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Review Article

Intricate internal anatomy of teeth and its clinical
significance in endodontics - A review
A.P. Tikku * # 
W. Pragya Pandey ** # 
Ivy Shukla*** 

Beyond the simple perception is often the intricate internal tooth anatomy and a complex root canal system. Root
canal treatment has transformed remarkably since the hollow tube theory was postulated in 1930. Research into
the morphology of the pulp has revealed that the dental pulp takes many intricate shapes and configurations
before reaching the tooth apex. The prospect of the treatment depends on accurate diagnosis followed by location,
cleaning and shaping and finally obturation of the root canal system. As a professional, one should be aware of all
the probable nooks and crannies of the complex root canal, its protean permutations and combinations, to render
the finest possible treatment. As is the case with any other treatment, endodontic therapy; if performed in the
properly delineated and precise manner spells more than 99% success rate. This review article attempts to bring
out the possible nuances of the complex root canal system and various methods of reckoning with these significantly
essential details.
Keywords: Intricate, internal, tooth anatomy, complex, root canal system


depends on the clinician’s knowledge and ability

Dental professionals conventionally have

to comprehend, visualize, perceive and prepare the

referred to the main/large passage lying at the core

root canal system. From the early work of Hess and

of the tooth as the pulp space and all effort was

Zurcher[1] to the contemporary studies regarding the

made to ensure debridement from that area only..

anatomic complexities of the root canal system, it

Factually, as we know now the root canal is a

has been well established that the root with a

complex system of finely tuned and synchronized

graceful tapering canal and a single apical foramen

small tributaries running all through the length and

is an exception rather than the rule. Investigators

breadth of the tooth dentine. Hence, it becomes

have very commonly encountered bifurcating

imperative for a clinician to fully understand this

canals, multiple foramina, fins, deltas, loops, cud-

system. Seasoned clinicians very aptly say - what

le-sacs, inter-canal links, C-shaped canals and

we cannot see, we cannot negotiate and what we

accessory canals in most teeth. The student and

cannot negotiate we fail to prepare! A good

the clinician must approach the tooth presuming,

obturation is possible only after meticulous cleaning

that these ‘Aberrations’ occur so often that they must

and shaping which eventually and ultimately

be considered normal anatomy

* Professor, ** Reader, ***
***Private Practice, # Dept. of Conservative Dentistry & Endodontics,  King George’s Medical University, Lucknow, India,  Chandra Dental College
and Hospital, Barabanki, India,  Lucknow, India.


assessable and reproducible 2) Relationships of the root canal orifice on then surely the task of locating orifices becomes the pulp chamber floor: easier. 161 . IVY SHUKLA Anatomy of the pulp-chamber floor • Law of Concentricity: The walls of the pulp A thorough investigation of the sulcus. is begun.P TIKKU. • Law of orifice location 1: the orifices of the 1) Relationships of the pulp chamber to the clinical root canals are always located at the junction of crown: the walls and the floor. tooth angulation. and contacts is mandatory before access • Law of the CEJ: The CEJ is the most consistent. The • Law of symmetry 2: except for the maxillary anatomic laws/patterns observed 2 are categorized molars. consistent landmarks exist and are quantifiable. teeth with calcified canals and from a line drawn in a mesial-distal direction teeth gouged from previous access openings. chamber. molars. carious broken down teeth. restorations. • Law of Centrality: the floor of the pulp chamber is always located in the center of the tooth • Law of orifice location 2: the orifices of the at the level of the CEJ (cemento-enamel- root canals are located at the angles in the floor- junction). chamber floor.(Figure-2) • Law of Color Change: the color of the pulp- 2) Relationships of the root canal orifice on the pulp- chamber floor is always darker than the walls. canal orifice. chamber and canal orifice position. If specific. Past literature describing pulp-chamber anatomy has been very general and undefined in determining the location and number of root canal orifice.(Figure-1) wall junction. Krasner and Henry2 in 2004 studied the pulp chamber of 500 extracted teeth and their consistent observation regarding the pulp chamber anatomy in all teeth led to the formulation of new laws. W. occlusion. This is especially beneficial in challenging cases like • Law of symmetry 1: except for maxillary heavily restored teeth. the orifices of the canals lie on a line into two groups: perpendicular to a line drawn in a mesial-distal 1) Relationships of the pulp-chamber to the clinical direction across the center of the floor of the pulp crown. forming guidelines for locating the pulp chamber and root Figure-1: Cross-section of mandibular molar. systematic and much more certain. coronal chamber are always concentric to the external clefts. the orifices of the canals are equidistant malposed teeth. surface of the tooth at the level of the CEJ.(Figure-2) locating orifices becomes an onerous task. where through the pulp chamber floor. PRAGYA PANDEY.ENDODONTOLOGY A. cusp position. Before tooth entry the clinician must repeatable landmark for locating the position of the visualize the expected location of the coronal pulp pulp-chamber. showing equality of distance of the pulp chamber walls from the external root surfaces (arrows).

