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Middle mesial canals in mandibular first

molars: A micro-CT study in different
populations

Article in Archives of Oral Biology · December 2015

DOI: 10.1016/j.archoralbio.2015.10.020

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 Archives of Oral Biology 61 (2016) 130–137

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Middle mesial canals in mandibular first molars: A micro-CT study in

different populations
Marco Aurélio Versiania,* , Ronald Ordinola-Zapatab , Ali Keleşc , Hatice Alcinc ,
Clóvis Monteiro Bramanteb , Jesus Djalma Pécoraa , Manoel Damião Sousa-Netoa
a
Department of Restorative Dentistry, Faculty of Dentistry, University of São Paulo, Av do Café s/n, Bairro Monte Alegre, CEP 14049-904 Ribeirão Preto, SP,
Brazil
b
Department of Endodontics, Bauru Dental School, University of São Paulo, Av. Octávio Pinheiro Brisola 9-75, Vila Universitária, CEP 17012-901 Bauru, SP,
Brazil
c
Department of Endodontics, Faculty of Dentistry, Ondokuz Mayıs Üniversitesi, 55139 Kurupelit-Samsun, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To describe the morphological aspects of middle mesial canals (MMC) in mandibular first
Received 23 May 2015 molars using micro-CT.
Received in revised form 26 September 2015 Design: Mandibular first molars collected from the Brazilian (n = 136) and Turkish (n = 122) populations
Accepted 21 October 2015
were scanned (voxel size: 9.9 mm) and mesial roots with MMC (n = 48) evaluated regarding several
morphological aspects. The incidence of MMC in each population was statistically compared using Chi-
Keywords: square test (a = 0.05).
Mandibular molar
Results: Overall, the incidence of MMC was 18.6% (48 out of 258 molars) and was significantly higher in
Middle mesial canal
Micro-CT
the Brazilian (n = 30; 22.1%) than in the Turkish (n = 18; 14.8%) population (p < 0.05). In both populations,
Root canal anatomy confluent configuration of the MMC was the most frequent anatomy. Most of the specimens with MMC
had 3 independent orifices (n = 26; 54.2%) and 3 apical foramina (n = 21; 43.8%). The mean minor diameter
of the MMC orifice (0.16 mm) was 3 times less than the other orifices (0.50 mm). In mesial roots with
independent configuration (n = 3; 6.3%), the mean volumes (mm3) of the MMC, mesiobuccal (MBC) and
mesiolingual (MLC) canals were 0.20  0.10, 0.75  0.28, and 0.88  0.19, respectively. In the specimens
with canal confluence (n = 26; 54.2%), MMC merged to the MBC (n = 8; 16.7%), MLC (n = 4; 8.3%), or to both
MBC and MLC (n = 14; 29.2%). Double mesial canal was observed in only 1 specimen. MMC with an
independent foramen was observed mostly in Brazilian specimens.
Conclusions: Incidence of MMC was higher in the Brazilian molars. Confluent configuration was the most
prevalent anatomic variation, while independent and fin configurations, as well as, double MMC, were
found only in a few specimens.
ã 2015 Elsevier Ltd. All rights reserved.

1. Introduction of teeth is a prerequisite for successful endodontic therapy

The main goal of endodontic therapy is to prevent or heal apical
periodontitis. Unfortunately, cleaning and shaping procedures are
adversely affected by the highly variable root canal anatomy. The
presence of additional canals needs to be recognized in order to
avoid incomplete instrumentation and the preservation of bacteria
and their toxins, which can compromise the outcome of the root
canal treatment. Therefore, the knowledge of the internal anatomy
* Corresponding author at: Department of Restorative Dentistry, Faculty of
Dentistry, University of Sao Paulo, Av. Do Café s/n, Bairro Monte Alegre, Ribeirão
Preto-SP, CEP 14040-904, Brazil. Fax: +55 16 3602 3982.
E-mail address: marcoversiani@yahoo.com (M.A. Versiani).
(Vertucci, 1984).
The mesial root of mandibular molars commonly presents 1
mesiobuccal (MBC) and 1 mesiolingual (MLC) canals; however,
other anatomical configurations have also been reported in the
literature (de Pablo, Estevez, Peix Sanchez, Heilborn, & Cohenca,
2010). In 1974, Barker, Parsons, Mills and Williams (1974) and
Vertucci and Williams (1974) were the first authors to demonstrate
the presence of an extra and independent canal in the mesial root
of mandibular molars using the clearing technique. Later,
Pomeranz, Eidelman, and Goldberg (1981) presented a compre-
hensive in vivo study describing its morphology and clinical
management. Since then, several authors have reported this
anatomical variation which has been termed intermediate canal
(Fabra-Campos, 1989), mesio-central canal (Navarro, Luzi, Garcia, &

