MICROSCOPES IN ENDODONTICS 0011-8532/97 $0.00 + .

20

THE RESECTED ROOT SURFACE

The Issue of Canal Isthmuses

Yeung-Yi Hsu, DDS, MS, and Syngcuk Kim, DDS, M Phil, PhD

Success rates of endodontic surgical procedures without the use of

the modem-day surgical operating microscope have varied. Rud and
colleagues> observed an 83% healing potential in 1972. Frank and co-
workers? reported 60% success in 1992. Other authors report healing
from surgical endodontic procedures as low as 49% or as high as 78%.8,
13,17,23 Several reasons for this difference are the criteria with which each
author claimed a success, time of reevaluation, and partly the fact that
in the past surgical procedures were limited mainly to the maxillary
anterior teeth. Today, endodontic surgical procedures have incorporated
many new techniques and innovations that allow for surgery in the
posterior area, a more viable treatment alternative than in the past.
Studies continued to find that posterior teeth (i.e., premolars and molars)
have a less favorable prognosis after surgery than anterior teeth (Fig. 1).
Friedman and associates'? stated that there was only a 44.1% success
rate on premolars and molars treated. Other authors have quoted that
molars which undergo apicectomy procedures alone can have a success
rate as high as 71% to 73%.15,17,20 This is in contrast to reported success
rates as high as 85% to 90% for anterior teeth.F: 14,28
Because of the varying success rates of endodontic surgery per-
formed on posterior teeth, an in-depth review is essential. Molars and
premolars have the highest failure rate in endodontic surgery as indi-
cated by previous studies. 15,17,20 Some observed reasons for these failures
could be explained by conventionally or surgically untreated root canal
systems, anatomic structures that hinder access to the root apices, or a

From the Department of Endodontics, School of Dental Medicine, University of Pennsylva-

nia, Philadelphia, Pennsylvania

DENTAL CLINICS OF NORTH AMERICA

VOLUME 41· NUMBER 3· JULY 1997 529

530 HSU & KIM

Figure 1. Recall evaluation 2 years after molar surgery of tooth #3. Periapical radiolucency
persists without resolution. The surgery was considered a failure.

poor seal at the apex because of the limitations of materials used.v "
One factor that was not introduced until Cambruzzi and Marshall in
19833 and Weller and colleagues in 199530 was the significant importance
of the molar isthmus in surgery (Fig. 2).

ISTHMUS

An isthmus is defined as a narrow strip of land connecting two

larger land areas or a narrow anatomic part or passage connecting two
larger structures or cavities.'? Green" in 1973 described the isthmus as a
corridor between the two roots. Other authors such as Pineda" in 1973
discussed this phenomenon as a lateral connection, while Vertucci" in
1984 stated that the isthmus was an anastomosis. Weller and colleagues'?
in 1995 described the canal isthmus as a narrow, ribbon-shaped commu-
nication between two root canals that contains pulp tissue.
The isthmus connection can be observed between any two root
canal systems that occur within one root. This becomes a significant
factor in the thorough debridement of the root canal system, specifically
in maxillary and mandibular premolars and molars. Pineda and Kuttler-s
in 1972 described mesial roots of mandibular first molars containing two
canals in 62% of the cases in contrast to mandibular second molars in
only 22% of the cases. Two canals in mesiobuccal roots of maxillary
first molars presented close to 48.5%, and maxillary second molars
demonstrated two canals in 27.2% of the cases." Skidmore and Bjornal"
in 1971 found two canals in the mesial root of mandibular first molars
93.3% of the time. Green'! in 1973 observed that in mandibular molars
the mesial roots had two root canal systems in approximately 87% of
the cases, and in the distal root two root canal systems were present in
 THE RESECTED ROOT SURFACE 531

Figure 2. Canal isthmus. A, A clinical view from a resected MB root of a maxillary premolar.
B, After retropreparation and root end filling. C, A scanning electron microscope picture of
canal isthmus. Note the connection between the two main canals.
532 HSU & KIM

