Endodontic Miscellany : Negotiation and

management of MB2 canal in maxillary second molar

Vasudev SK* and Goel BR**

ABSTRACT

Failure to find and to fill a canal influences the prognosis of endodontic

treatment. The frequency of second canal in mesiobuccal root of maxillary
second molar is quite high, so time should be devoted in its location and
treatment. The present article describes the possible location of these canals
and various methods proposed to help in locating the fourth canal. It is
almost axiomatic to accept the fact that the root system of the mesiobuccal
root of maxillary molars frequently has a root canal system containing more
than one canal. This fact should lead to an awareness that has to be reflected
in our routine practice of clinical endodontics.
Key Words: Maxillary second molar, fourth canal, MB2 canal.

Introduction However, few articles have dealt

The main objective of endodontic therapy
is thorough mechanical and chemical
cleansing of the entire pulp cavity and its
complete obturation with an inert filling
material1. A major cause of endodontic failure
when treating maxillary molars is the inability
to locate, debride, and fill the frequently
present second mesiobuccal canal. Ingle2 lists
the most frequent cause of endodontic failure
as apical percolation and subsequent diffusion
stasis into the canal. Before an article written
by Weine et al3 in 1969, virtually all dentists
thought of the mesiobuccal root (MBR) of
maxillary molars as having only one canal.
Since that article, many papers have been
published concerning the types of canal
systems present in that root and their
percentage.
* PG Student
** Prof. and Head
Deptt. of Conservative Dentistry and Endodontics
PMNM Dental College and Hospital
Bagalkot - 587 101
33
exclusively with the canal configurations in the
MBR of the maxillary second molar, possibly
because of assumption that the root is very
similar to the first molar. Some studies have
grouped first and second molars together and
reported combined results.
To categorize the canal system in each
root, Weine4 described four different types of
configurations as follows: type I, single canal
from the pulp chamber to apex; type II, two
canals leaving the chamber, but merging short
of the apex to form a single canal; type III, two
separate canals leaving the chamber and
exiting the root in separate foramina; and type
IV, one canal leaving the chamber, but dividing
short of the apex into two separate and distinct
canals with separate foramina.
Using a variety of methods to study canal
configurations, investigations from 1972 to
1984 reported the occurrence of two canals
in the MBR of the maxillary second molar to
the range from 12% to 38%5,6-7,8. In a study in
which a combination of methods was used,
Kulild and Peters9 found that 14 to 32 teeth
 Endodontology, Vol. 15, 2003

PALATAL
X
X X

Fig. 1. a) Modified accesspreparation

b) Classical access preparation
(43.8%) had two canals in the MBR of
maxillary second molar, when files were
placed in the orifices and radiographed. The
number of two canals increased to 25 to 32
(78.2%) when the orifices were counter sunk
with a bur before files were placed in the
canals. Finally, 30 of the 32 teeth (93.7%). had
two canals when the roots were sectioned
horizontally and examined histologically10.
MB2 canal system in maxillary second molar
reported so far is presented in the Table-1
Case Report
A forty year old man reported to the
Department of Conservative Dentistry and
Endodontics with chief complaint of pain in left
upper posterior region of mouth. There was a
history of root canal treatment of left maxillary
first molar one year back. On clinical
examination maxillary first molar was found
to be normal, caries was detected in second
molar and it was found to be tender on
percussion. Radiographic examination
revealed mesio-proximal caries in second
molar.
Fig. 2. Diagram of floor of pulp chamber in maxillary
molar. Xs represent centers of prepared MB2 canal
orifices in an in vivo study.
Rhomboidal access preparation was
done, and palatal as well as mesiobuccal and
distobuccal canals were located. On probing
the groove between mesiobuccal and palatal
canal orifices, another orifice was detected
which was mesiopalatal to the mesiobuccal
orifice. It was extremely narrow and even a
No.8 instrument could not negotiate it. Hence
troughing was done with a round bur, and the
canal was finally negotiated. Intraoral
periapical radiograph was taken with a slight
mesial angulation to reveal the type II MB2
canal. Later all the four canals were prepared
and obturated with cold lateral condensation
technique (Fig. 3-5).
Discussion
Several methods have been presented to
help locate the fourth canal. Foremost was a
modification of the access preparation to a
rhomboidal shape (Fig 1A) for maxillary molars
as compared to the classical triangular outline
(Fig 1B)11. This provides better visibility and