http://dx.doi.org/10.1016/j.archoralbio.2015.10.020
0003-9969/ ã 2015 Elsevier Ltd. All rights reserved.
 M.A. Versiani et al. / Archives of Oral Biology 61 (2016) 130–137 131

Garcia, 2007), third mesial canal (Holtzmann, 1997), accessory
mesial canal (Karapinar-Kazandag, Basrani, & Friedman, 2010), and
middle mesial canal (MMC) (Pomeranz et al., 1981; Azim, Deutsch,
& Solomon, 2015; Baugh & Wallace, 2004; Bond, Hartwell,
Donnelly, & Portell, 1988; Nosrat, Deschenes, Tordik, Hicks, &
Fouad, 2015). In the literature, this anatomical variation has been
found in a percentage frequency ranging from 0.26% (Kim, Kim,
Woo, & Kim, 2013) to 46.15% (Azim et al., 2015).
In recent years, micro-computed tomographic imaging (micro-
CT) has gained increasing significance in the study of hard tissues

Fig. 1. 3D models of 48 mesial roots of mandibular first molars with MMC grouped according to the canal configuration type. Specimens identified with numbers depicted in
black colour were obtained from the Brazilian population, whilst numbers in red colour identify specimens collected from the Turkish population. (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)
132 M.A. Versiani et al. / Archives of Oral Biology 61 (2016) 130–137

in endodontics as it offers a reproducible 3D technique for the
assessment of the root canal anatomy (Leoni, Versiani, Pécora, &
Sousa-Neto, 2014; Ordinola-Zapata et al., 2013). Using this
technology, Harris, Bowles, Fok, and McClanahan, (2013) found
the presence of more than 2 canals along any point of the mesial
root in 8 out of 22 mandibular molars (36.3%). Currently,
endodontic literature lacks a detailed morphological description
of the anatomy of the MMC in mandibular molars. Thus, the aim of
this study was to describe the morphological aspects of the MMC in
mandibular first molars collected from the Brazilian and Turkish
populations, using micro-CT imaging system.
2. Materials and methods
After ethics committee approval (protocol #2013/145), 258
two-rooted mandibular first molars, collected from Brazilian
(n = 136) and Turkish (n = 122) populations, were selected and
scanned in a micro-CT device (SkyScan 1172; Bruker-microCT,

Table 1
Number and percentage frequency distribution of different root canal configurations observed in the 48 mandibular molars with middle mesial canal (MMC).

Configuration Type 3D Models Brazil (n = 30) Turkey (n = 18) Total

(n = 48)
Frequency Configurations (n) Isthmus Frequency Configurations (n) Isthmus frequency (%)
(%) location (%) location

Independent 3 (10%) 3–3a – – – – 3 (6.30%)

Fin 4 (13.30%) 1–3b – – – – 4 (8.30%)

1–2–3 (2)c
2–3d

Confluent With 7 (23.30%) 3–1–3 Middle 7 (38.90%) 2–3–2–1 (2)f Middle 14

isthmus 2–3–2–1–2–3 (2) 5 (16.7%) 3–2–1e,f 5 (27.8%) (29.20%)
2–3–2–3 Apical 3–2–3–2–1; Apical
2–3–2–1–2 2 (6.7%) 3–1–2–1; 3–1–2–3 2 (11.1%)
3–2–1e,f; 2–3–2e,f 3–2–1–3