26% of the cases. In the mesiobuccal roots of the maxillary first molars,
two canals were observed approximately 52% of the time. Vertucci" in
1984 discovered that in mesiobuccal roots of maxillary first molars two
canals were apparent in 55% of the teeth studied, and in maxillary
second molars two canals presented approximately 29% of the time.
This is in contrast to the mesial roots of mandibular first molars, which
presented two canals close to 89%, whereas mesial roots of second
mandibular molars were described to contain two canals in nearly 73%
of the cases. Kulild and Peters> in 1990 found an incidence of a second
canal in the mesiobuccal roots of the maxillary first and second molars
to be approximately 95%. Thus, these findings show that the chance of
finding an isthmus is quite high because there are often two canals in
the mesial roots of mandibular first molars and mesiobuccal roots of
maxillary molars.
Maxillary and mandibular premolars are quite different from that of
molars. Maxillary first premolars are often birooted; however, Vertucci"
described two or more canals present in one root in close to 30% of the
cases studied, and the maxillary second premolars exhibited two or
more canals approximately 41% of the time. Regarding mandibular
premolars, first premolars retained two or three canals 27% of the time,
and second premolars presented an additional canal only 2% of the
time. Green!' stated that maxillary first and second premolars have two
roots 50% and 15% of the time. Then maxillary first premolars contained
two orifices on the floor of the pulp chamber 92% of the time, whereas
66% revealed two apical foramina. Maxillary second premolars pre-
sented with two orifices 28% of the time, with two apical foramina in
only 4% of the cases. Mandibular first premolars exhibited two orifices
14% of the time with only 6% providing two apical foramina. Two
orifices were present in 8% of the cases followed by 4% with two
foramina in mandibular second premolars." Thus, premolars can vary
widely in root canal anatomy, so it would be reasonable to expect some
type of an isthmus in this tooth.
Another important consideration for isthmuses are in C-shaped
molars. Cooke and Cox" first discovered the C-shaped anomaly in man-
dibular second and third molars in 1979. There are two common possible
outcomes for the C-shaped mandibular molar: (1) those that exhibit a
single, ribbonlike, C-shaped canal from orifice to apex and (2) those with
three distinct canals below the C-shaped orifice." Melton and colleagues"
discovered that this phenomenon can vary throughout the root canal
system structure. The more common form has been found to be the
second type of C shape. This paranormal situation can also be detected
in maxillary second molars. This type of C shape joins the distobuccal
root with the palatal root. These phenomena can lead to many significant
failures in conventional orthograde obturations and should be cautiously
examined for interconnections.
Mandibular anterior incisors also have been reported presenting
two canals within one root structure. Rankine-Wilson and Henry'" in
1965 observed two canals in 40% of the incisors studied. These teeth
 THE RESECTED ROOT SURFACE 533

presented with two foramina 87% of the time. Benjamin and Dowson-
in 1974 reported that 41% of mandibular incisors studied contained two
canals, whereas only 1.3% presented two foramina. Thus, this situation
also acquires more attention when discussing isthmuses for endodontic
surgical procedures.

