A maxillary first molar has typically three separate roots and in only about 4% of the cases just two roots are found. Two or more merged roots occur in about 5% of all cases. The presence of four roots is extremely rare. In second maxillary molars, merging of roots is much more common. A tooth’s usual number of root canals can also vary, with some types of teeth, or even some specific tooth roots, especially noted for variation. And because discovering and treating all canals is so vitally important for the success of a tooth’s endodontic work, dentists place great emphasis on searching for and identifying them using the.

Periapical Survey

Periapical radiographs give useful information about caries, periodontal condition, periapical pathology, shape of the roots, size of the teeth, position of impacted teeth, and spatial location of teeth not yet erupted. Measurements of the mesial-distal widths of the periapical images of nonerupted premolars and upper canines are essential for the prediction of tooth size in the Hixon-Oldfather and Iowa mixed-dentition space analyses. A periapical survey of a patient in the early mixed dentition is illustrated in Figure 5.1. These radiographs give an accurate image of the roots that serve as a pretreatment baseline for the posttreatment assessment of root resorption. The pretreatment radiographs can also show the presence of root resorption before treatment. A 16-inch-long cone paralleling or right angle technique is recommended for taking the periapical radiograph.

Figure 5.1. Periapical survey of the early mixed dentition. Arrows point to the tooth images measured for the revised Hixon-Oldfather and Iowa tooth size prediction methods.

During treatment, periapical radiographs are used to monitor the position and movement of nonerupted teeth and the growth of the roots of developing teeth. At the end of active treatment, these radiographs can assess the presence and effect of root resorption.

Panoramic Radiograph

The panoramic radiograph gives a complete view of the dentition and supporting bones (White and Pharoah 2004). The stage of development of nonerupted teeth and the dental age of the patient can be determined by rating root development of several teeth. The shape of the condyles of the mandible can be observed, and abnormal or asymmetric shapes of the condyles can be noted and related to patient symptoms. Views of the relationship of nonerupted third molars to second molars and surrounding structures can help shape treatment planning decisions for these teeth.

Several panoramic radiographs illustrate different developmental stages of growth, ankylosis, congenitally missing teeth, and impacted teeth in Figures 5.2 through 5.12. Figure 5.2 shows the erupted primary dentition and all of the developing nonerupted permanent teeth, except for the third molars. The early mixed dentition is shown in Figure 5.3. At this stage of development, the permanent incisors and first molars are erupted. In the late mixed dentition, at least one of the permanent canines or premolars has erupted. Figure 5.4 shows a patient with erupted permanent incisors, canines, first premolars, and first molars. The third molar buds are visible at this stage of development. The permanent teeth of an adult female are shown in Figure 5.5. All the permanent teeth, including the third molars, are in occlusion.

Figure 5.2. Panoramic of the primary dentition.

(Courtesy of Dr. Thomas Southard.)

Figure 5.3. Panoramic of the early mixed dentition.

Figure 5.4. Panoramic of the late mixed dentition.

(Courtesy of Dr. Harold Bigelow.)

Figure 5.5. Panoramic of an adult dentition including third molars.

(Courtesy of Dr. Harold Bigelow.)

Figure 5.6. Panoramic showing ankylosed tooth T and tipping of tooth #30 that have prevented the eruption of tooth #29.

Figure 5.7. Panoramic of a male patient with aberrant second premolars and taurodont molars.

(Courtesy of Dr. Cynthia Christensen.)

Figure 5.8. Panoramic of a patient congenitally missing an upper right second premolar and both lower second premolars. Primary second molars are retained and ankylosed (arrows).

(Courtesy of Dr. Theresa Juhlin.)

Figure 5.9. Panoramic of a patient who lost tooth A prematurely, which allowed the mesial migration of the upper right first molar that impacted the upper right second premolar.

Figure 5.10. Panoramic of a patient who lost tooth K prematurely, which allowed the mesial migration of the lower left first molar that impacted the lower left second premolar.

Figure 5.11. Panoramic of a patient with both maxillary canines impacted on the palatal side of the arch. The upper primary canines are retained.

Figure 5.12. Panoramic of an early mixed dentition with a supernumerary tooth (mesiodens) located between the maxillary central incisors (arrow).

(Courtesy of Dr. Samir Bishara.)

