A 19-year-old African-American male presented to the Emergency Clinic of the University of Pennsylvania, School of Dental Medicine, with the chief complaint of a toothache in his left maxilla. Due to deep decay in tooth #14 a diagnosis of symptomatic irreversible pulpitis with a normal periapex was made (Fig. 1). The patient’s medical history was non-contributory and an emergency pulpectomy was performed at the first visit. During examination with an operating microscope (JedMed/Kaps, St Louis, MO, USA) the anatomy of the first maxillary left molar was determined as follows: two cana  in the mesiobuccal root, one canal in the distobuccal root and a large palatal canal bifurcating approximately 4 mm from the working length with two separate foramina (Fig. 2). These five cana  were instrumented and medicated with Ca(OH)2. At the third visit all cana  were filled by a modified MicrosealTM technique (Analytic Endodontics, Orange, California, USA) and with zinc-oxide-eugenol cement (Grossman type). The final obturation showed some of the obturation material flowing in an additional canal located between the two bifurcating palatal cana  (Fig. 3). Doubt about the long-term success of the case was raised and it was decided to re-enter the palatal canal to evaluate the possible third apical branch. The gutta-percha was removed from the palatal canal up to the bifurcation level using a System B tip (Analytic Endodontics). This area was carefully inspectioned again under the operating microscope at high magnification (16–25_). This examination of the palatal root revealed the two cana  filled with gutta-percha and between them, in a more buccal position, a third canal orifice. Under the microscope it was possible to insert a size 15 K-file and the existence of a third foramen was confirmed using an electronic apex locator (Root ZX, J. Morita MFG. Corporation, Kyoto, Japan). A new radiograph was taken with a size 20 K-file in place (Fig. 4). The radiograph clearly showed the presence of a third palatal canal. This canal was instrumented and filled using the modified Microseal technique (Analytic Endodontics). A temporary restoration with IRM was placed and a permanent restoration was advised. The postoperative radiograph showed six separate cana  and six separate foramina of the tooth (Fig. 5). Twenty months later the patient was recalled for a follow-up. At the clinical examination the tooth was asymptomatic and the radiographic examination revealed normal periapical tissue (Fig. 6). However, the tooth had not yet been permanently restored at this recall visit and the patient was again instructed to return to his dentist for the restoration.

Figure 1. Preoperative radiograph.



Figure 2. Working length determination of five canals.



Figure 3. Obturation of five canals. Note obturation material flowing between the two bifurcating palatal canals.



Figure 4. Working length determination of the sixth canal.



Figure 5. Postoperative X-ray showing six separate canals with six separate foramina.



Figure 6. A total of 20 months follow-up. The radiograph shows the integrity of the root canal therapy and a normal periapex.