Endodontic Miscellany MB 2 Canal

MB2
PRESENTER: Dr. Minal Daga

GUIDES: Dr. Shashit Shetty B, Prof & HOD

Dr. Gurudutt Nayak
Dr. Manoj Hans

K.D. Dental College & Hospital, Mathura

 INTRODUCTION
 A thorough knowledge of tooth morphology, careful
interpretation of angled radiographs, proper access
preparation and a detailed exploration of the interior of the
tooth are essential prerequisites for successful outcome of
root canal treatment.

 One of the biggest mysteries in endodontics is the elusive

“mesiolingual” or “mesiopalatal” (MB-2) canal in maxillary
molars.

MB-1

MB-2 DB

P
PREVALENCE OF MB -2 CANAL

 Prior to an article written by Weine et al 1 in 1969, virtually all

dentists thought the mesiobuccal root of the maxillary molars
had only one canal.

 Various researches have shown that a large number of

mesiobuccal roots contain two canals, therefore, one must
assume that MB2 does exist in the mesiobuccal root of maxillary
molars and should always search for this fourth canal.
 STUDIES SHOWING PERCENTAGE OF MB-2 CANAL IN MAXILLARY FIRST MOLAR 11

AUTHOR YEAR NO. OF % OF MB-2 1 APICAL 2 APICAL

TEETH FORAMEN FORAMEN

HESS 1925 513 53% - -

OKAMURA 1927 - 53% - -
WEINE 1969 208 51.5% 37.5% 14.0%
PINEDA 1973 245 54.3% 31.5% 22.8%
POMERANZ E COLL. 1974 100 69% 21% 48%
VERTUCCI 1974 100 55% 37.0% 18%
SMITH 1977 50 64% 20% 44%
ACOSTA VIGOUROUX 1978 134 69.4% - -

VERTUCCI 1984 100 55% 37.0% 18.0%

NEAVERTH E COLL 1987 228 77.2% 15.4% 61.8%

KULID E COLL. 1990 51 96.1% 54.2% 45.8%

GILLES E COLL. 1990 21 90% - 33%

FOGEL E COLL 1994 208 71.2% 68.3% 38.7%

STROPKO 1999 80 93% 37.5% 62.5%
STUDIES SHOWING PERCENTAGE OF MB-2 CANAL IN MAXILLARY SECOND MOLAR

AUTHOR YEAR NO. OF TEETH % OF MB-2 CANAL

NOSONWITZ & BRENNER 1973 161 31.1%

WELLER AND HARTWELL 1989 299 21.4%

KULLID & PETERS 1990 32 93.7%

SINGH et al 1994 50 66%

STROPKO 1999 310 60%

ALAVI et al 2002 65 65.4%

 ANATOMY OF MESIOBUCCAL ROOT

 From early work by Hess & Zurcher 2 in 1925 to more recent

studies demonstrating the anatomical complexities of the root
canal, roots with a conical channel and a single apical foramen
have been known to be the exception rather than the rule.

 The maxillary molars are among the largest tooth in volume

and one of the most complex in root and canal anatomy.

 Cohen10 stated that “the maxillary first molar is the most

treated but the least understood posterior tooth with highest
endodontic failure rate.”
The mesiobuccal root of maxillary molar is flat mesiodistally and
often ribbon shaped that may end in one , two or three separate
foramina.

In 1969, Weine et al 3 provided the first clinical classification of

more than one canal system in a single root and used the
mesiobuccal root of maxillary first molar as the type specimen.

MESIOBUCCAL
ROOT
Weine’s classification of MB root canal configuration

TYPE
TYPE III
TYPEIII
TYPE IV
ANATOMICAL CONSIDERATIONS IN LOCATING MB-2

MB-2 CANAL

MB-1CANAL
 Mesial wall of pulp chamber forms a very acute angle with
the floor further making MB-2 difficult to negotiate.

 On occasions, MB-2 shares an orifice with MB1.When there

is shared or common orifice it is usually oval in shape.

.
LOCATION OF MB - 2
 PROTOCOL FOR LOCATING MB-2 CANAL

 There are a number of strategies that, when used in

combination, greatly increases the identification of MB2 orifice
and system. The most useful concepts and techniques are as
following 9:-

1. First of all strongly believe that, MB2 is always present!

2. Knowledge of intricate anatomy of root canal system.

3. Modify the classical triangular outline form of the access
preparation to rhomboidal.
 4. Use of magnification, in the form of loupes (x2.0 to x6.0) &
operating microscope (x4.0 to x30.0) has tremendously
increased the identification of mb-2 canals.
5. Start looking for MB2 only after MB1 is completely cleaned
and shaped and is ready for obturation.
6. Use a piezo-electric ultrasonic unit along with specially
designed tips(CPR, ProUltra) to remove the dentinal shelf
hiding the underlying orifice.
 7. Troughing procedure should be carried out if MB2 orifice is not
easily identified either with ultrasonic tips or with burs. The
idea is to remove the calcification.

