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Endodontic Topics 2012, 23, 6–33 2012 © John Wiley & Sons A/S
All rights reserved ENDODONTIC TOPICS 2012
1601-1538

Primary human teeth and their

root canal systems
BLAINE M. CLEGHORN, NORIKO B. BOORBERG &
WILLIAM H. CHRISTIE

A thorough knowledge of dental anatomy of both the permanent and primary dentition is essential for all
treatment aspects of these teeth. All too often, the study of the anatomy of primary teeth is given secondary
importance due to the fact that these teeth will exfoliate eventually. Rather than premature extraction, the
retention of primary teeth through restorative or endodontic means is evolving amongst dental practitioners and
endodontic and pediatric dental specialists. Thus, knowledge of the normal and abnormal anatomy of primary
teeth is required in making diagnosis and treatment decisions in young patients. In rare incidences, as in cases of
absent permanent premolars, primary teeth may be retained in the permanent arch and if the pulp becomes
diseased, endodontic treatment may be among the treatment options. This article provides a comprehensive
review of normal and abnormal morphology of the primary teeth with an emphasis on the roots and root canal
systems of each of the teeth in the primary dentition.

Received 17 September 2011; accepted 25 November 2011.

Introduction anatomy, which are often only reported as case

The primary dentition has numerous functions and is
important in a child’s development (Fig. 1) (1–5).
Finn describes the functions of the primary denti-
tion as space maintenance, digestion and assimilation,
speech development, stimulation of jaw growth, and
cosmetics (6). Each of these functions must be taken
into account in providing optimum dental treatment
for the young patient.
There has been a growing body of recent research
and publications on the dental anatomy of primary
teeth. With the ability to do evidence-based searches
of the literature, these publications may be added to
classic or earlier knowledge of the anatomy of
primary teeth. The authors have used PubMed and
MeSH terms to try to find all relevant aspects of
primary tooth crown and root anatomy and varia-
tions in morphology of primary teeth. Search topics
(key words) utilized included combinations of root
morphology, root canal morphology, primary or
deciduous teeth and dentition, supernumerary roots,
and anomalies. Furthermore, research findings have
identified many anomalies found in primary tooth
reports in the literature.
This paper will start with a general description of
the primary arch and teeth when compared to perma-
nent teeth. Tooth development timing and the erup-
tion sequence of primary teeth is described, followed by
a list and table of anomalies as presented in many case
reports. These anomalies are often neglected or under-
represented in textbooks beyond reporting of numbers,
gemination/fusion, size, and abnormal development
sites.
Finally, a tooth-by-tooth description of each tooth in
the arch is divided as external morphology, internal
pulp chamber morphology, root and canal number, and
canal system characteristics: size, curvature, length.
Using this information, a practitioner should be able to
perform optimum treatment in the primary dentition.
Description of the anatomy of
primary teeth
Although there is variation in the literature with respect
to development, eruption timing, eruption sequence,
and exfoliation, an average or generally accepted mean

6
 Primary human teeth and their root canal systems

is presented below. The key development times for the anomalies, among others. Another significant differ-
primary dentition are summarized in Table 1 while the ence is that each of the primary teeth normally exfoliate
eruption timing and sequence are presented in Table 2 as a succedaneous tooth takes its place. A summary of
(6–8). the significant characteristics of the primary teeth that
Age at eruption may vary by a few months, but the differ from the teeth in the permanent dentition as
sequence is followed, in general. The international found in the dental literature is provided in Table 3
tooth code for primary teeth is used. (6,9–14).
The morphology of the primary dentition is different Understandably because face size is smaller, the
in many respects from the permanent dentition, not primary teeth overall are much smaller than the per-
only in size of the crowns and roots. The differences manent teeth. The dentin and the enamel are thinner
include time of development, number of teeth, external as well and the pulp horns are larger. Much less overall
morphology, root canal morphology, and types of tooth structure is available, making the teeth (espe-
cially the mandibular anterior teeth) more difficult to
restore. Restorative preparations therefore are often
close to or involve the pulpal tissues (11,15). The
external dimensions of the teeth in the primary denti-
tion in Table 4 are mean dimensions calculated by
Goodacre from seven sources (15).
Although numerous papers have been published on
the root and root canal system morphology of perma-
nent teeth, comparatively few have been written on the
primary teeth (14). Hibbard & Ireland’s study of
the internal root canal systems of the primary molars
found that the greatest variations in the canal systems
occurred in the apical regions of the mesial roots of
the mandibular molars and the mesiobuccal roots of the
maxillary molars (14). Thinning of the isthmus in the
apical region of these teeth results in a more complex
Fig. 1. Tooth 85 after pulpectomy and provisional res- canal system of interconnecting branches and fine
toration. Courtesy of Dr. W.H. Christie.
lateral canals. Hibbard & Ireland’s study included not
Table 1: Key development times in the primary only intact teeth but also those in early stages of resorp-
dentition
tion. Newly erupted primary molar teeth with fully
4–6 months in utero All of the primary teeth begin developed roots exhibited a less complex root canal
to calcify system with one canal in each of the mesial and distal
Birth All of the primary teeth have roots of the mandibular molars and one canal in each of
some enamel formed the mesiobuccal, distobuccal and palatal roots of the
6 to 27–29 months of age All of the primary teeth erupt maxillary molars. This complexity in the root canal
systems increased over time due to the formation of
1 year after eruption The root(s) of each primary
secondary dentin and narrowing of the canal system
tooth are completely formed
and eventually the resorption process.
6–11 years of age The teeth in the primary Pulp therapy in the primary dentition in some situ-
dentition exfoliate
ations is comparable to the permanent dentition but

Table 2: Eruption timing and sequence of the primary teeth

Age in Months 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Maxillary A B D C E

