Background: Maxillary First molars are usually three rooted with three to maximum seven canals, making them among the most variable teeth with presence of canals. The occurrence of a four-rooted maxillary molar with addition of palatal root is an extremely rare anatomical variation, reported to be 0.047% of cases in Asian populations. Such variations can complicate diagnosis and endodontic treatment if not identified early and leads to Re Root Canal Treatment.

Cas Presentation: This report describes the endodontic management of a Maxillary First molar with four roots and additional present with palatal root. The patient reported with pain in left upper back tooth region and sensisbility tests with heat and cold showed no response. Initial periapical radiographs suggested unusual root morphology. Angled radiographs confirmed the presence of four roots and access cavity was modified. Endodontic treatment was performed under magnification, with careful biomechanical preparation and obturation of all four root canals.

Discussion: Anatomical variations in maxillary first molars are frequent, with a single palatal root most common, while two palatal roots are rare. Kim et al. found one palatal root with one canal in 150 cases. Christie et al. classified double palatal root molars into three types: Type I with long, divergent palatal roots and “cow horn” buccal roots; Type II with short, parallel roots; and Type III with grouped MB, MP, DP roots and a separate DB root. Baratto Filho et al. added Type IV, with fusion of the accessory palatal root to MB. Careful clinical observation, DOM, and DG16 probe enabled identification of an extra palatal canal without calcification, avoiding CBCT.