Basic Research—Technology
Prevalence of Second Mesiobuccal Canals in
Maxillary First Molars Detected Using
Cone-beam Computed Tomography, Direct
Occlusal Access, and Coronal Plane Grinding
Brent M. Hiebert, DDS, MSD, Kenneth Abramovitch, DDS, MS, Dwight Rice, DDS,
and Mahmoud Torabinejad, DMD, MSD, PhD
Abstract
Introduction: The purpose of this study was to deter-
mine the prevalence of the second mesiobuccal canal
(MB2) in 100 maxillary first molars using 3 independent
methods and a combination method. Methods: One
hundred extracted human maxillary first molars were
collected. The teeth were mounted in the maxillary first
molar extraction sockets of a human cadaver head. A
cone-beam computed tomographic (CBCT) scan was
taken of each tooth. Two radiology faculty independently
evaluated the CBCT volume for the presence of an MB2
canal. Additionally, teeth were accessed. If a canal was
not found, a preoperative CBCT scan was viewed fol-
lowed by a second attempt to locate an MB2 canal.
Lastly, the mesiobuccal root was dissected by grinding
in a coronal plane. Results: A review of CBCT volumes
found the presence of an MB2 canal 69% of the time. Ac-
cessing the tooth led to an MB2 detection of 78%. When a
CBCT scan was viewed, this brought the access detection
rate up to 87%. Coronal plane root grinding had an MB2
canal detection rate of 92%. Differences between each
method were statistically significant. Conclusions: The re-
sults of this study show that an MB2 canal is present up to
92% of the time. Direct access of teeth found statistically
significant more MB2 canals than viewing CBCT volumes
alone (P = .032). Therefore, exposing every patient to a
preoperative CBCT scan may not be appropriate. However,
taking a CBCT scan when an MB2 canal is not found clin-
ically can significantly increase the chances of finding an
MB2 canal (P < .001). (J Endod 2017;-:1–5)
Key Words
Cone-beam computed tomography, coronal plane
grinding, direct occlusal access, maxillary first molar,
mesiolingual canal, prevalence, second mesiobuccal canal
From the Department of Endodontics, Loma Linda University School of Dentistry, Loma Linda, California.
Address requests for reprints to Dr Brent M. Hiebert, Department of Endodontics, Loma Linda University School of Dentistry, 11092 Anderson Street, Prince Hall 4401,
Loma Linda, CA 92354. E-mail address: bhiebert@llu.edu
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.05.011
JOE — Volume -, Number -, - 2017
A lthough physically small
in size when compared
with other bodily tissues, an
Significance
This study combined 3 independent techniques as
well a combination technique as a unique way to
inflamed dental pulp can
evaluate the mesiobuccal root for the prevalence
inflict agonizing and unre-
of MB2 canals. This information can be used to
lenting pain to an individ-
help guide clinicians on appropriate CBCT scan in-
ual. Because of its unique
dications.
location, the dental pulp
can be both challenging to
locate and difficult to remove. Therefore, a thorough understanding of tooth morphology
and root canal anatomy is required when performing root canal therapy (1).
Of particular interest in the field of endodontics is the maxillary first molar, which
has been studied extensively (1–27). Variations and complex morphology, particularly
in the mesiobuccal root, have been demonstrated dating back to 1925 (2). In fact, the
maxillary first molar is the largest tooth in total volume and is generally considered the
most anatomically complex tooth (3).
Throughout the literature, much of the focus of the maxillary first molar has
revolved around the mesiobuccal root and the second mesiobuccal canal, which is
referred to as either the MB2 or the mesiolingual canal. Although not always located,
the MB2 canal is present on average 56.8% of the time when all studies are taken
into account (4). Depending on the study referenced and the method used, the pres-
ence of the MB2 canal ranges from 18.6% (5) to 96.1% (6). When the MB2 canal
cannot be located or properly treated, it may contribute to continued patient pain or
root canal failure (8).
Over the years, cone-beam computed tomographic (CBCT) studies (15–18, 24, 27),
laboratory studies (2, 6, 8–15, 22, 23), and clinical studies (5, 7, 19–21, 25, 26) have
examined the prevalence of the MB2 canal in maxillary first molars. These studies have
evaluated the prevalence of the MB2 canal using only 1 or 2 methods. A search of the
literature shows the absence of any study that has used the combination of CBCT
imaging, direct access, grinding, and a combination of CBCT imaging and access to
determine the prevalence of the MB2 canal in maxillary first molars.
The purpose of this study was to determine the prevalence of the MB2 canal in 100
maxillary first molars using 3 independent methods and a combination of these
methods: group 1, CBCT evaluation; group 2, direct occlusal access with a dental
MB2 Canals in Maxillary First Molars 1
Basic Research—Technology
operating microscope (DOM); group 3, direct occlusal access followed
by CBCT evaluation and reaccess; and group 4, coronal plane root
grinding of the mesiobuccal root.
Materials and Methods
Teeth Selection
One hundred extracted human maxillary first molars were
collected and analyzed. No information regarding age, sex, or clinical
history of the studied teeth was available. Selection specification for teeth
included normal crown anatomy, 3 separate roots, fully formed apices,
an intact pulpal floor, and no developmental anomalies. After extraction,
the teeth were placed in 5% sodium hypochlorite, debrided of peri-
odontal tissue, and rinsed under running tap water. The teeth were
then stored in physiologic saline until the beginning of the experiment.
Over the course of the study, 1 of the teeth with typical normal crown
anatomy was removed because of unusual root anatomy. The total num-
ber of teeth included in the study was 99 (50 #14 and 49 #3 teeth).
Group 1: CBCT Imaging
To simulate a clinical preoperative CBCT scan environment, an