Mandibular A B D C E

7
Cleghorn et al.
Table 3: Characteristics of teeth in the primary
dentition
Crowns
The crowns in the primary dentition are shorter relative to the
length of the root (i.e. smaller crown:root ratio).
The occlusal tables of primary molars are constricted buccolingually
and much narrower mesiodistally when compared to the
permanent molars.
Enamel and dentin are thinner compared to permanent teeth.
The thickness of the enamel and dentin of primary teeth is
approximately half that of permanent teeth.
The enamel rod direction in the cervical area is angled occlusally
compared to the apical direction in permanent teeth.
Crowns of primary teeth are characterized by significant cervical
constriction both in the mesiodistal and faciolingual dimension.
The primary molars have a pronounced buccal cervical bulge.
The contact areas of primary molars are flat and very broad
buccolingually compared to the permanent molars.
The crown color of the primary teeth is whiter and a lighter shade.
Roots
The roots of the primary molars have a greater flare, which
accommodates the developing crowns of the succedaneous
permanent premolars of the permanent dentition.
The mesiodistal width of the root of primary anterior teeth is much
narrower than the crown when compared to the permanent
anterior teeth.
The primary molar roots are relatively longer and more slender, i.e.
mandibular molar roots are narrower mesiodistally, maxillary MB
and DB roots are narrower mesiodistally, and maxillary palatal
roots are narrower buccolingually.
Pulp and root canal systems
The size of the pulp relative to the crown is larger in the primary
teeth.
Pulp horns are higher in proportion and are located closer to the
DEJ and to the outer surface of the crown.
Mesial pulp horns are higher than the distal pulp horns.
Pulp chambers are shaped comparable to the shape of the outline of
the crown from an occlusal view.
Pulp horns are present under each cusp of the primary molars.
The pulp chambers of primary mandibular molar teeth are normally
larger than the pulp chambers of primary maxillary molars.
The root canal systems of fully developed primary molars are
extremely tortuous and complex.
there are some important differences. Protective bases,
indirect pulp capping, direct pulp capping, pulpot-
omy, and pulpectomy are all treatment options in the
primary dentition given appropriate indications (16).
To successfully perform a pulpectomy on a primary
tooth, an intimate knowledge of the internal and
external morphology of each of the primary teeth is
required (14).
Pathological changes in bone as a result of pulpal
inflammation typically are located in the furcation
region of the primary molars in contradistinction to
the usual periradicular region in the permanent molars
(9,10,17,18).
8
Dammaschke et al. (19) studied the incidence,
location, and size of the accessory foramina in the
pulp chambers of primary and permanent molars. The
primary molars were found to have more foramina in
the pulp (3.5 per tooth compared to 2.5 per perma-
nent tooth) and were a larger size (10–360 mm
compared to 10–200 mm). The incidence of accessory
canals only in the furcation region was also studied
using primary molar teeth. Methods used in these
studies varied from injection of materials (vulcanite or
latex) (18,20,21) into the chamber and canals, dye
perfusion (22,23), digital radiographs, clearing and
histologic cross-sectioning (24), histology only (25),
and scanning electron microscope (SEM) (26,27).
The most effective method of identifying and follow-
ing a furcation canal seems to be serial-sectioning and
light microscopy but micro-computed tomography is a
method that will likely be used more in future studies.
Anomalies in primary teeth
Anomalies of the primary dentition can involve indi-
vidual teeth or multiple teeth. Case reports of an
anomaly involving an individual primary tooth are
included in the sections describing each of the indi-
vidual primary teeth. Anomalies of form and number
of teeth are normally more common in the perma-
nent dentition. Ethnic traits in comparison to a Cau-
casoid population will also be described. As opposed
to anomalies, these features should be considered
“normal” features in their respective ethnic groups.
The one exception is fusion*, which is reported to
have a higher incidence in the primary dentition than
in the permanent dentition (28–31). Hagman reports
that when the fusion occurs between the primary
lateral incisor and canine, there is a 75% chance the
permanent maxillary lateral incisor will be congenitally
missing. However, when the fusion is between two
primary incisors, there is only a 20% incidence of a
missing succedaneous permanent incisor (31). Yuen
et al. (32) studied “double”* primary teeth in a group
of 376 children aged 5 to 9 years of age in Hong
Kong. Most of the children in the study had double
*The term “double” tooth or teeth is used in some studies
in place of fusion or gemination, often due to the inability to
definitively determine whether fusion or gemination has
taken place.
 Table 4: Average dimensions of the primary teeth
Mesiodistal width of Faciolingual width of
Maxillary teeth Overall length Crown crown at crests of Mesiodistal width of crown at crests of Faciolingual width of
average:* of tooth length Root length curvature crown at CEJ curvature crown at CEJ

Primary Maxillary Central 17.0 mm 6.2 mm 10.8 mm 6.8 mm 4.9 mm 5.0 mm 4.2 mm
Incisors

Primary Maxillary Lateral 17.0 mm 6.1 mm 10.9 mm 5.4 mm 3.9 mm 4.6 mm 4.1 mm
Incisors

Primary Maxillary 19.5 mm 6.7 mm 12.8 mm 7.0 mm 5.0 mm 6.3 mm 5.3 mm

Canines

Primary Maxillary First 14.5 mm 5.7 mm MB 8.8 mm 7.5 mm 5.4 mm 8.9 mm 7.8 mm
Molars DB 8.2 mm
P 7.8 mm

Primary Maxillary Second 17.0 mm 6.2 mm MB 10.8 mm 9.0 mm 6.5 mm 10.1 mm 8.7 mm
Molars DB 9.7 mm
P 10.8 mm

Mesiodistal width of Faciolingual width of

Mandibular teeth Overall length Crown crown at crests of Mesiodistal width of crown at crests of Faciolingual width of
average:* of tooth length Root length curvature crown at CEJ curvature crown at CEJ

Primary Mandibular 14.7 mm 5.5 mm 9.2 mm 4.3 mm 3.1 mm 4.2 mm 3.7 mm

Central Incisors

Primary Mandibular 16.1 mm 6.1 mm 10.0 mm 4.5 mm 3.3 mm 4.3 mm 4.0 mm

Lateral Incisors

Primary Mandibular 18.1 mm 6.8 mm 11.3 mm 5.6 mm 4.1 mm 5.2 mm 4.4 mm

Canines

Primary Mandibular First 16.8 mm 6.3 mm M 10.5 mm 8.1 mm 6.6 mm 7.2 mm 5.7 mm
Molars D 8.9 mm

Primary Mandibular 17.3 mm 5.9 mm M 11.4 mm 9.9 mm 7.4 mm 8.9 mm 6.7 mm

Second Molars D 10.5 mm

*Depending on ethnic population origins and individual genetic variation, these dimensions may vary within the normal range of distribution.

