Treatment considerations of the middle mesial canal

of mandibular first and second molars

Howard H. Pomeranz, DDS, D a v i d L. Eidelman, DDS, and Mitchell G. Goldberg, DDS

T h e o c c u r r e n c e , i n s t r u m e n t a t i o n , a n d o b t u r a t i o n of t h e i s t h m u s
b e t w e e n t h e m e s i o b u c c a l a n d m e s i o l i n g u a l c a n a l s in m a n d i b u l a r first
a n d s e c o n d m o l a r s w e r e s t u d i e d in a h u n d r e d s u c h m o l a r s t h a t w e r e
c o n s e c u t i v e l y t r e a t e d in p r i v a t e practice. O f t h e o n e h u n d r e d cases,
t w e l v e s e p a r a t e m i d d l e m e s i a l canals w e r e i d e n t i f i e d a n d treated.
T h e m o r p h o l o g y of t h e s e m i d d l e m e s i a l c a n a l s w a s as follows: e i g h t
fins, t w o c o n f l u e n t canals, a n d t w o i n d e p e n d e n t canals. T h e s u r g i c a l
c o n s i d e r a t i o n s t h a t a r e n e c e s s a r y for t h e e x p o s u r e a n d r e t r o g r a d e
o b t u r a t i o n of t h e s e cases a r e also d e s c r i b e d .

The root canal space between the
mesial canals in mandibular first and
second molars has been shown to con-
tain tissue in varying amounts. Hess ~
has stated that, "in the mesial root
when the growth of the root is not
completed, there is only a single large
canal that is strongly compressed at its
middle. When first formed, the two
broad walls of the mesial root along
the center are so near to each other
that, by the deposit of new layers of
dentin, the middle part of the canal
becomes, with few exceptions, blocked
and impassable. Transverse sections of
the roots of older teeth frequently
show traces of a fine microscopic fis-
sure connecting the two canals; a com-
plete separation is quite rare and only
happens when an external division of
the root is present." Skidmore and
Bjorndal z and Hess ~ duplicated the
canal space of extracted teeth with
models to show transverse anastomoses
at all levels between the two mesial
canals in the mandibular molar root.
Barker and others 3 and Vertucci and that may be present.
Williams 4 used injections of dye into Currently, no investigation of
the canal space of extracted mandibu- instrumentation either clinically or on
lar molars to detect the presence of extracted teeth has been reported that
these interconnections and, in addi- describes whether the middle ~esial
tion, to demonstrate the presence of canal can be debrided by using routine
extra canals. biomechanical preparation. E1-Aziz
Root canal debridement has been and others ~3traced the mesial canals of
described as the most important phase 112 extracted mandibular first molars
of endodontic therapy? ,6 The endodon- with a smooth broach and found only
tic literature is replete with microscop- two mesial canals in all instances.
ic evidence of our inability to perform
this task thoroughly. 7~z Postdebride- Fig 1--During lateral condensation, mid-
ment examination of prepared root dle mesial canal apically joins mesiobuc-
canal walls has shown sections of cal canal.
smeared and packed necrotic debris,
irrigant crystals, and bacteria. Many
irregularities of the canal walls, such
as fins and irregular depressions, have
been reported to exist after completion
of instrumentation. It is axiomatic that
if a specific section of a canal or a
completely separate canal exists, an
attempt should be made at biomechan-
ical debridement to reduce the amount
of residual necrotic tissue and bacteria

