Clinical Research
Prevalence of Middle Mesial Canals and Isthmi in
the Mesial Root of Mandibular Molars: An
In Vivo Cone-beam Computed Tomographic
Study
Mehrnaz Tahmasbi, DDS,* Poorya Jalali, DDS,† Madhu K. Nair, DMD, MS,*
Sevin Barghan, DMD, MS,* and Umadevi P. Nair, DMD, MDS‡
Abstract
Introduction: Many studies have investigated the
morphology of the mandibular molar, but the prevalence
of the middle mesial (MM) canal in the mesial root of the
mandibular molar is still the subject of controversy. In
addition, in previous literature, a true MM canal has
not been clearly distinguished from an isthmus between
the mesiobuccal and mesiolingual canals. Therefore, the
objectives of this study were 2-fold:
1. To identify the prevalence of a true MM canal and/or
isthmus in the mesial root of mandibular molars us-
ing a sample of cone-beam computed tomographic
images
2. To analyze the configuration of MM canals and
isthmi in the mesial root of mandibular molars
Methods: Ninety limited field of view cone-beam
computed tomographic scans were observed. One hun-
dred twenty-two mature mandibular first and second
molars with no previous root canal treatment, no root
resorption, and intact crowns were retrospectively eval-
uated. Data regarding the sex, age, presence of MM ca-
nals, and number of root canals in the mesial root were
recorded. Result: Of the 122 teeth, 20 (16.4%) had true
MM canals. The prevalence of MM canals was 26% in
first molars and 8% in second molars (P < .05). The fre-
quency of isthmi in the mesial roots was 69.6%. The fre-
quency of isthmi was higher in second molars, but the
difference was not statistically significant (P > .05).
Conclusions: This study showed a high prevalence of
mandibular molars with MM canals or isthmi. The detec-
tion and biomechanical cleaning of these areas during
nonsurgical or surgical root canal treatment are critical.
(J Endod 2017;-:1–4)
From the *Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida Colleges of Dentistry and Medicine, Gainesville, Florida; †Department of
Endodontics, Texas A&M University College of Dentistry, Dallas, Texas; and ‡Department of Endodontics, University of Florida, Gainesville, Florida.
Address requests for reprints to Dr Uma P. Nair, Department of Endodontics, University of Florida, PO Box 100436, Room D10-39, Gainesville, FL 32610. E-mail
address: upnayar@gmail.com
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.02.008
JOE — Volume -, Number -, - 2017
Key Words
Cone-beam computed tomographic imaging, isthmus, mandibular molar, middle mesial
canal, root canal anatomy
A lthough the etiology of
failure in endodontic
treatment is multifactorial,
Significance
A high prevalence of MM canals (16.4%) and isthmi
(69.6%) was observed in the mandibular first and
the inability to identify and
second molars. The detection and biomechanical
debride all the existing ca-
cleaning of these areas during nonsurgical or surgi-
nals is one of the main
cal root canal treatment are critical.
causes that can negatively
affect a successful out-
come (1). It has been shown that there is a strong relationship between the presence
of untreated canal space and apical periodontitis (2). Therefore, a thorough knowledge
of the internal root canal anatomy is required to achieve the main objective of endodon-
tic treatment, which is to prevent or heal apical periodontitis (3). However, the vari-
ability in number and configuration of the canals can pose some clinical challenges
and prevent the clinician from achieving this goal.
Many studies have investigated the morphology of the mandibular molar, but the
prevalence of the middle mesial (MM) canal in the mesial root of the mandibular molar
is still the subject of controversy. Various methods have been used for detection of the
MM canal, and the frequency with which the canal was observed ranges between 0% (4)
and 46.2% (5). In addition, the MM canal has not been clearly defined in the literature.
Pomeranz et al (6) defined the MM canal as either a fin, confluent, or independent canal
between the mesiobuccal (MB) and mesiolingual (ML) canal. However, in this defini-
tion, a true canal is not clearly distinguished from an isthmus between the MB and ML
canals. Therefore, the objectives of this study were 2-fold:
1. To identify the prevalence of a true MM canal and isthmus in the mesial root of
mandibular molars using a sample of cone-beam computed tomographic (CBCT)
images obtained from a population in Florida
2. To analyze the configuration of MM canals and isthmi in the mesial root of mandib-
ular molars
Mid-mesial Canals and Isthmus Prevalence in Mesial Roots of Mandibular Molars 1
Clinical Research
Materials and Methods
The project protocol was reviewed and approved by the institu-
tional review board. CBCT images of 90 patients were randomly selected
from the database of the oral and maxillofacial radiology department.