9
Primary human teeth and their root canal systems
Cleghorn et al.

teeth in the mandible (334 children). They concluded

that double primary teeth that involve two adjacent
teeth have a high association with missing succeda-
neous teeth and that this anomaly is more prevalent in
Mongoloid (Asian and Aboriginal American popula-
tions) than Caucasoid populations.
Anomalies in the primary dentition involving more
than one tooth include fusion (30,33–44), double
teeth with a talon cusp (45), double tooth, talon
cusp and a supernumerary tooth (46), double teeth*
(29,35,47–67), double teeth and a supernumerary
tooth (68), fusion and gemination (69), oligodontia
(70), regional odontodysplasia (71), triple teeth (72–
76), hypodontia (29,57,60–63,65–67,77–81), single- Fig. 2. Cross-sectional cuts of the root and labial view
rooted molars (pyramidal molar) (82), hyperdontia of the primary maxillary right central incisor. Reprinted
with permission from Brown P, Herbranson E. Dental
(29,57,59–63,65–67,80,83–90), cusp of Carabelli Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
(61), protostylid (61), shovelling (61), talon cusps Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
(61,66), dens invaginatus (61), taurodontism (61), tions and Slices.
hypoplasia (66,91), invaginated teeth (57), macro-
dontia (61, 92), microdontia (61,66,92), and infraoc-
clusion (93).

Primary maxillary incisors

External morphology
The morphology of the primary maxillary central and
lateral incisors will be considered together due to their
similarities (Figs. 2 and 3). The crowns of the primary
maxillary incisors are wider mesiodistally than cervico-
incisally, which is opposite to the permanent maxillary
incisors. As such, the incisal ridge is wide mesiodistally.
The mesioincisal corner has a sharp, acute angled
outline while the distoincisal corner is slightly more
rounded. The labial crown surface is convex but Fig. 3. Cross-sectional cuts of the root and labial view
of the primary maxillary right lateral incisor. Reprinted
more so mesiodistally than cervicoincisally. The lingual with permission from Brown P, Herbranson E. Dental
crown surface has a concave lingual fossa bordered by Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
convex mesial and distal marginal ridges and the cin- Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
gulum. Notably, the lingual surfaces of these crowns tions and Slices.
are usually smooth without developmental pits or
grooves. When viewed from the proximal, the cer-
proximal crests of curvature (contour) are in the incisal
vical bulges labially and lingually are prominent. The
third of the crowns mesiodistally for both the primary
maxillary central and lateral incisors. The single root is
conical and tapers to a rounded apex. From the incisal
view, the crowns of both teeth are triangular in shape
*The term “double” tooth or teeth is used in some studies
in place of fusion or gemination, often due to the inability to
and taper lingually. Dimensionally, the overall lengths
definitively determine whether fusion or gemination has of the primary central and lateral incisors are compa-
taken place. rable. However, the crown of the primary maxillary

10

central incisor is slightly larger in all dimensions
(6,9,10,13,15,17,18).
Internal morphology
The internal morphology is consistent with the exter-
nal morphology of the tooth. The pulp chamber is
comparatively larger than the permanent counterparts
and has three incisal projections, similar to the incisal
mamelons. The pulp chamber and single pulp canal
taper to the rounded apical foramen (6,9,10,13,15,
17,18). An ex vivo study by Salama et al. (94) exam-
ined 10 primary maxillary central and 10 primary max-
illary lateral incisors and subjected half to a clearing
technique and half to sectioning. In addition to con-
firming the results of the previously mentioned
studies, they found that the apex in each of these teeth
consistently curved labially in the apical third, had no
bifurcations or accessory canals, and the canals were
round in shape.
Root number, form, and root canal system
The primary maxillary central and lateral incisors nor-
mally have a single conical or triangular-shaped root
and a large single canal (6,9,10,13,15,17,18).
Anomalies and ethnic variations
Talon cusps occur less frequently in the primary
dentition compared to the permanent dentition
(three times more frequent in the permanent denti-
tion) with most occurring in the maxillary arch (92%)
(95). Yoon & Chussid (95) report that the most
commonly affected teeth are the maxillary incisors.
Batra et al. (96) have reported what they believe to
be the first cases of labial talons cusps on primary
maxillary incisors. Both patients in the case report
had a cleft lip and palate (96). A study by King et al.
(61) of 936 five-year-old southern Chinese children
found shovelling of the primary maxillary incisors
present up to 98% of the time. Tratman’s classical
study in 1950 found shovelling of the maxillary inci-
sors a prominent ethnic trait in the permanent den-
tition (97). However, his sample size of primary teeth
did not find shovelling to be a significant character-
istic in the primary maxillary incisors in Mongoloid
populations (98).
Case reports of anomalies of the primary maxillary
incisors include lingual talon cusps (45,95,99–111),
Primary human teeth and their root canal systems
labial talon cusps (96), congenitally missing maxillary
lateral incisors (112), inverted impactions (113),
supernumerary roots (114), and dens invaginatus
(115) (Table 5).
Primary maxillary canine
External morphology
The primary maxillary canine has coronal anatomy
that is unique and differs from the permanent maxil-
lary canine in that the mesial cusp ridge of the primary
canine is longer than its distal cusp ridge (Fig. 4). The
labial surface of the primary maxillary canine is convex
and has a highly developed, prominent middle labial
lobe that extends to the cusp tip. The primary maxil-
lary canines are larger in all dimensions than the
primary maxillary central and lateral incisors. The
mesial and distal surfaces of the crown are convex but
there is a slight concavity in the cervical region of the
crown on its mesial surface. The lingual surface of the
crown is generally smooth without developmental pits
or grooves and has prominent convex mesial and distal
marginal ridges, a convex lingual ridge, and a convex
cingulum. The prominence of the middle labial lobe
and the lingual ridge results in a diamond-shaped
crown from the incisal view. The root tapers to a
rounded root apex and both the mesial and distal
surfaces of the root are relatively straight and flat
(6,9,10,13,15,17,18).
Internal morphology
The pulp chamber and pulp canal also conform to the
external morphology of the tooth. The central pulp
horn of the pulp chamber, though, is prominent and
has a considerable incisal extension (6,9,10,13,15,
17,18).
Root number, form, and root canal system
The primary maxillary canines normally have a single,
triangular-shaped root and a large single canal (6,9,10,
13,15,17,18).
Anomalies and ethnic variations
Case reports of anomalies associated with the primary
maxillary canine roots include unilateral or, more
11
12
Cleghorn et al.

