PARIPEX - INDIAN JOURNAL O F RESEARCH | Volume-9 | Issue-2 | February - 2020 | PRINT ISSN No. 2250 - 1991 | D OI : 10.

36106/paripex

O RIG INAL RESEARCH PAPER Endodontics

C O N F I R M I N G THE BEST C L I N I C AL METHOD KEY WORDS: MB2 Canal,

O F F I N D I N G THE MB2 CANAL IN MAXILLARY CBCT, Dental Operating
FIRST M O L A R – AN IN VITRO STUDY Microscope, Ophthalmic Dye

Dr. Mohammed
Haldia Institute of Dental Sciences and Research
Imtiaz
Dr. Debaprasad
Haldia Institute of Dental Sciences and Research *Corresponding Author
Das*
Dr. Anirban
Haldia Institute of Dental Sciences and Research
Bhattacharyya
Dr. Asim
Haldia Institute of Dental Sciences and Research
BikashMaity
Dr. SumanKar Haldia Institute of Dental Sciences and Research
Dr. Soham Datta Haldia Institute of Dental Sciences and Research
INTRODUCTION: Maxillary first molar is the largest tooth in terms of total volume and is generally considered the most
anatomically complex tooth due to its variation and complex morphology,particularly in the mesiobuccal root.
Throughout the literature,much of the focus of the maxillary first molar has revolved around the mesiobuccal root and the
second mesiobuccal canal, which is referred to as either the MB2 or the mesiolingual canal. Although not always located,
the MB2 canal is present on average 56.8% of the time when all studies are taken into account. Depending on the study
referenced to and the method used, the presence of the MB2 canal ranges from 18.6% to 96.1%. When the MB2 canal
cannot be located or properly treated,it may contribute to continuous patient pain or root canal failure.
METHOD: The purpose of this study was to ascertain the best clinical method to detect the MB2 canal in 100 maxillary
first molars that has gone through CBCT for confirming the presence of MB2 canal- using 3 independent methods: stage
ABSTRACT

1, wirect occlusal access; stage 2, direct occlusal access with dye and stage3, direct occlusal access with a dental
operating microscope (DOM);
RESULT: The prevalence of an MB2 canal with blinded CBCT volume evaluation was 89% (89/100).
Stage 1,Direct occlusal access of the tooth without magnification,showed an MB2 canal in 45% (45/100)of teeth.
Stage 2,Direct occlusal access with dye,led to an MB2 detection rate of 52% (52/100)of teeth.
Stage 3, Direct occlusal access of the tooth with magnification under dental operating microscope, demonstrated the
presence of an MB2 canal 88% (88/100) of the teeth.
When the prevalence of MB2 canals found in Group 1 (45%) was compared with groups 2 (52%),3 (88%) were all found to
be statistically significant (P = .032,P = .002,and P < .001,respectively).
CO N CL USIO N : In the above study it is seen that using magnification is the best clinical method for searching the MB2
canal in the maxillary first molar.