(Figure-2) joining into four at the apex. The the success of the treatment. re-dividing into two and terminating as one 162 . Divisions of the canals may not be beginning of the treatment. With the formulation sudden radiographic disappearance of a canal of these anatomic laws. Orifices located at the terminus of Developmental root fusion lines (D). 5 7 . four canals root canals are located at the terminus of the root extending from orifice to the apex and five canals developmental fusion lines. In these situations the Vertucci et al. but they have a tendency to break in root canal orifice and the apex of the tooth running certain clinical situations. Interestingly the only tooth to instrument separation demonstrate all eight configurations is the maxillary second premolar. These agitated by ultrasonic may help to clean the un- include three canals joining into one or two canals. Figure-2: Cross-section of mandibular molar showing: Equidistance of orifices (AB=AC) from the mesiodistal line (M-N). 4 Gulabivala et al. Even if a small part of obvious. 4 categorized the root canal system nickel-titanium rotary instruments should be into a more complex eight configurations preceded by hand files to avoid buckling and (Figure-3). it significantly jeopardizes is the narrowing of canal when they divide. This includes (i) broad through the root dentine. the practitioners can now might indicate a dividing canal. two canals obturation of simple tubular or tapered canals may joining. Classification of the root canal system Preparation of such canals could probably be effectively achieved using nickel-titanium rotary There are multitude pathways connecting the instruments. satisfactorily by mechanical preparation alone.ENDODONTOLOGY INTRICATE INTERNAL ANATOMY OF TEETH AND ITS CLINICAL SIGNIFICANCE IN ENDODONTICS . The use of sodium hypochlorite. Orifices perpendicular to the mesiodistal line (M-N). Branched canal configurations and inter-canal ramifications may examined render complete debridement of canal systems mandibular molars in a Burmese population and difficult. Simple tubular locate the site and number of root canals present. preferably found additional canal configurations. It was seen that gender. Figure-3: Classification showing Vertucci root canal system.A REVIEW • Law of orifice location 3: the orifices of the canal. suddenly becoming narrow. Weine 3 categorized the canal with abrupt apical curve (ii) wide canal root canal system in any root into four basic types. The two canals separating into three canals. (Types I. especially if they are fine. Over the past two decade there have been a plethora of published in-vitro studies and case reports depicting a variety of canal configurations. race and ethnic origin all play a role in determining the canal morphology Even the most proficient clinician cannot and hence should be considered during the always prophesize the exact site and number of preoperative evaluation stage of the root canal root canals present in any tooth before the therapy 6. instrumented parts of the root canal system 8. A tell-tale feature the canal is left unclean. four canals joining into two. IV and VIII) canals may be cleaned with greater predictability and much more ease.