The panoramic radiograph of a patient in the early mixed dentition who had an ankylosed mandibular right primary second molar is shown in Figure 5.6. The ankylosed molar sank below the normal teeth on either side of it, as growth of the alveolar bone took the normal teeth farther vertically. By the time a pediatric dentist saw the patient, the mandibular right permanent first molar had tipped forward over the occlusal surface of the akylosed primary molar. The mandibular right permanent second premolar is impacted beneath the ankylosed primary molar. Figure 5.7 is a panoramic radiograph of an early mixed-dentition patient (male) whose developing second premolars are displaced mesial to his primary second molars. Also, all of his erupted primary and permanent molars are prismatic or taurodont. In taurodont teeth, the pulp chamber is elongated and the distance between the bifurcation of the roots and the cementoenamel junction is greater than normal (Kovacs 1971). Normal distances are 4.8 ± 0.76 mm on the mesial side of permanent first molars. The distances on this panoramic film of the first molars are about 9 mm, not corrected for enlargement. Figure 5.8 shows the panoramic radiograph of a patient who had three congenitally missing second premolars—one maxillary and two mandibular. Arrows point to the retained and ankylosed primary second molars associated with the missing premolars. The panoramic radiograph of a patient in the early mixed dentition who lost prematurely a maxillary right primary second molar is shown in Figure 5.9. After the loss of tooth A, the maxillary right permanent first molar tipped mesially into the space formerly occupied by the lost primary second molar and is now blocking eruption of the maxillary right second premolar.

Figure 5.10 illustrates the premature loss of the mandibular left second primary molar in a late mixed-dentition patient. Loss of the primary molar allowed the mandibular left permanent first molar to tip mesially, causing the impaction of the mandibular left second premolar. An adult patient with both permanent maxillary canines impacted on the palatal side of the arch is illustrated in Figure 5.11. Please note that the primary maxillary canines were still retained in the mouth. Figure 5.12 illustrates a mixed dentition patient with a supernumerary tooth called a mesiodens located between the maxillary central incisors. Note the 90-degree rotation of the maxillary left central incisor and the diastema between the central incisors.

Occlusal Radiographs

Maxillary and mandibular occlusal radiographs provide useful supplemental information on the position of impacted teeth, especially canines and premolars (White and Pharoah 2004). A maxillary occlusal radiograph is taken as a pretreatment baseline view of the midpalatal suture whenever a rapid maxillary expander is used in treatment. The radiograph can be repeated during the expansion of the arch to observe whether the midpalatal suture has opened and how much it opened. Figure 5.13 is an occlusal view of the patient illustrated in Figure 5.11. The canines are far forward on the palate, near the roots of the permanent incisors. Also note the image of a supernumerary tooth in the middle of the palate between the canines. The supernumerary tooth is a mesiodens that is undergoing resorption, a fate common to many of these teeth. Figure 5.14 shows impacted maxillary second premolars in an adolescent patient. The teeth are erupting toward the midline suture of the palate. Figure 5.15 illustrates the opening of the mid palatal suture of an adolescent patient treated with a rapid maxillary expander. Note the V-shaped opening of the maxillary suture and the diastema created by the appliance. The mandibular occlusal radiograph of an orthodontic patient with cleidocranial dysostosis is shown in Figure 5.16. Note the presence of several supernumerary teeth and the severely impacted mandibular left permanent canine. The impacted canine was located on the labial side of the alveolus and was brought into the arch through orthodontic treatment.

Figure 5.13. View of two impacted canines and a resorbing supernumerary tooth located in the midline of the palate (arrow).

Figure 5.14. View of two ectopic maxillary second premolars.

Figure 5.15. View of the midpalatal suture opened by a rapid palatal expander.

Figure 5.16. View of the mandibular arch of a patient with supernumerary teeth and an impacted mandibular left canine (arrow).

Cone Beam Radiographs

Cone beam radiographs are shown of a patient who had ectopic lower second premolars and a maxillary supernumerary tooth. A conventional panoramic radiograph showed the ectopic teeth through their long axes, not showing where the crowns were located and how long the roots had grown. The supernumerary tooth was located in the upper right palate alongside the canine and premolars. Figure 5.17 is a coronal section through the lower second premolars that gives an excellent view of the developing lower right second premolar and the supernumerary in the upper right palate. Figure 5.18 is a sagittal view of the left mandible illustrating the development of the lower left second premolar. Figure 5.19 is a lingual volumetric view of the lower right second premolar. Figure 5.20 is a lingual volumetric view of the lower left second premolar. Figure 5.21 is an excellent lingual volumetric view of the supernumerary tooth.

Figure 5.17. Coronal view (cone beam computed tomography) of lower second premolars and supernumerary tooth.

Figure 5.18. Lateral, lingual (cone beam computed tomography) view of the lower left second premolar.

