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doi:10.1111/iej.

12508

REVIEW
Accessory roots and root canals in human anterior
teeth: a review and clinical considerations

H. M. A. Ahmed1 & A. A. Hashem2,3


1
Department of Conservative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia; 2Department
of Endodontics, Faculty of Dentistry, Ain Shams University, Cairo; and 3Department of Endodontics, Faculty of Dentistry,
Future University, Cairo, Egypt

Abstract teeth than in maxillary counterparts. However, max-


illary incisor teeth revealed the highest tendency for
Ahmed HMA, Hashem AA. Accessory roots and root
accessory root/root canal aberrations caused by
canals in human anterior teeth: a review and clinical
anomalies such as dens invaginatus and palato-gingi-
considerations. International Endodontic Journal.
val groove. Primary anterior teeth may also exhibit
Anterior teeth may have aberrant anatomical varia- external and internal anatomical variations in the
tions in the number of roots and root canals. A root, especially maxillary canines. Therefore, dental
review of the literature was conducted using appro- practitioners should thoroughly assess all teeth
priate key words in major endodontic journals to scheduled for root canal treatment to prevent the
identify the available reported cases as well as experi- undesirable consequences caused by inadequate
mental and clinical investigations on accessory roots debridement of accessory configurations of the root
and root canals in anterior teeth. After retrieving the canal system.
full text of related articles, cross-citations were identi-
Keywords: accessory, canine, central incisor, lat-
fied, and the pooled data were then discussed.
eral incisor, root, root canal.
Results revealed a higher prevalence in accessory
root/root canal variations in mandibular anterior Received 17 March 2015; accepted 9 July 2015

minimize the number of missed roots and root


Introduction
canals during treatment, thus increasing the rate of
A thorough knowledge of both root and root canal clinical success (Vertucci 2005, Cantatore et al.
morphology is a fundamental prerequisite for success- 2006).
ful root canal treatment (RCT) (Vertucci 2005). This Current knowledge on root and root canal morphol-
knowledge includes pre- and intra-operative aware- ogy is based on research findings and individual case
ness of landmarks associated with normal morphol- reports. Many clinicians perceive that a given tooth
ogy as well as any aberrant anatomy of the root and contains a specific number of roots and/or canals.
root canal system encountered in daily practice However, careful evaluation of published material has
(Vertucci 2005, Cantatore et al. 2006, Ahmed & shown that variations in root anatomy are common
Abbott 2012a). A good understanding of the external (D’Arcangelo et al. 2001). Maxillary anterior teeth are
and internal anatomical features of the root would well known to have a single root that usually encases
a single root canal; nevertheless, maxillary anteriors
with aberrant root/root canal anatomy exist (Lin et al.
2006, Kottoor et al. 2012). Similar deviation from the
Correspondence: Dr. Hany Mohamed Aly Ahmed, Department of
Conservative Dentistry, School of Dental Sciences, Universiti
normal anatomical features has been observed in
Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia mandibular anterior teeth (Kartal & Yaniko glu 1992,
(Tel.: +60129857937; e-mail: hany_endodontist@hotmail.com). Heling et al. 1995). Additional root canals that are

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 1
Accessory roots and root canals in anterior teeth Ahmed & Hashem