As the isthmus houses the dental in mandibular premolar at 2mm resection level. making complete debridement level.P TIKKU.ENDODONTOLOGY when the canals extend into the isthmus area. It was found to be 16% in dental pulp and pulp related tissue.16. W. it was in 1983 irregular canals or those with complex ramifications that Cambruzzi and Marshall are more satisfactorily obturated using the significant finding in molar surgery. 52% be observed between any two root canals within in maxillary premolar at 6mm resection level. An isthmus can maxillary premolar at 1mm resection level. it might serve as a potential site for bacterial 40% in mandibular premolar at 3mm resection growth and thus. The An isthmus is defined as a ribbon shaped inter- incidence of isthmus at different level section of canal connection 10 or transverse anastomosis or a the root were seen and reported by several corridor 11 between two root canals encompassing authors10. 163 . over in the isthmus can serve as a nidus for recurrent Isthmus infections and lead to failures of orthograde 9 13 first reported this endodontic treatment and endodontic surgery.14. The Type I Type II Type III Type IV ultrasonic tips can be used to prepare the isthmus Type V and subsequently fill the preparation with a suitable Figure-4: Classification of two canals that possess a definite surface. The tissue left thermoplasticized gutta-percha techniques . C-shaped canals and apical micro-fractures can easily be identified. The conventional way of cleaning this anatomic complexity with the use of full strength connection between the two main canals. However the introduction of surgical Type the true connection or corridor endodontic procedures to another level of throughout the section.The highest incidence was reported detecting and debriding it. operating microscope and ultrasonic has taken Type V. consideration first in 1971. sodium Type III. Cambruzzi and Type I Marshall17 recommended the use of methylene blue . deltas. PRAGYA PANDEY. IVY SHUKLA be achieved satisfactorily with cold lateral The implication of an isthmus was taken into condensation of gutta-percha points. 32% the same root. However. debridement and filling of the 12 (Figure-4) isthmus is essential but challenging. Whenever two or more mesiobuccal root of maxillary first molar and 15% root canals are present.15.11. however. Identification. Under the high magnification of microscope. accessory canals. in the mesial root of the mandibular first molar. anatomic structures like three canals that possess a definite hypochlorite and mechanical instrumentation was found to be limited in its connection between them. dye to visualize the isthmus on a resected root Type II . pulp. sophistication 19. an isthmus should be in the distal roots of mandibular molar at 3mm suspected and all attempts should be made in resection level. nearly 50% at 4 mm resection level in of this area indispensible. Classification of the isthmus: Isthmus classification was described by Hsu & Kim et al. action two or three canals with no notable communication. fins. which was 80% at 4 mm resection level.20 .

ENDODONTOLOGY INTRICATE INTERNAL ANATOMY OF TEETH AND ITS CLINICAL SIGNIFICANCE IN ENDODONTICS . C-shaped may present with a C-shape. may. the latter anomaly in mandibular second and third molars in of which may not be very obvious at first glance. An evaluation of the actual thickness occurrence of a C-shaped canal and its improper of canal walls in C-shaped roots should identify negotiation can lead to failure in endodontic therapy which walls are in danger zones for anti-curvature and hence should be gingerly examined. The introduction of micro-ultrasonic has Radiographic appearance of a C-shaped root greatly increased the endodontic success rates. Moreover it must be kept illustrated C-shape canal configuration in maxillary in mind that very little dentin separates the external first molars. maxillary first molars and maxillary second molars. but not always. described C-shaped canal in surface from the C-shaped canal system. The canal orifice those that exhibit a single.29 Canal curvatures A straight root canal extending the entire length of the root is uncommon The curvature may be a gradual curvature of the entire canal. 25 (Figure-5). Studies have been designed to evaluate the cross-sectional morphology of C-shaped canals and to identify the location and measure the minimum widths (MWs) of buccal and lingual walls. and during endodontic and restorative procedures. which first. 164 . ribbon like. The C-shaped canal has been roots may present with narrow root grooves that observed in mandibular first premolars. 1979. C-shaped canal depending on the exact nature and orientation of the root. increasing mandibular molars as a ribbon shaped canal that the probability of stripping or lateral perforation includes the mesiobuccal and distal canals. It may present as a single fused root or as Cooks and Cox 22 first discovered the C-shaped two distinct roots with a communication. 27 considered them to form a typical effective cleaning. and canal from orifice to apex and (2) those with three when it does. mandibular predispose to localized periodontal disease. sometimes the mesiolingual. root canal therapy. Fused roots and C-shaped . filing. it is no guarantee that it continues distinct canals below the C-shaped orifice. shaping and obturation during a radiographic image revealing fusion. There are two common possible large distal canal or the blurred image of a third outcomes for the C-shaped mandibular molar (1) canal in the middle of two roots. in mandibular second molars may be diverse. Newton et al. second and third molars. the more common form 23 spicily as a single canal. a sharp curvature of the canal near the apex. The presence of a C-shaped canal prevents Haddad et al. The danger zone. B: ribbon shape C-shaped canal including the mesiobuccal and distal canals. curvature of the canal with a straight apical ending. Melton and colleagues 26 AbouRass et al. root proximity. Yang et al. 28 described an anti-curvature filing discovered this phenomenon in technique in which the bulkier root structure was maxillary second molars where the C-shape joins filed away from the curvature and the thinner the distobuccal root with the palatal root. in fact be the first diagnostic indication of 24 such anatomical variance. A: mesiolingual canal.A REVIEW material 21. or a gradual Figure-5: Cross-section of a mandibular molar showing a C-shaped canal.

