Clinical Research

Micro–Computed Tomography Analysis of the Root Canal

Anatomy and Prevalence of Oval Canals
in Mandibular Incisors
Marcela Milanezi de Almeida, DDS, MSc, Norberti Bernardineli, DDS, PhD,
Ronald Ordinola-Zapata, DDS, PhD, Marcelo Haas Villas-B^oas, DDS, MSc,
Pablo Andres Amoroso-Silva, DDS, MSc, Christian Giampietro Brand~
ao, DDS, PhD,
Bruno Martini Guimar~ aes, DDS, MSc, Ivaldo Gomes de Moraes, DDS, PhD,
and Marco Antonio H ungaro-Duarte, DDS, PhD

Abstract
Introduction: This study aimed to describe the anat-
omy of the mandibular incisors by using micro–
computed tomography. Methods: Mandibular incisors
(n = 340) were scanned at 19-mm voxel size resolution,
and the numbers of canals were classified according to
Vertucci classification, as well as the major and minor di-
ameters of the root and root canals, presence of oval ca-
nals, and three-dimensional analysis of the apical third
were also measured. Data were presented in terms of
median and range for each anatomic classification.
Results: Overall, the specimens had 1 root canal
(N = 257). The second most prevalent anatomy was Ver-
tucci type III (N = 56). These anatomies represent 92%
of the sample. The medians of the major diameter at the
1-, 2-, and 3-mm level of the most prevalent anatomies
were 0.36, 0.39, and 0.47 mm for type I and 0.41, 0.51,
and 0.66 mm for type III, respectively. The apical volume
appears to be constant among these anatomies (0.63
and 0.59 mm3). Oval canals were found at the 1-mm
apical level, with a prevalence of 16.7% for Vertucci
type I and 37.5% for Vertucci type III. The presence of
oval canals increased at the 3-mm apical level to
32.4% and 76.2% for Vertucci type I and III classifica-
tions, respectively. Conclusions: Type I and III configu-
rations represent 92% of the mandibular incisors
studied. Within these anatomic configurations, oval-
shaped canals in the apical third were not uncommon
and more prevalent in the type III anatomy. (J Endod
2013;39:1529–1533)
Key Words
Dental anatomy, mandibular incisor, microcomputed
tomography, oval canals
A detailed knowledge of the number of the root canal systems and cross-section
morphology is required for successful root canal treatment (1). Failure to achieve
complete cleaning of the main root canals and lateral anatomy can lead to the failure of
the endodontic treatment because of the known infectious etiology of apical periodontitis.
The internal anatomy of the mandibular incisors has been described in several
studies that used clearing or cross-sectional methods (1–9). The results of these
studies show that mandibular incisors with single canals are the most common
reported anatomy. The second most prevalent anatomic variation includes the
presence of 2 canals that ends in a single foramen (Vertucci type III) (1, 5, 9).
Despite the presence of single canals at the apical third of the mandibular incisors,
the prevalence of oval canals is not uncommon (3).
Several studies have shown the difficulty to achieve efficient cleaning of the
mandibular incisors with oval root canal anatomy by using hand or rotary instruments
(10–13). In addition, the consequent unfilled spaces of this incomplete cleaning
usually decrease the quality of several filling techniques in this anatomy (14). Despite
the considerable number of studies describing the internal configuration of the mandib-
ular incisors, only a few studies have reported the apical diameters and the prevalence
of oval canals at the apical third (3, 8).
Micro–computed tomography (micro CT) has been intensively used in recent
years to get an in-depth description of the root canal configuration of different teeth.
Algorithms used in this method allow bidimensional and tridimensional analyses that
are impossible to obtain by using clearing or cross-sectional techniques (15). Thus,
the aim of this study was to describe the anatomy of the root canals of mandibular in-
cisors according to Vertucci classification and to evaluate the apical diameter, volume,
and root thickness at the apical level. In addition, the prevalence of oval canals at the
apical third was also determined.
Materials and Methods
Three hundred forty mandibular incisors that were extracted for nonrestorable
caries or periodontal disease from a Brazilian population were acquired after the ethics
committee in human research approved the protocol (CEP 131/2010). The age and sex
of the patients were unknown. Teeth with an open apex or with previous endodontic
treatment were excluded. The samples were scanned by using a Skyscan 1174

From the Department of Endodontics, Bauru Dental School, University of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
Supported by grants of CNPQ and FAPESP process (2010-16072-2), (2013-03695-0).
Address requests for reprints to Dr Ronald Ordinola-Zapata, Departamento de Endodontia, Faculdade de Odontologia de Bauru, Al. Octavio Pinheiro Brisolla 9-75,
CEP 17012-120, Bauru, S~ao Paulo, Brazil. E-mail address: ronaldordinola@usp.br
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.08.033