565

Coffae and Brilliant 14 microscopically
examined the effect of serial versus
nonserial preparation of the mesial
canals in extracted mandibular mo-
lars, and found that tissue removal in
the isthmus between the two mesial
canals was not significantly affected by
the type of instrumentation used. No
specific attempt was made to instru-
ment the isthmus itself. The mesiobuc-
cal and mesiolingual canals, however,
were significantly cleaner after serial
preparation.
The current study was undertaken
to describe the occurrence, debride-
ment, and obturation of middle mesial
canals in lower first and second molars
as observed during clinical treatment.
Definitions of terms
The middle mesial canal was clas-
sified as a fin when at any stage during
debridement, the instrument could
pass freely between the mesiobuccal or
mesiolingual canal and the middle
mesial canal.
T h e middle mesial canal was clas-
sified as confluent when the prepared
canal originated as a separate orifice
but apically joined the mesiobuccal or
mesiolingual canal (Fig 1-3).
Fig 2--Post space was prepared in mid-
dle mesial canal, which joined mesiolin-
gual canal.
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JOURNAL OF ENDODONTICS I VOL 7, NO 12, DECEMBER 1981
The middle mesial canal was clas-
sified as independent when the pre-
pared canal originated as a separate
orifice and terminated as a separate
foramen (Fig 4). A broad single mesial
canal in which three master cones
could be cemented to the apex at the
same time was also included as an
independent middle mesial canal
(Fig 5).
MATERIALS AND
METHODS
One hundred first and second man-
dibular molars that were consecutively
treated in a private endodontic practice
formed the material for this investiga-
tion. After complete serial preparation
of the mesiobuccal and mesiolingual
canals, the isthmus separating these
canals was probed for an orifice of a
middle mesial canal. If a lip of dentin
covered this area, it was removed with
a long shank bur revolving at low
speed. However, apical drilling to
expose or enlarge a possible orifice in
this area was not done. If an endodon-
tic explorer did not reveal a catch or a
possible orifice of a canal, further
exploration for a middle mesial canal
was discontinued. If a catch or possible
Fig 3--Middle mesial canal joins rnesio-
lingual canal. Post space was prepared in
mesiolingual canal.
orifice was found, a no. 8 reamer was
inserted to negotiate the canal. The
instrument was used with a pumping
motion to enhance apical movement.
Enlargement of the middle mesial
canal when it was present was gener-
ally more limited than for either the
mesiobuccal or mesiolingual canal.
This procedure was followed to avoid
lateral perforation because the middle
mesial canal is found in the narrowest
portion mesiodistally of this root. I
RESULTS
The 100 consecutively treated man-
dibular molars were composed of 61
first molars and 39 second molars. A
middle mesial canal was identified and
instrumented in 12 cases (including
seven first molars and five second
molars). These results are summarized
in the Table. During instrumentation
two mesiobuccal fins and six mesiolin-
gual fins were identified. Two of the
middle mesial canals were confluent.
One of these canals joined the mesio-
buccal canal and the other joined the
mesiolingual canal. One independent
canal (in a first molar) originated in a
separate orifice and terminated in a
separate apical foramen. The other
~g 4 Three independent mesial canals.
 JOURNAL OF ENDODONTICS I VOL 7, NO 12, DECEMBER 1981

independent canal began as the middle

portion of a single wide mesial canal
and terminated in the middle portion Table 9 Results of a clinical study i n v o l v i n g 100 c o n s e c u t i v e l y treated first and
of a wide apex in a second molar of a second molars s h o w i n g the incidence of the m i d d l e mesial canal.
15 year old. Seven of the 12 patients No. of Confluent Independent
were younger than 21 years of age, one Tooth teeth Fins canals canals
was 36 years old, two were in their First molars 61 5 1 1
forties, one in her fifties, and one in his Second molars 39 3 1 1
sixties.