Table 5: Case studies of anomalies and ethnic variations of the primary maxillary incisors
Anomaly Reference Number of teeth in study Other key information Type of study Comments

Dens Kupietzky, 2000 1 (Israel; 1-year-old Clinical and radiographic Type 1 dens invaginatus on a primary maxillary left lateral
invaginatus (115) male) examination incisor
(dens in
dente)

Talon Lee et al., 2007 57 cases (Hong Kong; Primary maxillary lateral Clinical and radiographic A total of 57 primary maxillary incisors exhibited talon cusps;
cusps (105) male and female incisors with talon cusps examination 35 primary maxillary central incisors had talon cusps; most,
patient pool over 3 had a much higher 32 of 35 (91.4%), had no underlying odontogenic
years) incidence of associated anomalies associated with the permanent successors; 23
anomalies than did primary maxillary lateral incisors exhibited talon cusps; 18
primary maxillary central of 23 (78.3%) of the maxillary lateral incisors with talon
incisors with talon cusps cusps were associated with anomalies (14 were
supernumerary teeth)
Tulunoglu et al., 1 (Turkey; 6-year-old Bilateral lingual talon cusps on the primary maxillary central
2007 (111) female) incisors
1 (Turkey; 3-year-old Bilateral lingual talon cusps on the primary maxillary central
male) incisors
Batra et al., 2006 1 (Sweden; 5-year-old Patient had cleft lip and Clinical and radiographic Facial talon cusps on the primary maxillary left lateral incisor
(96) female) palate; history of examination
Goldenhar syndrome in
family
1 (Sweden; 5-year-old Left-sided unilateral cleft Facial talon cusps on the primary maxillary left lateral incisor
female) lip with Simmonart’s
band and an incomplete
cleft of the alveolar
process
Cogulu & 1 (Turkey; 17-month- Clinical and radiographic Bilateral lingual talon cusps on the primary maxillary central
Oncag, 2006 old male) examination incisors
(116)
 Talon Johnston & 1 (USA; 5-year-old Hypodontia Clinical and radiographic Fusion of mandibular central and lateral incisors
cusps Franklin, 2006 White female) Microdontia examination Microdontia of primary dentition
(117) Late dental development Genetic confirmation of Late dental development
Taurdontism of primary syndrome Taurdontism of primary molars
molars
Lee et al., 2006 1 (Hong Kong; 6-year- Clinical and radiographic Primary maxillary right lateral incisor exhibited a lingual talon
(45) 6-month-old male) examination cusp
1 (Hong Kong; 7-year- Clinical and radiographic Primary maxillary right lateral incisor exhibited a lingual talon
2-month-old female) examination cusp
Jeevarathan 1 (India; 5-year-old Bilateral cleft lip Clinical and radiographic Rare case of a primary maxillary right lateral incisor with a
et al., 2005 female) examination labial and a lingual talon cusp
(104)
Hsu Chin-Ying 1 (Singapore; 4-year-old Clinical and radiographic Bilateral lingual talon cusps on the primary maxillary central
et al., 2001 Chinese male) examination incisors
(103)
Guncor et al., 1 (Turkey; 14-month- Clinical and radiographic Rare case of bilateral lingual talon cusps (7 reported cases) on
2000 (101) old male) examination the primary maxillary central incisors
Hattab & Tassin, 1 (Jordan; 17-month- Clinical and radiographic Rare case of bilateral lingual talon cusps (7 reported cases) on
1996 (102) old Jordanian-Arab examination the primary maxillary central incisors
male)
Liu & Chen, 2 (Taiwan; two Clinical and radiographic One twin exhibited lingual talon cusps on both primary
1995 (106) 12-month-old female examination maxillary central incisors while the other exhibited a lingual
twins) talon cusp only on the primary maxillary left central incisor
2 (Taiwan; 3-year-6- Both twins exhibited lingual talon cusps on both primary
month-old female maxillary central incisors
twins)
Meon, 1990 1 (Malaysia; 4-year-old Clinical and radiographic Lingual talon cusp present on primary maxillary left central
(108) male) examination incisor
Reddy & Mehta, 1 (India; 6-year-old Clinical and radiographic Lingual talon cusp present on primary maxillary right lateral
1989 (110) female) examination incisor
Morin, 1987 1 (USA; 1-year-old Clinical and radiographic Bilateral lingual talon cusps on the primary maxillary central
(109) Hispanic male) examination incisors

13
Primary human teeth and their root canal systems
 Table 5: Continued

14
Anomaly Reference Number of teeth in study Other key information Type of study Comments

Chen & Chen, 1 (China; 10-month- Clinical and radiographic Both primary maxillary central incisors had lingual talon cusps
1986 (99) old male) examination
1 (China; 6.5-year-old Lingual talon cusp present on primary maxillary left central
Cleghorn et al.

female) incisor
1 (China; 9-month-old Lingual talon cusp present on primary maxillary left central
male) incisor
1 (China; 13-month- Lingual talon cusp present on primary maxillary left central
old male) incisor
1 (China; 4-year-old Lingual talon cusp present on primary maxillary right central
male) incisor
1 (China; 6-year-old Lingual talon cusp present on primary maxillary left central
male) incisor
Mader & 1 (USA; 5-year-old Clinical and radiographic Lingual talon cusp present on primary maxillary right lateral
Kellogg, 1985 Caucasian male) examination incisor
(107)

Hypodontia Camporesi et al., 156 (Italy; 4 years and 156 non-syndromic
2010 (112) 2 month to 16 years
and 3 months with
unilateral or bilateral
cleft lip and palates)
Marechaux, 1 (Switzerland;
1986 (118) 1.5-year-old male)
Clinical and radiographic The prevalence of congenitally missing primary maxillary
unilateral cleft lip/palate examination lateral incisors (8.1%) and permanent maxillary lateral
(UCLP) or bilateral cleft incisors (27.9%) in UCLP patients was significantly higher
lip/palate (BCLP) than the control group; the prevalence of congenitally
patients were compared missing primary maxillary lateral incisors (17%) and
to a control group of permanent maxillary lateral incisors (60%) in BCLP patients
1,000 non-cleft was also significantly higher than the control group; the
lip/palate patients study also found that the hypodontia in CLP patients was
localized as the prevalence of missing maxillary second
premolars was comparable in the UCLP/BCLP patients
when compared to the non-cleft lip/palate control group
Clinical and radiographic Single primary maxillary central incisor was present (virtually
examination bilateral symmetrical); one maxillary central incisor was also
congenitally absent in the permanent dentition

Inverted Chen, 1990 1 (China; 3-year-old Clinical and radiographic Patient presented with bilateral inverted impaction on both
impaction (113) female) examination primary maxillary central incisors; the most likely aetiology
was deemed to be trauma; however no history of trauma
was reported by the parents

