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
micro–computed tomographic (micro-CT) imaging.
Methods: Micro-CT images of the mesial roots of 109
mandibular first molar teeth with independent mesio-
buccal (MB) and mesiolingual (ML) root canals were
analyzed. The deviations of the apical foramina of the
MB, ML, and middle mesial root canals from the
anatomic apex were measured. The vertical distance be-
tween the apical foramina of each mesial root canal in
relation to each other was also calculated. Results:
The distances from the apical foramina of the MB, ML,
and middle mesial root canals to the anatomic apex of
the mesial root were up to 2.51 mm, 3.21 mm, and
5.67 mm, respectively. There was no significant differ-
ence between the deviations of MB and ML root canals
from each other (P > .05). The middle mesial root canal
showed the greatest deviation compared with the MB
and ML canals (P < .05). Conclusions: The apical
foramina of mesial root canals of mandibular first molar
teeth showed greater variations from each other and
anatomic apices than previously reported. Clinically,
the use of electronic apex locators for the detection of
minor apical foramen of each mesial root canal is of
the utmost important. (J Endod 2018;-:1–3)
Key Words
Apical foramen deviation, micro–computed tomogra-
phy, root canal anatomy
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
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-
fecting the root canal sys-
ing deviations of the apical foramina of mesial root
tem through cleaning and
canals from their anatomic apices and recom-
shaping of root canals to
mends the use of electronic apex locators for the
an adequate geometry
determination of the working length because peri-
(1). Knowledge of root ca-
apical radiographs could be misleading because
nal anatomy is 1 of the
of the superimpositions of the deviated mesial
most important factors
root canals.
for accomplishing these
goals (2). However, the
complex internal anatomy of a root canal system often presents challenges for root canal
treatment (3, 4). Mandibular molars have been reported to exhibit a very complicated
internal anatomy because of their mesial roots showing branching, dividing, and
rejoining root canals, accessory root canals, isthmuses, and fins at different levels (5).
The internal anatomy of mandibular molar teeth has been revealed by several tech-
niques, including the clearing method, plastic resin injection, histology, radiography,
scanning electron microscopy, cone-beam computed tomographic imaging, and
micro–computed tomographic (micro-CT) imaging (6). Among these techniques,
micro-CT imaging has emerged as the most promising because it provides high-
resolution accurate images of the internal anatomy without destroying the specimen
(6). Micro-CT imaging has led to the discovery of new anatomic features of the root
canal system and a new classification system for categorizing root canal configurations
(4, 7).
Mesial roots of mandibular molars often have at least 2 root canals extending from
independent orifices to their own apical foramina. Conventional periapical radiography
of these root canals might cause superimposed images, which makes it difficult to differ-
entiate the terminus of root canals during routine root canal treatment (8). A previous
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
Deviations of Mesial Root Canals 1
Basic Research—Technology
the Turkish population. The ages of the patients were unknown. The
mesial roots of 269 mandibular molar teeth were scanned using a
micro-CT system (SkyScan 1172; Bruker-microCT, Kontich, Belgium)
with parameters of 100 kV and 100 mA. Slices presenting
2000  1330 pixel resolution with 10-mm pixel size were obtained
from each root using an 11-megapixel camera. Data were reconstructed
using NRecon software (v. 1.6.4, Bruker-microCT) with a beam-
hardening correction of 45%, smoothing of 2, and an attenuation coef-
ficient range of 0 to 0.06. CTAn and DataViewer (v.1.5, Bruker-
microCT) software were used to reveal the root canal configuration
of each root.
Micro-CT data sets of 106 specimens showing independent MB
and ML root canals with their own orifice and major apical foramina
were selected and further analyzed. The vertical distances between
the apical foramina of the MB and ML root canals were measured
and categorized as follows:
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.
The vertical distances between the apical foramina of the MB and
ML root canals and the anatomic apex of the root were also measured
and recorded (Fig. 1A and B). In the specimens showing middle mesial
root canals, deviations of the apical foramen of the middle mesial root
canal from the anatomic apex and the vertical distances between the api-
cal foramina of the MB to ML and middle mesial root canals were
measured.