Without 15 (50.00%) 3–2–3 (3)e ; 3–1–2–3 – 11 (61.10%) 3–2–3–2–3–2; 3– – 26 (54.10%)

isthmus 2–3–4–2; 2–3–4–3–2–3 2–4
(2) 3–1–3; 3–2–3–2–3
2–3–1e,f; 3–2–3–2–1; 1–3– (2)
2–1 3–2–4–2; 3–2–1
3–2–3–2–3; 3–2–3–2 (2)e,f;
3–2–3–4–2; 2–3–2e,f; 3– 3–2–3–1; 3–2–3e
2–3–2 2–3–2–1–2

Double MMC 1 (3.40%) 2–3–4–3–4 – – – – 1 (2.10%)

Some canal configurations observed in this study were also reported by:
a
Vertucci (1984).
b
Sert et al. (2004).
c
Peiris et al. (2008).
d
Gulabivala et al. (2001).
e
Al-Qudah and Awawdeh (2009).
f
Harris et al. (2013).
 M.A. Versiani et al. / Archives of Oral Biology 61 (2016) 130–137 133

Kontich, Belgium), at 100 kV, 100 mA and an isotropic voxel size of
9.9 mm. The gender and age of the patients were unknown, and
teeth were extracted for reasons not related to this study. Scanning
procedure was performed through 180 rotation around the
vertical axis, with a rotation step of 0.4 , using a 0.5-mm-thick
aluminium filter. After the reconstruction of the acquired
projection images into cross-sections slices (NRecon v.1.6.9;
Bruker-microCT), polygonal surface representations of the internal
anatomy of mesial roots presenting MMC were obtained (Fig. 1)
(CTAn v.1.14.4; Bruker-microCT) and classified according to
Pomeranz et al. (1981) into:
- Independent: three independent canals extend from the pulp
chamber to the apex;
- Fin: in the coronal third, MMC orifice is connect to the MBC and/
or MLC orifice(s) by a groove, but the mesial canals leave the root
in 3 separate foramina;
- Confluent: MMC leaves the pulp chamber, separately or not to
the other mesial canals, and joins the MBC and/or MLC by
transverse anastamosis, intercanal connections or isthmus
during its trajectory to the apical foramen.
The number and percentage frequency distribution of different
root canal configurations was calculated. The incidence of MMC in
each population was statistically compared using Chi-square test
with a significance level set at 5% (SPSS v11.0 for Windows; SPSS
Inc., Chicago, IL, USA). Additionally, the following analyses were
performed using CTAn v.1.14.4 software (Bruker-microCT): (1)
number, configuration (independent or confluent), and distance of
the mesial canal orifices 1.5 mm coronal to the furcation; (2) length
and depth (in mm) of the orifice confluence; (3) minor and major
diameters (in mm) of the independent orifices; (4) width of dentin
(in mm) toward the furcation side in relation to the MMC orifice;
(5) distance (in mm) from the orifice level to the confluence of the
MMC to the other mesial canals; (7) volume (in mm3) of the MMC,
MBC and MLC in mesial roots with independent configuration; and
(8) number of foramina.
3. Results
Table 1 summarizes the number and percentage frequency
distribution of different root canal configurations in 48 mandibular
first molars with MMC. Overall, the incidence of MMC was 18.6%
(48 out of 258 mandibular first molars) and was significantly
higher in the Brazilian (n = 30; 22.1%) than in the Turkish (n = 18;
14.8%) population (p < 0.05). Confluent anatomy was the most
frequent anatomical variation comprising 73.3% (n = 22) and 100%
(n = 18) of the Brazilian and Turkish molars with MMC, respective-
ly. Among this group of teeth, isthmus was observed in 29.2% of the
sample (n = 14). Independent (n = 3) and fin (n = 4) anatomies were
observed only in the Brazilian specimens, as well as, a double MMC
(n = 1).
Table 2 shows some morphological aspects of the root canal
system of mandibular first molars with MMC (n = 48). Overall, most
of the specimens had 3 independent orifices (n = 26; 54.2%) and 3
apical foramina (n = 21; 43.8%). The presence of mesial grooves
were more frequent in the Brazilian (n = 17; 56.6%) than in the
Turkish (n = 5; 27.8%) molars. MMC orifice was confluent to MBC
(n = 10; 20.8%), MLC (n = 8; 16.7%) and both MBC and MLC (n = 14;
8.3%) orifices in 22 out of 48 mesial roots. In specimens with 3
independent orifices (n = 26; 54.2%), the mean minor diameter of
the MMC, MBC and MLC orifices were 0.16, 0.46 and 0.50 mm,
respectively, while the major diameter were 0.40, 0.71 and
0.78 mm, respectively. Overall, the diameter of the MMC orifice
was 2–3 times less than the other orifices. In the specimens with
canal confluence (n = 26; 54.2%), MMC merged to the MBC (n = 8;
16.7%), MLC (n = 4; 8.3%), or to both MBC and MLC (n = 14; 29.2%) in
its pathway within the root canal system. In mesial roots with
independent configuration (n = 3; 6.3%), the mean volume of the
MMC, MBC and MLC was 0.20  0.10, 0.75  0.28, and 0.88  0.19
mm3, respectively.
Fig. 2 illustrates the mean distances and range of values (in mm)
between some anatomical landmarks and the MMC of mandibular
first molars. In the teeth with orifice confluence (n = 22; 45,8%),
mean length and depth of the mesial groove were 1.98  0.46 mm
(range 1.07–2.81 mm) and 1.54  1.89 mm (range 0.17–7.66),