not cleaned and filled may provide a source of persis- and the data were then analysed. Tables S1–S4 sum-
tent irritation, thus compromising the long-term suc- marize the accessory roots and root canals in maxil-
cess of RCT (Gondim et al. 2009). lary and mandibular anterior teeth.
This study attempts to correlate the potential occur-
rence of accessory roots/root canals in anterior teeth
Terminology and aetiology
with clinical practice. The aims are (i) to summarize
existing knowledge on aetiology and the prevalence of An accessory (also known as extra or additional)
accessory roots and root canals in anterior teeth, (ii) root/root canal refers to the development of an addi-
to describe their clinical and radiographic landmarks tional number of roots/root canals in teeth compared
using conventional and contemporary examination with that described in dental anatomy (Neville et al.
tools and (iii) to discuss the implications of such 2002, Ahmed & Luddin 2012).
anatomical variations on treatment procedures and Accessory root formation usually occurs through
clinical outcomes. two ways, either by splitting the Hertwig’s epithelial
root sheath (HERS) to form two similar roots, or by
folding of the HERS to form an independent root
Literature search methodology
which may have various morphological features
An electronic search was conducted, spanning the (Ahmed & Abbott 2012a). Whilst the exact aetiology
period from January 1970 to November 2014, to of accessory roots is still uncertain, several factors
identify investigations on accessory roots and root have been proposed, including different ethnicity, sev-
canals in anterior teeth. Related studies and case eral diseases and developmental anomalies, genetic
reports written in the English language and published factors, local traumatic injuries and external pressure
in major endodontic journals were included. (Kocsis & Marcsik 1989, Ahmed & Abbott 2012a,
• Australian Endodontic Journal, Kang & Kim 2014).
• Dental Traumatology (previously named as An accessory root canal is a common finding that
Endodontics and Dental Traumatology), occurs in the primary and permanent human dentition
• International Endodontic Journal, (Vertucci 2005, Ahmed 2013). Ethnicity, age, develop-
• Journal of Endodontics and mental anomalies and the formation of reparative den-
• Oral Surgery Oral Medicine Oral Pathology (subse- tine stimulated by external insults such as trauma,
quently renamed as Oral Surgery Oral Medicine caries, periodontal disease and restorative procedures
Oral Pathology Oral Radiology and Endodontology have been reported as contributing factors to the creation
until December 2011). of this anatomical variation (Neo & Chee 1990, Sert et al.
The following keywords were used in the search: 2004, Ahmed & Cheung 2012, Han et al. 2014).
1. ‘Accessory’ OR ‘Double’ OR ‘Extra’ OR ‘Four’ OR
‘Supernumerary’ OR ‘Supplemental’ OR ‘Three’
Morphological variations
OR ‘Two’ AND ‘Incisor’ AND ‘Root’ OR ‘Canal’.
2. ‘Accessory’ OR ‘Double’ OR ‘Extra’ OR ‘Four’ OR Accessory roots/root canals in normal anterior teeth (no
‘Supernumerary’ OR ‘Supplemental’ OR ‘Three’ developmental anomalies)
OR ‘Two’ AND ‘Canine’ AND ‘Root’ OR ‘Canal’.
The papers which met the criteria described in Maxillary anterior teeth. The formation of root and/or
Table 1 were selected, cross-citations were detected, root canal aberration does not necessarily correspond

Table 1 Inclusion and exclusion criteria of the literature search methodology

Inclusion criteria Exclusion criteria

Anterior teeth that have Anterior teeth that have a single root and a single canal fused with a supplemental or
more than one root supernumerary tooth were excluded. Owing to the great difficulty in differentiating
gemination from fusion with a supernumerary tooth (Mader 1979, Kremeier et al. 2007),
gemination was also excluded
Single-rooted anterior teeth Common configurations (2-1 and 1-2-1) in single-rooted mandibular anterior teeth
that have more than one root canal (Walker 1988, Kartal & Yanikog  lu 1992, Sert et al. 2004, Sert & Bayirli 2004) were
also excluded

2 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Hashem Accessory roots and root canals in anterior teeth

