JOURNAL OF ENDODONTICS
Copyright © 2001 by The American Association of Endodontists
CLINICAL ARTICLES
Operating Microscope Improves Negotiation of
Second Mesiobuccal Canals in Maxillary Molars
M Ömer Görduysus, DDS, PhD, Melahat Görduysus, DDS, and Shimon Friedman, DMD
This in vitro study investigated the prevalence, lo-
cation, and pathway of the second mesiobuccal
canal (MB-2) in 45 first and second maxillary mo-
lars using the operating microscope (OM). Initially
location and negotiation of MB-2 were attempted
without magnification. Teeth in which MB-2 was
not located or could not be negotiated were further
explored under OM. Roots where MB-2 could not
be negotiated even with OM were cross-sectioned
and inspected microscopically. Morphometric
measurements were performed to map the loca-
tion of MB-2. Without magnification an apparent
MB-2 orifice was located in 42 teeth and the canal
negotiated in 31 (69%). With OM one additional
apparent MB-2 orifice was located, and five previ-
ously identified canals were negotiated (total 80%).
The root cross-sections confirmed the absence of
MB-2 in all nine teeth where it was not negotiated.
Location of MB-2 varied randomly. In conclusion
MB-2 can be negotiated in 80% of maxillary mo-
lars, although an orifice is apparent in 96% of the
teeth. Ability to negotiate MB-2 is facilitated by OM.
The morphology of the root canal system in the mesiobuccal root
of maxillary molars has attracted the attention of researchers and
clinicians for the past 75 yr (1–19). Many studies have focused on
the prevalence of a second mesiobuccal (MB-2) canal, which has
been investigated with a variety of methods. In vitro root sections
(1, 3, 7, 9, 11, 15, 18), radiographs (2, 6, 9, 16), and clearing (5,
12, 16, 17) have demonstrated the presence of MB-2 canals in 52
to 96% of the teeth. Clinically MB-2 canals have been found less
frequently, from 16% (8) to 78% (13). The prevalence of MB-2
canals in second molars has been shown to be quite similar to that
of first molars (5, 11) or up to 28% lower (4, 12, 17, 19). The MB-2
canal can terminate in an independent foramen, classified as type
III (1), in 10% (4) to 71% (17) of the teeth. Otherwise it can be
683
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VOL. 27, NO. 11, NOVEMBER 2001
rudimentary, classified as type IV (6), or merge with the main
mesiobuccal canal, classified as type II (1).
Within the wide range of reported prevalence of MB-2 canals,
a clear increase in prevalence may be observed in the most recent
studies (10 –19). This is particularly evident in the clinical (10, 13,
14, 19) and clinical simulation (11, 16 –18) studies, in which MB-2
canals were found in more than 71% of the teeth. This considerable
increase has been attributed mainly to improved awareness of the
presence of MB-2 canals (17, 19). In addition the shape of the
access cavity in maxillary molars has been modified to facilitate
the location of MB-2 canals (4, 8), and new instruments, particu-
larly ultrasonic troughing tips (13, 19), have been used. Neverthe-
less MB-2 canals frequently elude clinicians.
In recent years the operating microscope (OM) was introduced
to endodontics and has significantly improved magnification and
illumination. Because the OM has become more widely used in
nonsurgical treatment procedures (20), clinicians have indicated
that it facilitates treatment of very fine canals, particularly the
MB-2 canal (19). One clinical simulation study (18) demonstrated
an increase in the number of MB-2 canals located from 51%
without the use of OM, to 82% with OM.
The purposes of this in vitro study of maxillary molars were to:
(i) compare the ability of endodontists to locate and negotiate
MB-2 canals in maxillary molars without magnification and with
the OM; and (ii) characterize the MB-2 canal with regard to
prevalence, location, pathway, and negotiability.
MATERIALS AND METHODS
A mixed population of 45 extracted human maxillary first and
second molars was used. There was no information available
regarding the causes and time of extraction of these teeth. Before
use the teeth were stored in 1% thymol solution for 1 wk, then
divided into three equal groups, and mounted in dentoforms. Each
group was operated on independently by one of three endodontists.
Conventional, extensive access cavities were completed in all
teeth without magnification. Slow-speed Mueller burs (Brasseler,
Savannah, GA) and SP-1 ultrasonic tips (Analytic Technology,
Orange, CA) were then used to uncover the MB-2 canal orifice.
Dentin was selectively removed from the pulp chamber floor and
at the mesial-axial line angle of the cavity, along the mesiobuccal
684 Görduysus et al.
FIG 1. Morphometric measurements applied to characterize the lo-
cation of MB-2 canals. MB ⫽ mesiobuccal canal orifice; MB-2 ⫽
second mesiobuccal canal orifice; P ⫽ palatal canal orifice.
subpulpal groove. After the MB-2 canal orifice was located at-
tempts were made to negotiate the canal with size 0.6, 0.8, or 10
K-type files. If these attempts were unsuccessful more dentin was
removed further apically to pursue the MB-2 canal deeper into the
root, and attempts to negotiate the canal were repeated. This
procedure was conducted using intermittent irrigation with 1%
NaOCl and a Stropko air irrigator (E.I.E., San Diego, CA). Dentin