embalmed human head (Science Care, Phoenix, AZ) with an intact
dentition was used. Before CBCT scanning, the mandible was resected
at the level of the maxillary occlusal plane, and the left and right maxil-
lary first molars were extracted. The experimental teeth were then
mounted in those extraction sockets. A CBCT scan (J Morita Veraviewe-
pocs 3de, Irvine, CA) was taken of each tooth when mounted using the
following presets: a small-volume 40 mm  40 mm field of view, high
resolution (0.125-mm3 voxel size), 80 kV, and 10 mA. One Volume
Viewer software (J Morita, Irvine, CA) was used to view each CBCT
scan. Two faculty from Loma Linda University’s Department of Radi-
ology and Imaging Sciences independently viewed and evaluated in
user-selected multiplanar views the mesiobuccal root for the presence
of an MB2 canal and the number of apical exit points. Each diagnosed
MB2 canal included image-supported screenshots. If an MB2 canal was
suspected but not definitively seen on the CBCT volume, it was not
considered present.
Both evaluators viewed and manipulated the CBCT volumes inde-
pendently and were completely blinded from the results of the other
tests. Initial calibration involved independent viewing and manipulation
of 35 CBCT volumes to standardize readings and agreement. Intraexa-
miner reliability was 94% (33/35).
Group 2: Direct Occlusal Access under a DOM
All aspects of this method were performed by the principle inves-
tigator under a DOM using at least 10 magnification. The preoperative
CBCT volumes were not available to the operator at this time. For docu-
mentation purposes, preoperative periapical (PA) radiographs were
taken from the buccal and mesial views of each unmounted tooth using
a stationary Nomad portable x-ray machine and digital sensor (Aribex,
Inc, Charlotte, NC). Images were viewable in the MiPACs Dental Enter-
prise Viewer (Medicor Imaging, Charlotte, NC). Each tooth was
randomly selected, and a standard access was made, in hand, directly
through the occlusal surface creating an ideal straight-line access. Ac-
cess preparations were refined, as needed, to a more rhomboidal
configuration to support the identification of the MB2 canal. All remain-
ing tissue was removed from the pulp chamber and canals using hand
files and sodium hypochlorite. If not immediately identified, the oper-
ator spent up to 15 minutes per tooth attempting to locate the MB2 canal
using a combination of hand files, rotary files, and ultrasonic instru-
ments. No more than 2 mm of tooth structure, apical from the pulpal
floor, was removed when necessary.
2 Hiebert et al.
Group 3: Direct Access Followed by CBCT Volume
Evaluation and Reaccess
After initial access and exploration, if an MB2 canal was not
located, the CBCT volume of that specific tooth was reviewed. If the
operator noted an MB2 canal on the CBCT volume, the operator re-
turned to the tooth and spent an additional 5 to 10 minutes attempting
further canal negotiation.
Group 4: Coronal Plane Root Grinding
After access of all samples, the teeth were selected at random by
the principal investigator. Using a high-speed handpiece equipped
with a long shank diamond bur, the mesiobuccal root of each tooth
was carefully ground under a DOM in the coronal plane until the canal
system was visualized. The number of canals was documented, and the
root canal system was classified according to Vertucci’s classification
system (8). Throughout the process of accessing and grinding, photo-
graphic and radiographic documentation was taken as shown in
Figure 1.
Statistical/Data Analysis
Statistical analysis was accomplished using SPSS software (IBM,
Armonk, NY). Chi-square analysis was performed to test and compare
the prevalence among the 4 methods of evaluation. All hypotheses
testing were conducted at an alpha level of 0.05.
Results
Results are outlined in Tables 1 and 2. The prevalence of an MB2
canal with blinded CBCT volume evaluation (group 1) was 69%
(68/99). Group 2, initial access of the tooth under a DOM, showed
an MB2 canal 78% (77/99) of the time. Group 3, initial access followed
by a review of the CBCT volume and return to the tooth, led to an MB2
detection rate of 87% (86/99). Group 4, root grinding, demonstrated
the presence of an MB2 canal 92% (91/99) of the time.
When the prevalence of MB2 canals found in group 1 (69%) was
compared with groups 2 (77%), 3 (87%), and 4 (92%), these differ-
ences were all found to be statistically significant (P = .032, P = .002,
and P < .001, respectively). Additionally, when group 2 (77%) was
compared with group 3 (87%), this difference was also found to be sta-
tistically significant (P < .001). Lastly, when group 3 (87%) was
compared with group 4 (92%), this difference was again found to be
statistically significant (P < .001).
In terms of Vertucci’s canal classification (8), the following canal
types were noted from root grinding: type I (8/99), type II (43/99), type
III (1/99), type IV (37/99), type V (1/99), and type VI (9/99). Addi-
tional information from grinding showed that 23% of type II canals
had 2 to 3 apical exit points, and 22% of type IV canals had an isthmus
present. In a similar fashion, the CBCT evaluation yielded 68 teeth with
an MB2 canal. Of these teeth, 44% (30/68) had 1 apical exit, and 56%
(38/68) had 2 apical exit points visible on the CBCT volume.
Discussion
Canal identification is critical to successful root canal treatment. In
a recent retrospective cohort study, Karabucak et al (27) evaluated the
prevalence of missed canals in endodontically treated teeth using CBCT
volumes. They found that when a canal was missed the tooth was 4.38
times more likely to have an associated lesion. Additionally, the MB2
canal was the most frequently missed canal.
Previous studies used CBCT scanning (15–18, 24, 27), laboratory
techniques (2, 6, 8–15, 22, 23), and clinical examinations (5, 7, 19–21,
25,26) to determine the prevalence of the MB2 canal in maxillary
JOE — Volume -, Number -, - 2017
 Basic Research—Technology