ISTHMUS FORMATION

The actual formation of the isthmus from embryonic ongm is

through the epithelial root sheath. In teeth with single roots, the inner
cells of the root sheath next to the dental pulp differentiate into odonto-
blasts and start secreting dentin matrix. As this matrix is laid down and
begins mineralizing, the epithelial root sheath cells secrete a thin layer
of cementum on this newly formed dentin structure. The cells then
continue to form dentin and cementum while breaks occur within the
root sheath epithelium. Degeneration of these root sheath epithelial cells
allows mesenchymal cells or ectomesenchymal cells to migrate into these
areas and differentiate to form cementoid to fill these gaps. Cementum
production continues as the tooth erupts into the oral cavity until root
formation is complete. Occasionally, defects in the root sheath can be
found. If the epithelial cell is defective, an odontoblast does not differen-
tiate. Thus, dentin formation does not occur. Without dentin formation,
cementum is not be deposited in this area. This condition then leads to
lateral and accessory canals, which is commonly observed in the apical
third of the root.'
In multiple-rooted teeth and roots with multiple canals, however,
another mechanism takes place. The mechanism of root formation is
similar to a single root trunk except in the cervical area, where the root
divides. The area where the tooth divides is known as the furcation
zone. Tonguelike projections of the epithelial root sheath develop and
proliferate until contact is made with other projections allowing fusion
take place. These epithelial projections then continue to proliferate and
divide. The original large opening forms two, three, or four openings,
which eventually become the orifice. As these multirooted areas continue
to grow, defects can occur during normal root formation similar to a
normal single root. Defects occur in multirooted teeth with a high
incidence. In this case, the tonguelike projections of the epithelial root
sheath do not completely fuse with one another. When this occurs,
lateral or accessory canals in the furcation area can form. An isthmus is
formed when an individual root projection is unable to close itself off.
Therefore, the approximation of the root projections can fuse completely
and form one root with one root canal system as in the distobuccal root
of maxillary molars. Alternatively, partial fusion results in the formation
of two root canals with an isthmus formed in between, such as the
mesial root of the mandibular first molar. No fusion leads to a large
ribbon-shaped canal that also forms an isthmus throughout the entire
534 HSU & KIM

root, which is a common finding in the distal root of the mandibular

first molars and maxillary second premolars.'

CLASSIFICATION OF ISTHMUS

There are five classifications of the canal isthmus. The root end
section was observed under the surgical operating microscope at 26 X
magnification. The resected root surface of teeth was stained with meth-
ylene blue dye. Type I was defined as either two or three canals with
no notable communications. Type II was defined as two canals that
possessed a definite connection between the two main canals. Type III
differs from the latter only with the presence of three canals instead of
two. Incomplete C-shaped canals with three canals were also included
in this category. When canals extended into the isthmus area, this was
deemed type IV. Type V was recognized as a true connection or corridor
throughout the section (Fig. 3).

TYPE I

TYPE II G---~
TYPE III G.-~
TYPEIV G---3
TYPEV G~
Figure 3. Isthmus classification.
 THE RESECTED ROOT SURFACE 535

Table 1. INCIDENCE OF ISTHMUSES

Percent of Two Percent of

Tooth/Root Authors Canals Isthmus

Mesiobuccal root of maxillary first Pineda 2 1 48.5 4.9

molar Green" 52 16
Cambruzzi" 48.5 30.1
Vertuccj29 55 52.5
Mesial root of mandibular first Skidmore" 93.3 54
molar Carnbruzzi" 77.8 60.2
Vertucci" 89 89
Distal root of mandibular molar Cambruzzi- 28.5 14.8
Skidmore'" 28.9 17.3

INCIDENCE OF THE ISTHMUS

The actual incidence of an isthmus has been reported by several

authors (Table 1).3,11,22,27,29,30 The authors further examined the incidence
and position of the canal isthmus on maxillary and mandibular premo-
lars as well as molars. Transverse serial sections of the apical 6 mm of
the root were prepared in J-mm increments. The apical side of each
section was stained with methylene blue dye and viewed under a
surgical operating microscope. In the maxillary premolar group, the
incidence of isthmus increases as the resected level is further away from
the apex. It ranges from 16% at the I-mm level to 52% at the 6-mm level
from the apex. This trend, however, is not found in mandibular premo-
lars. In mandibular premolars, the incidence of isthmus is constantly
around 30% from the 2-mm level up (Table 2; Fig. 4). In the mesiobuccal
root of the maxillary first molar, 60% of the root has two canals. The
incidence of an isthmus is highest in the apical 3- to 5-mm levels. In
teeth that have two canals, the 4-mm sections contain an isthmus 100%
of the time (Table 3; Fig. 5). In the mesial root of the mandibular first
molar, the incidence of two canals increases as the cut level goes up.
The highest incidence of isthmus at 4 to 6 mm. For instance, 80% of the

