars. For instance,
2 Case Reports in Dentistry

Figure 1: Panoramic radiograph of presenting patient confirms the lack of symmetry between single-rooted tooth #47 and contralateral tooth
#37 which presents with two distinct roots.

Weine et al. reported that only 1.3% of mandibular second occluso-mesial caries. On application of the cold test to the
molars had a single canal configuration all the way from an tooth, the patient responded with severe prolonged pain
orifice to an apex [9]. In line with that, Demirbuga et al. used compared to adjacent teeth. Tooth #47 was tender to percus-
advanced imaging technique and found the prevalence of sion but responded normally to palpation and bite tests. Peri-
such anatomic variant to be close to 2% [13]. Such high var- odontal probing generally ranged from 2 to 3 mm, without
iability in the root canal anatomy of this tooth emphasizes any increase in tooth mobility. The health of the surrounding
the importance of properly integrating theoretical knowledge mucogingival tissues was within normal limits. Radiographic
of dental morphology with the information obtained from assessment commenced by systematic evaluation of the
pretreatment radiographs. Furthermore, additional explora- already available panoramic radiograph (Figure 1). The
tion of internal anatomy should be made during treatment obtained preoperative periapical radiographs (Figures 2(a)
in order to avoid the possibility of untreated canal system. and 2(b)) demonstrated the presence of one large canal along
Several of the recent advances in endodontics have contrib- with one conical root and slight widening of the periodontal
uted to safe, predictable, and efficient root canal treatment. ligament space around the apex of tooth #47. A diagnosis of
Such developments include digital radiography, cone beam symptomatic irreversible pulpitis with symptomatic apical
computed tomography (CBCT), microcomputed tomogra- periodontitis of tooth #47 was established, and root canal
phy (micro-CT), dental operating microscope (DOM), ther- treatment followed by composite buildup and crown were
momechanically treated nickel-titanium files, and improved planned. Prior to treatment, CBCT (Planmeca Promax,
obturation devices [14–17]. The aim of this case report was Planmeca, Finland) was obtained in order to enable three-
to describe the diagnosis and management of rare root canal dimensional assessment of pulp space morphology. Further
configuration of a mandibular second molar, showing one evaluation of sagittal, coronal, and axial slices confirmed
canal in a single conical root, using the contemporary the presence of one large round-oval canal extending from
advancements in endodontics. the orifice level to the root apex without any evidence of
additional canals (Figures 2(a)–2(g)).
2. Case Report Local anesthesia was administered through inferior
alveolar nerve block using one carpule (1.8 ml) of 2% lido-
A 25-year-old Saudi Arabian man presented to the dental caine with 1 : 100,000 of epinephrine (Lidocaine HCl, Huons
clinic with a chief complaint of “severe pain to cold water” Co., Seoul, Korea). Another carpule was added for buccal and
in the lower right side of the jaw. The history revealed that lingual infiltrations. Following rubber dam isolation, caries
pain started about three weeks ago and has increased in excavation and access cavity preparation were accomplished
intensity over the past five days with occasional spontaneous using size 6 long shank round bur in a high-speed handpiece.
symptoms. The patient had several dental treatments done in Then, pulp extirpation was performed using barbed broach.
the past such as periodontal scaling, restorations, root canal The dental operating microscope (OPMI Pico, Carl Zeiss
treatment, and extractions, without any complications. The Surgical, Oberkochen, Germany) showed the presence of a
patient denied having any relevant medical condition such large round canal orifice located in the center of the pulp
as chronic illness, use of medication, allergy, or previous chamber floor (Figure 3(a)). Following irrigation with
hospitalization. 5.25% NaOCl, shaping of the coronal two-thirds of the canal
Upon extraoral examination, no significant findings were was performed using ProTaper Gold rotary files (Dentsply
noted. Intraoral examination showed tooth #47 with deep Maillefer) in the following sequence: SX, S1, and S2. Working
Case Reports in Dentistry 3

(a) (b)

(c) (d)

(e) (f) (g)

Figure 2: Preoperative radiographic assessment. (a) Straight-on and (b) angulated initial radiographs showing tooth #47 with deep occluso-
mesial caries along with large pulp space situated within a single conical root. (c, d) Sagittal and coronal CBCT slices suggest the presence of
one root canal configuration. (e–g) Further evaluation of the axial cuts in the coronal, middle, and apical thirds confirms the presence of
Vertucci Type I canal system.

length (WL) was determined using a size 20 K file attached to cialties, Tulsa, OK) in the following sequence: 25/0.06,
an electronic apex locator and then confirmed using a digital 30/0.06, 35/0.06, and 40/0.06. During the shaping procedure,
radiograph (Figure 3(b)). After that, size 10 and 15 K files EDTA gel (Glyde File Prep; Dentsply Maillefer, Ballaigues,
were precurved and placed against the canal walls to further Switzerland) was utilized as lubricant, and 5.25% NaOCl
explore the internal anatomy. Root canal shaping was then solution was used to irrigate the canal. Recapitulation and
completed using hybrid instrumentation technique. Canal verification of canal patency were frequently performed dur-
shaping to WL was first accomplished using S1 and S2 ing the procedure. Final irrigation was performed using 17%
instruments. After that, apical enlargement was performed EDTA (Meta Biomed Co. Ltd., Mandaluyong, Korea), after
using Vortex Blue rotary files (Dentsply Tulsa Dental Spe- which the canal was dried using sterile absorbent paper
4 Case Reports in Dentistry

