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JOURNAL OF ENDODONTfCS
Copyright 1995 by The American Association of Endodontists
Incidence and Position of the Canal Isthmus.
Part 1. Mesiobuccal Root of the Maxillary
First Molar
R. Norman Weller, DMD, MS, Stephen P. Niemczyk, DMD, and Syngcuk Kim, DDS, PhD
The mesiobuccal roots of 50 randomly selected
maxillary first molars were examined to assess the
incidence and position of the canal isthmus. Trans-
verse serial sections of the apical 6 mm of each
root were prepared in 1-mm increments. The apical
side of each section was stained with methylene
blue dye, viewed with a surgical operating micro-
scope, and videotaped.
Forty percent of the roots had one canal,
whereas 60% had two canals. None of the sections
had more than two main canals. The incidence of
an isthmus was highest in the apical 3- to 5-mm
levels. In teeth that had two canals, the 4-mm sec-
tions contained a complete or partial isthmus
100% of the time. The concept of a partial isthmus
was presented.
Failure to deal with the isthmus may explain why
some posterior teeth do not heal completely fol-
lowing endodontic surgery.
The success rate of surgical endodontics in posterior teeth is often
less than in anterior teeth. Friedman et al. (1) reported successful
results in only 44.1% of the premolars and molars treated. Other
authors (2-4) showed 71 to 73% success in apicoectomized mo-
lars. However, successful treatment in anterior teeth was reported
to be as high as 85 to 90% (5-7).
The maxillary first molar and, in particular, the mesiobuccal
root of this tooth, is frequently treated surgically (8). However, the
successful healing is lower than the mandibular first molar follow-
ing surgery (9). Possible factors affecting the success of endodon-
tic surgery are the complexity of the surgical procedure, untreated
root canals, or a poor apical seal of the root canal system. Another
factor that is not often considered is the canal isthmus.
An isthmus is a narrow, ribbon-shaped, communication between
two root canals that contains pulp or pupally derived tissue. It is
also known as a corridor (10), a lateral interconnection (11), or a
transverse anastamosis (12). Any root that contains two root canals
has the potential to contain an isthmus. The reported incidence of
an isthmus in the mesiobuccal foot of the maxillary first molar
380
Printed in U.S.A.
VOL. 21, No. 7, JuLY 1995
varies. Pineda (11) reported interconnections in 4.9% of the roots
examined. This percentage is definitely lower than the 16% re-
ported by Green (10) and the 30.1% reported by Cambruzzi and
Marshall (13). The highest percentage of an isthmus (52%) was
found by Vertucci (12). He also reported that 75% of the anasta-
moses were located in the middle and 15% were in the apical third
of the root.
Because of the possible importance of the canal isthmus in
surgical endodontics, especially in the mesiobuccal root of the
maxillary first molar, a more detailed investigation was under-
taken. The purpose of this study was to determine the incidence
and location of the isthmus. The type of root canal configuration
and the level of canal bifurcation or convergence were also exam-
ined.
M A T E R I A L S AND M E T H O D S
Fifty human maxillary left and right first molars were randomly
selected and stored in 10% formalin. The age, sex, and race of the
patients were unknown. The identification of these teeth as max-
illary first molars was confirmed by accepted criteria (14).
Using an ultrathin separating disk (Jel-Thin 9'S; Jelenko, Ar-
monk, NY), the mesiobuccal crown and root were resected in one
piece. The first cut was made through the buccal furcation to the
palatal root. The second cut was directed through the mesial
furcation and joined the first cut. The opening into the pulp
chamber was sealed with wax to prevent embedding material from
entering the root canal system.
Each root was embedded separately in clear resin (Caulk/
Dentsply, Milford, DE). Starting at the root apex, serial transverse
sections were made perpendicular to the long axis of the root, with
a low-speed diamond saw (Buehler Ltd., Evanston, IL) at 1-mm
increments to a level 6 mm from the apex. Each section was placed
in 5.25% sodium hypochlorite (Clorox; Clorox Co., Oakland, CA)
for 24 h to remove any organic material remaining in the root
canal. No endodontic instruments were placed into the root canals
of any specimen. Each section was rinsed in water and dried.
The serial sections of each root were arranged from the 1-mm
level to the 6-mm level. Only the apical sides of each section were
evaluated. The resected surface was stained with 2% methylene
blue dye (The Coleman & Bell Co., Norwood, OH) and examined
Vol. 21, No. 7, July 1995 Canal Isthmus 381