All the images were small field of view (FOV) CBCT studies that were
taken between January 1, 2011, and January 1, 2015, as part of a dental
examination for diagnosis and treatment planning purposes.
The CBCT unit used in this study was the CS 9000 3D (Carestream
Health, Inc, Rochester, NY) with an isotropic voxel size of 76 mm
and FOV of 50  37 mm. Exposure parameters were 60–90 kVp and
6–15 mA.
The CBCT images were viewed with Carestream Dental Imaging
Software 3D module v2.4 (Carestream Health, Inc) on a Dell Profes-
sional P2213 workstation (Dell, Round Rock, TX) with a 22-inch
Dell light-emitting diode monitor with a resolution of 1680  1050
pixels in a dimly lit room. The window/level of the images was adjusted
using the image processing tool in the software to ensure optimal visu-
alization. Two observers, an oral and maxillofacial radiology resident Figure 2. An axial CBCT image showing the middle mesial canal of tooth #18.
and a board-certified endodontist, were calibrated based on the criteria The arrow points to the isthmus.
and variants established before the evaluation session. All images were
analyzed simultaneously to reach a consensus for the interpretation of were classified into 6 categories based on the location of the MM canal/
the radiographic findings. Multiplanar images were interactively exam- isthmus beginning and end (7).
ined in a sequential fashion in all 3 dimensions, and findings were After data collection, data entry was performed in Excel (Micro-
correlated across these images to arrive at a conclusion. soft, Redmond, WA), and data analysis was performed with the help
Based on a previous study (6), a sample calculation was per- of Statistical Package for Social Sciences version 22 (SPSS Inc, Chicago,
formed using 95% confidence intervals. Approximately 120 to 130 IL). Differences in the prevalence of the MM canal and isthmus were
cases were needed to have a precision of 5%. Only first and second
mandibular permanent molars with no previous root canal treatment
and/or full-coverage restoration were included in the study. Teeth
with open apices, root resorption, or calcification were excluded
from the study. All teeth were analyzed using 3 planes (sagittal, axial,
and coronal). During examination of the teeth, the number of roots,
the number of root canals in the mesial root, and the configuration
of the root canal system in the mesial root were determined and re-
corded. In addition, the age and sex of each patient were recorded,
and patients were classified into 4 age groups: <20, 21–40, 41–60,
and >60. In the axial view, an isthmus was recorded when a narrow
ribbon-shaped communication was visualized between the MB and
ML canals. The MM canal was recorded when a radiolucency with a
distinct round cross section was visualized between the MB and ML
canals regardless of the presence or absence of an isthmus. The findings

Figure 1. A coronal CBCT image showing the middle mesial canal of tooth Figure 3. A coronal CBCT image showing the isthmus of tooth #19. The
#18. The arrow points to the middle mesial canal. arrow points to the middle mesial canal.

2 Tahmasbi et al. JOE — Volume -, Number -, - 2017


TABLE 1. Distribution of the Isthmi and Middle Mesial (MM) Canals Based on Their Presence in Different Axial Slices
Isthmus only, n (%)
Cervical third 37 (30.3)
Middle third 18 (14.8)
Apical third 54 (44.3)
The occurrence of a single isthmus or MM canal at more than one axial location was considered, which explains the cumulative frequency of more than 100%.
compared using the chi-square test. The level of significance was set at
P < .05.
Results
One hundred twenty-two mandibular first and second molars of 90
patients (34% males and 66% females, mean age = 45 years) were
analyzed. Of the 122 teeth, 20 (16.4%) had MM canals. The prevalence
of the MM canal was 26% in first molars and 8% in second molars
(P < .05) (Figs. 1 and 2). There was no statistically significant
difference between sex and prevalence of the MM canal, but
prevalence of the MM canal was significantly higher in the age group
of 41–60 years (P < .05). Among the 20 MM canals identified, 4 had
a separate orifice from the MB and ML canals, 8 shared the same
orifice with either the MB or ML canal, and the rest were branching
off from either the middle or the apical third of the MB or ML canal.
Only 3 of 20 MM canals had a separate apical foramen.
