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Basic Research—Technology

Deviations of Mesial Root Canals of Mandibular


First Molar Teeth at the Apical Third:
A Micro–computed Tomographic Study
Ali Keles, DDS, PhD, and Cang€
ul Keskin, DDS, PhD

Abstract
Introduction: The present study aimed to quantita-
tively analyze apical foramen deviations of mesial root
canals of mandibular first molar teeth by means of
E ndodontic treatment
aims to eliminate or
prevent infection by disin-
Significance
The present study shows clinically important
anatomic structures of the apical third by present-
micro–computed tomographic (micro-CT) imaging. fecting the root canal sys-
ing deviations of the apical foramina of mesial root
Methods: Micro-CT images of the mesial roots of 109 tem through cleaning and
canals from their anatomic apices and recom-
mandibular first molar teeth with independent mesio- shaping of root canals to
mends the use of electronic apex locators for the
buccal (MB) and mesiolingual (ML) root canals were an adequate geometry
determination of the working length because peri-
analyzed. The deviations of the apical foramina of the (1). Knowledge of root ca-
apical radiographs could be misleading because
MB, ML, and middle mesial root canals from the nal anatomy is 1 of the
of the superimpositions of the deviated mesial
anatomic apex were measured. The vertical distance be- most important factors
root canals.
tween the apical foramina of each mesial root canal in for accomplishing these
relation to each other was also calculated. Results: goals (2). However, the
The distances from the apical foramina of the MB, ML, complex internal anatomy of a root canal system often presents challenges for root canal
and middle mesial root canals to the anatomic apex of treatment (3, 4). Mandibular molars have been reported to exhibit a very complicated
the mesial root were up to 2.51 mm, 3.21 mm, and internal anatomy because of their mesial roots showing branching, dividing, and
5.67 mm, respectively. There was no significant differ- rejoining root canals, accessory root canals, isthmuses, and fins at different levels (5).
ence between the deviations of MB and ML root canals The internal anatomy of mandibular molar teeth has been revealed by several tech-
from each other (P > .05). The middle mesial root canal niques, including the clearing method, plastic resin injection, histology, radiography,
showed the greatest deviation compared with the MB scanning electron microscopy, cone-beam computed tomographic imaging, and
and ML canals (P < .05). Conclusions: The apical micro–computed tomographic (micro-CT) imaging (6). Among these techniques,
foramina of mesial root canals of mandibular first molar micro-CT imaging has emerged as the most promising because it provides high-
teeth showed greater variations from each other and resolution accurate images of the internal anatomy without destroying the specimen
anatomic apices than previously reported. Clinically, (6). Micro-CT imaging has led to the discovery of new anatomic features of the root
the use of electronic apex locators for the detection of canal system and a new classification system for categorizing root canal configurations
minor apical foramen of each mesial root canal is of (4, 7).
the utmost important. (J Endod 2018;-:1–3) Mesial roots of mandibular molars often have at least 2 root canals extending from
independent orifices to their own apical foramina. Conventional periapical radiography
Key Words of these root canals might cause superimposed images, which makes it difficult to differ-
Apical foramen deviation, micro–computed tomogra- entiate the terminus of root canals during routine root canal treatment (8). A previous
phy, root canal anatomy study reported that the major foramen of the middle mesial root canal exhibits devia-
tions from the root apex (9). The major foramina of the mesiobuccal (MB) and me-
siolingual (ML) roots might also present deviations from each other and the
anatomic apex. The aim of the present study was to quantitatively analyze the deviations
of mesial root canals of mandibular molars at the apical third by means of micro-CT
imaging.

Materials and Methods


Mandibular first molar teeth, which were extracted for reasons nonrelated to this
study and verified according to their coronal morphologic features, were collected from

From the Department of Endodontics, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey.
Address requests for reprints to Dr Ali Keles, Department of Endodontics, Faculty of Dentistry Ondokuz Mayıs University, 55400 Samsun, Turkey. E-mail address:
Alikeles29@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.02.028