was removed further apically until: (i) the MB-2 canal was suc-
cessfully negotiated; (ii) a perforation occurred; or (iii) it was
considered too risky to remove dentin further apically. The result
of the negotiation attempts was recoded for each tooth.
The teeth in which the MB-2 canal was not located, and those
in which the canal was located but could not be negotiated, were
submitted to further investigation under the OM (Protege, Global
Surgical Corp., St. Louis, MO). Because extensive access cavities
were already established there was no need to extend the outline
form to allow the microscopic view. Pursuit of the MB-2 canals
under OM consisted of further selective dentin removal along the
subpulpal groove. Again the results were recorded.
At this stage pulp chambers were photographed through the OM
with a magnification of ⫻6.4. These photographed images were
later projected onto a large screen and used to map the location of
the MB-2 canals. On the projected images a line (M-P line) was
drawn connecting the main mesiobuccal and the palatal orifices,
and a perpendicular line (MB-2 line) was drawn from the MB-2
canal to the M-P line. Three distances were then measured in
millimeters: palatal distance—along the M-P line, between the
mesiobuccal canal and the MB-2 line; mesial distance—from the
MB-2 canal to the M-P line; and distance between the mesiobuccal
and MB-2 canals (Fig. 1). These measurements were plotted and
the distribution calculated using the SAS System for Windows
Release 6.12 TS Level 0045.
With the files inserted into the main mesiobuccal and MB-2 canals,
the teeth were removed from the dentoforms. Two radiographs were
then exposed of each tooth, one from the buccal and the other from the
Journal of Endodontics
mesial to demonstrate the pathway of the MB-2 canal. To eliminate
interference, distal roots were resected before the mesiodistal radio-
graphs were taken. The mesiobuccal roots where no MB-2 canal was
identified were sectioned horizontally 4 and 8 mm from the apex, and
observed microscopically with ⫻24.0 magnification to verify the
absence or presence of the MB-2 canal.
RESULTS
In most teeth the MB-2 canal orifice was located without difficulty
but the canal could not be negotiated unless some dentin was removed
from the orifice level apically. Working without magnification MB-2
canals were located in 42 teeth (93%) and negotiated in 31 teeth
(69%). With the use of the OM the MB-2 canal was located in one
additional tooth (total 96%) and negotiated in five additional teeth
(total 80%) (Table 1). During the attempts to negotiate the canals, a
root perforation occurred in one tooth before the use of the OM and
in another tooth while working under the OM.
The location of the MB-2 canal varied considerably in relation
to the main mesiobuccal and palatal canal orifices. The location of
all MB-2 canals is plotted graphically in Fig. 2, and the mean
distances are summarized in Table 2. In 50% of the teeth the MB-2
canal was located within 0.5 mm from the mean mesial and palatal
distances, as represented by the square in the center of Fig. 2. The
MB-2 canal was consistently mesial to or directly on the M-P line.
The radiographs revealed that 15 (42.1%) of the 36 negotiated
MB-2 canals were type III, terminating in a separate foramen.
Twelve (33%) of the MB-2 canals were type II, and 9 were type IV
(Fig. 3). Many of the MB-2 canals were angled relative to the
pathway of the main mesiobuccal canals. Most frequently this
angle was inclined mesially, with the canal then curving back
distally. Furthermore the radiographs demonstrated the extent of
dentin removal required to allow negotiation of the MB-2 canal
(Fig. 4). In 23 teeth removal of dentin extended ⬍2 mm apically,
whereas in 4 teeth it extended as far as the midroot level.
Microscopic examination of the mesiobuccal root cross-sections
confirmed that the MB-2 canal was indeed absent in all nine teeth
where it could not be negotiated.
DISCUSSION
This study was undertaken to assess the potential of the OM to
facilitate treatment of very fine root canals. The MB-2 canal was
selected as a model because it is highly prevalent (11, 12) and yet
seems to be elusive in many cases (8, 13, 14, 18, 19). We chose not
to establish two separate groups to be worked on with or without the
OM, because the expected variability among the teeth would have
necessitated very large groups. Instead we followed the strategy used
by many clinicians in practice (20) and used the OM only after
attempts to manage without it were unsuccessful. To better simulate
clinical conditions teeth were mounted in dentoforms (18).
In 96% of the molars included in this study a second mesio-
buccal orifice was apparent; it was assumed to correspond to the
MB-2 canal. As in previous studies reporting a very high preva-
lence of MB-2 canals (11, 12, 17, 19), our observation was char-
acterized mainly by the presence of a subpulpal groove (7) ex-
tending palatally from the main mesiobuccal canal that, on probing
with sharp explorers and further exploration, disclosed an orifice-
like spot (13). However not all of these secondary orifices did lead
to a true root canal (13, 14, 19). We were able to verify the
Vol. 27, No. 11, November 2001 MB-2 Investigated with Operating Microscope 685