Diagnostic:

D0120 Periodic exam: Periodic oral examination-established patient

D0140 Limited oral exam: Problem focused

D0150 Comprehensive oral exam: Extensive examination, new or established patient

D0160 Detailed and extensive oral evaluation: Problem focused, by report

D0170 Re-evaluation-limited, problem focused: Established patient, re-evaluation, not a post-op visit

D0171 Re-evaluation-post operative office visit: A recheck after a procedure to evaluate healing

D0460 Pulp vitality tests: Pulp testing

D0470 Diagnostic casts: Impressions and pouring up of plaster casts of teeth / dental arch

D9110 Emergency treatment: Palliative (emergency) pain relief – minor procedure

D9430 Office visit: Case follow-up/observation examination (during regular scheduled hours)

X-Rays:

D0210 Intraoral complete series of radiographic images: X rays of all teeth and the whole mouth

D0220 Intraoral periapical-first image: Detects changes/pathology @ root tip

D0230 Intraoral periapical-additional image(s)

D0270 Bitewing-single image: Detects changes/decay between teeth

D0272 Bitewing-two images

D0273 Bitewings-three images

D0274 Bitewings-four images

D0277 Vertical Bitewings: 7-8 bitewing images taken in the portrait orientation

D0330 Panoramic radiographic image: A 2-dimentional image of the whole mouth and teeth

D0364 Cone beam CT capture and interpretation limited view: Less than one whole jaw

D0365 Cone beam CT capture and interpretation limited view: Full lower jaw (mandible)

D0366 Cone beam CT capture and interpretation limited view: Full upper jaw(maxilla)

5 Roots In Molar Volume

Interpretation and Report by a Practitioner Not Associated with the Capture: (D0380-D0391)

D0380 Cone beam CT interpretation limited view: Less than one whole jaw

D0381 Cone beam CT interpretation limited view: Full lower jaw (mandible)

D0382 Cone beam CT interpretation limited view: Full upper jaw (maxilla)

D0391 Interpretation of a diagnostic image by a practitioner

Tests and Examinations

D0460 Pulp vitality tests: Tests to determine which tooth (or teeth) are normal or diseased/need RCT or EXT

D0476 Special stains for microorganisms: Gram stains to determine the type of bacteria are present

Preventative

D1110 Prophylaxis-adult: Routine teeth cleaning/polish

D1120 Prophylaxis-child: Routine teeth cleaning/polish

D1206 Topical application of fluoride-varnish: A “paint-on” sticky fluoride application

D1208 Topical application of fluoride-excluding varnish: Gel fluoride application via trays

D1351 Sealant application-per tooth: A flowable acrylic that seals pits and fissures on teeth

D1353 Sealant repair-per tooth: Repair of a previous sealant that has worn or has debonded

Non-Surgical Endodontics:

D3120 Pulp cap (indirect): Removal of decay/site medication to heal pulp

D3220 Therapeutic pulpotomy: Emergency pulp chamber tissue removal for toothache relief

D3221 Gross pulpal debridement: Removal of complete pulpal tissue for toothache relief

D3230 Pulpal therapy (resorbable filling) anterior primary teeth: A root canal on a baby front tooth

D3240 Pulpal therapy (resorbable filling) posterior primary teeth: A root canal on a baby back tooth

D3310 Root canal-anterior: Root canal: front tooth

D3320 Root canal-bicuspid: Root canal: middle tooth

D3330 Root canal-molar: Root canal: back tooth

D3331 Treatment of root canal obstruction: Removal of a separated instrument, finding a Ca+ canal

D3332 Incomplete root canal therapy: Inoperable or fractured tooth, root canal procedure not completed

D3333 Internal root repair: Repair of perforation defects

D3346 Retreatment-anterior: To re-do a failing root canal: front tooth

D3347 Retreatment-bicuspid: To re-do a failing root canal: middle tooth

D3348 Retreatment-molar: To re-do a failing root canal: back tooth

D3351 Apexification-initial: To close/complete root tip development: Visit #1

D3552 Apexification-interim: Multiple visits/dressing change: Visit #2+

D3553 Apexification-final: Completion of root apex closure: Final visit

D3351 Calcification/repair: To induce bone growth to seal root surfaces (i.e. perforations, resorption)

D3355 Pulpal regeneration: Procedures to induce regrowth of pulpal tissue in an immature tooth

D3356 Pulpal regeneration-interim visit: Change of medication

D3357 Pulpal regeneration-completion of treatment: Removal of canal medication and filling of the canal