Table 2
Morphology of the root canal system of mesial roots of mandibular first molars with middle mesial canal from Brazilian and Turkish populations.

Root canal system of mandibular molars with MMC Brazil (n = 30) Turkey (n = 18) Total (n = 48)

Number of Orifices 1 4 (13.4%) – 4 (8.3%)

2 13 (43.3%) 5 (27.8%) 18 (37.5%)
3 13 (43.3%) 13 (72.2%) 26 (54.2%)

Number of apical foramina 1 3 (10.0%) 7 (38.9%) 10 (20.8%)

2 10 (33.3%) 6 (33.3%) 16 (33.3%)
3 16 (53.4%) 5 (27.8%) 21 (43.8%)
4 1 (3.3) – 1 (2.1%)

MMC orifice confluence (mesial groove) To MBC 7 (23.3%) 3 (16.7%) 10 (20.8%)

To MLC 6 (20.0%) 2 (11.1%) 8 (16.7%)
To MBC and MLC 4 (13.3%) – 4 (8.3%)

MMC canal confluence To MBC 7 (23.3%) 1 (5.6%) 8 (16.7%)

To MLC 2 (6.7%) 2 (11.1%) 4 (8.3%)
To MBC and MLC 4 (13.3%) 10 (55.6%) 14 (29.2%)

Mandibular molars with 3 independent orifices Brazil (n = 13) Turkey (n = 13) Total (n = 26)

Minor Diameter (mm) MMC orifice 0.16  0.09 0.15  0.06 0.16  0.08
MBC orifice 0.47  0.13 0.45  0.12 0.46  0.12
MLC orifice 0.50  0.12 0.49  0.11 0.50  0.11

Major Diameter (mm) MMC orifice 0.45  0.39 0.35  0.12 0.40  0.29
MBC orifice 0.68  0.18 0.74  0.26 0.71  0.21
MLC orifice 0.79  0.18 0.77  0.25 0.78  0.21

MBC, mesiobuccal canal; MMC, middle mesial canal; MLC, mesiolingual canal.
134 M.A. Versiani et al. / Archives of Oral Biology 61 (2016) 130–137

Fig. 2. Mean distance, standard deviation and range of values (in mm) between some reference landmarks and the MMC in 2 representative 3D models of mesial roots of
mandibular first molars. On the left: (a) length of the orifice confluence; (b) depth of the orifice confluence; and (c) distance from the orifice to the confluence of the MMC to
the MBC. On the right: (d) distance between MMC and MLC orifices; (e) width of dentin toward the furcation side in relation to the MMC orifice; and (f) distance between MMC
and MBC orifices.

