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The overleaped Endodontic canal: Exploration and management of MB2 canal by using protaper files

Introduction

 The aim of root canal treatment is meticulous cleaning, shaping and filling of the root canal system. A prerequisite for successful root canal treatment is the preparation of an adequate access cavity, location and identification of the root canal orificies. In order to achieve this it is important that the clinician have a detailed knowledge of the root canal morphology.

          To categorize the canal system in each root, Weine described four different types of configurations as follows: type I, single canal from the pulp chamber to apex; type II, two canals leaving the chamber, but merging short of the apex to form a single canal; type III, two separate canals leaving the chamber and exiting the root in separate foramina; and type IV, one canal leaving the chamber, but dividing short of the apex into two separate and distinct canals with separate foramina.       

       Hess and Zurcher1 noted the complexity of the mesiobuccal roots of first and second maxilllary molars. After the study of Weine et al,2 many similar studies were performed using different methods to assess canal morphology.3–7 The differences between these studies may be due to the examination of teeth in vivo or in vitro, using of dental loups or operating microscopes for location of the MB2 canal, radiographic examination or canal staining and root clearing method for identification of root canal system. Another reason of discrepancy between these findings may be related to racial origin of tooth sources. Previous studies have been mainly performed on teeth of American, Canadian and Japanese populations.2, 4, 8–13 Wasti et al14 found the prevalence of the MB2 canal in maxillary first molars of South Asian Pakistan 53.3% whilst Ng et al15 reported 67.8% of Burmese maxillary molars.Present case report describes the preparation and filling of mb2 canal by using protaper files

Case Report

   A thirtytwo-year-old man reported to the Department of Conservative Dentistry and Endodontics with chief complaint of pain in right upper posterior region of mouth. There was a history of spontaneous pain. On clinical examination maxillary first molar was found to be severely attrided and badly distructed by caries, and it was found to be tender on percussion. Radiographic examination revealed caries involving pulp with slight periodontal space widening.

 Rhomboidal access preparation is done, and palatal as well as mesiobuccal and distobuccal canals were located (Fig 1). On probing the groove between mesiobuccal and palatal canal orifices, another orifice was detected which was mesiopalatal to the mesiobuccal orifice. It was extremely narrow and even a No.8 instrument could not negotiate it. Hence troughing was done with a round bur, and the canal was finally negotiated.. Intraoral periapical radiograph was taken with a slight mesial angulation to reveal the type II MB2 canal.Later canal orifice were enlarged by using orifice shaper files Sx, canals were negotiated to the full length and working length estimation done by using apex locater(Root ZX) and confirmed by taking working length radiograph (Fig 2).

Initially MB2 canal is sequentially enlarged with hand files until its length.Then canal enlargement is done till the middle third by using by using S1, S2 files and till working length by using the F1 and F2 files. Master cone radiograph taken by placing cones corresponding to the F2 size (Fig 3).

Single cone obturation is done by using gutta-percha points corresponding to the F2 size by using zinc-oxide eugenol based sealer. Pre-fabricated metal post is cemented inside the palatal canal and core buildup is done by using core build up material. Tooth is prepared to receive PFM crown and cemented in its place after fabrication.

Discussion

Various methods have been proposed to locate the fourth canal first and foremost is modification of the access preparation to a rhomboidal shape for maxillary molars as compared to the classical triangular outline. This provides better visibility and accessibility. Thorough probing of the fissure or groove between the main canals was proposed in order to locate the orifice of another canal.This fissure or groove must often be deepened to remove any projections that might conceal the opening of the fourth canal. A troughing procedure must be accomplished with burs or ultrasonic instruments if the MB2 orifice was not easily identified. The MB2 orifice openings are usually found mesial to an imaginary line between the MB1 and palatal orifices, and commonly, about 2-3 mm palatal to the MB1 orifice. The MB2 canal can be challenging to negotiate. The MB1 canal normally departs the pulpal floor with only a slight mesial inclination. However, the MB2 canal usually has a marked mesial incline immediately apical to its orifice in the coronal 1 to 3 mm, so when an attempt is made to instrument the MB2, the tip of file tends to catch against the mesial wall of canal, preventing apical progress. Because the MB2 canal is smaller and usually more calcified than MB1, the problem is exacerbated. After locating the MB2 orifice, inclining the dental or ultrasonic handpiece to the distal, as far as the access preparation permits, allows the first few millimeters of this overlying "roof'' of calcified tissue to be safely eliminated. After this "refinement" of the access preparation, a more desired straight-line access can be achieved. To facilitate location and instrumentation of MB2 canal, the access has to be rhomboidal in shape to allow the necessary mesially directed shaping.On occasions, MB2 shares an orifice with MB1. When there is a shared or common orifice, it is usually oval in shape. Infrequently,the MB2 orifice is harbored within, or just apical to, that of the palatal canal. In any of the above instances, it will be very difficult, if not impossible, to observe the MB2 orifice. It is important the clinician has a strong conviction that MB2 system is present in all maxillary molars. In conjunction with dental operating microscope, a rhomboid access, and the use of specific instruments, other aids can occasionally be used to enhance the visualization of MB2 systems. They include the "champagne or bubble test" with warmed 2.6% NaOCl, staining the chamber with 1% methylene blue, the use of sharp explorers, looking for bleeding signs, and obliquely angled preoperative radiograph.It is of interest to note that the studies utilizing microscopes have reported a significantly higher percentage of MB2 canal system occurrences than the studies using other means of determination. Hence to treat maxillary  molar properly, an understanding of the morphogenesis of the mesiobuccal canal system is mandatory.