JOE — Volume 39, Number 12, December 2013 Micro-CT of Mandibular Incisor Internal Anatomy 1529
Clinical Research
micro-CT system (Bruker-microCT, Kontich, Belgium). The parameters
used were 50 kV, 800 mA, and a voxel size of 19.6 mm. The system in-
cludes a charge-coupled device camera (1304  1024 pixels). Radio-
graphic images of each sample were reconstructed by using the NRecon
software (Bruker-microCT). Three-dimensional models were recon-
structed after the segmentation and binarization processes with CTAn
v.1.12 software (Bruker-microCT). CTVol v.2.2.1 and data viewer soft-
wares (Bruker-micro CT) were used for visualization and evaluation of
the internal anatomy according to Vertucci classification (1). CTan soft-
ware was also used to calculate the apical volume of the samples from
the 1- to 3-mm apical level, and the results were expressed in mm3.
For the two-dimensional analysis, cross sections of the apical
portion of the teeth were selected. The cross sections selected from
the ‘‘stack’’ were determined at 1, 2, and 3 mm from the apex. The
more prevalent anatomies, Vertucci I and III, had their apical diameters
measured from the 1-mm to the 3-mm apical level. The short and long
diameters were obtained by measuring the mesiodistal and buccolin-
gual distances of the root canal, and the results were expressed in mil-
limeters. Other anatomic parameters such as the buccolingual and
mesiodistal root thickness at the apical level were also measured
(Fig. 1). These parameters were taken by using the measurement
tool of the data viewer software (Bruker-microCT). The measurements
were repeated twice to ensure reproducibility.
The presence of oval canals at the 1- to 3-mm apical level was
determined in the more prevalent anatomies, Vertucci types I and III
classifications, by using the ratio of the long and short diameters ac-
cording to Wu et al (3). This value represents the degree of circularity
of the root canal. The higher the value is, the more oval the canal is. The
Vertucci classification evaluation was made descriptively. The volume
and apical diameter at the 1- to 3-mm level were expressed as the me-
dian and range values. The presence of oval canals was expressed in
terms of percentages.
Results
The tridimensional evaluation of 340 root canal systems showed
that 324 teeth were plausible for classification according to Vertucci clas-
sification (1) (Table 1). The most prevalent anatomies were type I (75%)

Figure 1. Representative tridimensional reconstructions of mandibular incisors showing different Vertucci classifications. (A) Type I, (B) type I oval canal, (C)
type III, (E) type V, and 2 new classifications, (D) I-II-I-II-I and (F) I-II-III-I. The buccolingual (B-L) and mesiodistal diameters (M-D) of the root thickness of
Vertucci type I and III variations are shown in (G). The values represent median, 25%–75% percentiles, and range of the root thickness at 3 different levels (1–3
mm). The values are expressed in mm.

1530 Milanezi de Almeida et al. JOE — Volume 39, Number 12, December 2013
 Clinical Research
and type III (16%). Other root canal configurations were found after the

0.21 (0.09–0.34)

0.32 (0.07–1.09)
0.15, 0.22, 0.13
micro CT analysis: 1-2-1-2-1 (7 teeth), 1-3-1 (3 teeth), 1-3 (1 tooth),

0.33, 0.21

0.27, 0.21
0.29, 0.13

0.11, 0.14
1-2-3-1 (2 teeth), 1-2-1-2-1-2-1 (1 tooth), 2-1-2-1 (1 tooth), and 1-

MD 3

0.13
0.11
0.46
3-1-3 (1 tooth). Representative images of the different root canal anat-
omies are shown in Figure 1.
Considering the volume of the apical 3 mm, the means and ranges
of the apical volume of the more prevalent anatomies were 0.63 mm3
(0.08–2.58) for type I and 0.59 mm3 (0.18–1.45) for type III. The dis-
0.62 (0.15–1.04)

0.64 (0.14–1.58)
0.66, 0.97, 0.77
tributions of apical diameters for type I and III are shown in Figure 2.

Median and range of volume of root canal space at the apical level (mm3) and apical diameter from 1- to 3-mm level in the buccolingual (BL) and mesiodistal (MD) direction are also included. Individual values are reported when N < 5.
0.16, 0.88
0.76, 0.62

0.84, 0.21

0.26, 0.77
The medians of the buccolingual diameters for type I and III anatomy at
BL 3

1.19
0.13
0.96
1-, 2-, and 3-mm level were 0.36, 0.39, and 0.47 mm and 0.41, 0.51,
and 0.66 mm, respectively. The medians of the mesiodistal diameters
for type I and III anatomy at 1-, 2-, and 3-mm level were 0.26, 0.26,
and 0.29 mm and 0.22, 0.21, and 0.22 mm, respectively. Other volume
values and major and minor diameters of less prevalent anatomic var-
iations are shown in Table 1.
0.15 (0.07–0.23)