respectively. The distance (in mm) from the orifice to the canal
confluence ranged from 1.43 to 8.02 mm. In the specimens with
independent orifices (n = 26; 54.2%), MMC orifice was found at the
same mean distance from the MBC and MLC orifices, while the
width of dentin (in mm) toward the furcation side in relation to the
MMC orifice was 1.33  0.29 mm (range 0.80–2.20).
4. Discussion
The presence of a third canal in the mesial root of mandibular
first molars, known as middle mesial canal (MMC) was identified in
20 ex vivo (Vertucci, 1984; Barker et al., 1974; Vertucci & Williams,
1974; Navarro et al., 2007; Karapinar-Kazandag et al., 2010; Harris
et al., 2013; Ahmed, Abu-Bakr, Yahia, & Ibrahim, 2007; Shahi,
Yavari, Rahimi, & Torkamani, 2008; Çalişkan, Pehlivan, Sepetçiog lu,
Türkün, & Tuncer, 1995; de Carvalho & Zuolo, 2000; Gulabivala,
Aung, Alavi, & Ng, 2001; Sert, Aslanalp, & Tanalp, 2004; Villegas,
Yoshioka, Kobayashi, & Suda, 2004; Peiris, Pitakotuwage, Takaha-
shi, Sasaki, & Kanazawa, 2008; Al-Qudah & Awawdeh, 2009; Chen,
Yao, & Tong, 2009; Gu et al., 2010; Gulabivala, Opasanon, Ng, &
Alavi, 2002; Wasti, Shearer, & Wilson, 2001) (Table 3) and 6 in vivo
(Pomeranz et al., 1981; Fabra-Campos, 1989; Azim et al., 2015;
Nosrat et al., 2015; Kim et al., 2013; Goel, Gill, & Taneja, 1991)
(Table 4) studies, accounting for more than 5220 mesial roots.
Clearing and radiographic techniques were used in most of these
studies, and the reported incidence of MMC ranged from 0.82% to
37.5%. Undoubtedly, the conventional methodological approaches
in these studies have been successfully used over many decades
providing useful information to the clinicians about the internal
anatomy of the teeth. However, inherent limitations repeatedly
discussed in the endodontic literature regarding their lack of
accuracy in detecting extra canals, encouraged the search for
newer methodologies that could potentially surpass the anatomi-
cal challenges that the human dentition exhibits. Therefore,
despite considerable amount of information regarding MMC has
been published to date, very little information exists regarding its
morphology using highly accurate contemporary non-destructive
methodology such as the micro-CT imaging system used in the
present study.
In this scenario, particular attention must be paid to the
dissimilar incidences of MMC reported in the aforementioned
studies (0.82–37.5%), which have been explained through diversity
in sample size, study design, and/or racial factors (de Pablo et al.,
2010; Nosrat et al., 2015; Kim et al., 2013; Walker, 1988; Sert et al.,
2004; Al-Qudah & Awawdeh, 2009; Gu et al., 2010). Regarding the
latter, studies concur that ethnicity is a predisposing factor for
anatomical variations such as number of roots, but they failed to
demonstrate any direct relationship between ethnicity and
configuration of the root canal system (de Pablo et al., 2010). A
recent study found a significant difference in the incidence of MMC
between whites (12.2%) and nonwhites (29.4%) patients, but not
regarding the ethnicity (Nosrat et al., 2015). In the present study,
the significant difference in the incidence of MMC in the Brazilian
(n = 30; 22.1%) and Turkish (n = 18; 14.8%) populations suggests
that MMC in mandibular first molars may be race-related. It is
worth to mention an importance aspect when evaluating less
 M.A. Versiani et al. / Archives of Oral Biology 61 (2016) 130–137 135

Table 3
Summary of ex vivo studies on the incidence of middle mesial canal in the mesial root of mandibular first molars.