JOE — Volume -, Number -, - 2018 Deviations of Mesial Root Canals 1


Basic Research—Technology
the Turkish population. The ages of the patients were unknown. The canal from that of the MB canal was 0.78  0.58 mm. The distance
mesial roots of 269 mandibular molar teeth were scanned using a values ranged from 0.11–2.69 mm (Fig. 1B). In 39 specimens, the api-
micro-CT system (SkyScan 1172; Bruker-microCT, Kontich, Belgium) cal foramen of MB canals was located more apically than that of ML ca-
with parameters of 100 kV and 100 mA. Slices presenting nals (36.8%). In these specimens, the mean value for the deviation of
2000  1330 pixel resolution with 10-mm pixel size were obtained the apical foramen of the MB canal from that of the ML canal was
from each root using an 11-megapixel camera. Data were reconstructed 0.53  0.47 mm. The distance values ranged from 0.02–2.51 mm.
using NRecon software (v. 1.6.4, Bruker-microCT) with a beam- In the remaining 10 specimens, both root canals terminated at the
hardening correction of 45%, smoothing of 2, and an attenuation coef- same level (9.4%). There was no significant difference between the de-
ficient range of 0 to 0.06. CTAn and DataViewer (v.1.5, Bruker- viations of MB and ML root canals from each other (P > .05).
microCT) software were used to reveal the root canal configuration The distances from the apical foramina of MB, ML, and middle
of each root. mesial root canals to the anatomic apex of the mesial root were pre-
Micro-CT data sets of 106 specimens showing independent MB sented in Table 1. Middle mesial root canals showed the greatest devi-
and ML root canals with their own orifice and major apical foramina ation from the anatomic apex compared with MB and ML root canals
were selected and further analyzed. The vertical distances between (P < .05), whereas no significant difference was detected between
the apical foramina of the MB and ML root canals were measured the MB and ML canals (P > .05). In 6 specimens, deviation of the apical
and categorized as follows: foramen of the middle mesial root canal was greater than 2 mm, extend-
ing to 5.67 mm.
1. The apical foramen of the MB canal is located more apically.
2. The apical foramen of the ML canal is located more apically.
3. The apical foramina of the MB and ML canals are at equal levels. Discussion
The vertical distances between the apical foramina of the MB and The apical part of the root canal system has been considered crit-
ML root canals and the anatomic apex of the root were also measured ical for therapeutic and pathogenetic reasons (10). Therefore, com-
and recorded (Fig. 1A and B). In the specimens showing middle mesial plete understanding of this complex apical anatomy and its variations
root canals, deviations of the apical foramen of the middle mesial root is a prerequisite for successful endodontic treatment. Knowledge of api-
canal from the anatomic apex and the vertical distances between the api- cal anatomy will help clinicians to perform endodontic procedures by
cal foramina of the MB to ML and middle mesial root canals were preventing damage to the periradicular tissues and effectively disinfect
measured. the apical part of the root canal system. Micro-CT imaging has been re-
Data were analyzed using descriptive and frequency analyses. The ported as an effective and nondestructive method of evaluating the in-
Student t test and 1-way analysis of variance followed by post hoc Scheffe ternal anatomy of root canal configurations showing fine structures
tests were used to compare the measured features of MB, ML, and mid- (3, 11). The present study used micro-CT technology to reveal the po-
dle mesial root canals using SPSS 21.0 software (SPSS Inc, Chicago, IL). sitions of the apical foramina of mesial root canals in mandibular first
molar teeth with 2 separate MB and ML canals.
The distance between the anatomic apex and the major apical fo-
Results ramen has been extensively studied and reported as ranging from 0.2–
In 57 specimens, the major apical foramen of ML root canals was 3.0 mm depending on patient age and tooth type (2, 12). Another
located more apically than that of MB canals (53.8%). In these speci- important factor for the deviation of the major apical foramen is
mens, the mean value for the deviation of the apical foramen of the ML constant remodeling of the root apex by external root resorption and

Figure 1. Three- and 2-dimensional images of mesial roots of 2 mandibular molar teeth at the levels of apical foramina of the MB, ML, and middle mesial root
canals showed their deviations from the anatomic apex. (A) The apical foramen of the middle mesial root canal revealed a significantly greater deviation than those
of the MB and ML root canals. Deviations of apical foramina of MB and ML canals did not show statistical differences; however, in some specimens, deviation of the
apical foramen could reach greater values. (B) This specimen showed 2.69 mm deviation from the anatomic apex.

2 Keles and Keskin JOE — Volume -, Number -, - 2018


Basic Research—Technology
TABLE 1. Mean, Standard Deviation (SD), and Minimum-maximum Values of Conclusion
the Distance Values between the Apical Foramina of Mesial Root Canals and In conclusion, the apical foramina of mesial root canals of
Anatomic Apex (mm)
mandibular first molar teeth frequently showed deviations from each
Mean ± SD Minimum–maximum n other and the anatomic apex, extending up to 5.67 mm. The use of elec-
MB canal 0.70  0.51a 0.0–2.51 106 tronic apex locators to detect each apical foramen is highly important
ML canal 0.52  0.50a 0.0–3.21 106 because periapical radiography might be limited by the superimposition
MMC 1.34  1.15b 0.2–5.67 32 of root canals. Future micro-CT studies are required to determine the
MB, mesiobuccal; ML, mesiolingual; MMC, middle mesial root canal; SD, standard deviation. effect of age and cementum deposition on the deviation of the major api-
Different superscript letters at the same column show significant difference (P < .05). cal foramen.

cementum apposition (13). Unfortunately, in the present study, the ages Acknowledgments
of the patients from whom the specimens were collected were un- Supported by the Scientific and Technological Research Coun-
known. cil of Turkey (grant no. 114S002).
In the present study, a large number (N = 269) of mesial roots of The authors deny any conflicts of interest related to this study.
mandibular first molar teeth were scanned, and 106 (39.4%) roots pre-
senting 2 separate MB and ML apical foramina were detected. Only in 10
specimens (9.4%) did the MB and ML apical foramina terminate at the References
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