TABLE 1. Results of attempts by three endodontists to locate and negotiate MB-2 canals in a mixed population of maxillary first
and second molars, initially without magnification and then with the OM

Without Magnification With OM—Total

Endodontist Teeth
Located Negotiated Perforated Located Negotiated Perforated
A 15 13 8 — 13 9 1
B 15 14 12 — 15 15 —
C 15 15 11 1 15 12 —

Total 45 42 31 43 36
(93%) (69%) (96%) (80%)

FIG 2. Location of MB-2 canals in 36 maxillary molars relative to the

mesiobuccal canal orifices.

FIG 4. Radiographs of maxillary molars exposed from the buccal.

TABLE 2. Location of the MB-2 canal relative to the
Files are inserted in two mesiobuccal canals demonstrating the
mesiobuccal canal orifice
initial mesial, and subsequent distal, inclination of the MB-2 canal. In
Distance Mean (mm) SD the middle specimen note the extensive depth to which dentin was
removed to allow negotiation of the MB-2 canal.
Palatal 1.65 0.72
Mesial 0.69 0.42
Between canals 1.81 0.38 clinicians, advised to search for MB-2 canals in all maxillary molars
(12, 19), may persistently pursue the MB-2 canal each time they
identify the groove and a secondary orifice. They may invest consid-
erable time in this process and also assume some risk (11). Being
aware that in 10 to 20% of maxillary molars, the canal does not extend
far beyond the orifice may help clinicians save time and avoid risk
when negotiation of the MB-2 canal becomes unusually difficult.
By mapping the location of MB-2 canals, we have attempted to
offer clinicians definitive clues that could facilitate treatment.
Previous reports focused mainly on the distance between the main
mesiobuccal and MB-2 canals, at the orifice level (5, 11, 12) and
further apically in the root (11). We considered these measure-
ments alone an insufficient guide for the clinician, and therefore
have added the mesial and palatal “coordinates” of the MB-2
canals. Furthermore we have reported the location of the MB-2
canal at the point from which it could be negotiated, rather than the
location of its orifice. Because there is frequently a considerable
FIG 3. Radiographs of maxillary molars exposed from the mesial (the discrepancy between these two landmarks, we considered it more
distobuccal roots were resected) direction. Files are inserted in both clinically relevant to guide the clinician toward the former. Our
mesiobuccal canals, demonstrating three patterns of the MB-2 ca- mapping demonstrated that the location varied considerably in
nal: left ⫽ type III; middle ⫽ type II; right ⫽ type IV. relation to the other canals. This variability could be the result of
the combination of first and second molars in our study material.
Nevertheless the MB-2 canal was located either mesial to, or
presence of the MB-2 canal in only 84% of the 43 molars in which directly on the M-P line, within 3.5 mm palatally and 2 mm
a secondary orifice was identified. Similarly, in a recent clinical mesially from the main mesiobuccal canal. Comparable landmarks
study (19), ⬃16% of apparent MB-2 canals could not be traced far have been described in clinical reports (5, 10, 13, 14, 19).
beyond the orifice. The ability of a clinician to locate MB-2 canals largely depends on
Recognition of the discrepancy between apparent secondary ori- awareness and conviction of their existence (17, 19). Opinions vary,
fices and true MB-2 canals is clinically important. Conscientious however, regarding the importance of using the OM in this process.
686 Görduysus et al.
Fogel et al. (14) suggested that the OM might improve the ability to
find MB-2 canals beyond the 71% these investigators found using
telescopes and headlamp illumination. Using the OM in a clinical
simulation Baldassari-Cruz et al. (18) located MB-2 canals in an
additional 31% of the teeth, to a total of 82%. In a comprehensive
clinical report Stropko (19) concluded that the OM was instrumental
in his ability to locate MB-2 canals in 73% of the teeth. In contrast,
Henry (13) located MB-2 canals in 78% of teeth without using the
OM. In the present study MB-2 canals were usually located without
much difficulty; the MB-2 orifice, the main mesiobuccal orifice, and
the groove connecting them could be observed without magnification
in 93% of the teeth. We conclude, therefore, that the OM is not critical
for the location of MB-2 canals.
Negotiation of the MB-2 canals was much more challenging than
their location. This may be due to the “ledge” of dentin that frequently