Supernumerary Morrow & Clinical and radiographic All seven patients exhibited bilateral supernumerary roots on
roots Hylin, 1993 examination the primary maxillary central incisors
(114)

Enamel Klingberg et al., 47 primary teeth (16 Polarized light microscope, Analysis of the enamel revealed a high frequency of postnatal
morphological 2009 (119) incisors) from 25 scanning electron hypomineralized enamel and incremental lines. Dentin was
differences patients microscope, and X-ray normal.
microanalysis

Fig. 4. Cross-sectional cuts of the root and labial view
of the primary maxillary right canine. Reprinted with
permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
tions and Slices.
often, bilateral bifurcated roots (120–132), dens
invaginatus (133), and supernumerary primary canine
teeth (134) (Table 6).
Primary maxillary first molar
External morphology
Of all of the primary molar teeth, only the crown of
the primary maxillary first molar has any resemblance
to the succedaneous premolar tooth (Fig. 5). The
roots, however, of all primary molar teeth are distinctly
molar-form. The crowns of the other three primary
molars are very different anatomically to the human
premolar tooth that follows. The buccal surface of the
crown is convex. An indistinct buccal groove divides the
larger and wider MB cusp from the DB cusp (if present
at all). A prominent buccal crest of curvature is present.
Due to the greater length cervico-occlusally of the MB
cusp, the cervical line curves apically on the mesial half
of the crown surface. The cervical buccal bulge is much
more prominent on the mesial half of the crown. The
lingual crown surface is distinctly convex mesiodistally
and less convex cervico-occlusally. The ML cusp is large
and is separated from a much smaller, indistinct DL
cusp by a shallow lingual groove. The crown tapers
toward the lingual. Viewed from the mesial, the promi-
nent cervical crests of curvature are visible. The contact
Primary human teeth and their root canal systems
Fig. 5. Cross-sectional cuts of the root and buccal view
of the primary maxillary right first molar. Reprinted
with permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
tions and Slices.
area with the primary canine is in the occlusal third of
the crown and is buccal to center. The distal aspect of
the crown is narrower than the mesial. There is usually
a groove that travels over the distal marginal ridge onto
the distal surface of the crown. The distal contact area is
in the occlusal third of the crown and lingual to center.
The occlusal surface has three pits (mesial, central, and
distal) with the mesial pit the deepest and the distal pit
the shallowest of the three. The buccal groove divides
the MB from the DB cusps while the mesial groove and
distal groove divide the two buccal cusps from the ML
cusp (and the DL cusp if present) (6,9,10,13,15,
17,18).
Internal morphology
The internal morphology of this tooth is also consis-
tent with the external morphology of the tooth. The
pulp cavity includes a pulp chamber and three diver-
gent pulp canals. The pulp chamber is large when
compared to the permanent counterparts and has
three prominent pulp horns (possibly four) located
under the respective cusps. The most prominent pulp
horn is the MB followed by the ML and then the DB
(6,9,10,13,15,17,18).
15
Cleghorn et al.

Table 6: Case studies of anomalies and ethnic variations of the primary maxillary canines
Anomaly Reference Number of teeth in study Other key information Type of study Comments

Bifurcated Mochizuki et al., 2001 1 (Japan; 6-year-4-month-old Clinical and Bilateral primary maxillary and
roots (132) Japanese male) radiographic mandibular canines with
examination bifurcated roots
Ott & Ball, 1996 1 (USA; 8-year-6-month-old Also congenitally Clinical and Bilateral primary maxillary
(128) African-American male) missing 13 radiographic canines with bifurcated roots
permanent teeth; examination
no evidence of a
syndrome
1 (USA; 4-year-11-month-old Bilateral primary maxillary
African-American male) canines with bifurcated roots
1 (USA; 8-year-4-month-old Bilateral primary maxillary and
African-American male) mandibular canines with
bifurcated roots
Winkler & Ahmad, 1 (USA; 4-year-old Pueblo Clinical and Bifurcated primary maxillary
1997 (131) female) radiographic left canine
examination
Hayutin & Ralstrom, 1 (USA; 4-year-old-male) Clinical and Primary maxillary right canine
1992 (121) radiographic with a bifurcated root
examination
1 (USA; 20-month-old male) Primary maxillary right canine
with a bifurcated root
Saravia, 1991 (130) 1 (USA; 4-year-6-month-old Clinical and Bilateral primary maxillary
African-American male) radiographic canines with bifurcated roots
examination
1 (USA; 4-year-old African- Bilateral primary maxillary
American male) canines with bifurcated roots
Jones & Hazelrigg, 1 (USA; 5-year-old African- Clinical and Bilateral primary maxillary
1987 (127) American male) radiographic canines with bifurcated roots
examination
Paulson et al., 1985 1 (USA; 9-year-5-month-old Clinical and Bilateral primary maxillary
(129) African-American male) radiographic canines with bifurcated roots
examination (mesial and distal)
Bimstein & Bystrom, 1 (USA; 5-year-old African- Clinical and Bilateral primary maxillary
1982 (120) American male) radiographic canines with bifurcated roots
examination
Bryant & Bowers, 1 (USA; 5-year-old Caucasian Clinical and All four primary maxillary and
1982 (122) male) radiographic mandibular canines were
examination bi-rooted
Chow, 1980 (123) 1 (USA; 5-year-old African- Clinical and Bilateral primary maxillary
American male) radiographic canines with bifurcated roots
examination mesiodistally
Krolls & Donahue, 1 (USA; 5-year-old African- Clinical and Bilateral primary maxillary
1980 (126) American female) radiographic canines with bifurcated roots
examination
Kelly, 1978 (124) 1 (USA; 5-year-old African- Clinical and Bilateral primary maxillary
American female) radiographic canines with bifurcated roots
examination
Brown, 1975 (125) 1 (USA; 5-year-old female) Bilateral primary maxillary
canines with bifurcated roots

Dens Rabinowitch, 1952 1 (USA; 3-year-5-month-old Clinical and Primary maxillary left canine
invaginatus (133) Caucasian male) radiographic exhibited coronal
(dens in examination invagination, two distinct
dente) canals, and an accessory
root, consistent with a
diagnosis of “dens in dente”

Supernumerary Ferguson & Hauk, 1 (USA; 4-year-old male) Clinical and Erupted supernumerary
canine 1994 (134) radiographic primary maxillary left canine
examination was present; permanent
maxillary canine predecessor
was congenitally missing

