Dealing with extra canal in lower first molar

Fig. 1

A 30-year-old patient presented with spontaneous pain associated with the mandibular right first molar. Clinical and radiographic examination revealed deep distal and mesial caries approaching the pulp and pain with percussion.

Pulpal diagnosis: Symptomatic irreversible pulpitis with  Symptomatic apical periodontitis. 

Fig. 2

Complete isolation of the tooth using a rubber dam to ensure a sterile and dry operating field, which is critical for preventing microbial contamination during root canal treatment.

Pre-wedging is a simple but highly effective step in Class II caries management. This improves isolation, prevents iatrogenic damage to the adjacent proximal surface, and allows a more accurate proximal box shape. When the matrix system is later applied, this slight separation ensures a tighter final contact and reduces post-operative finishing. 

The removal of carious and all infected, soft dentin led to a wide carious exposure of the pulp tissue. Note the inflammatory tissue appearance and initial hemorrhagic response upon entry into the pulp chamber.

Fig. 3

Clinical and radiographic views of a mandibular first molar demonstrating an uncommon distal root configuration. Under dental operating microscope magnification, careful troughing along the developmental groove revealed three distinct canal orifices merging into a single apical foramen (3–1 configuration), consistent with Gulabivala’s classification. The access cavity was refined to achieve straight-line entry to all canals. 

Exploration was performed using a #10 K-files.

Ultrasonic tips were employed to conservatively expose the canal entrances under high magnification (×8–×16).

Canal negotiation and working length determination were confirmed with an apex locator and radiographs. 

Cleaning and shaping were accomplished using NiTi rotary instruments to 30.04# with 2.5–5.25% NaOCl irrigation

Fig. 4

Master cones were selected, fitted precisely to working length, and verified radiographically to confirm proper adaptation. Obturation was carried out using the warm vertical compaction technique with a bioceramic sealer, ensuring complete three-dimensional sealing of the complex canal system.

The postoperative radiograph demonstrates dense, homogeneous obturation with no voids, confirming adequate filling of all merged distal canals and the mesial root canal system.

Fig. 5

Final Restoration Protocol: After confirming the root canal seal, the internal access cavity was micro-roughened and debrided using air-abrasion with 29-micron Aluminum Oxide particles (Aquacare system). This surface treatment ensures optimal micromechanical retention and enhanced resin-dentin bond strength. The direct final restoration was built using an incremental layering technique: a fiber-reinforced composite (ever-X Posterior) was placed as a bulk dentin replacement, capped with a conventional packable composite to restore the anatomical contours and occlusal function.

Fig. 6

Ahmed Eslam Khaled

Co founder of shiny dental clinic ,Egypt

Fellow at styloitaliano endodontics

Dentist at Benha University