Canal configuration in the mesiobuccal

root of the maxillary first molar and its

endodontic significance
Franklin S. Weine, B.S., D.D.S., M.S.D.,* Harry J. Healey, B.A.,
D.D.S., M.S.D.,“* Harold Gerstein, B.X., D.D.S.,**” and
Leonard Evanson, B.S., D.D.X., M.S.,“*** Chicago, Ill.,
and Indianapolis, Ind.
NORTHWESTERN UNIVERSITY DENTAL SCHOOL, INDIANA UNIVERSITY
SCHOOL OF DENTISTRY,LOYOLAUNIVERSITY SCHOOL OFDENTISTRY,
AND UNIVERSITY OF ILLINOIS COLLEGE OFDENTISTRY

T he ultimate objective of endodontic therapy has been stated to be the ob-

literation of the prepared root canal space with an inert material in order to
restore the integrity and state of good health of the treated tooth in the dental
arch.l According to Ingle,2 the most common cause of endodontic failure is
apical percolation, with the largest percentage of eases failing due to incomplete
canal obliteration. Other reasons for failure in this category include leaving a
canal completely unfilled and inadvertently removing a silver point. Quite often
a canal is left unfilled because the operator has failed to recognize its presence.
Rankine-Wilson and Henry3 and others 4p5 have described the not uncommon
finding of a bifurcated canal in mandibular incisors, cuspids, and premolars.
Green6 gave an exhaustive description of the presence of auxiliary and secondary
canals among all the teeth in the dental arch. Therefore, it is the obligation of
those interested in endodontics to be thoroughly familiar with root canal
anatomy, in both normal and abnormal situations, in order to keep this cause
of endodontic failure to a minimum.

*Assistant Professor of Endodontics, Northwestern University Dental School.

*“Professor and Chairman, Department of Endodontics, Indiana University School of
Dentistry.
***Associate Professor of Endodontics, Loyola University School of Dentistry.
***“Assistant Professor of Endodontics, University of Illinois College of Dentistry.

419
 In Inglc’s’ chart listing t,hc freqllcncy of trcatmcnt of teeth, rompilcd from
1957 t,o 1962, the maxillary first molar rclpresented 5.45 per cent of cn(lodontic
cases. In Wcine’s7 study, ho\vcYer, that tooth represented 31.6 per cent 01’ pulpal
exposures. With an increased desire of the patient for tooth rctention as well
as t,he availability of improved instruments and techniques, it can be assumed
that maxillary first molars will be treated more and nlore.s-lo Also contributing
to this frequency is the increasing endodontic-periodontic therapy collaborat,ion,
since the maxillary molar is one of the most frequent candidates for root
amputation.ll, I2
We were impressed by the fact that maxillary first molars that did not
respond properly to routine surgical and/or nonsurgical treatment were brought,
to successful conclusions by the discovery and treatment of a second mesiobuccal
canal. (See case histories.) Therefore, we decided to s,ection the mesiobuccal
roots of extracted maxillary first molars to determine canal configuration and
the incidence of an additional canal.

METHOD
The mesiobuccal roots of 208 extracted maxillary first molars were sectioned
from a mesial approach in a buccolingual direction, using a coarse sandpaper
disk. The root canal or canals were exposed, when possible, from the roof of the
pulp chamber to the apex, and the typical configurations were classified and
tabulated.

RESULTS
The canal configurations fell into three general categories:
Type I. A single canal from the pulp chamber to the apex.

Fig. 1 Fig. 2 Fig. 9

Fig. 1. Single canal configuration.
Fig. 2. In this mesiobuccal root, two canals emerge from the floor of the chamber and
merge to form a single apical foramen.
Fig. 3. Two separate canals and apical foramina are present in this mesiobuccal root.
Volume 28 Canal configuration and its endodontic significance 421
Number 3

Table I. The number and percentage of the total sampling of the mesiobuccal
roots that were tabulated in each category
Type I Type II Type III
Number of teeth 101 78 29
Per cent of total 48.5 37.5 14.0

Fig. 4. From a mesial view, the width of the mesiobuccal root at the trifurcation level is
approximately two thirds of the buccolingual dimension.