Enamel Klingberg et al., 2009 47 primary teeth (10 canines) Polarized light Analysis of the enamel revealed
morphological (119) from 25 patients microscope, a high frequency of
differences Ehlers–Danlos syndrome scanning post-natally hypomineralized
(EDS) electron enamel and incremental
microscope, lines; dentin was normal
and X-ray
microanalysis

16
 Primary human teeth and their root canal systems

Root number, form, and root canal system molar. It is essentially a four-cusped tooth, often with
a small fifth (Carabelli cusp) cusp present on the
The maxillary first molar normally has three roots
lingual surface of the ML cusp (Fig. 6). This tooth is
(MB, DB, and palatal), but some studies have shown a
larger than the primary maxillary first molar but
relatively high incidence of fusion of the distobuccal
smaller than the permanent first molar.
and palatal roots (14,135,136) (Table 7). The palatal
There is a prominent cervical buccal ridge but the
root is the longest and is curved, followed by the MB
ridge is less prominent than that found on the
root. The DB root is the shortest and smallest in
primary first molars. Like the other primary molars,
diameter of the three roots (6,9,10,13,15,17,18).
the cervical ridge is most prominent on the mesial
The root canal system of the maxillary first molar is
half of the crown. Two buccal cusps are present. The
complex and variable (Table 8). The MB, DB, and
MB cusp is wider and longer than the DB cusp and
palatal roots most commonly have one canal present in
they are divided by the buccal groove. The lingual
each root, although two canals can be found in the
surface of the crown is convex and the two lingual
MB and DB roots. Even when there is fusion of the
cusps are divided by the lingual groove. The ML
DB and palatal roots, three canals is the most common
cusp is wider and longer than the DL cusp. The fifth
configuration (14,135–137).
Carabelli-like cusp, when present, is situated on the
lingual surface of the mesiolingual cusp (comparable
Anomalies and ethnic variations to the permanent maxillary first molar). The mesial
surface of the crown is convex both buccally and lin-
Case reports of fusion of the maxillary molars are
gually in the cervical third of the crown. The buccal
relatively uncommon. Caceda et al. (50) reported a
and lingual surfaces flatten as they converge occlu-
non-syndromic case report of fusion of a primary
sally to a narrow occlusal table. A broad flat con-
maxillary first and second molar. Fusion of the
tact area is present and is shaped like an inverted
primary molars has been reported in the otodental
crescent. The distal surface of the crown also exhibits
syndrome (138,139) and Russell-Silver syndrome
convex, prominent cervical bulges. The crown then
(49). Taurodontism and hypodontia of primary molar
flattens and tapers occlusally to a narrow occlusal
teeth associated with Wolf-Hirschhorn syndrome has
table.
also been reported by Johnson & Franklin (117)
The four functional cusps vary in size. The ML
(Table 9). King et al. (61) report a high incidence of
cusp is largest followed by the MB, DB, and then the
80% for the Carabelli cusp trait in southern Chinese
DL cusp. The oblique ridge is a prominent feature
children.
and is comparable in anatomy to the oblique ridge of
the permanent maxillary first molar. The pits present
Primary maxillary second molar on the occlusal surface are the mesial, central, and
distal pits. The central pit is usually the deepest. The
oblique ridge usually confines cavity preparations to
External morphology
either the mesial or distal portions of the tooth
The primary maxillary second molar closely resembles unless caries has undermined the ridge (6,9,10,13,
a smaller version of the permanent maxillary first 15,17,18).

Table 7: Number of roots in the primary maxillary first molar

Number of Number of Two roots (fused
roots (maxillary teeth (canal distobuccal and Other
first molar) Reference studies) One root palatal roots) Three roots variations

Bagherian et al., 2010 (135) 27 — 21 (77.7%) 6 (22.3%) —

Zoremchhingi et al., 2005 15 — 8 (53.3%) 7 (46.7%) —

(136)

Hibbard & Ireland, 1957 (14) 17 — 5 (29%) 12 (71%) —

17
 Table 8: Root canal system—primary maxillary first molar

18
Number of canals and apices Number of teeth
(maxillary first molar) Reference (canal studies) One canal Two canals Three canals Other variations*

Mesiobuccal root Bagherian et al., 2010 (135) 27 25 (92.6%) 2 (7.4%) — —

Aminabadi et al., 2008 (137) 40 40 (100%) — — —
Cleghorn et al.

Zoremchhingi et al., 2005 (136) 15 14 (93.3%) 1 (6.7%) — —

Hibbard & Ireland, 1957 (14) 17 8 (47%) 6 (35%) — 3 (18%)

Distobuccal root Bagherian et al., 2010 (135) 27 26 (96.3%) 1 (3.7%) — —

Aminabadi et al., 2008 (137) 40 40 (100%) — — —
Zoremchhingi et al., 2005 (136) 7 7 (100%) —
Hibbard & Ireland, 1957 (14) 12 10 (83%) — — 2 (17%)

Palatal Bagherian et al., 2010 (135) 27 27 (100%) — — —

Aminabadi et al., 2008 (137) 40 40 (100%) — — —
Zoremchhingi et al., 2005 (136) 7 7 (100%) —
Hibbard & Ireland, 1957 (14) 12 12 (100%) — — —

Fused distobuccal and palatal roots Zoremchhingi et al., 2005 (136) 8 — 8 (100%) — —
Hibbard & Ireland, 1957 (14) 5 1 (20%) 4 (80%) — —

*variations include apical ramifications, voids, connecting branches, and lateral fibrils

Table 9: Case studies of anomalies and ethnic variations of the primary maxillary first molars
Anomaly Reference Number of teeth in study Other key information Type of study Comments

Fusion Caceda et al., 1994 (50) 1 (USA; 6-year-old Clinical and radiographic Fusion of the primary
African-American male) examination maxillary right first and
second molars

Taurodontism Johnston & Franklin, 1 (USA; 5-year-old Hypodontia Clinical and radiographic Fusion of mandibular
2006 (117) Caucasian female) Microdontia examination; genetic central and lateral
Late dental development confirmation of incisors; microdontia of
Taurdontism of primary syndrome primary dentition; late
molars dental development;
taurdontism of primary
molars