to a similar aberration in the morphology of the missed during radiographic interpretation (Ahmed &
crown (Ahmed & Cheung 2012). A number of cases Cheung 2012).
document the presence of single-rooted maxillary Root canal configuration type IV (2-2) (Vertucci
anterior teeth with two canals, or double-rooted max- 2005) is the most common accessory anatomical
illary anteriors, with normal clinical crown compared variation reported in single- and double-rooted maxil-
with the contra-lateral tooth (Hatton & Ferrillo 1989, lary anterior teeth (Table S1). Other configurations,
Lambruschini & Camps 1993, Reid et al. 1993, Gen- such as type (2-1) (Thompson et al. 1985, Al-Nazhan
ovese & Marsico 2003, Low & Chan 2004, Sponchi- 1991) (Fig. 1c) and type (1-2) (Calvert 2014)
ado et al. 2006, Gondim et al. 2009). This finding (Fig. 1a), have also been reported. Morphological
indicates the importance of careful radiographic studies demonstrated a supplemental configuration
examination and intra-operative exploration of the type (1-2-1) in both maxillary lateral incisors and
pulp chamber and canal system after access cavity canines in Turkish and Chinese population groups
preparation. ß alisßkan et al. 1995, Sert & Bayirli 2004, Weng
(C
Accessory roots and root canals in maxillary ante- et al. 2009). Interestingly, Gondim et al. (2009)
rior teeth may occur in a mesio-distal (Berbert et al. reported a double-rooted maxillary lateral incisor that
1976, Furman & Wagner 1976, Thompson et al. had three separate root canals. Root canal configura-
1985, Hatton & Ferrillo 1989, Collins 2001, Low & tion type (1-3) may also occur in single-rooted maxil-
Chan 2004, Sponchiado et al. 2006, Calvert 2014) lary anterior teeth (Fig. 2).
(Figs 1a and 2) or in a labio-palatal relation (Reid
et al. 1993, Lin et al. 2006, Gondim et al. 2009) Mandibular anterior teeth. Accessory roots and root
(Fig. 1c). The former type can be easily identified in canals have also been reported in mandibular anterior
routine parallel periapical radiographs. However, the teeth, but these tooth types seem to exhibit more
latter type is more difficult to identify and usually complex anatomical variations than their maxillary
requires radiographs from different angulations (Kaffe counterparts (Table S2). Numerous supplemental con-
et al. 1985), or cone-beam computed tomography figurations have been identified in different population
(CBCT) views. Despite the importance of such different groups using methods such as staining and clearing
radiographic views, proper intra-operative exploration (Sert & Bayirli 2004, Sert et al. 2004) (Fig. 1e) and
of the pulp chamber aids in locating such canals if microcomputed tomography (Milanezi de Almeida

(a) (b) (c) (d) (e)

Figure 1 (a) Periapical radiograph showing a maxillary left central incisor with associated periapical radiolucency (white
arrows). Accessory root canal [(type 1-2) yellow arrow] is identified in the distal portion of the apical third of the root. The
portal of exit is located in the mid-way of the periapical radiolucency. (b) Periapical radiograph showing a mandibular canine
having root canal configuration type (2-2). (c) Single-rooted maxillary canine that have a root canal configuration type (2-1).
(d) A sample of double-rooted mandibular canine. (e) A cleared mandibular incisor having two root canals with two separate
exits. An intercanal communication is observed in the apical third of the root (configuration type 2-1-2).

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 3
Accessory roots and root canals in anterior teeth Ahmed & Hashem

(a) (b) (c)

(d) (e)

Figure 2 Maxillary central incisor with three root canals. (a) Preoperative radiograph showing maxillary left central incisor
with shorter root than contralateral tooth and apical periodontitis. There was no obvious shadow of the canal and the root
apex was broad. (b) With the aid of ultrasonics, two canals were located and hand files were introduced into the canals. How-
ever, they were not centralized. (c) Ultrasonics were used again deep into the root, and a third canal was located (patency was
established by a small K file). (d) A photograph showing the three canal orifices under a surgical microscope (13.69). (e) Post-
operative radiograph showing filling of the root canals using mineral trioxide aggregate.

et al. 2013, Leoni et al. 2014), as well as clinical roots/root canals. Anterior teeth that have accessory
investigations using CBCT (Han et al. 2014). In con- roots/root canals may reveal a normal-shaped, but
trast to maxillary anteriors, the frequent location of relatively larger, crown compared with the contra-lat-
such canals in a buccolingual direction usually com- eral tooth (Henry 1970, Christie et al. 1981,
plicates their clinical identification using conventional Michanowicz et al. 1990, Peix-Sanchez & Minana-
radiographs. Laliga 1999). However, this should not be considered
Root canal configuration types (2-2) and (1-2) are as a general rule because accessory roots/root canals
the most common accessory anatomical variations in can also exist with a normal-sized crown (Hatton &
single-rooted mandibular anteriors (Table S2) (Figs 1b Ferrillo 1989, Genovese & Marsico 2003, Low &
and 3). In contrast to maxillary canines, double-rooted Chan 2004, Sponchiado et al. 2006, Gondim et al.
mandibular canines have been documented in a num- 2009). In addition, the crown can be seriously dam-
ber of investigations (Hession 1977, Sharma et al. aged (Thompson et al. 1985, Lin et al. 2006, Calvert
1998, Mikrogeorgis et al. 1999, Versiani et al. 2011, 2014), restored, or the contra-lateral tooth may be
Han et al. 2014) (Fig. 1d), which may have three missing (Lin et al. 2006).
canals (Heling et al. 1995). The occurrence of double Accessory roots can be identified by probing of the
roots in mandibular incisors has also been reported cervical root which may reveal bifurcations, especially if
(Kocsis & Marcsik 1989, Loushine et al. 1993). accompanied with gingival recession (Ahmed & Abbott
2012a). The presence of an extra root may be associated
Identification landmarks
with the absence of mobility despite the presence of
Preoperative assessment – clinical. Good anticipation remarkable probing depths (Genovese & Marsico 2003).
and proper observation of the coronal and radicular Mandibular anteriors with middle and apical root bifur-
landmarks are essential for the detection of accessory cations usually cannot be identified by probing.