Data were analyzed using descriptive and frequency analyses. The
Student t test and 1-way analysis of variance followed by post hoc Scheffe
tests were used to compare the measured features of MB, ML, and mid-
dle mesial root canals using SPSS 21.0 software (SPSS Inc, Chicago, IL).
Results
In 57 specimens, the major apical foramen of ML root canals was
located more apically than that of MB canals (53.8%). In these speci-
mens, the mean value for the deviation of the apical foramen of the ML
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
canal from that of the MB canal was 0.78  0.58 mm. The distance
values ranged from 0.11–2.69 mm (Fig. 1B). In 39 specimens, the api-
cal foramen of MB canals was located more apically than that of ML ca-
nals (36.8%). In these specimens, the mean value for the deviation of
the apical foramen of the MB canal from that of the ML canal was
0.53  0.47 mm. The distance values ranged from 0.02–2.51 mm.
In the remaining 10 specimens, both root canals terminated at the
same level (9.4%). There was no significant difference between the de-
viations of MB and ML root canals from each other (P > .05).
The distances from the apical foramina of MB, ML, and middle
mesial root canals to the anatomic apex of the mesial root were pre-
sented in Table 1. Middle mesial root canals showed the greatest devi-
ation from the anatomic apex compared with MB and ML root canals
(P < .05), whereas no significant difference was detected between
the MB and ML canals (P > .05). In 6 specimens, deviation of the apical
foramen of the middle mesial root canal was greater than 2 mm, extend-
ing to 5.67 mm.
Discussion
The apical part of the root canal system has been considered crit-
ical for therapeutic and pathogenetic reasons (10). Therefore, com-
plete understanding of this complex apical anatomy and its variations
is a prerequisite for successful endodontic treatment. Knowledge of api-
cal anatomy will help clinicians to perform endodontic procedures by
preventing damage to the periradicular tissues and effectively disinfect
the apical part of the root canal system. Micro-CT imaging has been re-
ported as an effective and nondestructive method of evaluating the in-
ternal anatomy of root canal configurations showing fine structures
(3, 11). The present study used micro-CT technology to reveal the po-
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-
ramen has been extensively studied and reported as ranging from 0.2–
3.0 mm depending on patient age and tooth type (2, 12). Another
important factor for the deviation of the major apical foramen is
constant remodeling of the root apex by external root resorption and
JOE — Volume -, Number -, - 2018

TABLE 1. Mean, Standard Deviation (SD), and Minimum-maximum Values of
the Distance Values between the Apical Foramina of Mesial Root Canals and
Anatomic Apex (mm)
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
ML canal 0.52  0.50a 0.0–3.21 106
MMC 1.34  1.15b 0.2–5.67 32
MB, mesiobuccal; ML, mesiolingual; MMC, middle mesial root canal; SD, standard deviation.
Different superscript letters at the same column show significant difference (P < .05).
cementum apposition (13). Unfortunately, in the present study, the ages
of the patients from whom the specimens were collected were un-
known.
In the present study, a large number (N = 269) of mesial roots of
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
same level and show equal distance from the anatomic apex. In the ma-
jority of specimens (55.6%), ML root canals terminated more apically
than MB canals, with values up to 2.69 mm. Moreover, the distance be-
tween the apical foramen of the MB canal and the anatomic apex was
greater than that of the ML canal; however, no significant difference
was detected between MB and ML root canals. In some specimens,
the apical foramen showed considerable deviations from the anatomic
apex, exceeding the previously reported 3 mm.
Middle mesial root canals usually have a small orifice deep
within the isthmus or a developmental groove between the orifices
of the MB and ML root canals, and they either join these canals
or show an independent configuration with their own apical
foramina (1). Accessing the middle mesial root canal is difficult
because of the location of their orifices. However, the inability to
locate and treat middle mesial root canals might compromise treat-
ment outcomes and lead to persistent apical periodontitis because
untreated canals might harbor microorganisms and their by-
products (8, 14). In the present study, the deviation of the apical
foramen of middle mesial root canals from the anatomic apex was
greater compared with MB and ML root canals. A previous study
measured the variation range of the apical foramen of middle
mesial root canals from the anatomic apex and reported it as
0.2–2.4 mm, with some specimens extending beyond 3 mm (9).