(a) (b)

(c) (d)

Figure 3: (a) Accessed cavity preparation shows the presence of one large root canal located in the center of the pulp chamber. (b) Working
length determination radiograph. (c) Master gutta-percha cone radiograph. (d) Final radiograph showing dense obturation with sealer puffs.

points. The snug fit of a size 40, taper 0.06 master gutta- only a single large canal or two root canals that may or may
percha cone was evaluated radiographically (Figure 3(c)). not join within the canal system or a C-shaped canal config-
The canal was then obturated with gutta-percha cone and uration [18]. However, systematic evaluation of CBCT slices
AH26 sealer (Dentsply Maillefer) using a hybrid technique revealed the presence of one large round canal. This observa-
combing cold lateral and warm vertical compaction tech- tion was confirmed upon access cavity preparation as careful
niques (Figure 3(d)). The pulp chamber was then cleaned inspection of the pulpal floor with the dental operating
using alcohol-moistened cotton pellet, after which the access microscope demonstrated the presence of one round orifice.
cavity was temporized with Cavit. After one week, the Cone beam computed tomography (CBCT) is a reliable
patient reported complete resolution of the symptoms. The and noninvasive approach that is often used in the diagnosis
tooth was restored using post-retained composite buildup and treatment plan of endodontic cases. The American Asso-
and then referred for the fabrication of a full coverage resto- ciation of Endodontists and American Academy of Oral and
ration. The patient gave his informed consent for the publi- Maxillofacial Radiology published a joint position statement
cation of this case. related to the use of CBCT [19]. The need for CBCT should
be considered if the evaluation of differently angled periapical
3. Discussion radiographs fails to provide conclusive information or if
additional information in the buccolingual dimension is
This case report describes the endodontic management of a required. In cases deemed appropriate for the acquisition of
mandibular second molar tooth with a single root canal aided CBCT scan, a narrow field of view which is associated with
by the contemporary advancements in the field. Assessment reduced radiation dose and higher spatial resolution is
of preoperative periapical radiographs demonstrated the recommended [19]. The statement states that CBCT should
presence of one root with a large canal space suggesting the only be used as an adjunctive tool in certain situations such
likelihood of C-shaped canal configuration. In fact, when as assessment of teeth with complex or unusual root canal
only one root is present, the root canal system may contain anatomy, identification of calcified canals, evaluation of the
Case Reports in Dentistry 5

outcome of endodontic treatment, and planning of surgical of a similar anatomic configuration on the contralateral
retreatment. Other indications for CBCT acquisition include tooth when examining the preoperative radiograph of a
the diagnosis and management of dentoalveolar trauma, particular case. In our case, however, careful inspection of
resorptive defects, and dental implants [14, 19, 20]. a magnified panoramic radiograph has clearly shown the
Previous studies on the root canal anatomy of mandibu- presence of a two-rooted mandibular second molar on the
lar second molars confirm the rarity of our reported case. contralateral side.
For instance, such observation was not documented in pre-
vious studies among American [8], Turkish [21], Thai [22], 4. Conclusion
Malaysian [23], and even Saudi Arabian populations [24].
Furthermore, Weine et al., Demirbuga et al., and Gulabivala This case report presented the endodontic management of
et al. reported a low prevalence rate of 1.3%, 2.1%, and 2.2% unusual root canal configuration of a mandibular second
among American, Turkish, and Burmese populations, molar, a single root canal from an orifice to an apex, aided
respectively [9, 13, 25]. Rahimi et al. evaluated root canal by the contemporary digital advancements in endodontics.
configuration of mandibular second molars among Iranian This report highlighted the importance of textbook knowl-
subpopulations using a clearing technique. In their study, edge, radiographic examination, and careful intraoperative
only 6 out of the 139 teeth (4.3%) demonstrated the presence exploration as the main cornerstones in investigating pulp
of the Vertucci Type I configuration discussed in this case space anatomy. Clinicians need to employ the diagnostic
report [26]. Interestingly, Fava et al. published a case report and therapeutic tools available at their disposal in order to
documenting the presence of one root and one root canal in optimize the quality of care provided to their patients. Fur-
all maxillary and mandibular second molar teeth of the same thermore, clinicians should be aware of the various root canal
patient [11]. The information obtained from the different configurations of each tooth, as it may impact subsequent
studies on root canal anatomy of teeth has important clinical treatment procedures as well as the long-term outcome of
implications. Whilst some of the endodontic procedural the case.
errors are encountered during the search for missing or
additional root canals, such mistakes can be minimized if Conflicts of Interest
the clinician has an awareness of the expected location and
dimensions of the pulp chamber as well as an understanding The authors declare that they have no conflicts of interest.
of the usual and less frequent root canal configurations.
Although additional canals are more common, the clinician
should also be aware that in certain situations; there is a
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