Managing of three rooted upper first premolars

Fig. 1

Case 1: Due to deep level of buccal furcation and to small diameters , in the first phase of shaping, the buccal canals aren’t scoutable : working lenght is reached after US instrumentation to enlarge mesio-distally the access.

Last rx is 8 years follow.

Fig. 2

Case 2: After coronal lengthening procedures and proper rubber dam isolation , chamber opening is managed to allow a conservative shaping, performed by low conicity and hight flessibility reciprocating files.

Fig. 3

Case 3: The shape of the chamber is extended in depth and also the palatal canal arise from chamber at a deeper level than usual.

Last rx is 3 years follow up.

Fig. 4

Case 4: Due to previous cervical composite restauration, the buccal canals are calcified.

US instrumentation with small active points is necessary to reach the buccal orifices.

Fig. 5

This type of anathomy requests a proper management of chamber opening  widening the buccal aspect to allow better access to each buccal canal. (8-9).

We can have two differet chamber type: three differt canal orifices that leave chamber separately or buccal root that leave the chamber as a single canal and divide into two separate and distinct canals. (9)

• PREOP DIAGNOSIS: it’s hard to detect this type of anatomy but, there are some elements we can detect before treatment such as the point in which radioopacity becomes quickly less evident that can indicate the point of trifurcation. (fig 5)

Fig. 6

Another preop xr element to look forthat may suggest the presence of threerooted premolars is that if the mesial-distal width of the mid-root image appears equal to or grater than the mesial-distal width of the crown image, then the tooth most likely has three roots.(8) (fig.6)

Fig. 7

• CHAMBER OPENING: thre chamber of a threerooted premolar is similar to upper molar chamber reduced in dimension; we requires an access cavity modification into a "T" shape, mesial-distally extending the buccal aspect of the usual outline form. (fig. 7,8)

Another clear sign that identifies this kind of anatomy is a buccal orifice not in line with the cusps like the palatal one.

Fig. 8

• INSTRUMENTATION scouting is crucial to identify the curvatures and to allow shaping to be as much conservative as possible. 

In case of calcification of the coronal third ultrasonic intrumentation is needed.

In some cases the two buccal canals arise from a common narrow channel which originates from the pulp chamber.

This configuration restricts the access to each buccal canal and produces a “s” shaped curvatures; this situation can be rectified by extending a trough apically in depth, over and between the two canals eliminating the coronal curvatures.(8)(fig.11)

Intracanal preparation have to be the more conservative as possible due to the small diameters of the roots, avoiding lateral strip perforations or dentinal cracks.

• CLEANING: cleaning phase need hypoclorite activation to reach all the endodontic space including apical third, because of Irrigant replacement was limited to 1-1.5 mm apical to the needle tip, expecially in small diameters.(10)
•  OBTURATION: obturation technique must be choosen related to anathomy. Vertical warm condensation could be used provided that small heat pluggers passively reach 4-5 mm to the WL. Carrier techniques and single cone technique are effective alternatives
• .POST-ENDO RESTORATION: If a core post build-up is needed is much more preferable to place the post in palatal root avoiding further dentin removal.