Type II. A larger buccal canal and a smaller canal located lingual
to the former which merged from 1 to 4 mm. from the apex.
Type III. Two distinct canals and two distinct apical foramina, with
the buccal canal being larger and usually longer from the
roof of the chamber to its apical foramen.
Of the 208 teeth sectioned, 101 (48.5 per cent) exhibited the Type I (single
canal) configuration (Fig. l), seventy-eight (37.5 per cent) showed the Type II
(bifurcated canal but common apical foramen) appearance (Fig. 2)) and
twenty-nine (14.0 per cent) were classified as Type III (two separate canals)
(Fig. 3).

DISCUSSIONS AND CONCLUSIONS

Preliminary to the beginning of seeConing of the mesiobuccal root of the
maxillary first molar, a view from the proximal surface gave an entirely new
picture of that root when compared with the buccal view as is typically seen in
a periapical radiograph (Fig. 4). Whereas the root is relatively slender mesio-
distally, it is broad buccolingually and usually extends two thirds of the bucco-
lingual width of the tooth at the trifurcation level.
This is a significant factor when root amputation is to be performed to treat
a periodontal problem. If the lingual portion of the amputation is placed too far
422 Weine et al. O.S.,o.ilz. & O.P.
Sq,tcllllwr, 1 MD

buccally, a spiculc of root will remain to continue or compound tllc pcriodont;~l

irritation.
Adding the teeth from Types I and II togcthttr, it is noted that, ~6: l)cr cent
of the roots sectioned displayed a single apical foramcn. If tllc single canal in
Type I cases and one of the two canals in Type 11 cases wcrc trcatcd cndodon-
ticslly and properly instrumentally prepared and filled, the chance of success
would be excellent. In the Type II cases, the unfilled canal, rcgardlcss of any
retained tissue and/or debris, would be sealed from the apical ant1 orill tissues.
This situation is occasionally noted in maxillary second premolara when one
canal is filled and one is unfilled, but since a common apex existed, nhich was
properly sealed, success resulted.
However, if a root resection becomes necessary in a Type II case! it is pos-
sible that the unfilled canal mill be exposed to the pcriapical environment and
allow for the retention of tissue fluids, debris, and microorganisms, thus increas-
ing the chances of failure due to apical percolation. Therefore, it, is snggcstetl
that in cases involving resection of the mesiobuccal root a long buccolingual
preparation be made and filled with the material of the operator’s choice (silver
amalgam, zinc oxide-eugenol, etc.) I32I4 in order to seal off a possibly present
and unfilled canal. Since t,he cross section of the root in this area frcyucntly
has a dumbbell (or figure-of-eight) shape, care must be taken to avoid pcrfora-
tion of the isthmus. Usually two round or oval but touching preparations
allow for this possibility. This procedure would also be needed, of course, in
the resection of Type III cases (Fig. 5).
In addition to causing complications in resections, Type III configurations
may cause problems in nonsurgical treatment, In these cases, if only the larger
canal is prepared and obliterated, then one of t,wo situations might arise. If
the tissue in the unfllled canal is vital and inflamed, as a result of cithcr the
pretreatment condition of the tooth or its endodontie manipulation, pain
might persist following the supposed end of therapy. If the tissue in the
unfilled canal is necrotic, it might cause the development of a periapical area
or perpetuate an existing initial lesion. When one of these conditions occurs
following an apparently effective endodontic treatment effort, the possible

Fig. 5. In this mesiobuccal root, a dumbbell shape is present after resection. In order to
reverse fill without perforating the isthmus, two round but touching preparations are made.
Volume 28 Canal confi.quration and its endodontic significance 423
Number 2

Pig. 6. Radiographs of Case 1. Preoperative view (A) shows a routine maxillary first
molar with pulpal involvement through both the mesial and distal horns. In the postoperative
view (R), both mesiobuccal canals are filled with silver points while the distobuccal and
palatal are obliterated with gutta-percha.