0.17(0.14–0.66)

0.21, 0.12, 0.14

0.22, 0.11, 0.16
0.14, 0.13, 0.13

The long-short diameter ratios were measured in Vertucci type I

0.10, 0.34
0.32, 0.12
MD 2

0.10
0.12

0.33

and III anatomies. Other anatomic variations were not included in the
Apical diameter (mm)

analysis because of the low number of samples. The percentage of oval

canals at different apical levels is shown in Table 2. Oval canals were
more prevalent in Vertucci type III anatomy at the 1-mm apical level
(37%) in comparison with the Vertucci type I anatomy (16%). The
values of the buccolingual and mesiodistal root thicknesses are shown
0.37 (0.18–0.69)

0.43(0.14–0.89)

0.27, 0.41, 0.20

0.55, 0.81, 0.52
0.17, 0.33, 0.21

in Figure 1. The measurements indicated that the mandibular incisor

0.88, 0.18
0.48, 0.21

root was thicker in the buccolingual direction. Lower values of dentin

BL 2

0.64
0.33

0.63
TABLE 1. Distribution of Less Prevalent Anatomic Types According to Vertucci Classification Including Other Anatomic Variations

were found in the mesiodistal measurements.

Discussion
Several root canal configurations in the mandibular incisors have
0.17 (0.06–0.29)

0.25 (0.16–0.72)

0.17, 0.22, 0.21

0.24, 0.20, 0.16
0.13, 0.21, 0.14

been described in the literature (5–7, 16). According to previous

0.12, 0.26
0.32, 0.15

studies, the presence of Vertucci type I anatomy in the mandibular

MD 1

0.17
0.21

0.26

incisors can vary from 55% (6) to 87% (8). Two previous studies
from Turkish populations found a smaller percentage of Vertucci
type I anatomy in the mandibular incisors (6, 16). These studies
reported between 30%–38% and 55% of single-root canals, respec-
tively, in the mandibular incisors. The percentage of Vertucci type I
0.31 (0.09–0.77)

0.38 (0.10–0.54)

0.37, 0.24, 0.24

0.45, 0.34, 0.19
0.13, 0.28, 0.12

anatomy found in this study (75%) is similar to the 70% and 75% ob-
0.85, 0.18
0.44, 0.19

tained by Vertucci (1) for the mandibular central and lateral incisors.
BL 1

0.34
0.28

0.53

Madeira and Hetem (7) also found 88% of Vertucci type 1 anatomy in
both mandibular incisors.
In the present study, at least 12 anatomic variations were found;
the most prevalent was type III from Vertucci classification (16%). This
anatomy begins with 1 canal leaving the cervical third, divides into 2
0.74 (0.19–1.49)

0.64 (0.32–1.19)

within the root, merges, and exits as 1 canal (2). This type was also
0.51, 1.11, 0.30
Volume (mm3)

0.30, 0.63
0.88, 0.50
1–3 level

the second most prevalent anatomy in the lateral and central mandib-
0.63

0.60

0.62
0.58
1.42

ular incisors as observed by Pineda and Kuttler (5), 19%–23%; Ver-

tucci (1), 18%–22%; Kartal and Yanikoglu (6), 20%; and Boruah
and Bhuyan (9), 22%. In our study, no discrimination between the cen-
tral and lateral mandibular incisors was made because previous studies
did not show differences between the internal anatomy and root canal
length between them (1, 7, 17).
N

3
1
2
8
1

1
7
2
1
1

It is important to note that although our data showed that 25% of

the mandibular incisors presented some type of ramification or divi-
Vertucci classification

sion of the internal anatomy, just 3.2% (11 teeth) terminated in 2 or

more canals at the apical third, which is in concordance with the liter-
ature (1, 2, 5–7). The presence of 2 canals at the apical third in the
1-2-1-2-1-2-1

mandibular incisors is not a common finding. The literature reports

prevalence between 1% and 7% (1, 2, 5–7). This low probability
2-1-2-1
1-2-1-2-1
1-3-1

1-3-1-3
1-2-1-2

1-2-3-1
Others

can give the impression that a proper cleaning of the apical

1-3

millimeters can be reached in a great percentage of mandibular

2-1
1-2

incisor variations. However, the presence of a single canal in the

JOE — Volume 39, Number 12, December 2013 Micro-CT of Mandibular Incisor Internal Anatomy 1531
Clinical Research

Figure 2. Buccolingual (B-L) and mesiodistal (M-D) diameter distributions expressed in mm found at 1- to 3-mm apical levels in Vertucci type I (A) and III (B)
variations. The mean (red line) is also shown.

