The influence of dental operating microscope in locating the mesiolingual canal orifice

Lynne A. Baldassari-Cruz, DDS,a Jeffrey P. Lilly, DDS, MS,b and Eric M. Rivera, DDS, MS,c Iowa City, Iowa
UNIVERSITY OF IOWA

Objective. The purpose of this study was to evaluate the influence of using the dental operating microscope (DOM) for detection of the mesiolingual (ML) canal orifice in extracted maxillary molars compared with unaided vision (no loupes or headlamps). Study design. Using a clinical simulation model system, we mounted 39 maxillary molars in a dentoform and placed them into a mannequin. After rubber dam placement and preparation of standard access, 2 attempts were made to locate the ML canal with unaided vision. Then the teeth were examined by using a DOM. Finally, all teeth were sectioned, stained, and evaluated with the DOM for actual presence of an ML canal. Results. ML canal orifices were detected in 20 of the teeth with a sharp explorer and mirror. In the remaining teeth, 12 ML canal orifice were located by using the DOM. Qualitative nonparametric comparisons were used. Conclusions. The results of this study indicate that the DOM provides increased opportunity for the dentist to detect canal orifices.

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:190-4)

One of the goals of nonsurgical root canal treatment is location and debridement of all canals whenever possible.1-3 In the treatment of maxillary molars, locating and negotiating a mesiolingual (ML) canal in the mesiobuccal (MB) root (also referred to as minor, lateral, secondary, accessory, second mesial, or MB2) may have implications to the long-term prognosis.4 Research in vitro has demonstrated wide variation in the prevalence of the ML canal. Hess5 evaluated the number of canals in 513 extracted maxillary first and second molars and found that 54% had 4 canals. Pineda and Kuttler6 reported finding 4 canals in 51.5% of first and second maxillary molars combined. Weine,7 using maxillary first molars, located 4 canals in 62%. In an SEM analysis of maxillary molars, Gilles and Reader8 found 70% to 90% of ML canals in MB roots. Most recently, Weine et al9 examined 293 extracted maxillary first molars from a Japanese population and found that 68% demonstrated more than 1 canal in the MB root.9 The relative success of finding an ML in an in vivo setting has been poor. Hartwell and Bellizzi,10 in a review of treatment records involving 714 maxillary first and second maxillary molars, found a fourth canal
Professor, University of Iowa, Iowa City. Faculty, University of Iowa, Iowa City; in private practice, Des Moines, Iowa. cAssociate Professor and Head, Department of Endodontics, University of Iowa, Iowa City. Received for publication Sep 21,2000; returned for revision Nov 13, 2000; accepted for publication Jun 19, 2001. Copyright 2002 by Mosby, Inc. 1079-2104/2002/$35.00 + 0 7/15/118285 doi:10.1067/moe.2002.118285
bAdjunct aAssistant

in 18.6% of first molars and 9.6% of second molars. These findings were about half of those reported in studies by Seidberg11 (33%) and Pomerantz and Fishelberg (28.2%).12 Fogel et al13 evaluated the use of 2.5 magnification telescopes with fiberoptic headlamps for locating ML canals in maxillary first molars in vivo. After access preparation, a groove, approximately 1 mm in depth, was made along the floor of the pulp chamber lingual to the MB canal orifice, following the developmental groove between the MB and palatal canals. They found that 148 of 208 (71.2%) MB roots had 2 treatable canals.12 Several techniques have been recommended in the English-language literature, with respect to locating the ML canal. Neaverth et al14 discussed a method of minor canal detection in the MB root in a clinical investigation of 228 maxillary first molars. They described a heart-shaped access opening, a distal approach because of the dentinal shelf present on the mesial, and countersinking the floor lingual to the major canal to locate the minor canal orifice. Weller and Hartwell15 have stated that there is an increased probability of finding this canal if the initial access is changed from a classical triangular shape to a more rhomboidal shape. They also advised that the developmental groove between the MB and palatal canals be explored, often by deepening it, to locate a fourth canal. In a retrospective study of 1134 maxillary molars treated with the modification of a rhomboidal access, the authors were able to detect 4 canals in 39% of maxillary first molars and 21.4% of second molars. Stropko16 found 73% to 93% MB2 in a recent clinical study that examined 1732 maxillary molars. In Kulild and Peters17 study of first and

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second maxillary molars, a second canal was located in the coronal half of 95.2% of the roots, by hand instruments in 54.2%, after modifying the access in 31.3% and after sectioning and viewing with a measuring microscope in 9.6%. Location of root canals has previously been evaluated in vivo and in vitro in research articles by using dental loupes, fiberoptic head lamps, scanning electron microscopy, and sectioning for microscopic observation.1,7,11,16-30 The DOM provides enhanced illumina-

Fig 1. A, Drawing of access to demonstrate typical location of mesiolingual (ML) canal in relationship to mesiobuccal (MB), distobuccal (D), and palatal canals in a maxillary molar. Photographs of maxillary molar before (B) and after (C) ML canal trench preparation.

tion and magnification for dental procedures on both hard and soft tissues, giving advantage to designing and reflecting gingival tissue flaps.1,16-19 The dental operating microscope has been associated with obtaining favorable treatment results in a study in vivo of endodontic surgery with improved postoperative symptoms.16,18 Literature describing the use of the dental operating microscope for nonsurgical routine procedures is limited. Very recently, a study in vitro using the DOM for gutta percha removal showed no

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Fig 2. Methodology flow chart.

significant difference in the debris remaining in the canal compared with re-treatment without the use of the DOM.31 The purpose of this study was to evaluate whether the adjunctive use of the DOM would increase detection of ML canal orifice in the MB root of extracted maxillary first and second molars, when not found with unaided vision in an in vitro mannequin setting.