Author(s) Year Method Sample % Root Canal Configurations

MMC
Vertucci and Williams 1974 CL 100 1% Independent (n = 1)
Barker et al. 1974 CL, R N.R. N.R. Independent (n = 1)
Vertucci 1984 CL 100 1% Independent (n = 1)
Walker 1988 CL 100 1% Independent (n = 1)
Çalişkan et al. 1995 CL 100 3% Independent (n = 3)
de Carvalho and Zuolo 2000 DOM 93 17.2% N.R.
Gulabivala et al. 2001 CL 139 10.8% Independent (n = 1); 3–1 (n = 3); 3–2 (n = 2); 2–3 (n = 9)
Wasti et al. 2001 CL 30 3% Independent (n = 1)
Gulabivala et al. 2002 CL 118 6.7% Independent (n = 2); 3–2 (n = 1); 3–1 (n = 2); 2–3 (n = 2); 3–4 (n = 1)
Sert et al. 2004 CL 200 1.5% Independent (n = 3)
Villegas et al. 2004 CL 63 5% Independent (n = 3)
Ahmed et al. 2007 CL 100 4% N.R.
Navarro et al. 2007 CT 27 14.8% N.R.
Peiris 2008 CL 177 4.52 Independent (n = 2); 2–3 (n = 2); 1–2–3 (n = 2); 3–2–1 (n = 2)
Shahi et al. 2008 CL 209 0.95% Confluent canals (n = 2). Configuration N.R.
Al-Qudah and Awawdeh 2009 CL 330 6% 3–3 (n = 1); 2–3 (n = 5); 2–3–1 (n = 2); 2–3–2 (n = 3); 3–1 (n = 2); 3–2 (n = 4); 3–2–1 (n = 1); 3–2–3 (n = 2)
Chen et al. 2009 CL 183 6% Independent (n = 10)
Gu et al. 2010 Micro- 122 0.82% Independent (n = 1)
CT
Karapinar-Kazandag 2010 DOM 48 18% 3–2 (n = 5; 3 MMC merged with MBC and 2 with MLC), 3–1 (n = 2) (data from negotiated canals)
et al.
Harris et al. 2013 Micro- 22 36.36% 2–3–1 (n = 1); 2–3–2 (n = 1); 2–3–1–2 (n = 1); 2–3–2–1 (n = 1); 2–4–3–2 (n = 1) 3–2–1 (n = 2); 3–4–3–2–1
CT (n = 1)

CL, clearing technique; CT, computed tomography; DOM, dental operating microscope; MBC, mesiobuccal canal; Micro-CT, micro-computed tomography; MLC, mesiolingual
canal; MMC, middle mesial canal; N.R., not reported; R, radiograph.

common anatomic variations (Al-Qudah & Awawdeh, 2009), which
is the detailed morphological analysis of a large number of
mandibular first molars with MMC (n = 48), when compared to
previous anatomical investigations on this subject (Tables 3 and 4).
However, Brazilian and Turkish populations may present a genetic
variability because of the coexistence of multiple ethnicities.
Therefore, these results must be taken with caution as larger
populations of known ethnic backgrounds are needed to achieve
an adequate statistical power for genetic association (Hong & Park,
2012).
Some authors support the view that MMC canals can be easily
located in patients of a younger age group, but progressively
decrease its incidence with age (Table 4) (Pomeranz et al., 1981;
Fabra-Campos, 1989; Azim et al., 2015; Nosrat et al., 2015; Kim
et al., 2013; Goel et al., 1991). It has been also postulated that,
during the growth of the root, the connective pulp tissue is
compressed by the accumulation of secondary dentin, which
would form vertical dentinal partitions inside the root canal cavity,
thus creating 3 mesial root canals (Pomeranz et al., 1981; Peiris
et al., 2008). Though, considering that these hypotheses were not
proven by an experiment, it is also possible that some of the
anatomical variations found herein, such as the confluent anatomy
without isthmus (Fig. 1), are not age-related changes, but instead
they are natural canal configurations.
In the literature, 3 main morphological aspects of MMC
regarding its relation to the other main root canals in the mesial

Table 4
Summary of in vivo studies on the incidence of middle mesial canal in the mesial root of mandibular first molar.