Endodontic Surgery:

D3410 Apicoectomy-anterior: Root tip surgery: front tooth

D3421 Apicoectomy-bicuspid: Root tip surgery: middle tooth

D3425 Apicoectomy-molar: Root tip surgery:back tooth

D3426 Apicoectomy-additional root: Root tip surgery: extra roots

D3428 Bone graft in conjunction with periapical surgery: Placement of biologics to aid in healing

D3429 Bone graft in conjunction with periapical surgery: Each additional tooth in the same site

D3430 Retrograde filling: A surgically placed root-end filling

D3431 Biologic materials to aid in bone and soft tissue healing

D3432 Guided tissue regeneration: Placement of a resorbable barrier to aid in root surgery

D3450 Root amputation: Removal of one root of a tooth

D3470 Intentional reimplantation: Removing/treating/replacing a tooth into its own socket

D3910 Surgical procedure for the isolation of a tooth: Procedures to help attach a rubber dam

D3920 Hemisection: Sectioning/removal of half of two rooted tooth

D4249 Crown lengthening: Procedures to enhance/expose root for restorative enhancement

D0501 Histopathologic Exam: Sampling and microscopic examination of oral disease

D7111 Extraction of a primary tooth: Removal of the remnants of a “baby” tooth

D7140 Extraction of a permanent tooth: Forceps removal of an “adult” tooth

D7210 Extraction of a permanent tooth: Removal of an adult tooth requiring flap, bone removal

D7270 Reimplantation/splint: Replacing/stabilizing a knocked-out tooth

D7272 Tooth transplantation: Extraction and moving/implanting the tooth to a different site in the mouth

D7285 Biopsy-hard tissue: Sampling and microscopic examination of bone or tooth structure

D7286 Biopsy-soft tissue: Sampling and microscopic examination of surgical soft tissue

D7288 Brush biopsy: Sampling of oral soft tissue using a brush for microscopic examination

D7430 Cystectomy (<1.25cm): Removal of a small cyst

D7431 Cystectomy (>1.25cm): Removal of a large cyst

D7510 Incision and drainage: Lancing a swollen area to relieve infection

D7270 Reimplantation/splint: Replacing/stabilizing a knocked-out tooth

Restorative:

D2140 to 61 Amalgam: Placement of a metal, compactable filling, 1 to 4 surfaces.

D2330 to 94 Composite: Placement/bonding of a plastic tooth colored filling, 1 to 4 surfaces

D2920 Re-cement crown: Reglue a single crown to tooth

D2952 Cast gold post/core: A casted single unit post/core to attach a crown to a root

D2954 Prefabricated post/core: A standard post/core to attach a crown to a root

D2955 Post removal: Using ultrasonics and operating microscope to remove a post

D2970 Temporary crown: To make a temporary crown or “cap”

D2980 Crown repair: To repair a crown necessitated by restorative material failure

D3950 Post space preparation: Removal of a root canal filling for a post

D6930 Re-cement bridge: Reglue multiple, attached crowns to teeth

D9120 Sectioning of a fixed bridge: Cutting apart and removing part of a bridge

5 Roots In Molar Mass

Drugs:

D9610 Therapeutic drug: By injection, single administration, one medication

D9612 Therapeutic drugs: By injection, two or more administrations, different medications

Other:

D3960 Internal bleaching initial/subsequent visits: To lighten a single, dark tooth

D3999 Unspecified: Misc., by report

D5410 Adjustment of a complete denture-maxillary (“upper”)

D5411 Adjustment of a complete denture-mandibular (“lower”)

D5421 Adjustment of a partial denture-maxillary (“upper”)

D5422 Adjustment of a partial denture-mandibular (“lower”)

D9910 Desensitizer application: Medication to decrease thermal pain

D9943 Occlusal guard adjustment: Adjustment of a night guard or bruxing splint

D9951 Occlusal adjustment: Selective bite adjustment

5 Roots In Molar Extraction

Many of the listed procedures do not fall under what is considered “mainstream endodontics” as a specialty, but include procedures typically offered in a general practice or other dental specialties like oral surgery, periodontics, prosthodontics, etc. They are listed because of our experience that many of the patients that we treated under moderate to deep sedation/general anesthesia needed the other non-endodontic procedures performed while they were asleep. Completing these procedures in conjunction with the endodontic treatment would enhance the success of the case, help get the patient out of pain, or prevent another problem “waiting to happen” while the patient was under anesthesia just the one time.

5 Roots In Molar Formula

This saves the patient time, money, minimizes risk and promotes a culture of safety.