4 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Hashem Accessory roots and root canals in anterior teeth

(a) (b) (c) (d)

Figure 3 (a) Periapical radiograph showing a left mandibular lateral incisor scheduled for RCT. No break point or abrupt
diminishing of the canal was detected in the straight on radiograph. (b) The postoperative radiograph reveals extrusion of the
sealer into an empty space in the root indicating multiple communications with untreated accessory root canal (white arrows).
(c) The tooth was scheduled for another exploration, and the access was extended at the expense of the cingulum. A second
canal was detected (blue arrow). (d) Post-filling radiograph showing the two root canals. Each canal has a separate portal of
exit (yellow arrows).

Preoperative interpretation – radiographic. Despite the have the opportunity to evaluate CBCT images, and
inherent limitations of conventional radiographic in some cases, its use is essential to achieve clinical
views which provide 2D images of 3D objects, good success (Patel et al. 2015). The sagittal, coronal and
quality preoperative periapical radiographs with more axial CBCT images provide 3D imaging with relatively
than one horizontal projection aid in accurately lower effective radiation doses than other CT systems
detecting root canal bifurcations and outline of the and eliminate the problem of geometric distortion and
periodontal ligament, thus facilitating the interpreta- superimposition of roots/root canals (Patel et al.
tion of internal and external root anatomy (Kaffe 2007). The use of an operating microscope guided by
et al. 1985, Ahmed & Abbott 2012a, Paes da Silva a previous CBCT image would be useful in treating
Ramos Fernandes et al. 2014). Notably, increasing teeth with complex anatomical variations (Patel et al.
the horizontal projection (≥40 beam angulation in 2015). CBCT can also be used as an educational tool
mandibular incisors) complicates the ability to detect (Han et al. 2014).
canals owing to overlapping of adjacent teeth (Klein Intraoperative identification. Complete removal of the
et al. 1997). In teeth with necrotic pulps, the pres- roof of the pulp chamber during access cavity prepara-
ence of an apical rarefaction on the lateral side of the tion allows a full view of the internal anatomy of the
root (Fig. 1a) or two periapical radiolucent areas chamber. The configuration of the access cavity in
around the root surface may also suggest the pres- anterior teeth that comprise accessory roots/root
ence of an extra root/root canal (Funato et al. 1998, canals may show considerable variations (Sharma
Lin et al. 2006). et al. 1998, Low & Chan 2004, Maden et al. 2010). A
Using magnifying devices or loupes during interpre- common reason for failure to identify a second canal is
tation of radiographs is beneficial as several details inadequate access opening into the tooth which leaves
may become evident once magnified. The application a lingual shelf of dentine over the second (usually the
of digital radiography provides an enhanced image lingual) canal (Kabak & Abbott 2007).
processing (Sanderink et al. 1994, Nair & Nair 2007). Careful visualization using magnification and explo-
Cone-beam computed tomography is a modern ration of the pulp walls and floor can facilitate the
diagnostic modality that may be useful when conven- detection of accessory roots/root canals. Tactile
tional radiographs provide limited information and examination of the root canal walls with a small
further details are necessary (Han et al. 2014). Nowa- pre-curved endodontic file can detect root canal bifur-
days, many specialists dealing with complex cases cations undetected during radiographic interpretation.

