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Tratamiento endodóntico de un primer premolar superior con 3 raíces: reporte de un caso clínico

Tratamiento endodóntico de un primer premolar superior con 3 raíces: reporte de un caso clínico

Autora principal: Ana Cristina Reyes Dozal

Vol. XVI; nº 24; 1106

Endodontic treatment of the maxillary first biscuspid with 3 roots: clinical case report

Fecha de recepción: 28/11/2021

Fecha de aceptación: 27/12/2021

Incluido en Revista Electrónica de Volumen XVI. Número 24 – Segunda quincena de Diciembre de 2021 – Página inicial: Vol. XVI; nº 24; 1106


Reyes Dozal Ana Cristina¹, D.D.S. García Zamarrón Diana², D.D.S. Constandse Cortés Denise3, Davila Constandse Yahir Alejandro4

  1. D.S. Student at Universidad Autónoma de Ciudad Juarez. México.
  2. D.S.- Endodontics. Professor at Universidad Autónoma de Ciudad Juárez. México.
  3. D.S.- Endodontics. Professor at Universidad Autónoma de Ciudad Juárez. México.
  4. S. in Biological Sciences- Biomedical Concentration student at the University of Texas at El Paso. Registered Dental Assistant. EEUU.


El conocimiento de la anatomía dentaria y sus variaciones anatómicas son imprescindibles en la práctica odontológica profesional con el objetivo de alcanzar el éxito del tratamiento. Durante la exploración del diente se busca el diagnóstico correcto a la primera intención, sin embargo las variaciones anatómicas llegan a ser muy complejas y el profesional debe estar capacitado para cualquier situación. Dentro de la literatura se describe con baja incidencia la presencia de tres conductos radiculares y tres raíces en un primer premolar superior dentro de las variaciones anatómicas. En el presente artículo se describe un caso clínico de un primer premolar superior con tres conductos radiculares y tres raíces con su respectivo tratamiento de conductos radiculares que fue atendido en la clínica de pregrado de endodoncia en la Universidad Autónoma de Ciudad Juárez.

Palabras clave: anatomía dentaria, variaciones anatómicas, tratamiento de conductos radiculares.


The knowledge of dental anatomy and its anatomical variations are essential in the professional practice of dentistry with the aim of achieving treatment success. During the examination of the tooth, the correct diagnosis is sought as the primary goal, although, the anatomic variations can be very complex and the working professional must be qualified to assess any situation. The literature describes, the presence of three root canals and three roots on the maxillary first bicuspid within the anatomical variations with low prevalence. The present article describes a clinical case of a maxillary first bicuspid with three root canals and three roots and its respective root canal treatment, which was treated at the UACJ (Universidad Autonoma de Ciudad Juarez) endodontic undergraduate clinic.

Keywords: dental anatomy, anatomical variations, root canal treatment.

Los autores de este manuscrito declaran que:

Todos ellos han participado en su elaboración y no tienen conflictos de intereses
La investigación se ha realizado siguiendo las Pautas éticas internacionales para la investigación relacionada con la salud con seres humanos elaboradas por el Consejo de Organizaciones Internacionales de las Ciencias Médicas (CIOMS) en colaboración con la Organización Mundial de la Salud (OMS)
El manuscrito es original y no contiene plagio
El manuscrito no ha sido publicado en ningún medio y no está en proceso de revisión en otra revista.
Han obtenido los permisos necesarios para las imágenes y gráficos utilizados.
Han preservado las identidades de los pacientes.


For the success of endodontic treatments, knowledge of the morphology of the root canal is required. A primary reason for the failure of treatment of root canals is the lack of knowledge about dental anatomy, whether internal or external. The variation of the morphology of the pulp cavity, especially in teeth with multiple roots, is a constant issue for the diagnostic and success of endodontic treatment. The amount of primary canals may also vary within the same type of tooth, therefore creating different configurations at the bottom of the pulp chamber. 1

The maxillary first bicuspids, specifically, show a complex anatomy, with respect to the variation in amount of roots and in internal configuration. Soares and Leonardo (2003) emphasized that the maxillary first bicuspids present a highly varied root canal morphology, in which the presence of three root canals and three roots is found.2 The prevalence is demonstrated by the literature with a variation of 1-5% in the maxillary bicuspids.1

Good quality x-rays are mandatory for the precise recognition of canals, especially when the anatomical details of the root that are not clearly visible or defined, are analyzed. The disappearance or sudden narrowing of root canals must be accounted for during the pre-surgical x-ray examination. If the path of the root canal cannot be traced, straightened, or instantly enlarged, the possibility of an additional canal in the same canal or additional root must be considered.3

The use of studies of digital images is important for handling endodontic issues. They provide better insight on three-dimensional images, which allows for a proper diagnostic. Cone Beam Computerized Tomography (CBCT) also allows the diagnostic of root canal absorptions, fractures, and perforations, among other examples. The high variation and complexity of the root canal system, canal accessories, and multiple foramen as common findings has been demonstrated. In endodontics, radiological interpretation is crucial for the diagnostic and treatment plan. Although, the interpretation of an x-ray image can be limited by the internal dental anatomy and the surrounding structures due to it being a two-dimensional image.4  


A 27 year old female patient without any apparent general pathology went to the endodontics clinic at the Universidad Autonoma de Ciudad Juarez requiring a root canal due to a fractured tooth. As the clinical examination of an intraoral exploration was conducted, the right maxillary first bicuspid showed increased coronal loss while presenting a lingual fracture. A pre-surgical x-ray was taken and the diagnosis gave positive results for the thermal test, and percussion tests. Due to the absence of a periapical lesion, in accordance with the information that was collected, an “Asymptomatic Irreversible Pulpitis” was diagnosed along with the treatment being a pulpectomy (Fig.1).