In the present study, the mean distance of the apical foramen of mid-
dle mesial root canals from the anatomic apex was 1.34  1.15 mm.
The deviation was significantly greater than those of MB and ML ca-
nals, and in some specimens, it reached up to 5.67 mm. In such
specimens, failure to locate and treat these root canals might result
in the formation of periodontic-endodontic lesions at the furcation
area.
JOE — Volume -, Number -, - 2018
Basic Research—Technology
Conclusion
In conclusion, the apical foramina of mesial root canals of
mandibular first molar teeth frequently showed deviations from each
tronic apex locators to detect each apical foramen is highly important
because periapical radiography might be limited by the superimposition
of root canals. Future micro-CT studies are required to determine the
effect of age and cementum deposition on the deviation of the major api-
cal foramen.
Acknowledgments
Supported by the Scientific and Technological Research Coun-
cil of Turkey (grant no. 114S002).
The authors deny any conflicts of interest related to this study.
References
1. Saleh I, Ruyter I, Haapasalo M, Ørstavik D. Survival of Enterococcus faecalis in in-
fected dentinal tubules after root canal filling with different root canal sealers
in vitro. Int Endod J 2004;37:193–8.
2. Vertucci FJ. Root canal morphology and its relationship to endodontic procedures.
Endod Topics 2005;10:3–29.
3. Keleş A, Keskin C. Apical root canal morphology of mesial roots of mandibular first
molar teeth with Vertucci type II configuration by means of micro–computed to-
mography. J Endod 2017;43:481–5.
4. Keleş A, Keskin C. A micro-computed tomographic study of band-shaped root canal
isthmuses, having their floor in the apical third of mesial roots of mandibular first
molars. Int Endod J 2018;51:240–6.
5. Villas-B^oas MH, Bernardineli N, Cavenago BC, et al. Micro–computed tomography
study of the internal anatomy of mesial root canals of mandibular molars. J Endod
2011;37:1682–6.
6. Ordinola-Zapata R, Bramante C, Versiani M, et al. Comparative accuracy of the
clearing technique, CBCT and micro-CT methods in studying the mesial root canal
configuration of mandibular first molars. Int Endod J 2016;50:90–6.
7. Ahmed H, Versiani M, De-Deus G, Dummer P. A new system for classifying root and
root canal morphology. Int Endod J 2016;50:761–70.
8. Versiani MA, Ordinola-Zapata R, Keleş A, et al. Middle mesial canals in mandibular
first molars: A micro-CT study in different populations. Arch Oral Biol 2016;61:
130–7.
9. Versiani MA, Ahmed HM, Sousa-Neto MD, et al. Unusual deviation of the main fo-
ramen from the root apex. Braz Dent J 2016;27:589–91.
10. Ricucci D, Siqueira JF. Biofilms and apical periodontitis: study of prevalence and
association with clinical and histopathologic findings. J Endod 2010;36:1277–88.
11. Keleş A, Keskin C. Detectability of middle mesial root canal orifices by troughing
technique in mandibular molars: a micro–computed tomographic study. J Endod
2017;43:1329–31.
12. Dummer PM, McGinn J, Rees DG. The position and topography of the apical canal
constriction and apical foramen. Int Endod J 1984;17:192–8.
13. Blaskovic-Subat V, Maricic B, Sutalo J. Asymmetry of the root canal foramen. Int
Endod J 1992;25:158–64.
14. Karabucak B, Bunes A, Chehoud C, et al. Prevalence of apical periodontitis in
endodontically treated premolars and molars with untreated canal: a cone-beam
computed tomography study. J Endod 2016;42:538–41.
Deviations of Mesial Root Canals 3