covers the orifice (4, 8, 10 –14, 16, 17). Another complication is the
tortuous pathway of some of these canals (9) that can include one or
two abrupt curves in the coronal portion (11). In addition the MB-2
canal almost invariably emerges from the pulp chamber floor at a
considerable mesial-buccal angle (10, 11, 13, 15). For these reasons a
file inserted into the orifice is forced to bend sharply toward the
mesial-buccal direction. Attempts to insert the file from the distal-
palatal direction (4, 10) are frequently fruitless, because after the file
travels just 1 to 2 mm its tip engages the canal wall at the next sharp
bend (11). To address these obstacles, various amounts of dentin must
be removed to uncover completely the orifice and pursue the MB-2
canal 1 to 3 mm deeper into the root (10, 11, 14, 19). This procedure,
referred to as “countersinking,” usually includes troughing along the
mesiobuccal subpulpal groove with a distinct orientation toward the
mesial (11, 19) direction. In the process the location of the MB-2 canal
shifts from that of the original orifice. Most frequently the canal shifts
closer to the mesial contour of the root (11, 19) and the axial wall of
the access cavity must be moved mesially (4, 11, 13, 14, 17, 19).
The “countersinking” procedure must be performed with preci-
sion. Because it is carried deeper apically, the dimensions of the
root become narrower and tolerance is drastically reduced, partic-
ularly around the MB-2 canal (11). The selective removal of dentin
in this area requires specialized instruments, skill, and confidence
(13, 17, 19). Particular caution must be exercised to prevent per-
foration of the distal aspect of the root into the furcation (11). It is
at this challenging stage that the OM offers a significant advantage,
as demonstrated by our results. Using the OM to pursue difficult
MB-2 canals dentin was removed between 2 mm and midroot level
in nearly one-third of the teeth to increase the number of negotiated
MB-2 canals from 31 to 36, 45 teeth examined. Because all nine
remaining teeth did not demonstrate the MB-2 canal in cross-
section, we can suggest that use of the OM allowed us to negotiate
all of the existing MB-2 canals. This finding seems to support
Stropko’s (19) conclusion that the OM improves the ability to treat
MB-2 canals above and beyond what can be achieved without it.
As is common knowledge today magnification and illumination
provided by the OM enhance the clinician’s control in difficult
procedures. Particularly, selective dentin removal to pursue small
anatomical features can be conducted with greater precision, min-
imizing the amount of peripheral dentin removed. Therefore, with
sufficient OM training and experience, the efficiency of pursuing
difficult MB-2 canals is improved, reducing both clinical time and
risk. It should be noted, however, that one perforation occurred in
this study during work with the OM, suggesting that even with
magnification and illumination caution is still necessary.
The pathway of the MB-2 canal is as variable as the location. The
tortuous coronal portion of the canal that frequently complicates
Journal of Endodontics
negotiation (11, 19) is eliminated by the “countersinking” procedure.
Beyond this level the canal can be either relatively straight, turn
slightly to distal and buccal, or turn sharply to buccal or palatal, which
again makes negotiation attempts difficult. In approximately one-fifth
of the teeth the pathway does not lead to an apical foramen (6, 16, 19).
In another third or half of the teeth the MB-2 canal merges with the
main mesiobuccal canal (1, 9 –12, 14 –16, 19).
Despite the fact that MB-2 canals frequently do not terminate in
independent foramina, their treatment is clinically important.
Leaving the canal untreated may allow microorganisms to colonize
the space, leading to infection and treatment failure (1, 14, 17).
Even partial treatment of the canal will enhance the chance of
success. This study and others (18, 19) have demonstrated that
treatment of MB-2 canals can be facilitated and improved with the
use of the OM.
Drs. M. Ö. Görduysus and M. Görduysus are affiliated with the Department
of Endodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey.
Dr. Friedman is affiliated with Department of Endodontics, Faculty of Den-
tistry, University of Toronto, Toronto, Ontario, Canada. Address requests for
reprints to Dr. M. Ömer Görduysus, Kenedi Cad. No 18/14, Kavaklidere,
Ankara, Turkey O6660.
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