DISCUSSION

Of the 100 molars examined, 61%
were first molars. Seven of the 12
(58.3%) middle mesial canals treated
were in first molars. These data tend
to support Hess's claim that variation
in anatomical form is just as great in
second molars as in first molarsJ
(Barker and others, 3 however, found
more anatomical variation in the first
molar than in the second molar). The
age distribution with seven of the 12
middle mesial canals occurring in
patients younger than 21 years old also
supports Hess's t claim that in early
root development the isthmus is more
open and negotiable.
Only two instances were found in
the literature that reported the pres-
ence of an independent middle mesial
canal with a separate orifice and a
separate apical foramen. Vertucci and
Williams 4 found one in 100 extracted
first molars. Barker and others 3
reported the incidence in hundreds of
specimens to be uncommon and gave
an example of only one case.
T h e closest correlation to the trans-
verse cervical anastomoses discussed
by Skidmore and Bjorndal 2 and Ver-
tucci and Williams 4 would be the fins
encountered in this study. The trans-
verse whole anastomoses described by
Skidmore and Bjorndal 2 may correlate
with the broad independent middle
mesial canal found in this study.
More mesiolingual fins were
encountered in this study than mesio-
buccal fins. Although there is no
obvious reason for such a difference, it
may be related to Grossman's 6 conclu-
sion that mesiolingual canals perhaps
tend to be slightly larger than mesio-
buccal canals.
The surgical implication of the clin-
ical findings reported here and those
reported by other laboratories are most
important. When apical surgery is
performed on the mesial root of a
mandibular molar, the apex should be
resected at a 45 ~ angle to enable the
operator to prepare and obturate the
canals. A small preparation of ade-
quate depth and circumference should
be made in each mesial apex. The two
preparations should then be connected
using a small bur such as a no. 1/2
round or a no. 556 tapered fissured
bur in a straight handpiece at low
speed, provided the mesiodistal thick-
ness of the root is sufficient. T h e
connecting preparation should be
made with satisfactory depth to allow
for retention of the filling and should

Fig 5 Broad single-canaled mesial root

into which three independent master Fig 6--Left and right, oblong retrograde amalgam filling at mesial apex of mandibular
cones ~ere cemented during lateral con- molar sealing mesiobuceal, mesiolingual, and middle mesial canals and transverse mid-
densation. dle and apical anastomoses.

567

be widened adequately to accommo-
date the condensing instrument. The
amalgam filling subsequently placed
will seal the mesiobuccal, mesiolin-
gual, and other anatomic variations
that commonly occur in the root (Fig
6). In general support of this concept
W e i n e ~ suggests " t w o r o u n d b u t
t o u c h i n g p r e p a r a t i o n s " in t h e s h a p e of
a figure-eight. T a n z i l l i a n d others, ~s
u s i n g a s c a n n i n g electron microscope,
have shown that retrograde amalgam
seals a r e defective. T h e r e f o r e , it is
m o s t i m p o r t a n t , w h e n e v e r possible, to
d e b r i d e a n d o b t u r a t e the m i d d l e m e s i a l
c a n a l to reduce the n e e d for apical
s u r g e r y or to e n h a n c e t h e r e t r o g r a d e
amalgam seal if apical surgery is
necessary.
SUMMARY
A clinical s t u d y was c o n d u c t e d to
i n v e s t i g a t e the occurrence, i n s t r u m e n -
t a t i o n , a n d o b t u r a t i o n of t h e m i d d l e
m e s i a l c a n a l in m a n d i b u l a r first a n d
second molars. M a t e r i a l for t h e s t u d y
w a s o b t a i n e d f r o m 100 s u c h m o l a r s
t h a t w e r e consecutively t r e a t e d in p r i -
vate practice. T w e l v e m i d d l e m e s i a l
orifices w e r e identified, w h i c h gave
rise to e i g h t fins, two c o n f l u e n t canals,
a n d t w o i n d e p e n d e n t canals. I n per-
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JOURNAL OF ENDODONTICS I VOL 7, N O 12, DECEMBER 1981
f o r m i n g a p i c a l s u r g e r y in this a r e a , a n
a t t e m p t s h o u l d be m a d e to seal t h e
m i d d l e m e s i a l canal a n d t r a n s v e r s e
m i d d l e a n d a p i c a l a n a s t o m o s e s as well
as the m e s i o b u c c a l a n d m e s i o l i n g u a l
canals.
The authors thank Dr. Francis E. Shovlin
and Mr. Robert D'Augustine for their contribu-
tions to this manuscript, and Miss Saroj R.
Mansukhaney for her help in preparing the
manuscript.
Dr. Pomeranz is clinical associate professor,
department of endodontics, College of Medicine
and Dentistry of New Jersey, New Jersey
Dental School, and is in private practice, Mill-
burn, NJ. Drs. Eidelman and Goldberg are
assistant attendings in Oral Surgery, Overlook
Hospital, Summit, N J, and are in private prac-
tice in Union, NJ. Requests for reprints should
be directed to Dr. Pomeranz, Suite 102, 75
Main St, Millburn, NJ 07041.
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