The frequency of isthmi in the mesial roots was 69.6%. The fre-
quency of isthmi was higher in second molars, but the difference
was not statistically significant (P > .05) (Fig. 3). In 30.3% of the
cases, isthmi were present in the cervical third, 14.8% in the middle
third, and 44.3% in the apical third (Table 1). Nineteen molars
(15.5%) had isthmi beginning from the cervical third and
continuing into the apex. In addition, among all the mandibular first
and second molars, 8 second molars with C-shaped canals (6.5%),
1 radix entemolaris (0.8%), and 1 4-rooted second molar were
identified. The distribution of isthmi and MM canals are shown in
Tables 1 and 2.
Discussion
Various techniques have been used to study the root canal
morphology of mandibular molars, and each method has some advantages
and disadvantages. The methods that were used in in vitro studies include
plastic casts (4), staining and clearing (8), an operating microscope (9),
and micro–computed tomographic imaging (10–12). Although some of
these techniques allow a thorough analysis of fine details of the root
canal system, it can be argued that because of the possibility of previous
endodontic or periodontal disease and root canal calcifications,
extracted teeth are not fair representatives of healthy human teeth. This
may explain why the prevalence of the MM canal reported in most of
the previous studies on extracted teeth was lower than that reported in
this study. To the best of our knowledge, there is no study evaluating the
accuracy of CBCT imaging for detecting MM canals. However, it has
TABLE 2. Distribution of Isthmi and Middle Mesial (MM) Canals in Mandibular Molars Based on the Location of the MM Canal or the Isthmus’s Beginning and End
Isthmus only, n (%)
Confined to cervical third 15 (12.3)
Cervical third to middle third 3 (2.4)
Cervical third to apical third 20 (16.4)
Confined to middle third 7 (5.7)
Middle third to apical third 8 (6.6)
Confined to apical third 26 (21.3)
Total 79 (64.7)
JOE — Volume -, Number -, - 2017
Clinical Research
MM canal, n (%) Isthmus or MM canal, n (%)
13 (10.7) 50 (41)
16 (13.1) 34 (27.9)
11 (9) 65 (53.3)
been shown that the accuracy of CBCT imaging with a 6  6 FOV and a
voxel size of 0.125 is 96% for detecting the second MB canal (13). In
this study, the CBCT imaging that was used had a smaller FOV and voxel
size compared with their study, and the image artifacts were reduced by
excluding root canal–treated teeth and teeth with full-coverage restora-
tions. Therefore, we can confidently infer that the method that was used
in this study was accurate in detecting MM canals.
Clinical in vivo studies with an operating microscope have the
advantage of exploring negotiable MM canals in nonextracted teeth
(5, 14); however, differentiating a true MM canal from an isthmus
may not be practical (5). This factor may have accounted for a higher
incidence of MM canals in those studies (46% and 20%, respectively)
compared with this study, in which a true canal was differentiated from
an isthmus between the ML and MB canals. In this study, true MM canals
were detected in 16.4%, and isthmi were detected in 64.7% of cases. We
found that 10.7% and 30.3% of total cases had MM canals and isthmi
beginning from the cervical third, respectively. Therefore, in total,
41% of cases had spaces between the MB and ML canals (either in
the form of a true canal or isthmus), which would be likely negotiable
and detectable clinically because of their cervical location in the root.
This finding is consistent with a study by Azim et al (5) in which com-
bined true MM canals and isthmi were detected in 46% of mandibular
molars under magnification after troughing in the mesial root within a
2-mm depth.
The question is, regardless of the nature of the space between the
MB and ML canal, is it necessary to instrument this space? The apical
part of the canal is the most critical domain for therapeutic and patho-
genetic reasons (15). Findings of this study show that in only 2.4% of the
total cases did MM canals exit from a separate apical foramen. Although
this finding should not be clinically translated as the cleaning and
shaping of these canals being insignificant, this may imply that missing
an MM canal in a mandibular molar may not be as dramatic as missing a
second MB canal in a maxillary molar, in which 46% of cases have a
separate apical foramen (16). Despite this, the answer to the previous
question is clear. It has been shown that there is an association between
untreated canals and isthmi and apical periodontitis (2, 15). The
untreated canals and isthmi can be covered with biofilm or even
further clogged with bacteria in treated cases. Also, if not
instrumented, these areas would not be reached by disinfecting
irrigants (15). Even if the irrigant reaches these spaces alone, it may
not be effective in eradicating the biofilm (15). Therefore, irrespective
of the presence of an MM canal or isthmus, it is recommended to instru-
ment and thoroughly irrigate these areas.
