Case Report/Clinical Techniques
Identification of Independent Middle Mesial Canal in
Mandibular First Molar Using Cone-Beam Computed
Tomography Imaging
Sung-Ho La, DDS, MS,* Dong-Ho Jung, DDS, MS,† Eun-Cheol Kim, DDS, PhD,‡
and Kyung-San Min, DDS, PhD†
Abstract
Introduction: The root canal treatment of a mandibular
molar with aberrant canal configuration can be diagnos-
tically and technically challenging. Methods: This case
T he main objective of root canal treatment is the thorough mechanical and chemical
cleansing of the entire pulp space followed by complete obturation with inert filling
material (1). Therefore, it is imperative that aberrant anatomy is identified before and
report presents the clinical management of a mandibular during root canal treatment of such teeth.
first molar with three separate mesial canals including Since Vertucci and Williams (2) first reported the presence of a middle mesial
middle mesial canal, which was confirmed by cone- (MM) canal in a mandibular molar, there have been multiple case reports of aberrant
beam computed tomography (CBCT) images. Results: canal morphology in the mesial root (3–9). In a clinical evaluation of 100 mandibular
Posttreatment images revealed three independent root molars, Pomeranz et al (6) found that 12 molars had MM canals in their mesial roots
canals in the mesial root obturated efficiently to the and classified them into three morphologic categories as follows: fin, confluent, and
accepted lengths in all three canals. Conclusion: This independent. According to their classification, an independent canal implies the canal
case report highlights the usefulness of CBCT imaging originated as a separate orifice and terminated as a separate foramen, and only two
for accurate diagnosis and management of the unusual cases were identified as independent. Goel et al (9) reported mandibular first molars
canal morphology. (J Endod 2010;36:542–545) had MM canals in 15.0% of specimens. Among these MM canals, only 6.7% of MM
canals were independent.
Key Words Radiographic examination using conventional intraoral periapical views is impor-
Cone beam computed tomography imaging, mandibular tant for the evaluation of the canal configuration. However, it has its inherent limitation
molar, middle mesial canal to assess the root canal system completely. Conventional multidetector computed
tomography (CT) imaging has been widely used in medicine since the 1970s and
was introduced in the endodontic field in 1990 (10). Recently, cone beam CT
(CBCT) imaginig has been shown to provide comparable images at reduced dose
From the *Seoul-Miso Dental Clinic and Departments of and costs to be considered as an alternative to multidetector CT imaging in endodontics
†
Conservative Dentistry and ‡Oral and Maxillofacial Pathology,
School of Dentistry, Wonkwang University, Iksan, South Korea. (11). Cotton et al (12) reported a number of useful applications of CBCT imaging in
This paper was supported by Wonkwang University in 2010. endodontics. Furthermore, Matherne et al (13) suggested that CBCT imaging is useful
Address requests for reprints to Dr Kyung-San Min, Depart- even in identifying the root canal system. To our knowledge, however, there has been no
ment of Conservative Dentistry, School of Dentistry, Wonkwang clinical report that identifies an independent MM canal using CBCT imaging effectively.
University, 344-2 Shinyong, Iksan, South Korea 570-749. E-mail In this report, we present clinical detection and management of an independent MM
address: [email protected].
0099-2399/$0 - see front matter canal in mandibular first molar by using CBCT imaging.
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2009.11.008
Case Report
A 43-year-old woman whose medical history was noncontributory presented to the
dental clinic with spontaneous pain in the right molar area. A clinical examination
showed an extensive previous gold restoration in the right lower first molar (Fig. 1A).
The patient presented severe lingering pain to cold water applied to the isolated tooth.
A radiograph showed no specific pathosis on the tooth and its periapical tissue, but peri-
apical pathosis was shown in an adjacent second premolar (Fig. 1B). Furthermore,
a moderate periodontal problem existed on the first molar. Diagnoses of irreversible pul-
pitis without apical periodontitis of the right mandibular first molar and pulp necrosis
with chronic apical periodontitis of the right second premolar were made.
