Challenges in the endodontic treatment of upper premolars with atypical anatomy: Report of 2 cases

Introduction: Comprehensive knowledge of the internal morphology of teeth is essential for successful endodontic treatment. Maxillary first premolars most commonly present with two roots and two canals (approximately 70% of cases). About 25% of cases, they exhibit a single root with one or two canals, while the presence of three roots and three canals occurs in approximately 4% of cases and is considered an atypical anatomical variation. Objective: To describe the diagnosis and management of maxillary first premolars with atypical root canal anatomy. Case Reports: Case 1: A 25-year-old male patient in good general health presented to the UAS Postgraduate Endodontics Clinic for root canal treatment. The patient was asymptomatic at the time of consultation. Percussion testing was negative, and pulp sensibility testing elicited a response at 7 seconds. Clinical examination revealed interproximal caries. Periapical radiographic evaluation showed a radiolucent lesion in the interproximal area extending close to the pulp chamber. Three roots and three root canals were identified. Case 2: A 42-year-old female patient, also in good general health, attended the same clinic for root canal treatment. She reported no symptoms. Percussion tests were negative, and pulp sensibility testing showed a response at 5 seconds. Clinical examination revealed significant loss of tooth structure. Radiographic assessment demonstrated a radiolucent area adjacent to the pulp chamber and confirmed the presence of three roots and three canals. Diagnosis: Based on clinical and radiographic findings, both cases were diagnosed with asymptomatic irreversible pulpitis. Treatment: Conventional root canal therapy (biopulpectomy) was performed in both cases. Results: Endodontic treatment allowed preservation of the affected teeth in the oral cavity despite their atypical morphology. Conclusions: Unusual root canal morphology in maxillary first premolars presents a clinical challenge. Accurate diagnosis through careful radiographic evaluation, cone-beam computed tomography (CBCT), and magnification is essential for successful management.