Internal morphology
The internal morphology of this tooth is consistent
with the external morphology of the tooth. The pulp
cavity includes a pulp chamber and three or four pulp
canals. The pulp chamber is larger comparatively to the
permanent counterparts and has four prominent pulp
horns (sometimes five) located under the respective
cusps. The most prominent pulp horn is the MB fol-
lowed by the ML, DB, and then the DL (6,9,10,13,
15,17,18).
Root number, form, and root canal system
The primary maxillary second molar normally has
three roots that are widely separated (14,135,136) but
Fig. 6. Cross-sectional cuts of the root and buccal view
of the primary maxillary right second molar. Reprinted
with permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rotations
and Slices.
Table 10: Number of roots in the primary maxillary second molar
Number of roots Number of teeth
(maxillary second molar) Reference (canal studies)
Bagherian et al., 2010 14
(135)
Zoremchhingi et al., 15
2005 (136)
Hibbard & Ireland, 1957 23
(14)
Primary human teeth and their root canal systems
some specimens exhibit fusion between the distobuc-
cal and palatal roots (14,135). The palatal root is the
longest followed by the MB root. The DB root is the
shortest and roundest of the three roots. Each root
usually contains a single canal system (6,9,10,13,15,
17,18) (Table 10).
The root canal system of the maxillary second molar
is also complex and variable. The MB, DB, and palatal
roots most commonly have one canal present in
each root, although two canals have been found in the
MB and DB roots in some studies (14,135–137)
(Table 11).
Anomalies and ethnic variations
Anomalies are infrequently associated with the primary
maxillary second molars (Table 12) but case reports
include a four-rooted molar (140). A rare anomaly of
double palatal roots also occurs in permanent maxillary
molar teeth, most frequently in second molars (141).
The photographs of the extracted primary tooth in
Kavanagh & O’Sullivan’s case report resemble a type I
variant with four divergent roots. Taurodontism and
hypodontia of primary molars has been noted in
Table 9 (142).
Primary mandibular incisors
External morphology
The primary mandibular incisors are the smallest of the
primary teeth (Figs. 7 and 8). The crown of the
primary mandibular central incisor is shorter cervico-
incisally, narrower labiolingually and has a shorter root
than the primary mandibular lateral incisor. In fact, it
is smaller in all dimensions compared to the primary
mandibular lateral incisor.
Two roots (fused
distobuccal and Other
One root palatal roots) Three roots variations
— 4 (28.6%) 10 (71.4%) —
— — 15 (100%) —
— 8 (35%) 15 (65%) —
19
 Table 11: Root canal system—primary maxillary second molar

20
Number of canals and apices Number of teeth Other
(maxillary second molar) Reference (canal studies) One canal Two canals Three canals variations*

Mesiobuccal root Bagherian et al., 2010 (135) 14 14 (100%) — — —

Aminabadi et al., 2008 (137) 36 36 (100%) — — —
Cleghorn et al.

Zoremchhingi et al., 2005 (136) 15 7 (46.6%) 8 (53.3%) — —

Hibbard & Ireland, 1957 (14) 23 11 (48%) 4 (17%) 1 (4%) 7 (30%)

Distobuccal root Bagherian et al., 2010 (135) 14 14 (100%) — — —

Aminabadi et al., 2008 (137) 36 26 (72.2%) 10 (29.1%) — —
Zoremchhingi et al., 2005 (136) 15 11 (73.3%) 4 (26.6%) — —
Hibbard & Ireland, 1957 (14) 15 15 (100%) — — —

Palatal Bagherian et al., 2010 (135) 14 14 (100%) — — —

Aminabadi et al., 2008 (137) 36 36 (100%) — — —
Zoremchhingi et al., 2005 (136) 15 9 (60%) 6 (40%) — —
Hibbard & Ireland, 1957 (14) 15 15 (100%) — — —

Fused distobuccal and palatal roots Hibbard & Ireland, 1957 (14) 8 3 (38%) 5 (62%) — —

*variations include apical ramifications, voids, connecting branches, and lateral fibrils

Table 12: Case studies of anomalies and ethnic variations of the primary maxillary second molars
Other key
Anomaly Reference Number of teeth in study information Type of study Comments

Supernumerary Kavanagh & O’Sullivan, 1998 1 (Ireland; 10-year-old Clinical and radiographic The primary maxillary right second
roots (140) Caucasian male) examination and molar exhibited normal coronal
photograph morphology; 4 roots were
present and included the MB,
DB, MLi, and DL; the accessory
root appeared to be the
mesiopalatal (ML)

Retained Ith-Hansen & Kjaer, 26 (Denmark; 25 patients, male Clinical and radiographic Primary molars persisted unaltered
primary 2nd 2000 (142) and female, followed for 16 examination from a root resorption up to 15
molars years) years after the normal exfoliation
time period; infraocclusion was
obvious

Fig. 7. Cross-sectional cuts of the root and labial view of
the primary mandibular left central incisor. Reprinted
with permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rotations
and Slices.
Fig. 8. Cross-sectional cuts of the root and labial view of
the primary mandibular left lateral incisor. Reprinted
with permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rotations
and Slices.
The labial surface of the crowns of the primary man-
dibular incisors is convex in all directions, especially so
in the cervical third of the crown. Both incisal
ridges are flat and straight with sharper mesioincisal
angles than distoincisal angles. The primary mandibu-
lar lateral incisor corners are slightly more rounded.
Primary human teeth and their root canal systems
The incisal ridge of the primary mandibular lateral
incisor slopes cervically as it approaches the primary
canine. The lingual fossa is slightly concave and like
the primary maxillary incisors is bordered by the
convex mesial and distal marginal ridges and the cin-
gulum. The lingual surfaces of these crowns are similar
to the primary maxillary incisors and are usually
smooth without developmental pits or grooves. The
proximal crests of curvature (contour) are in the incisal
third of the crowns mesiodistally for both the primary
mandibular central and lateral incisors. From the
incisal view, the crowns of both teeth are triangular in
shape and taper lingually like the primary maxillary
incisors (6,9,10,13,15,17,18).
Internal morphology
The internal morphology is consistent with the
external morphology of the tooth. The pulp chamber
is larger when compared to the permanent counter-
parts and is wider mesiodistally (i.e. more round).
The pulp chamber and single pulp canal taper to the
rounded apex (6,9,10,13,15,17,18). Finn indicates
that the primary mandibular central incisor has a
clear demarcation (constriction) between the pulp
chamber and pulp canal and that this is not
evident in the primary mandibular lateral incisor
(6).
Root number, form, and root canal system
The primary mandibular central and lateral incisors
(like the primary maxillary incisors) normally have a
single, conical root and a large single canal (6,9,10,
13,15,17).
Anomalies and ethnic variations
Case reports of anomalies reported for the primary
mandibular incisors include hyperdontia (143) and
lingual talon cusps (144) (Table 13).
Primary mandibular canine
External morphology
The primary mandibular canine is comparable to
the permanent mandibular canine in that the mesial
21
Cleghorn et al.