mandibular incisor is often accompanied by another complexity, the
presence of oval canals at the apical third.
Wu et al (3) defined an oval canal when the cross-sectional long:-
short diameter ratio, measured in a certain cross section, was $ 2. In the
present study, the prevalence of oval canals increased from 16% at the 1-
mm level to 32% at the 3-mm level in the Vertucci type I anatomy. The
results found at the 1-mm level were similar to values previously reported
for this anatomy (3). The Vertucci type III anatomy showed a higher prev-
alence of oval canals, between 37% and 76% at the apical third. Previous
studies have pointed out the difficulty to instrument the oval canals of the
mandibular incisors by using manual instruments (11), nickel-titanium
rotary techniques (13, 18), or even to obturate them (14). Also, when
performing apical surgery, the clinician should emphasize the cleaning
of oval canals to eliminate debris, pulp remnants, or necrotic tissue in
these irregularities, which eventually may lead to failure (19).
One important variable that affects the cleaning is the diameter of
the root canal. In this study a great variation of values at all the evaluated
levels was found, mainly in the buccolingual diameter (Fig. 2). Our data
showed that the mesiodistal distance (minor diameter) maintains con-
stant values in the 3 apical mm, with overall values between 0.20 and
0.25 mm. The buccolingual diameter (major diameter) usually in-
creases progressively in the coronal direction (Fig. 2). This pattern
was also observed in the root thickness measurements because of the
lower values of dentin thickness found in the mesiodistal diameter as
previously reported (20).
The medians of the buccolingual diameter of the root canal at 1 mm
from the foramen in the more prevalent anatomic variations were 0.36
and 0.41 mm, results similar to previous studies (3, 8). However,
these data must be carefully considered because higher apical
diameters than 0.40 mm at the 1-mm level were not uncommon
(Fig. 2). One solution could be to instrument the root canals until the
0.80-mm diameter because only 2 samples from the 257 teeth with 1 ca-
nal theoretically could not be fully instrumented by using this diameter.
However, a large round preparation by using tapered instruments to
shape all the possible apical diameters can significantly weaken the
dentin thickness at the mesiodistal wall. This measure showed a thickness
between 1.5 and 2.0 mm, which could leave the root susceptible to perfo-
ration or fracture (18, 21). One clinical solution for this problem is the
use of irrigation methods that allow the distribution of the irrigant
solution to the apical third to improve the dissolution ability of sodium
hypochlorite. A previous study (22) showed that an apical enlargement
before the ISO #40 with a 0.04 taper is essential to get a significantly
larger volume of irrigant at the working length when negative apical pres-
sure is used; in addition, larger diameters than ISO #40 with a 0.04 taper
fail to show significant differences in the volume of irrigant solution at the
working length (22). Another accepted option to clean the apical third of
narrow oval canals is the use of the self-adjusting file (23, 24). A previous
study showed that rotary instrumentation by using a 40.02 instrument
leaves 53% of untouched walls at the apical third in comparison with
12% when the self-adjusting file was used (23). To facilitate these pro-
cedures, modifications of the pulp chamber access to get direct access
to the apical third have also been recommended (25). In addition,
whereas a direct correlation of complete mechanical cleaning with
outcome in mandibular incisors is unknown, a previous apical surgery
study (26) showed that unfilled isthmus and gaps are associated with fail-
ure of root canal treatment.

TABLE 2. Number and Percentage (%) of Oval Canals in Vertucci Type I and III Anatomy
0–2 >2–4 >4–6 >6–8 <10 <12 Total oval canals
Long:short diameter ratio type I (N = 257)
1 mm 214 (83.2) 37 (14.4) 4 (1.5) 2 (0.7) 0 0 43 (16.7)
2 mm 188 (73.1) 57 (22.1) 9 (3.5) 3 (1.1) 0 0 69 (26.9)
3 mm 174 (67.7) 65 (25.2) 11 (4.2) 7 (2.7) 0 0 83 (32.4)
Long:short diameter ratio type III (N = 56)
1 mm 35 (62.5) 15 (26.7) 3 (5.3) 3 (5.3) 0 0 21 (37.5)
2 mm 23 (41) 23 (41) 3 (5.3) 3 (5.3) 1 (1.7) 3 (5.3) 33 (58.9)
3 mm* 14 (23.7) 24 (40.6) 13 (22) 4 (6.7) 1 (1.6) 3 (5) 45 (76.2)
Different long:short diameter ratios at different levels were measured according to Wu et al (3).
*In type III anatomy, 59 canals were found at the 3-mm level.

1532 Milanezi de Almeida et al. JOE — Volume 39, Number 12, December 2013

Conclusion
The occurrence of a single canal and Vertucci type III configura-
tion represented 92% of the mandibular incisors studied. Within these
anatomic configurations, oval-shaped canals in the apical third were not
uncommon and were more prevalent in the type III anatomy. The inci-
dence of 2 or more root canals at the apical third was 3.2%.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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