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Dental Tribune Middle East & Africa Edition | 1/2017 15 Celtra® Duo Zirconia-Reinforced Lithium Silicate (ZLS) Block Celtra Duo (ZLS) is the one and only material block that provides you with an unsurpassed level of freedom, control, and workflow flexibility, resulting in a final restoration in which to have complete confidence with respect to the clinical, functional, and esthetic outcomes. Restorations made with Celtra Duo (ZLS) possess a chameleon effect, enabling them to blend in with surrounding teeth for a natural vitality and lifelike appearance. For more information, visit celtra-dentsplysirona.com Developed to make a difference CA25-110513_CeltraAds_v5_REV.indd 1 1/17/17 1:52 PM restoration and monitoring. Surgi- cal excision of the periapical lesion is planned only if no signs of healing appearduringthemonitoringphase. Discussion The variability of the root canal sys- temofmaxillarymolarsposesacon- stant challenge for the dentist who wishes to provide successful endo- dontictreatment. The number, form and configura- tion of root canals present in maxil- lary first molars have been thorough investigated in the literature for almost a century. They are the larg- est teeth in volume and of the most complex in root and canal anatomy. The three individual roots of the maxillary first molar form a tripod. Thepalatalrootgenerallyisthelong- er, has the larger diameter and offers theeasiestaccess.Itoftencurvesbuc- cally at the apical one third and can contain one, two or three root canals in various percentages according to studies of apical canal configura- tions and case reports. The distobuc- cal root is conical and may have one or two canals. The mesiobuccal root may contain one, two or three root canals and is the most studied root inthemouth. A number of factors contribute to thevariationfoundinmaxillarymo- lar anatomy studies. Variations may result because of ethnic background, age, gender or the population stud- ied. Of the various comprehensive max- illary first molar ex vivo studies in the dental literature, Baratto Filho et al reported a maxillary first molar with three roots and seven root ca- nals. Recently, Kottoor et al. reported a CBCT guided endodontic manage- ment of a maxillary first molar with seven root canals. Moreover, in an- other more recent case report, Kot- toor et al. reported the endodontic managementofafirstmaxillarymo- larwitheightcanalsystemsbyusing cone beam computed tomography scanning. CBCT scanning is a relatively new diagnostic imaging modality that has been used in endodontics for the effective evaluation of the root canal morphology. Additionally, CBCT imaging aids in the diagnosis of endodontic pathosis, assessing root and alveolar fractures, analysis of resorptive lesions, identification of pathosis of nonendodontic origin, and presurgical assessment before root-end surgery. CBCT images are reconstructed using significantly lower radiation doses compared with alternative conventional com- puted tomography scanning. This is because with CBCT scanning the raw data are acquired in the course of a single sweep of a cone-shaped x-ray source and reciprocal detector around the patient’s head. The effi- cient use of the radiation beam and theeliminationoftheneedforacon- ventional image intensification sys- tem used in conventional computed tomography scanners resulted in a huge reduction in radiation expo- sure making the clinical use more consistentwiththeALARAconcept. Matherne et al. investigated the use of CBCT scanning in identifying root canal systems and compared it with images obtained by using digital radiography. They concluded that CBCT images always resulted in the identification of greater number of rootcanalsystemsthandigitalimag- es. Baratto Filho et al. evaluated the internal morphology of maxillary first molars by ex vivo and clinical assessments using operating micro- scope and CBCT scanning. He con- cludedthatanoperatingmicroscope and CBCT scanning were important for locating and identifying root ca- nals, and CBCT scanning can be used as a good method for initial identifi- cation of maxillary first molar inter- nalmorphology. In the present case, CBCT scanning was used for the pre-surgical evalua- tionofalargeperiapicallesion.Thor- oughevaluationoftheCBCTimaging resulted in the additional detection of the complex root canal anatomy. CBCT axial images revealed the pres- ence of three roots and seven root canals, namely mesiobuccal1 (MB1), mesiobuccal2 (MB2), mesiobuccal3 (MB3), distobuccal1 (DB1), distobuc- cal2 (DB2), mesiopalatal (MP) and disto- palatal (DP). The negotiation and management of all the canals was accomplished with the indis- pensable aid of the dental operating microscope. The role of microscopic magnifica- tion is well documented in the en- dodontic literature. Buhrley et al. had preformed an in vivo study to determine the practitioner’s ability to locate the MB2 canal in maxillary molarsusingtheDOMand/ordental loupes. They concluded that when the maxillary first molars were con- sidered separately, the frequency of MB2 canal detection for the micro- scope,dentalloupes,andnomagnifi- cation groups were 71.1%, 62.5%, and 17.2%,respectively. In the present case, successful nego- tiation of all canals was largely de- pendent on the use of pre-surgical CBCT mapping and microscopic magnification, which allowed for the identification of the seven dis- tinct root canal orifices with ease. Hence, clinicians should familiarize themselves with dental microscopy and new imaging technology, such as CBCT scanning, to get additional anatomic information in endodon- ticpractice. Figure 2a. Pre-operative radiograph 2b. Sagittal slices reveal- ing two canals in the mesiobuccal root 2c. Sagittal slice reveal- ing two palatal canals in a single root 2d & 2e. Panoramic slices revealing the extend of the periapical lesion 2f. Transverse axial slices revealing7root canalorifices(Yellowarrows) Figure 3a. Clinical microscopic view of the pulp floor suggesting themissedcanalorificesaftertheCBCTmapping3b.Microscopic view of the mesiobuccal root canal orifices during Passive Ultra- sonicIrrigationsuggestingtheconvergenceoftheMB1andMB3 canals (No streaming on the MB2 canal suggests a separate ca- nal system) 3c,d & 3e. Microscopic view of the root canal orifices after the completion of the obturation procedures 3f. Postopera- tiveradiographrevealing thecomplicatedroot canalanatomy Dr. Antonis Chaniotis DDS, MDSC is a graduate of the University of Athens Dental School, Greece (1998). In 2003 he completed the three-year postgraduate program in Endodontics at the University ofAthensDentalSchool. Since 2003, he owns a limited to micro- scopicEndodonticsprivatepracticeinAth- ens,Greece. For the last ten years, he served as a clini- cal instructor affiliated with the under- graduate and postgraduate programs at the University of Athens, Athens Dental School,Endodonticdepartment,Greece. In 2012 he was awarded the title of Clinicalfellow teacherat theUniversityof Warwick,WarwickdentistryUK. He lectures extensively nationally and internationally and he has published ar- ticlesinlocalandinternationalJournals. He currently serves as an active member of theHellenicSocietyofEndodontology( ESEfullmembersociety),aboardmember of the Academy of Microscope Enhanced Dentistry(AMED) andacertifiedmember of the European Society of Endodontol- ogy(ESE) ◊Page14 CONE BEAM Dental Tribune Middle East & Africa Edition | 1/201715 CA25-110513_CeltraAds_v5_REV.indd 11/17/171:52 PM