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 5
Accessory roots and root canals in anterior teeth Ahmed & Hashem

A ‘catch’ on the way towards the apical foramen may techniques are to be used as these require more den-
indicate the presence of an accessory canal orifice tine to be removed to accommodate the heat carriers,
(Ahmed & Abbott 2012a, Ahmed & Cheung 2012). delivery needles and pluggers. Enhanced vision
Other landmarks could be the eccentric location of an through magnification and illumination is important
endodontic file on a radiograph during working in controlling warm compaction procedures (Calvert
length determination and inconsistent apex locator 2014).
readings (Thompson et al. 1985, Kabak & Abbott
2007). The presence of continuous bleeding in teeth Accessory roots/root canals in anterior teeth caused by
with a vital pulp despite complete canal instrumenta- developmental anomalies
tion can also suggest the presence of accessory root
canals (Kabak & Abbott 2007). Dens invaginatus. Definition, aetiology and morphology:
Postoperative assessment. If one canal is left Dens invaginatus is a developmental anomaly that
untreated during mechanical instrumentation, the results in an invagination of the enamel organ into
additional canal can often be located after filling. Fill- the dental papilla prior to calcification of the dental
ing material (root canal sealer and thermoplasticized tissues (Alani & Bishop 2008). The exact aetiology of
gutta-percha if applied) can propagate from the filled this anomaly is unclear, and many theories have
canal into the missed canal through intercanal com- been proposed including growth retardation of a focal
munications, if present, and appear in the postopera- group of cells, external forces, trauma, infection and
tive radiograph as a radiopaque line connecting to an genetic factors (Alani & Bishop 2008). The prevalence
empty space (Fig. 3). Therefore, the outline of the fill- of dens invaginatus in individuals ranges from <1%
ing material inside the root canal system should be to >26% (H€ ulsmann 1997, Alani & Bishop 2008).
examined carefully after canal filling. Oehlers (1957) classified dens invaginatus into three
Endodontic management. In addition to the use of types: Type I (most common) – is an enamel-lined
well angulated, exposed and processed periapical minor form that occurs within the confines of the
radiographs, an electronic apex locator would aid crown not extending beyond the amelocemental junc-
determining the working lengths of these canals to tion. Type II – is an enamel-lined form that invades the
avoid procedural errors that may occur as a result of root but remains confined as a blind sac. Communica-
the superimposition of files, especially when the tion with the dental pulp may or may not occur in this
canals are in a labiolingual direction (Gondim et al. type. Type III – is a form that penetrates through the
2009). root perforating at the apical area showing a ‘second
Prior to mechanical instrumentation, evaluating foramen’ in the apical or periodontal area (no immedi-
the morphological features, including the thickness of ate communication occurs with the pulp). The invagi-
the root dentine and canal curvatures, will assist in nation may be completely lined by enamel, but
selecting the most appropriate instrumentation tech- cementum is frequently found lining the invagination
nique (Gonzalez-Plata & Gonzalez-Plata 2003, (Oehlers 1957). This anomaly arises most commonly
Sponchiado et al. 2006). The occurrence of double- in maxillary lateral incisors and less frequently in
rooted anterior teeth that have small or thin roots maxillary central incisors, mandibular anteriors and
with abrupt apical curvatures as well as normal roots canines (H€ ulsmann 1997, Alani & Bishop 2008)
encasing narrow canals has been reported (Heling (Table S3). The problems that arise in association with
et al. 1995, Orguneser & Kartal 1998, Peix-Sanchez this entity appear to be primarily related to the degree
& Minana-Laliga 1999, Gonzalez-Plata & Gonzalez- of bacterial invasion along the invagination, which
Plata 2003). Thus, careful attention is required to can eventually lead to the involvement of the pulp
avoid undesirable consequences such as strip perfora- and/or periodontal ligament (Narayana et al. 2012).
tion caused by over-enlarging the canals or fracture Identification landmarks. Dens invaginatus type III,
of endodontic instruments (Heling et al. 1995, Gonza- and occasionally type II, may result in the formation
lez-Plata & Gonzalez-Plata 2003). of double root canals [configuration type (2-2)]
The application of both cold lateral and warm com- (Table S3). Clinically, the crown of an affected tooth
paction techniques is a valid approach for canal filling may appear normal or have size and shape alterations
of such cases (D’Arcangelo et al. 2001, Lin et al. such as greater labio-palatal/mesio-distal diameter
2006, Sponchiado et al. 2006, Calvert 2014). How- and peg- or barrel-shaped teeth (Soares et al. 2007,
ever, attention should be paid if warm compaction Bishop & Alani 2008). Radiographically, a blunder-