Table 1. Studies of canal configuration of the MBR of the maxillary second molar
Investigator Method of study No. of One MB Two MB
Teeth Canal Canals
Nosonowitz and Brenner (1973)14 Post - op evaluation 161 68.9% 31.1
Weller and Hartwell (1989)11 Radiographic 299 78.6 21.4
Kulild and Peters (1990)9 Sectioning and 32 6.3 93.7
microscopic exam
Singh et al. (1994)15 Clearing 50 34 66
Stropko (1999)12 Patient records 310 40 60
Alavi et al. (2002)16 Injected dye 65 44.6 65.4
34
Vasudev SK et al.
accessibility. Thorough probing of the fissure
or groove between the main canals was
proposed in order to locate the orifice of
another canal.
This fissure or groove must often be
deepened to remove any projections that
might conceal the opening of the fourth canal.
A troughing process must be accomplished
with burs or ultrasonic instruments if the MB2
orifice was not easily identified.
The MB2 orifice openings are usually
found mesial to an imaginary line between the
MB1 and palatal orifices, and commonly, about
2-3 mm palatal to the MB1 orifice. The MB2
canal can be challenging to negotiate. The
MB1 canal normally departs the pulpal floor
with only a slight mesial inclination. However,
the MB2 canal usually has a marked mesial
incline immediately apical to its orifice in the
coronal 1 to 3 mm, so when an attempt is
made to instrument the MB2, the tip of file
tends to catch against the mesial wall of canal,
preventing apical progress. Because the MB2
canal is smaller and usually more calcified
than MB1, the problem is exacerbated. After
locating the MB2 orifice, inclining the dental
or ultrasonic handpiece to the distal, as far as
the access preparation permits, allows the first
few millimeters of this overlying roof of
calcified tissue to be safely eliminated. After
this refinement of the access preparation, a
more desired straight line access can be
achieved. To facilitate location and
instrumentation of MB2 canal, the access has
to be rhomboidal in shape to allow the
necessary mesially directed shaping.12
On occasions, MB2 shares an orifice with
MB1. When there is a shared or common
orifice, it is usually oval in shape. Infrequently,
the MB2 orifice is harbored within, or just apical
to, that of the palatal canal. In any of the above
instances, it will be very difficult, if not
impossible, to observe the MB2 orifice. The
smear layer can be removed with 17% aqueous
EDT A, the canals can be rinsed with a solution
of 95% ethanol, and air-dried. The operator
35
Management of MB2 canal...
must always look for the existence of additional
canals throughout the entire process.12
The distance between the centers of the
orifices of the prepared canals with separate
apices ranges from 3 mm,and for the canals
with common apices, 1-2 mm. The average
distance between the centers of the prepared
canals with separate apices was 1.8 mm and
1.3 mm with common orifices (Fig 2)12.
It is important the clinician has a strong
conviction that MB2 system is present in all
maxillary molars. In conjunction with dental
operating microscope, a rhomboid access,
and the use of specific instruments, other aids
can occasionally be used to enhance the
visualization of MB2 systems. They include the
champagne or bubble test with warmed 2.6%
NaOCl, staining the chamber with 1%
methylene blue, the use of sharp explorers,
looking for bleeding signs, and obliquely
angled preoperative radiograph13.
It is of interest to note that the studies
utilizing microscopes have reported a
significantly higher percentage of MB2 canal
system occurrences than the studies using
other means of determination.
To treat maxillary second molar properly,
an understanding of the morphogenesis of the
mesiobuccal canal system is mandatory.
Initially the canal in the MBR is the shape of a
kidney bean. With continued deposition of
secondary dentin, the isthmus between the
poles become narrower and eventually may
even close, resulting in two canals. Because
the mesiolingual segment of canal surrounds
the smaller of the poles of the kidney bean, it
will close off leaving a small space, thus
making it more difficult to locate. At first there
is one large ribbon-shaped apex, which, as
the tooth matures, begins to constrict,
eventually leaving one or more foramina.
Therefore, depending on the age of the tooth,
the MBR may have a variety of
configurations10.

Fig. 3. Master cone radiograph taken on
radiovisiography showing all four canals.
Fig. 5. Post obturation radiograph (Mesial view)
Conclusion
When treating maxillary molar, the operator
should assume that there are two canals
present in the MBR. Only after a thorough
search for a second canal and after it is
determined that further preparation would be
fruitless or cause a perforation, should the
operator accept treating only one canal. If
therapy fails on the MBR, it may be because
the second canal was not Iocated and treated,
and this should be considered carefully in the
retreatment, either by surgical or nonsurgical
methods.
References
1. Vertucci FJ. Root canal anatomy of the human
permanent teeth. Oral Surg 1984; 58: 589-99.
2. Ingle JI. Endodontics. 2nd Ed., Philadelphia, Lea and
Febiger, 1976: 43.
3. Weine FS, Healy HJ, Gerstein H, Evanson L. Canal
configuration in the mesiobuccal root of maxillary first molar
and its endodontic significance. Oral Surg 1969; 28: 419.
36
Endodontology, Vol. 15, 2003
Fig. 4. Post obturation radiograph, clearly showing the
obturated MB2 canal (Distal view)
4. Weine FS. Endodontic Therapy, 5th Ed., India,
Harcourt Brace & Company Asia PTE Ltd, 1996 pp. 243.
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