Author(s) Year Method Sample % MMC Patient’s age (n) Canal configuration
Pomeranz et al. 1981 R (Pr) 61 11.5 <21 (n = 7) Independent (n = 1)
36 (n = 1) Fin (n = 5)
>40 (n = 2) Confluent (n = 1)
>50 (n = 1)
>60 (n = 1)
Fabra-Campos 1989 R (Pr), M 760 2.6% 11–15 (n = 8) Independent (n = 1)
16–20 (n = 5) 3–2 (13 MMC confluent with MBC)
21–25 (n = 1) 3–2 (6 MMC confluent with MLC)
26–30 (n = 3)
31–35 (n = 2)
>36 (n = 1)
Goel et al. 1991 R (Pr) 60 15% N.R. (n = 9) Independent (n = 4)
Confluent (n = 5)
Kim et al. 2013 CBCT (Pr), M 1,952 0.26% 13–69 2–3–2 (n = 3)
(mean of 28.8) 3–2 (n = 2)
a
Nosrat et al. 2014 R (Re), M 75 20% <20 (n = 9) Independent (n = 3)
21–40 (n = 5) Fin with no separate orifice (n = 5)
>40 (n = 1) Confluent (n = 7)
(mean 35)
Azim et al. 2015 R (Pr), M 56 37.5% 9–71 Independent (n = 4)
(mean 34) Confluent (n = 33)
3–1 (n = 5)