Figure 1. Photographic and radiographic documentation. (A) Coronal plane root grinding displaying canal anatomy highlighted with methylene blue dye or pencil.
(B) A PA radiograph with hand files in MB1 and MB2 canals. (C) A coronal plane slice from CBCT volume demonstrating the MB2 canal. (D) An axial plane slice
from CBCT volume demonstrating the MB2 canal. (E) Direct access showing the MB2 canal with and without hand files.

first molars. This study has combined 3 independent techniques as well 78% and 92% of the time, respectively. These percentages fall within
a combination technique as a unique way to evaluate the mesiobuccal the range of other laboratory studies in the literature.
root for the prevalence of MB2 canals. Our study showed that direct CBCT volume interpretation identified the MB2 canal 69% of the
access and root grinding under a microscope identified an MB2 canal time, which is slightly higher than most previous CBCT studies.

TABLE 1. Prevalence of Second Mesiobuccal (MB2) Canals among 4 Methods

MB2 present/found MB2 not present/not found % MB2 present
Group 1: CBCT evaluation 68 31 69 (68/99)
Group 2: access evaluation 77 22 78 (77/99)
Group 3: access + CBCT evaluation + reaccess 86 13 87 (86/99)
Group 4: root grinding evaluation 91 8 92 (91/99)

CBCT, cone-beam computed tomography.

