Fig. 1

A female patient, 40 years old with no concomitant diseases, was referred for endodontic treatment of tooth 24; the referring doctor had problems with proper diagnosis of anatomy, finding, and instrumentation of root canals. The referring doctor included an X-ray photo where the outline of the extra root can be seen. Clinical diagnosis: irreversible symptomatic pulpitis tooth 24. On extra-oral examination, no abnormalities, lymph nodes not palpable and not painful, skin coat without changes. On intra-oral examination, tooth 24 with IRM temporary filling on the chewing surface. Percussion,,-,, palpation,,-,, no pockets, no mobility. My attention was also drawn to the not typical structure of the crown of the tooth, which was flattened in the mesiodistal direction, which could also indicate the presence of an additional root.

Fig. 2

CBCT examination 5cmx5cmx5cm cross-section showed the presence of an additional buccal root which may have contributed to the referring dentist's therapeutic difficulties. The peri apical tissues were unchanged, and no perforation or transport of anatomical orifices was found. Interestingly, the adjacent tooth 25 had an atypical C-type anatomy in the buccal root, which is extremely rare. The patient was informed of the clinical situation, possible complications, and prognosis.

Fig. 3

CBCT examination 5cmx5cmx5cm (Carestream 8200) front section showed the presence of an additional buccal root.

Fig. 4

After a previous thorough CBCT analysis, minimally invasive instrumentation of MB and DB canals by crown down to ISO 25.06/30.02 and palatal canal to ISO 30.06  was performed. Performed disinfection of the endodontic space with 5.25% sodium hypochlorite solution and 40% citric acid solution. The liquids were activated with PUI. An intra-oral radiograph was taken in an oblique projection with gutta-percha points. The radiograph confirmed proper canal preparation. Due to minimally invasive access and canal preparation, it was not possible to insert gutta-percha points into all canals at the same time, so two extra radiographs were taken, one with gutta-percha points in the buccal canals and another one in the palatal canal.

Fig. 5

An intra oral radiograph was taken in an oblique projection with gutta-percha point in palatal root canal.

Fig. 6

The appearance of the pulp chamber after the phases of shaping and cleaning.

Fig. 7

Obturation was performed using the vertical compaction method using AH+ epoxy sealer and calibrated gutta-percha cones; calibration was performed with a calibration ruler. After obturation, an intra-oral radiograph was taken in oblique projection - the canals were filled correctly. 

Fig. 8

About the author:

Mariya Kubatska graduated medical university of Gdansk in 2014. Since graduation highly interested in Endodontics. Member of the European Society of Endodontology, the American Association of Endodontists, member of Polish Endodontic Association, and the Department of Endodontology of the Polish Dental Society. Since 2023 Style Italiano Endodontics fellow. International speaker. Lecturer in Esdent Dental Training Company. Author of case reports in Polish dental magazines. Since 2018 Mariya has worked in Oslo, Norway, focusing on endodontics. In private life piano lover. 


In conclusion, the presence of three-rooted premolars, also known as "miniature molars," is a rare anatomical variation that poses challenges for endodontists. The prevalence of this variation varies across different populations and countries, with some regions showing higher occurrences than others. The morphological variations of three-rooted premolars, categorised into two types based on the arrangement of buccal and palatal roots, add to the complexity of their treatment.

Diagnosing three-rooted premolars can be intricate, often requiring advanced imaging techniques such as CBCT to analyse root canal anatomy. Access preparation is a critical step, necessitating a modified approach for these unique cases. Instrumentation becomes particularly challenging due to potential curvatures and delicate root structures, with the risk of complications like strip perforation due to thin dentin areas. Caution must be exercised during instrumentation, especially for buccal canals, to avoid over-instrumentation of danger zones. A conservative and minimally invasive approach is recommended, involving instruments with a small or regressed taper to mitigate risks.

In the realm of endodontic treatment, addressing three-rooted premolars demands precision, skill, and a comprehensive understanding of their intricate anatomy.


Root and Root Canal Morphology of Maxillary First Premolars: A Literature Review and Clinical Considerations. Ibrahim Ali Ahmad, BDS, MSc, JBE,* and Mohammad Ahmad Alenezi, BDS, MFDRCSI, MScD.

An Ex Vivo Study of Root Canal System Configuration and Morphology of 115 Maxillary First Premolars. Thomas Gerhard Wolf, DDS,*† Christoph Kozaczek, DDS,* Mark SiegristLT,‡
Madlena Betthasuser, DDS,x Frank Paque, DDS,k and Benjamín Brisen~o-Marroquín, DDS, MDS, Dr med dent*†

Clinically Relevant Dimensions of 3-rooted Maxillary Premolars Obtained Via High-resolution Computed Tomograph. Rafael Chies Hartmann, DDS,* Flavia E.R. Baldasso, DDS,* Carolina P. Stu€rmer, DDS,* Monique Dossena Acauan, DDS,* Roberta Kochenborger Scarparo, DDS, MS, PhD,* Renata Dornelles Morgental, DDS, MS, PhD,* Susan Bryant, MS,†
Paul M. Dummer, DDS, MS, PhD,† Jose Antonio Poli de Figueiredo, DDS, MS, PhD,* and Fabiana Vieira Vier-Pelisser, DDS, MS, PhD*

An Ex Vivo Study of Root Canal System Configuration and Morphology of 115 Maxillary First Premolars.Thomas Gerhard Wolf, DDS,*† Christoph Kozaczek, DDS,* Mark Siegrist, LT,‡Madlena Bettha€user, DDS,x Frank Paque, DDS,k and Benjamín Brisen~o-Marroquín, DDS, MDS, Dr med dent*†

Identification and endodontic management of three canaled maxillary premolars. Steven M.Sieraski, DDS, MS,Gary.N Taylor, DDS, MS, and Richard A.Kohn, DDS, MS