FIG 1. Representative examples of sections with a complete isthmus FIG 2. Representative examples of sections with a partial isthmus
(original magnification x32). (arrow) (original magnification x32).

TABLE 1. Canal configurations in the mesiobuccal root of TABLE 2. Level of convergence of type II canals
maxillary first molars
Level from No. of %
Canal No. of % Apex (mm) Roots
Configuration Roots 6
Type I 20 40 5
Type II 10 20 4 3 30
Type III 17 34 3 3 30
Type IV 3 6 2 4 40
1
Total 50 100
Total 10 100

with a surgical operating microscope (.lED MED Instrument Co., TABLE 3. NO. of canals at each level
St. Louis, MO) at X32 magnification. A videotape of each level
Level from No. with % No. with %
was made for evaluation. Apex (mm) 1 Canal 2 Canals
Using this videotape, two of the authors simultaneously viewed
6 23 46 27 54
each section and determined the number of root canals present and
5 21 42 29 58
the presence or absence of an isthmus. If an isthmus was present, 4 25 50 25 50
it was classified as complete or partial. A complete isthmus was 3 29 58 21 42
one with a continuous, narrow opening between the two main root 2 30 6O 20 4O
canals (Fig. 1). A partial isthmus was classified as an incomplete 1 37 74 13 26
communication with one or more patent openings, through the
section, between the two main canals. The opening could be of any
size (Fig. 2). After all the sections were evaluated, the type of canal canals that merged short of the apex to form a single root canal. A
configuration present in each root was classified according to type III configuration had two separate canals through each sec-
Weine (15). Briefly, a type I configuration had a single canal tion. Finally, a type IV configuration had a single canal that
present at each level. A type II configuration had two separate divided short of the apex into two separate root canals.
382 Weller et al. Journal of Endodontics

TABLE 4. Incidence of an isthmus at each level in sections with two canals

Level from No. with

NI % CI % PI % CI + PI %
Apex (ram) 2 Canals
6 27 5 18.5 4 14.8 18 66.7 22 81.5
5 29 5 17.2 4 13.8 20 69.0 24 82.8
4 25 0 0 3 12.0 22 88.0 25 100.0
3 21 2 9.5 3 14.3 16 76.2 19 90.5
2 20 7 35.0 1 5.0 12 60.0 13 65.0
1 13 9 69.2 1 7.7 3 23.1 4 30.8
NI, no isthmus; CI, complete isthmus; PI, partial isthmus.