INTRODUCTION Finding its location in clinical practice is highly complex due

Endodontic disease could negatively affect the quality of life to the excessive dentin deposition in the opening of the canal
of patients. The success of endodontic treatment depends on and the difficulty in visually accessing maxillary molars. 3
the proper cleaning, shaping, and obturation of the entire root Therefore,knowledge of the morphology of the root canal
canal system. 1 system is extremely important in planning endodontic
therapy, as its success relies on thelocation of all of the canals
The permanent maxillary 1st molars are one of the most thatcan then be disinfected,shaped,and filled. 5
frequently endodontically treated teeth and it is ofparticular
interest in the field of endodontics because of its variations Investigators reported varying prevalence of the second
and complex morphology, particularly in the mesiobuccal mesiobuccal canal of maxillary first molar. The prevalence of
root which has been demonstrated dating back to 1925. In a second mesiobuccal canal in the mesial root varies between
fact, the maxillary first molar is the largest tooth in total 26% (Pecora 1992) and 93.5% (Sert & Bayirli 2004).
volume and is generally considered the most anatomically Nikoloudaki et al (2015) attributed these variations to the
complex tooth.2 different methods that were used for the detection of the MB2
canal. 3
A high percentage of treatment failures occurs due to the
failure to detect the presence and location of the second The prevalence of two canals in laboratory studies is higher
mesiobuccal canal (Mb2), located in the mesiobuccal root of (60.5%) to that reported in clinical studies (54.7%) (Cleghorn
the 1st maxillary molars which prevents the correct et al 2006).6
implementation of biomechanical instrumentation, irrigation
and obturation.3 The purpose of this study was to ascertain the best clinical
method to detect the MB2 canal in 100 maxillary first molars
This canal often goes unnoticed, which can be attributed to that has gone through CBCT for confirming the presence of
the fact that it departs the pulp chamber at a sharp mesial MB2 canal- using 3 independent methods:
inclination and is then bent again in the distal direction,
making its detection highly challenging. 4 Stage 1:Direct occlusal access
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PARIPEX - INDIAN JOURNAL O F RESEARCH | Volume-9 | Issue-2 | February - 2020 | PRINT ISSN No. 2250 - 1991 | D OI : 10.36106/paripex
Stage 2:Direct occlusal access with dye
Stage 3: Direct occlusal access under a dental operating
microscope (DOM)

M ATERIALS AND METHODS

One hundred extracted human maxillary first molars were
collected and analyzed.

No information regarding age, sex, or clinical history of the

studied teeth was available.

Selection specification for teeth included normal crown

anatomy,3 separate roots, fully formed apices, an intact pulpal
floor, and no developmental anomalies.

After extraction, the teeth were placed in 5% sodium

hypochlorite, debrided of periodontal tissue, and rinsed
under running tap water. The teeth were then stored in
physiologic saline until the beginning of the experiment.

C B C T IM AG I N G
The experimental teeth were numbered from 1 to 100. Teeth
were positioned in a wax slab such that the slab consisted of
25 teeth arranged in the configuration of 5 column and 5 rows
and there were 4 such slabs. A gutta-percha cone was placed ACCE SS O P E N IN G
on the right side of the wax slab to identify in the CBCT image, An access cavity was prepared under light using 2 and #4
later each slab was scanned with CBCT (Kodak, 9300c, U.S.A). Endo access bur (Maillefer, Dentsply, Switzerland).
The voxel of 0.2 mm was used with an exposure of 16 min.
Initial penetration was made in the exact center of the mesial
pit, with the bur directed towards the palatal using a high
speed hand piece to the depth of dentin. The larger palatal
canal was located first after which safe-ended #0152 Endo-Z
bur (Maillefer, Dentsply, Switzerland) was used, keeping it in
contact with the floor of the pulp chamber and moved
mesiobuccally to the center of the MB cusp.

The MB canal was explored beneath the cusp tip, and the bur
was moved distally and slightly palatally to locate the
distobuccal canal orifice. A conventional triangular access
was modified to a trapezoidal shape to improve access to the
additional canals. Final finishing and funneling of cavity walls
was done with Endo-Z fissure bur. After an adequate access
The record of the number of canals and their variations was
cavity preparation, the contents of the pulp chamber were
recorded by two exam i ners , an Endodontist, and a
Radiologist. removed using an endodontic excavator and subsequent
irrigation with a 2.5% sodium hypochlorite solution. The pulp
Both evaluators viewed and manipulated the CBCT volumes chamber floor was explored using an endodontic explorer,
independently and were completely blinded from the results DG-16 (Maillefer, Dentsply, Switzerland). Exploration of
of the other evaluations. Initial calibration involved groove connecting the canal orifice was performed with the
independent viewing and manipulation of CBCT volumes to use of k-files #6,#8, or #10 (Mani,Japan).
standardize readings and agreement.
Prepared specimens were then explored for MB2 in the
following sequence:

Stage 1: Teeth were checked with naked eye (unaided vision)

for second canal in the MB root with the help of explorer and
then k-files #6, #8 and #10 and Ethylenediaminetetraacetic
acid was used to negotiate MB2 canal. If canal was not located
by naked eye, samples were subjected to stage 2.