MM canal, n (%) Total, n (%)
0 15 (12.3)
8 (6.6) 11 (9)
4 (3.3) 24 (19.7)
1 (0.8) 8 (6.5)
7 (5.7) 15 (12.3)
0 26 (21.3)
20 (16.4)
Mid-mesial Canals and Isthmus Prevalence in Mesial Roots of Mandibular Molars 3
Clinical Research
In addition, in the present study, the combined prevalence of the
isthmus and the MM canal in the apical third of the mesial roots was
53.3%. This finding is inconsistent with an in vivo study (17) that eval-
uated the frequency of canal isthmi in mandibular first molars during
root end surgery. In that study, a frequency of 83% was reported for
isthmi (with or without MM canals) in the mesial root; however, the
samples included in the study were limited to molars subjected to
root end surgery. Considering that the presence of isthmi in those sam-
ples may have been one of the etiologies of failure in the first place, this
may explain the higher prevalence of isthmi reported in their study
compared with the present study.
In conclusion, the presence of a canal isthmus is one of the main
causes of failure of nonsurgical and surgical endodontic treatments in
mandibular molars (18). Isthmi or MM canals at the apex of the mesial
root may act as portals of exit; therefore, detecting and cleaning these
areas during surgical root canal treatment is a critical step.
Acknowledgments
The authors deny any conflicts of interest related to this study.
References
1. Crump MC. Differential diagnosis in endodontic failure. Dent Clin North Am 1979;
23:617–35.
2. Karabucak B, Bunes A, Chehoud C, et al. Prevalence of apical periodontitis in
endodontically treated premolars and molars with untreated canal: a cone-beam
computed tomography study. J Endod 2016;42:538–41.
3. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med
Oral Pathol 1984;58:589–99.
4. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first
molar. Oral Surg Oral Med Oral Pathol 1971;32:778–84.
4 Tahmasbi et al.
5. Azim AA, Deutsch AS, Solomon CS. Prevalence of middle mesial canals in mandib-
ular molars after guided troughing under high magnification: an in vivo investiga-
tion. J Endod 2015;41:164–8.
6. Pomeranz HH, Eidelman DL, Goldberg MG. Treatment considerations of the middle-
mesial canal of mandibular first and second molars. J Endod 1981;7:565–8.
7. Estrela C, Rabelo LE, de Souza JB, et al. Frequency of root canal isthmi in human perma-
nent teeth determined by cone-beam computed tomography. J Endod 2015;41:1535–9.
8. Gulabivala K, Aung TH, Alavi A, et al. Root and canal morphology of Burmese
mandibular molars. Int Endod J 2001;34:359–70.
9. Karapinar-Kazandag M, Basrani BR, Friedman S. The operating microscope en-
hances detection and negotiation of accessory mesial canals in mandibular molars.
J Endod 2010;36:1289–94.
10. Villas-B^oas MH, Bernardineli N, Cavenago BC, et al. Micro–computed tomography
study of the internal anatomy of mesial root canals of mandibular molars. J Endod
2011;37:1682–6.
11. Harris SP, Bowles WR, Fok A, et al. An anatomic investigation of the mandibular first
molar using micro-computed tomography. J Endod 2013;39:1374–8.
12. Wolf TG, Paque F, Zeller M, et al. Root canal morphology and configuration of 118
mandibular first molars by means of micro–computed tomography: an ex vivo
study. J Endod 2016;42:610–4.
13. Mirmohammadi H, Mahdi L, Partovi P, et al. Accuracy of cone-beam computed to-
mography in the detection of a second mesiobuccal root canal in endodontically
treated teeth: an ex vivo study. J Endod 2015;41:1678–81.
14. Nosrat A, Deschenes RJ, Tordik PA, et al. Middle mesial canals in mandibular mo-
lars: Incidence and related factors. J Endod 2015;41:28–32.
15. Ricucci D, Siqueira JF. Biofilms and apical periodontitis: study of prevalence
and association with clinical and histopathologic findings. J Endod 2010;36:
1277–88.
16. Kulid JC, Peters DD. Incidence and configuration of canal systems in the
mesiobuccal root of maxillary first and second molars. J Endod 1990;
16:311–7.
17. Von Arx T. Frequency and type of canal isthmuses in first molars detected by
endoscopic inspection during periradicular surgery. Int Endod J 2005;38:
160–8.
18. Hsu YY, Kim S. The resected root surface. The issue of canal isthmuses. Dent Clin
North Am 1997;41:529–40.
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