JOE — Volume -, Number -, - 2017 MB2 Canals in Maxillary First Molars 3

Basic Research—Technology
TABLE 2. Statistical Differences among Methods Using Chi-square Analysis
CBCT: MB2 Access: MB2 Access + CBCT + reaccess:
found (%) found (%)
Group 1 vs group 2 69 78
Group 1 vs group 3 69
Group 1 vs group 4 69
Group 2 vs group 3 78
Group 3 vs group 4
This increased identification may be because of the advancements in
CBCT technology. It could also be because of the experience of the in-
dividuals reading the volumes, the sample of teeth used, or, perhaps, the
interpretation of the CBCT volumes. In the classic study by Goldman et al
(28), it was demonstrated that individuals interpret radiographs differ-
ently. A more recent study by Parker et al (29) evaluated different
groups of individuals in their ability to detect periapical lesions in
CBCT volumes and compared this with interpretation by oral and maxil-
lofacial radiologists. They reported that a clinician’s experience level
appears to correlate with his or her ability to correctly diagnose disease.
Additionally, they found that endodontic faculty agreed with the oral
maxillofacial radiologist only 80% of the time. In another recent study
(30), it was shown that endodontists may be more accustomed to as-
sessing endodontic problems using CBCT imaging compared with other
specialists. Therefore, in future studies, it would be beneficial to have
endodontists review the CBCT volumes in addition to oral maxillofacial
radiologists to see if differences exist.
To overcome anatomic and treatment challenges, practitioners
may prescribe a CBCT scan preoperatively, intraoperatively, or postop-
eratively. CBCT imaging allows the assessment of root morphology in 3
dimensions (31), which may help determine whether the MB2 canal is
present or even negotiable (32). If the canal is not present or calcifica-
tion prevents negotiation, then the tooth structure can be preserved,
reducing fracture potential (33). In this study, 22 sample teeth did
not have an identifiable MB2 canal when initially accessed. To evaluate
its effectiveness, preoperative CBCT scans of each of these 22 teeth were
viewed, which provided additional information. After a review of the
CBCT volume of each tooth without an initially detected MB2 canal,
14 of the 22 teeth were noted to have an MB2 canal. Of these teeth,
the MB2 canal was clinically negotiated in 9 teeth. Viewing the CBCT vol-
ume resulted in an increase from 78%–87% prevalence of MB2 canal
detection. This difference was statistically significant (P < .001).
Also of interest in this study was the finding that 22% of type IV ca-
nals had an isthmus present. This is significantly lower compared with
Weller et al’s finding (23) that a complete or partial isthmus was present
100% of the time at the 4-mm level.
The results of this in vitro study add to the literature and provide
clinicians with additional knowledge on the prevalence of MB2 canals
when treating maxillary first molars. This information can be used to
help guide clinicians in making educated decisions on when a CBCT
scan may be advantageous. The results of this study show a statistically
significant higher likelihood of detecting an MB2 canal through direct
visualization or access versus reading a CBCT volume. Therefore,
exposing every patient to a preoperative CBCT scan may not be appro-
priate, as outlined in the 2015 American Association of Endodontists
and American Academy of Oral and Maxillofacial Radiology joint posi-
tion statement (34). However, if after access an MB2 canal is not iden-
tified, performing a CBCT scan would significantly increase the potential
of finding an MB2 canal. If a CBCT scan is necessary, to limit radiation it
may be beneficial to forgo multiple preoperative PA radiographs and
instead take 1 small-volume CBCT scan, which can be as low as 2 to
7 standard PA radiographs (31). In a recent study by Rodriguez et al
4 Hiebert et al.
Root grinding: MB2
MB2 found (%) present (%) P value
.032
87 .002
92 <.001
87 <.001
87 92 <.001
(30), their findings suggest a preoperative CBCT scan can provide
much more diagnostic information than a preoperative PA radiograph.
This would allow a detailed review of the tooth and the surrounding
anatomy, providing more efficient treatment.
Conclusion
Although not always clinically negotiable, the results of this study
show an MB2 canal is present up to 92% of the time. Direct occlusal
access of teeth found significantly more MB2 canals than viewing
CBCT volumes alone (P = .032). Therefore, exposing every patient to
a preoperative CBCT scan may not be appropriate. However, taking a
CBCT scan when an MB2 canal is not found clinically can significantly
increase the chances of finding an MB2 canal (P < .001).
Acknowledgments
The authors deny any conflicts of interest related to this study.
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MB2 Canals in Maxillary First Molars 5