STAGE 2:The teeth in which we failed to locate MB2 canals

were examined with Opthalmic dye,ophthalmic dye,strip was
used to apply dye to the area of interest. Firstly saline was
collected in the dappen dish, and then ophthalmic strip was
dipped in the saline solution. This strip was then placed in the
access cavity for around 3 to 5 minutes.This dye was absorbed
by the tissue present at the orifice. Blue curing light was then
applied from the buccal aspect of the tooth. Dye which was
absorbed by the tissue present at the orifice reflects
fluorescent color on application of blue light. This helps in
locating the MB2 canal.
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PARIPEX - INDIAN JOURNAL O F RESEARCH | Volume-9 | Issue-2 | February - 2020 | PRINT ISSN No. 2250 - 1991 | D OI : 10.36106/paripex
CBCT is a relatively recent innovation that overcomes many of
the limitations of conventional radiography. It has many
applications in Endodontics because it's three dimensional
images allow inspection of the tooth in the axial, coronal, and
sagittal planes. The axial plane is particularly useful in
helping the clinician to determine the number of rootcanals
and their location relative to one another. 10

Studies have also shown that CBCT images accurately depict

anatomical structures without significant magnification or
distortion.10

Various techniques have been applied to enable the

identification of MB2 canals, such as modification in the
access cavity preparation, use of digital radiography
Following this the teeth in which MB2 canal which could not be technology, orcontrast media. 4
traced after Stage 2, we advanced to examination under an
operating microscope at 19X magnification (Global Surgical Access cavity modifications and canal detection techniques,
Corporation's G6 microscope, six steps of magnification, in combination with technological advancements in
magnification range of 2.1x to 19.2x.) magnification and illumination, have greatly assisted in the
detection and treatment of the MB2 canals. 4
S T A G E 3: M a g ni fi c a t i o n me t ho d : U s i n g o p e r a t i ng
microscope gives us the maximum magnification in the In addition, to the use of bur and explorers to search out the
clinical setting so the chances of finding MB2 canal is very additional hidden orifices, endodontic ultrasonic tips are now
high. Hence operating microscope would be considered as commonly employed for the same purpose. 4
the final aid for the detection of the MB2 canal. Operating
microscope of 19X magnification was used as“gold standard” Ophthalmic dyes (e.g. fluorescein sodium, rose bengal) are
for detection of MB2 canal in maxillary first molar. currently b e i n g used in O pt hamolo gica l diagnostic
procedures and for locating damaged areas of the cornea due
RESULT to injury or disease. 11
The prevalence of an MB2 canal with blinded CBCT volume
evaluation was 89% (89/100) assessed by the Endodontist When these dyes come into contact with vital or non-vital pulp
and this value was 86% (86/100) as detected by the tissue they are readily absorbed by the connective tissue
Radiologist. elements of the pulp in the chamber and root canal system.
When exposed to blue light, these dyes dramatically
Stage 1: Direct occlusal access of the tooth without fluoresce, showing scattered tissue segments that contrast
magnification,showed MB2 canal in 45% (45/100)of teeth. with the surrounding monochromatic dentin. It is this quality
that makes them useful in the location of pulp tissue in root
Stage 2: Direct occlusal access with dye, led to MB2 detection canals, especially in those that are calcified and have tissue
rate of 52% (52/100)of teeth. remnants within.11