In order to begin the treatment, a middle superior alveolar (MSA) nerve block was implemented with a lingual reinforcement. The entire procedure was done with full isolation, using a rubber dam and a 2A clamp. Once the pulp chamber was reached, a hemorrhage arose and was controlled by removing the tissue around the crown of the tooth. During the examination, two canals were found, a buccal canal and a lingual canal.

During the first appointment, a hybrid technique was used for the mechanical instrumentation of the coronal and coronal-middle two thirds of each canal with Dentsply type K files, while also using no. 2 and 3 Gates Glidden drills to widen the canals. By using an endo finger gauge, the working length of both canals was documented, and it was noted that the buccal canal had a length of 16.5 mm and the lingual canal had a length of 18.5 mm, using the buccal cuspid as a reference (Fig. 2).  The shaping of the apical third proceeded while constantly irrigating with sodium hypochlorite (NaClO) at 2.5%, in between each file in order to clean and remove the residual layer.  The buccal canal was prepared with files from 10 to 30 and the lingual canal with 10 to 35, in which the 30 and 35 were determined as the last files, in other words as the memory file for each canal. Once the memory file was determined, it was dried with no. 30 and 35 paper points in order to add the calcium hydroxide as an intracanal medication, covering it with a cotton ball and provisit temporal cement.

For the second appointment, the medication was removed, and during the dental exploration, a third canal was observed. Once again, a hybrid technique was used in order to determine a working length of 17.5 mm in length, which categorized it as a mesiobuccal canal (Fig 3). The canal was then instrumented with files of 10 to 30, determining the 30 file as the memory file. The step-back of the canals was conducted while constantly irrigating with NaClO at 2.5%. Subsequently, the canals were dried with paper points and calcium hydroxide was applied as intracanal medication.

For the duration of the third appointment, the calcium hydroxide was removed, an irrigation protocol for the final cleaning of the canal was implemented, a saline solution was used to remove excess calcium hydroxide through irrigation, and drying was done by using paper points. Using a MonoJect syringe, 17% ethylenediaminetetraacetic acid (EDTA) was applied to the canal and once this procedure was done, to remove the EDTA, saline solution was used to irrigate once more. For the final filling of the canals, a lateral compaction technique was applied, using a master cone 30 for the distobuccal and mesiobuccal canals and a master cone 35 for the lingual canal. Sealapex was used to accomplish a three-dimensional seal of the canal with the help of M-F (Medium-Fine) and F-F (Fine-Fine) gutta-percha cones. To finalize the procedure, glass ionomer cement was utilized to rebuild (Fig.4).


There is a low percentage of maxillary first bicuspids with three root canals and three roots, as stated by the cited texts. In a study conducted through the diaphonization of teeth, Vertucci FJ & Geagauff (1979), it was found that 5% of maxillary first bicuspids had three root canals, each with a different root apex.2

Ja Loh (1998) assessed 957 teeth utilizing a visual and digital radiological examination for a publication in Singapore. The study did not display any indication of a case in which the maxillary first bicuspid had three root canals, which could have been caused by the race that was examined.2

In a Turkish study, Kartal, et al., the occurrence of a maxillary first bicuspid with one, two, or three root canals and roots, was compared. According to the authors, 8.66% of the bicuspids had one, 89.64% had two, and 1.66% had three root canals. Going by the amount of roots, 37.31% of maxillary first bicuspids had one, 61.32% had two, and 1.33% had three roots. Due to similar anatomy, maxillary bicuspids with three roots are occasionally considered small molars.3

There are diverse studies about anatomical variations of the maxillary first bicuspid that exist in different countries, and the percentage varies based on the location. Nonetheless, the existence of different internal and external anatomical designs should not be disregarded.


The anatomy of the maxillary first bicuspid root can be unpredictable, therefore, the dental professional in charge must have the necessary knowledge to expect any anatomical variation and, hence, achieve a suitable treatment, avoiding any dental infection, excess wear, or puncturing of the tooth root.

Nowadays, the Cone Beam Computerized Tomography (CBCT) study helps greatly when it comes to the tooth that will undergo treatment, especially when a 2-dimensional image does not provide the correct information about the structure of the tooth root. This study also acts as a complement to x-rays, allowing a high-resolution 3-dimensional image and a proper diagnosis. It is recommended that research is continually done on the topic of variation of dental anatomy, for example for diaphonization, with CBCT, x-rays, clinical revisions, vulcanization, scanning electron microscope, among others; in order to know the prevalence as well as the highly recommended studies for dental practice.


Works Cited

  1. Borges, A.H., Estudio de las variaciones anatómicas de los premolares: reporte de cuatro casos clínicos, Acta Odontologica Venezolana. 12/08/2013. Sitio web:
  1. Fábio Duarte da Costa Aznar, ETAL. TRATAMIENTO ENDODÓNTICO DE UN PRIMER PREMOLAR SUPERIOR CON 3 RAÍCES – RELATO DE CASO CLÍNICO. Acta Odontologica Venezolana. 03/11/2006. Sitio Web:
  2. Zeliha, Ugur. Et. Al. Maxillary first premolars with three root canals: two case reports. Journal of Istanbul University Faculty of Dentistry.Published 2017, Oct 2.
  3. Oviedo Muñoz, Pàmela. Et. Al. Tomografía computarizada Cone Beam en endodoncia. Revista Estomatológica Herediana. Revista Estomatológica Herediana. vol. 22, núm. 1, enero-marzo, 2012, pp. 59. Lima, Perú.