Burs specifically recommended to be used are :

Ultrasonic tip

Munce discovery burs LN Bur Moller Burs

8. Use of microopeners also aid in locating canal orifices.
9. Use of dyes can help locating orifices in the pulp chamber.
Sable seek, methylene blue, or ophthalmic dyes (e.g.
fluorescein sodium, rose bengal) are appropriate choices.

Methylene blue dye Fluorescein sodium strips

10. Transilluminating the pulp chamber with an external fiber
optic light source allows differentiation of sclerotic dentin from
normal dentin. This in turn allows precise removal of the
sclerotic dentin to locate root canal orifices.
11. Presence of hemorrhagic spots on the pulpal floor
indicates the site of canal orifices.
12. White line test - During access preparation the dentin powder
created by drilling often collect along the groove joining the
orifices. This forms a white line that guides way to the orifice

MB-1

WHITE LINE
13.Champaign bubble test – When the pulp chamber is flooded
with warm solution of 5% sodium hypochlorite, bubbles are
visualized emanating from organic tissue indicating presence
of canals.

14. Irrigating with 17% EDTA to remove the smear layer, then
with pure alcohol enhances accessibility.
 15. Conventional Radiographs -Use multiple straight and
obliquely angled radiographs both preoperatively and
intraoperatively.
16. Specialized Radiographic Imaging

 The amount of information gained from conventional

radiographs and digitally captured periapical radiographs is
limited by the fact that the three-dimensional anatomy of the
area being radiographed is compressed into a two-dimensional
image. 4

 Newer diagnostic methods such as computerized axial

tomography (CT) scanning and cone beam computed
tomography (CBCT) 5,6,7,8 greatly facilitate access to the internal
root canal morphology.
 One distinct advantage of CT scanning over the conventional
radiograph is that it allows the operator to look at multiple
slices of tooth roots and their root canal systems.4

 Various investigations have shown that CBCT scanning

resulted in the identification of greater number of root canal
systems than digital images & is one of the a good method for
initial identification of maxillary molars internal morphology.
NEGOTIATING MB-2 CANAL

●
First exploratory file to be inserted
in the MB-2 canal should be no. #06
or no. #08 or no. #10.

●
In order to create access, the file tip
should be worked to the point where
resistance is met, pulling the file to the
mesial to remove the overhanging dentin.
●
A thin film of water or alcohol
enhances visibility at this point

●
One can hold the file with a
hemostat to increase visibility.
●
Once the operator gains experience
ultrasonics or burs can be used to
make the orifice more visible.

●
When the initial access glide path is
sufficient, the file begins to increase
its penetration of the canal space.
●
Slow and incremental removal of the cervical
ledge obscuring the true path of the MB2
canal following watch winding approach will
enable accurate negotiation of the full canal
length with time and patience.

●
The mesiobuccal root often curves
distally, hence anticurvature filling 39
should be done while keeping in mind
the change in working length that
follows.
 CONCLUSION

 “Success is the ability to go from one failure to another

with no loss of enthusiasm’’.

 Various studies have proved that the maxillary molars has

some of the highest failure rates in endodontic treatment due to
the presence of a second canal in the mesiobuccal root that the
clinician fails to detect, debride and obturate.

 The increased operator experience, increased time per

appointment and the use of an operating microscope results in
an increase in the number of MB-2 canals located.
 REFERENCES
1. Weine FS, Healy HJ, Gerstein H, et al. Canal configuration in the mesiobuccal root of the maxillary
first molar and its endodontic significance. Oral Surg. 1969;28:419-425.
2. Hess W, Zurcher E, eds. The anatomy of the root canals of the teeth of the permanent and deciduous
dentitions. New York: William Wood and Co; 1925.
3. Weine FS. Endodontic Therapy. 5th ed. St Louis, Mo: Mosby; 1996.
4. Patel S, Dawood A, Whaites E, et al. New dimensions in endodontic imaging: part 1. Conventional
and alternative radiographic systems. Int Endod J 2009;42:447–62.

5. Patel S, Dawood A, Ford TP, et al. The potential applications of cone beam computed tomography in
the management of endodontic problems. Int Endod J 2007;40: 818–30.
6. Nair MK, Nair UP. Digital and advanced imaging in endodontics: a review. J Endod 2007;33:1–6.
7.Cotton TP, Geisler TM, Holden DT, et al. Endodontic applications of cone-beam volumetric
tomography. J Endod 2007;33:1121–32.
8.Tyndall DA, Rathore S. Cone-beam CT diagnostic applications: caries, periodontal bone assessment,
and endodontic applications. Dent Clin North Am 2008;52:825–41.
9. RUDDLE, C.J.:Microendodontics : Identification & treatment of MB2 system. J. Calif. Dent. Assoc
25:313, 1997.
10.Frank J. Vertucci, etal :Tooth morphology & access cavity preparation , Pathways of the pulp:
Stephen Cohen, 9 edn.
11.MARINI, R., DOMINI, R., BERUTTI, E.,: La presenza del quarto canale nei primi molari superiori.
Min Stom. 35: 137, 1986.
Thank you