After administering local anesthesia, rubber dam isolation, previous restoration,
and all carious tissue were removed, and an adequate endodontic access was made. The
pulp chamber floor showed four orifices corresponding to 4 root canals: mesiobuccal,
mesiolingual (ML), distobuccal, and distolingual (Fig. 1C). Working lengths were esti-
mated by using an electronic apex locator (Root ZX; Morita, Tokyo, Japan) and then
confirmed with a radiograph. All canals were cleaned and shaped with Protaper rotary
instruments (Dentsply-Maillefer, Ballaigues, Switzerland) under copious irrigation with
542 La et al. JOE — Volume 36, Number 3, March 2010
Case Report/Clinical Techniques
Figure 1. Pretreatment clinical (A) and radiographic view (B) of the right mandibular first molar with extensive gold restoration. (C) Floor of the pulp chamber
showing conventional two orifices in the mesial root.
5.25% sodium hypochlorite. After preparation, the root canals were in- By exploring the fissure located on the lingual aspect of the ML
serted with gutta-percha cones (Diadent, Seoul, Korea) to reconfirm canal orifice with a sharp endodontic explorer, a ‘‘stick’’ was encoun-
working lengths. The angled radiograph implied the presence of an tered. We decided to perform multisliced scans of the mandible with
additional canal because the mesial root seemed to have another informed consent from the patient. The first molar was focused, and
root apex (Fig. 2A). the morphology was obtained in transverse, axial, and sagittal sections
Figure 2. (A) A radiograph after master cone placement implies the possibility of additional canal in mesial root. (B) CBCT image showing three independent
mesial canals (white arrows). (C) Pulpal floor showing three mesial canal orifices (black arrows).
JOE — Volume 36, Number 3, March 2010 Identifying Independent Middle Mesial Canal in Mandibular First Molar Using CBCT 543
Case Report/Clinical Techniques
Figure 3. Posttreatment periapical radiograph (A) and CBCT images (B, transverse image and C, longitudinal image) showing three distinct and independent
canals throughout their course.
of 1.0-mm thickness using the CBCT scan (Implagraphy; Vatech, Seoul, an image field size similar to that of ordinary dental films. This type of
Korea). The transverse images revealed that the mesial root had three machine generally yields considerably lower effective doses than conven-
root canals, and the canal we had originally considered as ML canal tional CBCT machines and a similar dose with two to three periapical
was actually an MM canal (Fig. 2B). According to Pormeranz’s classi- radiographs, particularly when just a small volume is examined (16).
fication, the MM canal was classified as ‘‘independent.’’ The MM canal In this case report, we confirmed the presence of three mesial
had a separate orifice and an apical foramen. canals that were independent throughout their course in the root using
All three mesial canals including the MM canal were cleaned, CBCT imaging. In the cone-fit radiograph, we noticed the possibility of
shaped, and obturated by using Duo alpha & beta (BNL Co., Seoul, a presence of an MM canal. As described earlier, the MM canal we de-
Korea) with gutta-percha and sealer (AH-plus, Dentsply-Maillifer) tected at first was misdiagnosed as an ML canal. MM canals are usually
(Fig. 3A). The adjacent second premolar was also endodontically located centrally between the mesiobuccal and ML canals, and we, the
treated, and periodontal management was performed on these teeth. clinicians, had trouble in locating the ML canal. In this particular case,
Posttreatment CT images revealed three independent root canals in the CT images clearly revealed three independent canals in the mesial
the mesial root obturated efficiently with gutta-percha to the accepted root, and the images were very helpful in detecting the relative location
lengths in all three canals (Fig. 3B and C). The patient experienced of each canal. Furthermore, we could confirm that the canals were ob-
no posttreatment discomfort and was subsequently referred for appro- turated properly with CT images.
priate coronal restoration. Treating additional aberrant canals can be challenging, but the
inability to find root canals may cause failures. The evaluation of
CBCT images can result in better understanding of root canal anatomy,
Discussion which enables the clinician to investigate the root canal system and to
Many dental clinicians tend to perceive a given tooth will contain
clean, shape, and obturate it more efficiently.
a predetermined number of roots and/or canals. However, a careful
evaluation of the literature shows deviations from the norm in that tooth
morphology is not uncommon. Among these anatomic variances, References
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Case Report/Clinical Techniques
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