middle mesial canal

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Mandibular first molar middle mesial canal : 

Mandibular first molar middle mesial canal Carmen Cohn

Slide 2: 

With the advent of magnification, the astute clinician must be aware of literature reports that state that the mandibular first molar has a 1-15 % chance of a fifth canal. Middle mesial canal of the mandibular first molar: a case report and Literature review. Baugh. JOE 2004

Slide 3: 

Middle mesial canal of the mandibular first molar: a case report and Literature review. Baugh. JOE 2004

Slide 4: 

Fabra – Campos (1989): 760 first mandibular molars 20 (2.6 %) had three canals in the mesial root. 13 (65 %) intermediate canal joined the mesiobuccal canal in the apical third. 6 (30 %) it joined the mesiolingual canal in the same area. 1 case - the intermediate or third canal retained its individual nature and ended in an independent foramen.

Slide 5: 

Pomeranz’s Classification for Middle Mesial Canals (1981) Fin - when an instrument could pass freely between the mesiobuccal or mesiolingual canal and the middle mesial canal Confluent -when the canal originated as a separate orifice but joined the mesiobuccal or mesiolingual canal in the apical third of the canal Independent - if it remained separate from orifice to apical foramen

Slide 6: 

Dr. Castellucci

Slide 7: 

Dr. Castellucci

Slide 8: 

Dr. J Avillon

Slide 9: 

Dr. M. Dreyer

Slide 11: 

Dr. M. Dreyer

Slide 12: 

Dr. D. Rakich

Slide 14: 

Dr. Rajiv Patel

Slide 15: 

Many reports deal with three orifices in the mesial root, but very few describe three independent canals, indicating a rare anatomical configuration. Three independent canals in the mesial root of a mandibular first molar. Ricucci. Endod Dent Traumatol. 1997

Slide 16: 

Apical foramina: in mesial root two apical foramina were observed in 60 percent of specimens, three in 6.7 percent and four in 3.3 percent (n=60 teeth). (Goel 1991 Study of root canals configuration in mandibular first permanent molar). The morphological pattern of separate apical terminations of the three mesial root canals, is a very rare one (Holtzmann 1997 Root canal treatment of a mandibular first molar with three mesial root canals).

Slide 18: 

Dr. Dan Shalkey

Slide 19: 

Dr. D. Rakich

Slide 22: 

Dr J. Khademi

Slide 23: 

“This is not an extra canal but rather the sequelae of instrumenting the isthmus between the mesiobuccal and mesiolingual canals.” Mandibular first molars with three mesial canals. Mortman. Gen Dent. 2003

Slide 24: 

Isthmus?

Slide 25: 

Isthmus - a narrow, ribbon-shaped communication between two root canals, that contains pulp tissue (Weller 1995)

Slide 26: 

The incidence of canal isthmuses in mesial roots of mandibular first molars ranges from 54 to 89% (Hsu & Kim 1997). In studies evaluating serial sections at different levels from the apex, the highest incidence of canal isthmuses in mesial roots of mandibular first molars was found at 3-5 mm from the apex (Weller 1995, Hsu & Kim 1997, Teixeira 2003)

Slide 27: 

Type I Type II Type III Type IV Type V Frequency and type of canal isthmuses in first molars detected by endoscopic inspection during periradicular surgery.Von Arx Int Endod J. 2005 Mandibular first molar Mesial root (n=52) One canal (no isthmus) 3 (6%) Two canals (no isthmus) 6 (11%) Two canals (with isthmus) 43 (83%) Mesial roots of mandibular first molars most often presented with type IV and V canal isthmuses.

Slide 28: 

Courtesy Dr. B. Schein

Slide 29: 

Von Arx Int Endod J. 2005

Slide 30: 

So, what do we treat, canal or isthmus… …or BOTH?

Slide 31: 

Clinical case Courtesy Dr. D. Shalkey

Slide 32: 

Failure 11 months p.o.

Slide 33: 

There was no indication of a third mesial canal or an isthmus between the MB and ML canals in the chamber.

Slide 34: 

???

Slide 35: 

Huge lateral canal coming off the ML canal.

Slide 37: 

Coronal Apical Isthmus Middle mesial (no isthmus!)

Slide 38: 

With the high isthmus incidence in mind, we should search for any permeable space in the mesial root anatomy and clean, shape and obturate it as thorough as possible. Never forget that even a rare occurrence, the presence of additional POE in the mesial root of mandibular teeth is possible and when not sealed, could lead to failures of the RCT.

Slide 39: 

It is very difficult to completely clean an isthmus, especially at 3-5 mm from the apex. If a canal performed in an isthmus is helping its cleaning and shaping , we can do as many canals as possible (without damaging the root structure) in order to divide the isthmus and facilitate the access of disinfectants to spaces that files can’t reach.

Slide 40: 

Conclusions: The difficulties in cleaning and shaping the canal system of the mesial root during conventional root canal treatment may lead to eventual failure necessitating retreatment. The relatively high incidence of canal isthmuses in mesial roots of mandibular molars indicates the necessity to carefully explore the root anatomy searching for every additional ‘way’ through this intricate system, and its possible portal of exit (POE).

Slide 41: 

Thank you