Table 2. INCIDENCE OF ISTHMUSES AT DIFFERENT LEVEL SECTIONS OF

MAXILLARY AND MANDIBULAR PREMOLARS

Maxillary Premolars Mandibular Premolars

Level from Percent of 2 Percent of Percent of 2 Percent of

Apex (mm) Canals Isthmuses Canals Isthmuses

1 46 16 16 10
2 67 27 42 32
3 62 26 40 28
4 62 30 46 30
5 70 40 42 22
6 78 52 48 36
536 HSU & KIM

60

-
r--
#50 f---

III
~ 40 f---
J::
Cii .....-
-
~
-; 30 r-- _r--
Cl
cu
'E
- f-- f-- f-- - f-- i - f-
20 ,
Q) "
~

I
f- f-- f-- f-- f-- f-
~ 10 ir

i ~ ,. I-
I;
o
2 3 4 5 6
Level from Apex (mm)

Figure 4. Incidence of isthmus in maxillary and mandibular premolars. Dark bar = maxil-
lary; white bar = mandibular.

4-mm sections contain isthmuses. In the distal root, the incidence of two
canals is between 8% and 22%. The incidence of an isthmus also drops
between 2% at the 'l-mm level and 20% at the 6-mm level from the apex
(Table 4; Fig. 6). Thus, when considering surgical procedures in the
posterior teeth, clinicians must be aware of the isthmus and routinely
look for this anatomic variation.

CLINICAL SIGNIFICANCE

Even with the high percentage of isthmuses that were found by

researchers, conventional mechanical cleaning and shaping methods can-
not physically debride this vitally important area. According to Senia
and colleagues" in 1971, the only way to clean such anatomic variations
is through the use of chemical irrigants such as full-strength sodium

Table 3. INCIDENCE OF ISTHMUSES AT DIFFERENT LEVEL SECTIONS OF THE

MESIOBUCCAL ROOT OF MAXILLARY FIRST MOLAR

Level from Percent of 2 Percent of

Apex (mm) Canals Isthmuses

1 26 8
2 40 26
3 42 38
4 50 50
5 58 48
6 54 44
 THE RESECTED ROOT SURFACE 537

60 ,.....
,.....

-
~
~40
Q)
50
,.....
~
~
10-

~
I---

I-
-
en
.!
c 30
Q) - -
- ~ ~
··'1 -
.~
~ 20 - ...
:. ,, - ~ ~ '-

10

o J
- -
!.~.
"1'1
--- ~ I" r-

2 3 456
Level from Apex (mm)

Figure 5. Incidence of isthmus in the mesiobuccal root of maxillary first molars, White bar
= percentage of two canals; dark bar = percentage of isthmus,

hypochlorite. Even with the use of full-strength sod ium hypochlorite

and mechanical instrumentation, the amount of tissue dissolution was
significantly limited. The significance of an isthmus was taken into
consideration conventionally first in 1971; however, it was not until 1983
that Cambruzzi and Marshall? first reported this signi fican t finding in
molar surgery . This are a, which can lead to failures of conventional
orthograde endodontic treatment, must also be considered in failures of
traditional endodontic surgery. The tissue that can be left over after
traditional surgical procedures with a microhead handpiece and micro-
burs can be a nidus for recurrent infections.
With previous surgical procedure methods, obtaining a biologic seal
at the apical area was virtually impossible. First, viewing an d inspecting
the root surface was almost un attainable. This was partially due to the
inadequate light source used . In form er da ys, the lamp attached to the

Table 4. INCIDENCE OF ISTHMUSES AT DIFFERENT LEVEL SECTIONS OF

MANDIBULAR FIRST MOLARS

Mesial Root Distal Root

Level from Percent of 2 Percent of Percent of 2 Percent of

Apex (mm) Canals Isthmuses Canals Isthmuses

1 22 6 8 2
2 46 30 10 8
3 76 64 18 16
4 82 80 16 16
5 96 80 16 16
6 96 74 22 20
538 HSU & KIM

80
_ 70 -:\. -
#.
~ 60
..... .---
ji
:::J

-E 50 :+
.r:::: , ~: I--
.!!l 40

~t
C1l
Cl
oS 30
~
I: I. ·r ,~
-
IIi ~
...C1l~ 20 I > e: ~ \
,
I--
I '·
r·
D. 10
n -
I---