The radius is calculated on the basis of of the endodontic instrument and most important.ENDODONTOLOGY A.(Figure-6) more straightened guide path is created before any Radius of curvature: The line (S) between the attempt is made of taking rotary files around these points M and N is the chord of the hypothetical abrupt curves. considering both the angle of curvature together with the radius of the curve is supposedly the exact method of describing the canal curvature. canal. the size and the hypothetical circle. this line was parallel to the long iatrogenic damage. the size and flexibility radius (r).P TIKKU. Only few studies have M and N31 . using push-pull M). According to the Schneiders method. It is quite challenging to enlarge a canal with a great angle in degree and an abrupt short curve without any transportation regardless of whether rotary nickel-titanium or stainless steel hand instruments are used. A second line (b) was drawn to canals is to pre-curve the instrument prior to intersect the apical foramen (point N) with the point instrumentation and try to negotiate the entire root where the canal began to leave the long axis (Point canal length at the first attempt. which is specified by its constriction of the root canal. Canal the computer program. a more abrupt curve of the canal corresponds to a smaller radius of curvature. Such procedures significantly reduce circle that defines the curved part of the the chances of ledge formation. The most common method used to 2 sin S describe canal curvature was published by Schneider. PRAGYA PANDEY. Henceforth the radius can curvature be calculated using the following formula:- can be Berbert&Nishiyamas 30 measured either by method or by Schneiders 31 Radius of curvature (r) = method. size 08(introduced into the The preparation of curved canals is canal prior to instrumentation) in the coronal straight challenging and has an increased likelihood for portion of the canal.(Figure-6) The curved part of the canal Success in negotiating a narrow curved canal between the points M and N is the circular arc of depends on the degree of curvature. Angle of curvature: A straight line (a) was drawn Figure-6: Angle of Curvature ( ) along the silver point. The point where the canal deviated the clinicians generally tend to under prepare these from this line to begin the canal curvature was canals. The angle of curvature(á) is formed by lines a movements rather than twisting movements until a and b 31 . the measured length of the chord (S) between points the skill of the operator. The key to dealing with severely curved marked as point M. Whereas the angle of curvature is independent of the radius.The chord (S) was measured by using actually measured the canal curvature. To avoid any procedural errors axis of the canal. IVY SHUKLA Double curvatures in the form of ‘S’ may also occur. 165 . W.