6 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Hashem Accessory roots and root canals in anterior teeth

buss opening of the invagination into the periodontal is essential. If resolution does not occur, then consid-
ligament (pseudo-canal) is a characteristic feature of eration may need to be given to RCT (Bishop & Alani
dens invaginatus type III, whereas type II usually 2008).
appears as a tear-shaped loop into the pulp space or a Dens invaginatus with an irreversibly inflamed pulp.
radiolucent pocket usually surrounded by a radio-opa- RCT of all canals is indicated when the pulp show
que enamel border (Bishop & Alani 2008). 3D imag- signs of irreversible inflammatory changes. This treat-
ing using CBCT helps in identifying the morphology ment approach is associated with difficulty in locating
of the individual dens so that appropriate treatment the rudimentary root canal because of the atypical
planning and treatment options, which must assess internal morphologic complexity (Walvekar & Behbe-
the risk to benefits along with the patient preference hani 1997, Kusgoz et al. 2009). Invaginations may
and compliance, can be selected (Narayana et al. also restrict sufficient cleaning and shaping. Remov-
2012). ing the central mass of the dens under magnification
is one option, especially if the root canals are in close
Endodontic management approximation to the invagination (keeping the
invagination and root canals separate in the apical
Dens invaginatus with a normal pulp. Treatment of such area is better to preserve the apical constriction) (Pai
anterior teeth is dictated by the anatomical complex- et al. 2004). If this procedure is not applicable, then
ity of each individual case. Reports of cases where the copious irrigation using sodium hypochlorite is rec-
two root canals (or one of them) are not involved in ommended to disinfect the root canals (Kusgoz et al.
the treatment exist in the literature (Greenfeld & Cam- 2009, Kfir et al. 2013). The treatment of dens invagi-
bruzzi 1986, H€ ulsmann 1997, Kfir et al. 2013). Selec- natus type II is less problematic because the anomaly
tive treatment of the invagination is challenging and does not extend to the apex (Rodekirchen et al. 2006,
resistant to instrumentation because of the enamel George et al. 2010).
lining (Soares et al. 2007). Along with the inconsis- The application of calcium hydroxide as a medica-
tent shape, rotary instrumentation is therefore not ment between treatment appointments in these cases
recommended for use because of the increased likeli- is controversial; this medicament may be extremely
hood for file fracture (Bishop & Alani 2008). The difficult to remove from such a complex space, thus
application of stainless steel (SS) or nickel titanium potentially compromising the effective obturation of
(NiTi) files using reciprocation motion could be an the invagination space (Kfir et al. 2013). Other
area for future investigations. Some authors speculate medicaments, such as Ledermix, have been suggested
that ultrasonic tips are more useful than SS and NiTi as an alternative because it is easier to remove by irri-
endodontic instruments (Bishop & Alani 2008). Nota- gation; however, attention should be focused to the
bly, applying ultrasonics requires adequate coolant to staining potential of such medicaments in anterior
prevent potential effects on the neighbouring vital teeth (Ahmed & Abbott 2012b). The canals can be
pulp tissues because of the heat generated during fric- filled normally, and an apical plug of MTA can be
tion (Kfir et al. 2013). used for filling the apical portion of the invagination
Using an operating microscope in such cases has before applying thermoplasticized gutta-percha (Stef-
proved to be a valuable clinical asset for the operator; fen & Splieth 2005).
the microscope aids in the precise and sophisticated Other treatment protocols. A report described suc-
execution of treatment techniques without compro- cessful management of a maxillary lateral incisor with
mising the tooth structure (Jung 2004, Rodekirchen dens invaginatus, double canals and immature apex
et al. 2006). Thermoplasticized gutta-percha or min- via apexification using calcium hydroxide for
eral trioxide aggregate (MTA) (indicated when the 6 months, and the canal was then filled using the lat-
apical flow of the softened gutta-percha is difficult to eral compaction technique (Jung 2004). Surgical
control) is often used for filling the invagination (de intervention (apicectomy followed by root-end filling
Sousa & Bramante 1998, Kfir et al. 2013). Transpar- using either Super EBA, MTA or other materials) has
ent 3D plastic models fabricated from CBCT data can also been reported (H€ ulsmann 1997, Ortiz et al.
provide an effective guide for treating the invagina- 2004, S€ ubay & Kayatasß 2006, Soares et al. 2007). In
tion without jeopardizing the vitality of the pulp (Kfir severe cases, extraction of the tooth could be the
et al. 2013). Despite the high predictability of this treatment of choice (H€ ulsmann 1997,  Stamfelj et al.
treatment approach, close follow-up and monitoring 2007).

