Endodontic management of maxillary premolars with three roots: a case series

Background: Three-rooted maxillary premolars represent rare anatomical variations that pose significant diagnostic and clinical challenges in endodontic treatment. Failure to recognize additional roots or canals increases the risk of persistent infection and treatment failure. This case series describes the diagnostic approach and clinical management of maxillary premolars with complex three-rooted anatomy, emphasizing the importance of advanced imaging and magnification in achieving successful treatment outcomes. Case description: Three patients were referred for endodontic evaluation of maxillary premolars with suspected complex anatomy. Clinical examination, pulp testing, and periapical radiographs were supplemented with cone beam computed tomography (CBCT). All three cases exhibited distinct three-rooted morphology, with CBCT scans proving essential for identifying bifurcations, confluence, and previously missed canals. Access cavity modification with ultrasonic tips facilitated straight-line access and detection of additional canals. Chemo-mechanical preparation was performed with 2% sodium hypochlorite and 17% ethylenediaminetetraacetic acid using rotary instruments. Following obturation, postoperative radiographs were taken to verify treatment quality. Conclusion: This case series emphasizes the importance of recognizing anatomical variations in maxillary premolars. It also demonstrates the essential role of CBCT imaging and magnification in the diagnosis and management of complex root canal systems.