In long oval /flat canals reaming action varies greatly at each vertical level of the canal. periodontal tissue begins. working width at working length (Min IWW0) and Ideally during root canal preparation the instruments consequently incomplete cleaning of the root canal and the techniques used should always conform to system 32. obturated 34. the maximal initial horizontal dimensions shaped. (Figure-7) (Max IWW) may be several times larger than the minimal initial dimension (Min IWW) at different 166 . The dogma of enlarging the canal three and retain the original shape of the canal to maximize sizes larger than the first file that binds to the apex the cleaning and minimize unnecessary weakening might not be applicable in all the cases. Max IWW 12 is dimension (working length) but is also more difficult probably three to four times larger than Min to investigate. because the horizontal dimension IWW12 32. In an oval. Apical anatomy at working length (Min IWW0) may be the same as 32 Current descriptions of the horizontal The anatomy of the root apex was first dimensions (cross-sections) of the root canal : described by Kutler 1)Round: Max IWW** equals Min IWW* features that constitute the root apex (Figure-7) are 32 33 .A REVIEW Horizontal shapes and dimension of root canal levels of the canal. long-oval. is where the pulp tissue ends and the ** Maximum Initial working width. Very may lead to in-complete debridement of the root few clinical attempts and studies have been done to canal system. Circumferential filing can better determine the working width of the canal and hence conform to the outline of the horizontal dimension it is very aptly referred to as the “Forgotten of the root canals at different levels of the canal. The space approximately the same. Anatomic and histologic apical constriction (minor apical foramen).Enlarging of the canal during root canal Comprehending the concepts of working width can treatment is known to all but how large is large reduce the underestimation of the minimum initial enough is a question that still needs serious attention.ENDODONTOLOGY INTRICATE INTERNAL ANATOMY OF TEETH AND ITS CLINICAL SIGNIFICANCE IN ENDODONTICS . to improve the apical seal when the canal is 5)Irregular: Cannot be defined by 1-4. 2)Oval : Max IWW is greater than Min IWW (Up cementodentinaljunction (CDJ) and apical foramen to two times more) (major apical foramen). Dimension”. Min IWW The horizontal dimension of the root canal Max IWW at working length (Max IWW0). of the tooth structure . But 12 system is not only more complicated than the vertical mm short of working length. In a maxillary cuspid. CDJ the point where cementum meets * Minimum Initial working width. dentine. or in between the major and minor foramen is funnel flat canal. the lesser and the constriction the canal widens as it exits the roots at greater initial horizontal dimensions are the apical foramen or major diameter. Apical limit of canal 3)Longoval : Max IWW is two or more times greater instrumentation and obturation is the apical than Min IWW(up to 4 times more) constriction which is not only the narrowest part 4)Flattened: Max IWW is four or more times greater of canal but a morphologic landmark that can help than Min IWW. From the apical In a relatively round canal.

IVY SHUKLA Few tips to see the unseen: 1.P TIKKU. to prevent under and over preparation. Figure-7: Morphology of the root apex. 3. multiple vertical lines indicates thin root which may be hourglass shaped in cross section. PRAGYA PANDEY. Whenever the outline of the root is unclear. teeth can better reveal the anatomic variances. running parallel to the test file in the radiograph. It is imperative that radiographs should be Failure to accurately determine the working length taken. The radiograph also gives several clues to the entire procedure and avoiding extravagant apical anatomic aberration: lateral radiolucency indicates enlargement. from minimum two angulations before may lead to perforation through the apical attempting endodontic treatment. an perforation of the apical foramen. is usually seen in maxillary first premolars. 36 called the ‘Fast Break’. abrupt ending of a large canal signifies a bifurcation. ledging and the presence of lateral or accessory canals. one should suspect a second canal. one should constricted (D) Parallel constriction which need to suspect an additional root canal 36. constriction into four main types: (A) Traditional has an unusual contour. a knob like image indicates an apex that curves towards or away from the X-ay beam (Bull’s eye).ENDODONTOLOGY A. This is especially helpful in detecting the fourth Figure-8: Types of Apical Constriction 167 . When the radiograph shows that the root canal shadow suddenly stops in the radicular region it can safely be assumed that it has bifurcated or trifurcated into finer diameter tributaries at that point. measure the working length maintaining it throughout 4. This diagnostic clue as pointed out by Slowey. together with overfilling. zipping. 35 classified (Figure-8) the apical 2. overextension. Dummer et al. Thus the focus should be to accurately opposite buccal) 37. hence susceptible to strip or lateral perforations 36. W. 5. If an extra dark line is apparent in the coronal third of the root. be analyzed. To confirm this dichotomy a second radiograph may be exposed from a mesial angulation of 10 to 30 degrees. All these Mesial angulation technique is used for identifying procedural errors will increase the incidence of two canals wherein the lingual root always appears postoperative pain and failure of the root canal mesially on the film (SLOB rule –same lingual treatment. incomplete debridement or short fillings. Angled views of constriction. or strays in any way from single constriction (B) Tapering constriction (C) Multi- the expected radiographic appearance. particularly in the coronal part of the root. transportation.