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 7
Accessory roots and root canals in anterior teeth Ahmed & Hashem

Palato-gingival groove Greenfeld & Cambruzzi 1986, Gu 2011), whereas


others were unable to find a patent root canal space
Definition, aetiology and morphology. Palato-gingival
in the accessory root even with 3D radiographic
groove (also known as radicular lingual groove or
imaging (Sch€ afer et al. 2000, Yavuz et al. 2008,
disto-lingual groove) is a developmental anomaly that
Gandhi et al. 2011).
is usually found on the palatal aspect of the root of a
Endodontic management. The treatment of double-
maxillary incisor tooth. It usually begins in the cen-
rooted/canalled anterior teeth with palato-gingival
tral fossa area, extends over the cingulum and contin-
grooves has not been evaluated in a controlled inves-
ues apically down the root surface (Peikoff et al.
tigation, but multiple case reports describe treatment
1985, Lara et al. 2000, Schwartz et al. 2006). The
modalities ranging from RCT of both roots/root canals
prevalence of this anomaly ranges from <1% to 18%
followed by periodontal treatment including curettage
(Kogon 1986, Lara et al. 2000, Sch€ afer et al. 2000,
to resection of the accessory root, odontoplasty and
Schwartz et al. 2006).
application of autogenous bone grafts or freeze-dried
The aetiology of this groove is not fully understood.
bone allografts and enamel matrix derivative (Sch€ afer
It could represent an infolding of the enamel organ
et al. 2000, Low & Chan 2004, Schwartz et al. 2006,
and HERS or an alteration of genetic mechanisms
Yavuz et al. 2008, Gandhi et al. 2011). The applica-
(Ennes & Lara 2004, Schwartz et al. 2006). Its pre-
tion of NaOCl at >3% concentration and ultrasonic irri-
dominance in the maxillary lateral incisors suggests
gation may be beneficial (Low & Chan 2004, Schwartz
another possibility that the groove results from an
et al. 2006), especially if the canal is C-shaped
undesirable position of the lateral incisor during
(Schwartz et al. 2006). In several clinical situations,
development where it is surrounded by the central
filling the cervical and mid-root portions of the root
incisor and canine that start initial calcification ear-
canal system with a resin material or glass–ionomer
lier making this tooth germ highly susceptible to fold-
cement is preferred to facilitate odontoplasty of the root
ing (Lara et al. 2000).
groove (Schwartz et al. 2006). However, this procedure
Despite the occasional occurrence of double-rooted
would complicate root canal retreatment if indicated.
incisors caused by the palato-gingival groove, its clini-
cal implications are important because the groove can
Association with other abnormalities
lead to combined endodontic–periodontal lesions
(Sch€afer et al. 2000). The groove potentially provides Fusion of a single-rooted anterior tooth with a super-
a pathway for oral microorganisms to penetrate into numerary or supplemental tooth would result in a
the periodontal ligament tissues. When a breach ‘double tooth’ encasing two canals. A ‘double tooth’
occurs in the periodontal attachment and the groove is not discussed in this study (exclusion criteria –
is involved, a self-sustaining localized periodontal Table 1); however, it appears essential to highlight
pocket can develop along the length of the groove the association of anterior teeth that have accessory
(Schwartz et al. 2006). This inflammatory process root canals with such anatomical aberrations (i.e.
persists because of the potential communication path- anterior tooth encasing more than one root canal
ways between the pulp and periodontal tissues (Peik- fused with a supernumerary tooth having its own
off et al. 1985, Ahmed 2012). canal). Hosomi et al. (1989) and Peyrano & Zmener
Identification landmarks. Clinically, the operator can (1995) reported the occurrence of maxillary central
identify the groove on the palatal aspect of the root and mandibular lateral incisors (encasing two sepa-
of a maxillary incisor tooth, together with its contin- rate root canals each) fused with supernumerary
uation apically down the root surface, which may teeth (encasing one canal), respectively.
correspond with a narrow periodontal pocket and The association of double-rooted/canalled anterior
bone loss (Schwartz et al. 2006). The usual appear- teeth with other abnormalities in the crown such as
ance of the second root in a mesio-distal direction enamel hypoplasia (Al-Nazhan 1991), dens invagina-
facilitates its identification during radiographic exami- tus (Greenfeld & Cambruzzi 1986, H€ ulsmann & Hen-
nation. The root canal system of double-rooted inci- gen 1996) and palato-gingival groove accompanied
sors having a palato-gingival groove shows with a talon cusp (Fabra-Campos 1990) has also been
considerable variations (Table S4). Some authors reported. In some severe cases, the association of
reported the successful detection of two root canals in abnormalities is difficult to interpret (Mangani & Rud-
the main and accessory roots (Peikoff et al. 1985, dle 1994, Kottoor et al. 2012).