 Conclusion

   Hence while treating the maxillary molars operator should always search for additional mb2 canal, otherwise that may leads to root canal failure. Also endodontic treatment of these additional canals with rotary instruments overall reduces the time and increases the prognosis. 

References

   1. Hess W, Zurcher E. The Anatomy of the Root Canals of the Teeth of the Permanent and Deciduous Dentitions. Newyork: William Wood & Co; 1925. pp. 1–39. 

2. Weine FS, Healey HJ, Gerstein H, Evanson L. Canal configuration in the endodontic significance. Oral Surg Oral Med Oral Pathol. 1969;28:419–425. 

3. Kulild JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod. 1990;16:311–317.

4. Weine FS, Hayami S, Hata G, Toda T. Canal configuration of the mesiobuccal root of the maxillary first molar of a Japanese sub-population. Int Endod J. 1999;32:79–87. [P

5. Alavi AM, Opasanon A, Ng YL, Gulabivala K. Root and canal morphology of Thai maxillary molars. Int Endod J. 2002;35:478–485.

6. Sempira HN, Hartwell GR. Frequency of second mesiobuccal canals in maxillary molars as determined by use of an operating microscope: a clinical study. J Endod. 2000;26:673–674.

7. Gulabivala K, Aung TH, Alavi A, Ng YL. Root and canal morphology of Burmese mandibular molars. Int Endod J. 2001;34:359–370.

8. Pomeranz HH, Fishelberg G. The secondary mesiobuccal canal of the maxillary molars. JADA. 1974;88:119–124.

9. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol. 1984;58:589–599.

10. Neaverth EJ, Kotler ML, Kaltenbach RF. Clinical investigation (in vivo) of endodontically treated maxillary first molars. J Endod. 1987;13:506–512.

11. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal configurations. J Endod. 1999;25:446–450.

12. Fogel HM, Peikoff MA, Christie WH. Canal configuration in the mesiobuccal root of the maxillary first molar: a clinical study. J Endod. 1994;20:135–137.

13. Peikoff MD, Christie WH, Fogel HM. The maxillary second molar: variations in the number of roots and canals. Int Endod J. 1996;29:365–369.

14. Wasti F, Shearer AC, Wilson NH. Root canal systems of the mandibular and maxillary first permanent molar teeth of south Asian Pakistanis. Int Endod J. 2001;34:263–266.

15. Ng YL, Aung TH, Alavi A, Gulabivala K. Root and canal morphology of Burmese maxillary molars. Int Endod J. 2001;34:620–630.

 

        

 

 

 

 

 

 

 

 

 

 

 

 

About the Author

1) Dr Manjunath H Malur MDS 

 Assistant professor,Department of Conservative and Endodontics, PMNM Dental College and Hospital Bagalkot-587101, Karnataka, INDIA.  e-mail:drmanjunathmalur@gmail.com Mob-+919686878128

2) Dr Mallikarjun Goud K  MDS

Professor and Head, Department of Conservative and Endodontics,Bapuji Dental College and Hospital Davangere, Karnataka, INDIA

3) Dr Harsha Ghanti BDS

Lecturer, Department of Pedodontics, PMNM Dental College and Hospital Bagalkot-587101, Karnataka, INDIA. e-mail: ghantidrharsha4@gmail.com

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