MATERIAL AND METHODS Thirty-nine extracted maxillary first and second molars were used in this study. The extracted teeth were stored in a 1% thymol solution for 2 months. The teeth were mounted into a dentoform with acrylic, which extended 5 mm below the cementoenamel junction, then mounted onto a dental chair mannequin (Columbia Dentoform, Long Island, NY). Radiographs of all teeth were made while in the dentoform by using an XCP, 70 KVP, 10 mA, and 0.4 second of exposure. Angulations of 20 mesial and 0 vertical were used to incorporate the best reproducibility for analyzing canal morphology of the MB root.9,15,18,19 Without the use of magnification or headlamps (unaided vision), standard endodontic access was performed by using a highspeed hand-piece with a 557 fissured bur, sharp explorer, mirror, and 2.5% sodium hypochlorite irrigation. After the MB, distobuccal, and palatal canals were located, an attempt was made to locate the ML canal again with unaided vision by using only a sharp explorer and a mirror. If the ML canal was not located, a 700L bur was placed 2 to 3 mm into the orifice of the MB canal and a trench was prepared at that depth toward the lingual and slightly mesial into and through

Fig 3. A and B, Schick image demonstrating the ML canal in MB root after laboratory sectioning and staining at 25.

the mesial dentinal shelf.2,3 This trench was again explored with unaided vision by using only a sharp explorer and a mirror to locate an ML canal. Fig 1, A is a drawing of a standard access with typical canal locations demonstrated. Fig 1, B and Fig 1, C show access before and after trench preparation at 3 magnification. These images were made with a digital camera system (Canon model number EOS D30, Tokyo, Japan). A ML canal orifice was either located or not located. If not, the teeth were then evaluated by using a Zeiss DOM (Carl Zeiss, Inc, Oberkochen, Germany) at 25 magnification to search for the ML canal. Again, an ML canal was either located or not located (Fig 2). The MB roots of all teeth were then sectioned in an axial plane 5 mm below the cementoenamel junction, then stained with methylene blue dye (Fig 3). All sections were examined by using the DOM at 25 magnification to determine the actual presence or absence of the ML canal

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Fig 4. Bar graph depicting percentage of ML canals located with unaided vision, dental operating microscope (DOM), and after sectioning.

orifice. Each tooth served as its own control. Two evaluators, both second-year endodontic residents, performed all the examinations and procedures involved in the study. Both evaluated all teeth for ML canal detection.

cation. This allows the most direct illumination of the magnified image.16-18,29 It has been reported that these benefits are somewhat balanced by the steep learning curve to become familiarized with and proficient in DOM use.19 The ML canal in MB roots of maxillary molars can be extremely challenging to locate. To accomplish this, one must be well trained in the knowledge of pulp morphology to know typical location and number of existing canals.2-28 Different methods of access modification to increase frequency of locating the ML canal have been demonstrated.2,11,14,26 The modification of the access cavity to include a trench preparation from the mesiobuccal canal in mesial palatal direction, where the ML canal may typically be found, increased the frequency of ML canal orifice detection. Combined with the knowledge of root canal system morphology and accessibility, enhanced vision to the area allows the operator to achieve maximum results. ML canal detection was increased by the addition of the DOM in our study, from 51% to 82% in 39 test teeth. Fogel et al13 located and treated 71.2% of ML canals with the addition of enhanced vision by using fiberoptic headlamps and 2.5 loupes. In our study, with the addition of the DOM we located 82% of the ML canals in 39 maxillary molars. Negotiation of detected canals was not part of this study. The nonparametric statistics of quantifying the numbers of detected ML canals for each category was in agreement with both operators.

RESULTS Fig 4 summarizes the results of this study. With the use of only a sharp endodontic explorer and mouth mirror (unaided vision, no adjunctive use of illumination or magnification), 20 ML canal orifices were detected out of the 39 teeth, representing 51%. After evaluation of the same 39 teeth with the DOM, an additional 12 ML canal orifices were detected in the remaining 19 teeth (63%). In other words, these 12 canal orifices were not located without the use of the DOM. Overall, 82% of ML canals were detected in 39 experimental teeth by using both methods of discovery. In the lab, after sectioning and staining all the teeth, 3 additional ML canals were identified in the remaining 7 teeth. These 3 canals were not detected with unaided visual examination or with the DOM. A total of 35 ML canals were identified out of 39 experimental teeth. DISCUSSION The DOM has become more popular for surgical and nonsurgical endodontics.16-18,29 Some reasons for this increased use may be choice of magnification and a variable intensity of light, which is focused down the shaft of the optic piece, parallel to the field of magnifi-

CONCLUSIONS Our study demonstrated that the adjunctive use of the DOM increased the ability for the dental clinician to locate an ML canal.
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