~ I :i ~ J
o
2 3 4 5 6
Level from Apex (mm)

Figure 6. Incidence of isthmus in mandibular molars. Dark bar = mesial root; white bar =
distal root.

dental chair was positioned for optimum performance. This light initially
has to travel through the oral cavity to the tooth desired. Then the light
enters another cavity, where the root was resected, which was about
only approximately 10 to 15 mm in diameter." Aside from the limiting
light source, the clinician was hindered in viewing the resected root
surface with his or her own eyes. In conjunction with the average root
diameter being approximately 6 mm, the clinician then had to view the
apical root canal system that was enlarged only to about a size of 0.30
mm or ISO size 30. Another disadvantage for clinicians was the use of
the marched handpiece and microburs. This handpiece was used to
approximate the resected root surface and drill a hole directly into the
root canal system. A microbur was usually a small 1;4 round bur or
inverted cone bur." This bur was used in conjunction with the handpiece
to remove possible leakage areas around the apical end. It was difficult,
however, to direct the bur and head of the handpiece directly along the
long axis of the root. This encompassed with the larger head of the
handpiece made visibility and tactile senses almost impossible.
Many new surgical methods for treating these teeth have been
introduced. The surgical operating microscope was probably one of the
most important. The increased illumination that the microscope provides
is invaluable. The concentrated beams of two light sources within the
microscope can intensify the brightness directly onto the small bony
crypt where the root apex lies. This joined with the magnification that
the microscope has incorporated into its system enhances visualization
significantly. Now clinicians can observe the entire illuminated root
surface from 4 X magnification all the way to 32 X magnification de-
 THE RESECTED ROOT SURFACE 539

pending on the microscope's capabilities. (See the article by Rubinstein.)

The use of methylene blue dye also helps to view the resected root
surface. This blue-staining dye can enhance the visualization of the
entire resected root surface by deposition on soft tissue and empty
spaces. Isthmuses, missed canals, leaking orthograde or previous retro-
grade fillings, and fractures can be accurately stained and enhanced
with this dye. Finally, micromirrors give the clinician the ability to
inspect the entire resected root surface directly with a great deal of
accuracy. With the use of methylene blue dye, micromirrors, and the
surgical operating microscope, the clinician can predictably visualize the
farthest lingual or palatal extent of the root with any isthmuses or
ramifications that are present.
Mechanical cleaning ultrasonic units and their associated tips, intro-
duced to the endodontic community by Carr' in 1992, have aided in
thorough debridement of the apical root canal system. (See the article
by Carr.) These newly developed instruments increased the clinician's
skills in many ways. The design of the tips made them much more
useful in root end preparations coaxial to the root surface. They also
enhanced a desired preparation depth of 3 mm into the orthograde
filling. The cutting tips of ultrasonics also enhance the preparation of
the isthmus reported by Engle and Steiman" in 1995. They compared
ultrasonic tips with the microhead handpiece and microburs for prepar-
ing the isthmus of mandibular molars and maxillary premolars. Ultra-
sonic instrumentation alone proved to be the most effective. Further-
more, the chance of root perforations was significantly reduced. Thus,
the use of ultrasonics coupled with the surgical operating microscope
can enhance the operator's preparation significantly when the isthmus
is present.

CONCLUSION
In the past, the canal isthmus was often overlooked, and it was also
difficult to prepare if located. Now, with the adjunct of the surgical
operating microscope and microsurgical equipment, clinicians can view
the resected root surface better, identify the isthmus, and prepare it with
an ultrasonic tip. The recognition and management of the canal isthmus
is one factor that may improve the success rate of surgical endodontics
in posterior teeth.

ACKNOWLEDGMENT
Special thanks to Drs. R. Aguilar, M. Collura, J. Kang, and A. Krygier for their efforts
in isthmus morphology research.

References
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teeth. Oral Surg 38:122, 1974
540 HSU & KIM

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Address reprint requests to

Yeung-Yi Hsu, DDS, MS
Department of Endodontics
4001 Spruce Street
Philadelphia, PA 19104