CBCT, cone-beam computed tomography; M, magnification (loupes or dental operating microscope); MBC, mesiobuccal canal; MLC, mesiolingual canal; MMC, middle mesial
canal; N.R., not reported; R, radiograph; Pr, prospective; Re, retrospective.
a
Data included mandibular first and second molars.
136 M.A. Versiani et al. / Archives of Oral Biology 61 (2016) 130–137
root of mandibular molars have been described as independent, fin
and confluent anatomies (Pomeranz et al., 1981). From a clinical
standpoint, this classification system is very useful; however, it is
of limited depth considering the huge amount of variations in the
anatomy of the MMC (Fig. 1). In this way, in this study the confluent
anatomy was subdivided into with or without isthmus. Unfortu-
nately, the limitations of conventional tools in studying certain
features of the root canal system are prone to a wide range of
interpretation (Peiris et al., 2008). For instance, in clinical practice
a thin and deep groove may be confounded with an extra root canal
which help to explain the high incidence of MMC (37.5%) recently
reported in an in vivo study using dental operating microscope
(Azim et al., 2015). In this way, non-destructive micro-CT
technology can allow the development of accurate 3D models of
the internal anatomy and assist in obtaining quantitative
morphometric data that are impossible to acquire using conven-
tional methodologies such as clearing, radiography or sectioning
techniques. Nevertheless, as any other methodological approach,
micro-CT technology has also limitations: (i) scanning and
reconstruction procedures take considerable time; (ii) the
technique is not suitable for clinical use; (iii) the equipment is
quite expensive; and (iv) the complexity of the technical
procedures requires a high learning curve and an in-depth
knowledge of dedicated software.
Improvements in the digital imaging systems have also enabled
in vivo evaluation of the root canal anatomy using non-destructive
methods, such as cone-beam computed-tomography (CBCT). CBCT
has been proved to be a more accurate and precise imaging tool for
detecting extra canals than conventional periapical radiograph.
Kim et al. (2013) used this technology to evaluate 1952 mandibular
first molars from 976 patients and found only 2 teeth with MMC
(0.26%). This low incidence can be explained because CBCT systems
hampered by insufficient spatial resolution and slice thickness for
detecting more complex anatomical configurations in which fine
ramifications are present. In contrast, micro-CT provides a better
assessment of fine anatomical structures because of the possibility
of using a higher exposure time and lower voxel sizes than CBCT
during the scanning procedures. However, to date, only 2 ex vivo
studies aimed to evaluate the incidence of MMC in mandibular
molars using micro-CT technology. Gu et al. (2010) evaluated 122
mandibular molars from native Chinese population and found only
1 teeth (0.82%) with 3 independent root canals in the mesial root,
while Harris et al. (2013) reported the presence of MMC in 36.36%
of their sample, which was higher than in the present study (18.6%;
48 out of 258 mandibular first molars); however, the limited
sample size (n = 22) of that study reduces the impact of the results
(Harris et al., 2013).
MMC orifice is often hidden by a dentinal projection of the
mesial aspect of pulp chamber walls making its detection
challenging (Karapinar-Kazandag et al., 2010). In order to find
MMC orifice, this dentin projection must be carefully removed
under a better illumination and magnification (Karapinar-Kazan-
dag et al., 2010; de Carvalho & Zuolo, 2000), using ultrasound tips
(Kontakiotis & Tzanetakis, 2007) or long shank rounded burs
(Nosrat et al., 2015). In the present study, MMC orifice was found to
be in a developmental groove between the MBC and MLC in 22
specimens (45.8%). In contrast to the literature, in which MMC
orifice was detected closer to the MLC (Karapinar-Kazandag et al.,
2010), a higher incidence of confluence to the MBC in both
populations (n = 10; 20.8%) was observed herein (Table 2).
Clinically speaking, an extensive exploration of the grooves
between mesial orifices has been a significant factor for accessing
additional root canals (Karapinar-Kazandag et al., 2010; Azim et al.,
2015). However, the length (1.07–2.81 mm) and depth (0.17–
7.66 mm) of this groove must be taken into consideration during its
troughing because of the small dentin thickness toward the
furcation side in relation to the MMC orifice (0.80–2.20 mm),
which increases the risk of root perforation (Karapinar-Kazandag
et al., 2010; Azim et al., 2015). Thus, it would be advisable that
clinicians use less tapered instruments during MMC preparation in
order to avoid excessive dentin removal (Azim et al., 2015).
In accordance with previous studies (Tables 3 and 4), the
analysis of the pathway of the MMC showed that it merged to the
other mesial canals in a high percentage of the sample (73.3% and
100% of the Brazilian and Turkish mandibular molars, respective-
ly), in a distance from the orifice level that ranged from 1.43 to
8.02 mm. The variety of canal morphologies observed herein also
included 1 molar with a double MMC among the Brazilian molars.
To date, quite a few studies have reported this anatomical variation
in the mesial root of mandibular molars (Goel et al., 1991;
Kontakiotis & Tzanetakis, 2007).
In clinical practice, while preparation and disinfection of
independent and fin anatomies are relatively easy, branched canal
configurations and intercanal ramifications, such as in the
confluent anatomy, may render complete debridement of canal
system difficult. Because mechanical instrumentation of these
areas is unfeasible, our efforts should concentrate on efficient
delivery and activation of irrigants to achieve proper disinfection
(de Pablo et al., 2010; Gulabivala et al., 2001) avoiding subsequent
need for retreatment or surgical intervention. If surgery becomes
necessary in roots with MMC, the natural anatomy is altered, and
additional anatomic features such as undebrided isthmus,
transverse anastomoses, lateral connections or multiple foramina
need to be addressed (Leoni et al., 2014). In this way, surgical
microscope (Karapinar-Kazandag et al., 2010; Azim et al., 2015;
Nosrat et al., 2015; Kim et al., 2013; de Carvalho & Zuolo, 2000) and
ultrasound (Reeh, 1998) would help clinicians to better visualize
the apex, incorporating all canals and the isthmus into the root-end
preparation to ensure complete debridement and sealing of the
root canal system (Leoni et al., 2014).
Considering the limitations of the present study, the incidence
of MMC was higher in the Brazilian molars. Confluent configura-
tion was the most prevalent anatomic variation, while indepen-
dent and fin configurations, as well as, double MMC, were found
only in a few specimens.
Acknowledgments
The authors deny any conflicts of interest. This study was
supported by FAPESP (2013/03695-0, 2012/16072-2), CNPq
(168179/2014-8), and TUBITAK (Grant #114S002).
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