endodontic endoscopes help us to further search and find the normal structures. Alavi A. fracture lines. St. and additional canal orifices including apical constrictions. abfractions and 5. Mg Y-L.. Aung TH. Weine FS. an extra distal mind the various laid down guidelines and laws to root in a mandibular molar. 5thedn.1925. Ethnicity has a significant influence on much inside the area we work. magnifying optical 7. Root canal morphology and its relationship to endodontic procedures. 168 . Rankow HJ. Vertucci FJ.48:19-34. diagnosis. the root canal to ensure an acceptable endodontic and Eskimo population 38 Korean and Indian population 39. Seelig A. entire length and breadth of the tooth. Louis: Mosby.2002:231-92. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1974. Knowledge of normal root curvatures may finely tuned small tributaries running through the be quite helpful in interpretation of the radiographs. the buccal. 8th ed. Surgical operating microscopes. Radix Entomolaris. is often seen in Oriental comprehend and perceive the unseen complexities . third dimension that the clinician must visualize to achieve success in Endodontic treatment. Cleaning and shaping the root canal system. J Endod 1995.1996:243.NewYork:William Wood & Co. eds. root divisions. Gilles R. success rate. provide only two dimensional blueprint of the actual three dimensional pulp anatomy.Vertucci FJ. Root canal morphology of the human maxillary second premolar. canal takes in leaving the pulp chamber.38:456-464. 9. shape and obturate anatomy is seen more commonly in Chinese. Burns RC. 8. J Endod 2004.34:359-370. It is crucial For example. first as an aid to the 6. Unfortunately radiographs 9. 4. The Anatomy of Root Canals of the teeth of the Permanent and Deciduous dentitions. Mesiobuccal root of the maxillary first molar. Fiberoptic transillumination can reveal calcifications. Kratchman SI. 10. In: Cohen S. Obturation of the root canal system. Dent Clin N Am 2004.A REVIEW Conclusion canal in the mesiobuccal root of the maxillary first It would be quite erroneous to refer to this molars and in the distal roots of the mandibular first molars 36. and components of unprepared as well as prepared root canal morphology. Similarly C-shaped and details to efficiently clean.21:380-383. Iqbal MK. then periodically during treatment. Niemczyk SP. Kim S: Incidence and position of the canal isthmus: Part 1. Since during endodontic treatment we cannot see 7. Ruddle C. orifice locations.48:203-215. Zurcher E. loupes. The endodontic pathfinder inserted into the References : orifice openings will reveal the direction that the 1. Dent Clin N Am 2004.40 . Endod Top 2005. St. Weller RN. complex system simply as the “Root Canal”because it actually is a very complex system of 6.ENDODONTOLOGY INTRICATE INTERNAL ANATOMY OF TEETH AND ITS CLINICAL SIGNIFICANCE IN ENDODONTICS . Gulabivala K. 3. we must keep in aberrant anatomy.Louis:MosbyYearbook Inc. can identify curvatures. Pathway of the pulp. variations 8. IntEndod J 2001. Tactile perception with a hand instrument 2. It is the 10.30:5-16. Root and canal morphology of Burmese mandibular molars. Endodontic Therapy. Nonsurgical ultrasonic endodontic instruments. Hess W. Anatomy of the pulp chamber floor. Krasner P. obstructions. palatal roots of permanent maxillary to be aware and admire the various complexities molars often have sharp apical curvatures towards of the spaces we are expected to clean and fill.10:3-29. Radiography is needed.

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