presence of a second mesiobuccal canal should be explored before the tooth is

condemned or surgical intervention is scheduled.
It should be mentioned that whereas the presence of bifurcated canals in
mandibular anterior t,eeth and premolars and maxillary premolars can be
determined by pretreatment radiographs from various angles, it is most
difficult to see a second canal in mesio buccal roots of maxillary molars. This
is due to the very small. width of the second canal and its close proximity to
the larger canal. However, when a radiograph is taken with instruments in
place for length measurement, once the second canal is located, aiming the
cone from the distal aspect will usually produce a view of good diagnostic
value.
Since it is extremely difficult to determine which canal configuration is
present,, it is suggested t,hat whenever the mesiobuccal canal of the maxillary
first molar is resected, the endodontist assume that a Type II or III is present
and the long buecolingual preparation and apical filling should be employed.
In attempting to locate the additional canal, the orifice is usually found
just palatal to the orifice of the main mesiobuccal canal. However, since the
canal usually passes toward t,he mesial and palatal directions as it emerges
from the pulp chamber, an instrument must be entered from the distal and
buccal directions in order to traverse the canal. With the course of the canal
being toward the buccal aspect as it approaches the apex, it is suggested that
a slight buccal curve be placed in the exploring instrument.lj
In view of the frequency with which a second canal appears, and the
rarity with which it is filled, it is surprising that a high percentage of success
is enjoyed in the treatment of this tooth. Evidently, in many cases where
two distinct canals are present and only one is treated, the root canal cements,
most of which contain a eugenolate, act as a dressing for a deep pulpotomy.
It is situations of this type that may account for some of the cases of
cognitive dissonance in endodontics, as described by Seltzer and Bender.16
424 Weine et al.

Fig. 7. Radiographs of C?:tsc 1’. ‘l’lrr prcopl’ratirc film /iI) shows a radiolucency around
the mesiobuccal root. In the film taken 6 months l’ostoI)(‘rativclS (B), the canals have been
filled with silver points but thr :rr<la 1,:~ f’:riIr(l 1 o h(‘al. Six months following surgical inter-
vention (C), healing is apparent.

CASE REPORTS
CASE 1
A 28.year-old woman was reftarred because of intermittent pain in the upper right
quadrant. Diagnostic tests indicated a chronic pulpitis in the first molar. At the first appoint-
ment, the pulp was extirpated from the palatal canal, and instrumentation of the buecal
canals was commenced. At the second appointment, the patient reported little diminution of
pain. Further exploration disclosed a second mesiobuccal canal with vital tissue. Following
extirpation of this tissue, the patient had no further symptoms and the case was completed
by routine procedures (Fig. 6).

CASE 2
A 55-year-old man was referred for treatment of a maxillary left first molar. Radiographic
examination (Fig. 7,A) revealed a periapical radiolucency in proximity to the mesiobuccal
root. Routine procedures were followed, and the canals were filled with silver points. At the
6.month postoperative period, the rarefied area had failed to heal (Fig. 79) and a root
resection was performed, with insertion of an apical amalgam filling. At the time of surgical
intervention, a second mesiobuccal canal was discovered. At subsequent radiographic examina-
tions the area appeared resolved (Fig. 7,C).

SUMMARY
The mesiobuccal roots of 208 teeth were sectioned buccolingually from the
mesial aspect and the canal configurations were cat.egorized. One hundred
Volume 28 Canal configuration and its endodontic significance 425
Number 3

one (48.5 per cent) had a single canal, 78 (or 37.5 per cent) showed two
canals which merged toward a single apical foramen, and twenty-nine (14.0
per cent) displayed two distinct canals with separate apical foramina.
The frequency of occurrence of the bifurcated or double canal must be
taken into consideration when surgical treatment is planned and as a possible
cause of otherwise unexplained failure.
Case histories are presented to illustrate these situations.
The authors acknowledge the assistance of the Class of 1970 of Northwestern University
Dental School in the sectioning of the teeth used in this study.

REFERENCES
1. Healey, H. J.: Endodontics, St. Louis, 1960, The C. V. Mosby Company.
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Teeth, J. Am. Dent. A. 70: 1162. 1965.
4. Somder, R. F., Ostrander, F. fi., and Crowley, M. C.: Endodontics, ed. 2, Philadelphia,
1961, W. B. Saunders Company.
5. Wheeler, R. C.: Textbook of Dental Anatomy and Physiology, ed. 3, Philadelphia, 1958,
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6. Green, D.: Morphology of the Pulp Cavity of Permanent Teeth, Our, Sum., ORAL MED. &
ORAL PATH. 8: 743, 1955.
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