Stage 3: Direct occlusal access of the tooth with magnification The success rate of all these efforts combined has been
under dental operating microscope, demonstrated the considerably low, whereas with the aid of magnification, the
presence of an MB2 canal 88% (88/100)of the teeth. frequency of locating MB2 canals has b e e n greatly
enhanced. 4
When the prevalence of MB2 canals found in Group 1 (45%)
wascompared with groups 2 (52%), 3 (88%) were all found to Alaçam et al. proposed that operating microscope and
be statistically significant (P = .032, P = .002, and P < .001, ultrasonics when used together effectively increased the
respectively). identification of MB2 canals in permanent maxillary first
molars. 4
DISCUSSION
Canal identification is critical to successful root canal Buhrley et al. in their study showed that the use of
treatment. Ina recent retrospective cohort study, Karabucak et magnification increased MB2 detection rate by almost three
al e v a l u a t e d t h e p r e v a l e n c e of m i s s e d c a n a l s in times when compared to thatof non-magnification. 4
Endodontically treated teeth using CBCT volumes. They
found that when a canal was missed the tooth was 4.38 times C O N C L US IO N
more likely to have an associated lesion. Additionally, the MB2 From this study it can be concluded that the prevalence of
canal was the most frequently missed canal. 7 MB2 canal in the maxillary first molar is 89% as found by the
CBCT scan.
The frequency and risk of missed canal anatomy are strictly
linked with the complexity of the root canal system. 8 Clinically direct access opening without magnification can
search MB2 canal in 45% of teeth and when dye used, this
One potential reason that explains why MB2 canals are finding increases to 52% but this finding increases upto 88%
frequently missed is that these canals often occur at levels when access done under microscopic magnification.
deeper than thatof the chamber floor.9
So we can conclude from the above study that using
Failure to treat extra canals is a risk factor for persistent apical magnification is the best clinical method for searching the
periodontitis since it might harbour microbial biofilm. MB2 canal in the maxillary first molar.
Therefore, it is prudent to better understand the tooth root
morphology by means of 3D imaging technology to anticipate REFERENCES
the challenge of root canal treatment. It has been reported that 1. Ben studebaker et al( 2017) the incidence of second mesiobuccal canals
when extra canals in the Mesiobuccal root are suspected, the located in maxillary molars with the aid of co n e- beam computed
access cavity should be modified to locate their potential tomography,joe
2. Brent M. Hiebert et al (2017) prevalence of second mesiobuccal canals in
canal orifices. 9 maxillary first molars detected using cone-beam computed tomography,

www.worldwidejournals.com 67
1
PARIPEX - INDIAN JOURNAL O F RESEARCH | Volume-9 | Issue-2 | February - 2020 | PRINT ISSN No. 2250 - 1991 | D OI : 10.36106/paripex
direct occlusal access, and coronal plane grinding, JOE http: //dx. Doi.
Org/10.1016/j.Joen.2017.05.011
3. Yomna Mohammad Gamal EL-Din Saadi (2012) Protocol submitted to the
Faculty of Dentistry, Cairo University, In partial fulfilment of the requirements
for Master Degree in Oral and Maxillofacial Radiology, Research Code:
Rad2:5:1
4. Kartik S et al (2017) comparative evaluation of second mesiobuccal canal
detection in maxillary first molars using magnification and illumination,
saudi endodontic journal
5. Frank J. Vertucci et.al (2005) Root canal morphology and its relationship to
endodontic procedures,Endodontic Topics 2005,10,3–29.
6. Blaine M. Cleghorn et. Al (2006) Permanent Maxillary First Molar: A Literature
Review,JOE —Volume 32,Number 9,September 2006
7. Bekir Karabucak et. Al (2016) Prevalence of Apical Periodontitisin
Endodontically Treated Premolars and Molars with Untreated Canal: A Cone-
beam Computed Tomography,StudyJOE —Volume 42,Number 4,April 2016
8. Rohan gupta et al (2019), efficacy of cone beam computed tomography in the
detection of MB2 canals in the mesiobuccal roots of maxillary first molars: an
in vitro study,journal of conservative dentistry
9. Khalid Alfouzan et.al (2019) Detecting the Second Mesiobuccal Canal in
Maxillary Molars in a Saudi Arabian Population: A Micro-CT Study, Hindawi
Scanning Volume 2019,Article ID 9568307,6 pages
10. Sanjyot mulay et al (2016), accuracy of various diagnostic aids in detection of
MB2 canal in maxillary first molar:in vivo study , jp-journals-10015-1369
11. Sashi nallapati et al (2004), use of ophthalmic dyes in root canal location,
Endodontic practice.

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