8 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Hashem Accessory roots and root canals in anterior teeth

Accessory roots and root canals in the primary anterior Conclusions


teeth
The prevalence of accessory root/root canal variations
Several reports have documented the occurrence of
in mandibular anterior teeth is higher than maxillary
accessory roots and root canals in the primary ante-
counterparts. Maxillary incisor teeth have the highest
rior teeth at various levels of the root in children of
tendency for accessory root/root canal aberrations
different ethnic groups (Barker et al. 1975, Chow
caused by anomalies such as dens invaginatus and
1980, Krolls & Donahue 1980, Morrow & Hylin
palato-gingival groove. Primary anterior teeth may
1993, Mochizuki et al. 2001, Dhanpal & King 2009,
exhibit external and internal anatomical variations in
Musale & Hegde 2010, Talebi et al. 2010, Cleghorn
the root, especially maxillary canines. Owing to the
et al. 2012). The concurrent existence of double-
wide morphological divergence of the root and root
rooted canines has been reported in both jaws (Ott &
canal system in human anterior teeth, dental practi-
Ball 1996, Mochizuki et al. 2001, Dhanpal & King
tioners should be aware of such anatomical variations
2009), but the prevalence of double-rooted primary
to minimize the risk of failure because of inadequate
canines appears to be higher in the maxilla than the
debridement of inaccessible or undetected parts of the
mandible (Mochizuki et al. 2001). This finding is
root canal system. Modern diagnostic devices, recent
opposite to that of the permanent dentition. The
endodontic (and periodontal) techniques and current
occurrence of coronal and apical root bifurcations
advances in endodontic biomaterials could pave the
indicates that the potential for developing supernu-
way for high levels of success in managing
merary roots in the primary anterior teeth is present
such anatomical variations in the human anterior
throughout the course of root formation (Ott & Ball
dentition.
1996). The double roots are usually located in a
mesio-distal direction, and they can be identified dur-
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12 International Endodontic Journal © 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Hashem Accessory roots and root canals in anterior teeth

Table S1. Summary of studies and reported cases – Table S3. Summary of studies and reported cases –
accessory roots and root canals in permanent maxil- dens invaginatus in permanent anterior teeth that
lary anterior teeth (no developmental anomalies). have more than one root canal.
Table S2. Summary of studies and reported cases – Table S4. Summary of studies and reported cases –
accessory roots and root canals in permanent mandibu- permanent anterior teeth that have palato-gingival
lar anterior teeth (no developmental anomalies). groove and more than one root canal.

© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal 13