![ [ Complete Isthmus (CI}
[] Partial isthmus (Pi)
[] Total Isthmus (el + Pl)
40
i i i i
1 2 3 5 5
Level from Apex (ram)
FIG 3. Percentage of a complete isthmus, a partial isthmus, and the
total number of isthmuses at each level (mm) from the apex.
RESULTS
The results are listed in Tables 1 to 4. One root canal was found
in 40% of the roots examined, and two canals were present 60% of
the time (Table 1). All of the canals classified as type II converged
into one canal within 2 to 4 mm of the apex (Table 2), whereas in
three roots the canals that bifurcated into two separate canals (type
IV) did so more than 3 mm from the root apex.
Table 3 shows the number of canals at each level within the root.
None of the sections had more than two main root canals. For those
sections with two canals (Table 4 and Fig. 3), the incidence of an
isthmus, either complete or partial, was highest in the 3- to 5-ram
sections. For instance, the 4-ram sections contained a complete
isthmus 12% and a partial isthmus 88% of the time for a combined
total of 100%.
DISCUSSION
The number of root canals and canal configurations (Table 1) in
the present investigation are in agreement with previous studies
(10-12). It is possible, however, that had the entire root been
sectioned, the types of canal systems might have been different.
For instance, those roots classified as type I might have had two
canals more coronally (type II). Likewise, a type III system could
have been a type IV canal.
Weine et al. (16) defined a type II configuration as a larger
buccal canal and a smaller lingual canal that merge from 1 to 4 mm
from the apex. All of the roots that were classified as type II in this
investigation joined 2 to 4 mm from the apex (Table 2). This is
important because, when a root is surgically resected, the lingual
canal may be exposed. If that canal had not been obturated before
the surgical procedure, then the untreated canal could contribute to
failure of the case unless identified and sealed with a retrofilling.
The same principles hold true for type III canal configurations.
The incidence of a complete isthmus in this study was much
lower than the reports by Cambruzzi and Marshall (13) and Ver-
tucci (12). Cambruzzi and Marshall (13) examined the beveled
surface of both maxillary first and second molars. They did not
report the incidence in each tooth, but only reported a combined
number. It is possible that more isthmuses were present in the
second molars than in the first molars. Vertucci (12) examined the
entire root canal systems of transparent specimens. Even though he
reported a 52% incidence of transverse anastamoses, only 15%
were found in the apical third of the root. This more closely agrees
with our findings.
The concept of a partial isthmus has not been presented before.
Any openings on the resected root surface may contain microor-
ganisms or necrotic tissue or act as a portal of exit for an unin-
strumented or unfilled part of the root canal system. This may
explain why some cases of apparently well-obturated and sealed
canals do not heal following endodontic surgery. Continued leak-
age through a complete or partial isthmus could prevent a success-
ful result.
There were many more sections at each level of the root con-
taining a partial isthmus than a complete isthmus (Fig. 3). When-
ever any part of the mesiobuccal root is resected, and two main
canals are located, the results of this study indicate that the pres-
ence of an isthmus must be assumed. The area between the two
canals should always be prepared and sealed with a retrofilling.
Several factors made visualization of the apical morphology
possible. Methylene blue dye was used to stain each section. The
dye made it easier to see each root canal and isthmus present. The
operating microscope was also invaluable to this investigation. The
high-intensity light and high magnification made viewing of even
the partial isthmus openings possible.
In the past, not only was the canal isthmus often overlooked, but
it was also very difficult to prepare if located. Now, with the advent
of microscopic endodontic surgical techniques, we are able to view
the resected surface of the root better, identify the isthmus, prepare
it with an ultrasonic tip, and seal it with appropriate materials. The
recognition and treatment of the canal isthmus may be one factor
that will reduce the failure rate of surgical endodontics in posterior
teeth, especially the mesiobuccal root of the maxillary first molar.
Dr. Weller is director, postgraduate endodontJcs;Dr. Niemczyk is director,
undergraduate endodontics; and Dr. Kim is chairman, Department of End-
odontics, School of Dental Medicine, University of Pennsylvania,Philadelphia,
PA. Address requests for reprints to Dr. Syngcuk Kim, Louis I. Grossman
Professor and Chairman, Department of Endodontics, School of Dental Med-
icine, University of Pennsylvania, 4001 Spruce Street, Philadelphia, PA
19104- 6003.
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A Word to the Wise

We seem to have a surfeit of disputacious by nature persons in our society. A tactic common to such folk
is the use of the phrases, "just for the sake of argument" or "to play the Devil's advocate," by which they then
introduce mindless, time-wasting, and irrelevant "issues." This plague on modern life could be averted by
heeding C. S. Lewis' assessment of a raised objection that it was "in one sense very right, very charitable
...and very sensitive. It has every amiable quality except that of being useful."

Zachariah Yeomans