Table 13: Case studies of anomalies and ethnic variations of the primary mandibular incisors
Other key
Anomaly Reference Number of teeth in study information Type of study Comments

Hyperdontia Pashley, 1987 1 (USA; 6-year-old Normal size, Clinical and Patient exhibited 6
(143) African-American shape, color radiographic examination primary mandibular
male) incisors; normal number
of succedaneous incisors

Talon cusps Hegde & Kumar, 1 (India; 5.5-year- Clinical and Lingual talon cusp
1999 (144) old female) radiographic examination present on primary
mandibular left central
incisor

the mesial surface of the primary maxillary canine. The

lingual surface of the crown is generally smooth
without developmental pits or grooves and has convex
mesial and distal marginal ridges, a convex lingual
ridge, and a convex cingulum. These convexities are
less prominent than those of the primary maxillary
canine. Due to the prominence of the middle labial
lobe and the lingual ridge, the tooth is diamond-
shaped from the incisal view. The root tapers to
a rounded apex and both the mesial and distal
surfaces of the root are relatively flat (6,9,10,13,15,
17,18).

Fig. 9. Cross-sectional cuts of the root and labial view
of the primary mandibular left canine. Reprinted with
permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
tions and Slices.
Internal morphology
The pulp chamber and pulp canal conform to the
external morphology of the tooth. The central pulp
horn of the pulp chamber has an incisal extension,
as does the primary maxillary canine (6,9,10,13,15,
17,18).

Root number, form, and root canal system

cusp ridge of the primary canine is shorter than its
The primary mandibular canines normally have a
distal cusp ridge (Fig. 9). The labial surface of the
single, conical root that tapers toward the lingual and
primary mandibular canine is convex and has a
a large single canal (6,9,10,13,15,17,18).
well-developed, prominent middle labial lobe that
extends to its cusp tip. The primary mandibular
canines are larger in all dimensions than the primary
Anomalies and ethnic variations
mandibular central and lateral incisors and are
smaller mesiodistally than the primary maxillary Anomalies associated with the primary mandibular
canine. canines include bifurcated roots and root canal
The mesial and distal surfaces of the crown are system (122,132,143), fused mandibular lateral
convex but there is a slight concavity in the cervical incisor to canine (41), and dens invaginatus (145)
region of the crown on its mesial surface as there is on (Table 14).

22
 Table 14: Case studies of anomalies and ethnic variations of the primary mandibular canines
Anomaly Reference Number of teeth in study Other key information Type of study Comments

Bifurcated roots Mochizuki et al., 2001 1 (Japan; 6-year-4- Clinical and radiographic Bilateral primary
(132) month-old Japanese examination maxillary and
male) mandibular canines
with bifurcated roots
Ott & Ball, 1996 (128) 1 (USA; 8-year-4-month- Clinical and radiographic Bilateral primary
old African-American examination maxillary and
male) mandibular canines
with bifurcated roots
Bryant & Bowers, 1982 1 (USA; 5-year-old Clinical and radiographic All four primary maxillary
(122) Caucasian male) examination and mandibular canines
were bi-rooted

Fusion Peretz & Brezniak, 1992 1 (Israel; 8-year-old male) Formocresol pulpotomy, Clinical and radiographic Fused tooth interfering
(41) separation and examination with eruption of
composite restoration succedaneous
permanent right lateral
incisor
Alpoz et al., 2003 (33) 1 (Turkey; 9-year-old Absence of both Clinical and radiographic Bilateral fusion of
male) permanent lateral examination; periapical mandibular primary
incisors and panoramic lateral incisor and
canine teeth
Chalakkal & Thomas, 1 (India; 8-year-old male) Absence of both Clinical and radiographic Bilateral fusion of
2009 (34) permanent lateral examination; periapical mandibular primary
incisors and panoramic lateral incisor and
canine teeth

Dens invaginatus Holan, 1998 (145) 1 (Israel; 5-year-old male) Clinical and radiographic Primary mandibular left
(dens in dente) examination canine exhibited Type
2 dens invaginatus

23
Primary human teeth and their root canal systems
Cleghorn et al.
Primary mandibular first molar
External morphology
The morphology of the crown of this tooth is unique
and does not resemble any other permanent or
primary human tooth (Fig. 10). The mesial marginal
ridge is extremely well developed and, according to
Finn (6), resembles a fifth cusp. The buccal surface of
the crown is convex with a prominent cervical bulge.
Similar to the primary maxillary first molar, the promi-
nence is greater and extends more cervically on the
mesial portion of the crown. The MB cusp is wider
mesiodistally and longer cervico-occlusally than the
DB cusp and the cusps are separated by a shallow
buccal groove. The lingual crown surface is convex
mesiodistally and cervico-occlusally. Two cusps are
present lingually with the ML cusp being wider and
longer than the DB cusp. The two cusps are separated
by an indistinct lingual groove. The mesial surface of
the crown is relatively flat while the distal surface is
more convex.
There are three prominent pits on the occlusal
surface. The deepest pit is the central pit followed by
the mesial pit. The distal pit is usually very shallow.
The three pits are connected by the central devel-
opmental groove. Other prominent grooves are the
Fig. 10. Cross-sectional cuts of the root and buccal view
of the primary mandibular left first molar. Reprinted
with permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
tions and Slices.
24
mesial marginal groove and mesiobuccal triangular
groove.
Internal morphology
There are four prominent pulp horns present. The
most prominent is the MB pulp horn which is very
large and needs to be carefully considered when pre-
paring occlusal and mesio-occlusal cavity preparations
(6). The DB pulp horn is less prominent. The ML
pulp horn is located just mesial to the ML cusp. This
pulp horn is second in height but third in size (MB >
DB > ML > DL).
Three pulp canal systems are usually present, with
one or two found in the single mesial root and one in
the distal root. A double mesial canal system is present
in the mesial root, which is ribbon-shaped and subse-
quently separates into two canals from below the pulp
chamber. The distal root contains a single ribbon-
shaped canal but sometimes narrows with age into two
canals (wide buccolingually and narrow mesiodistally)
(6,9,10,13,15,17,18). There is a considerable varia-
tion in number and shape of canal systems in this
primary tooth (see Table 15).
An ex vivo study by Salama et al. (94) examined 10
primary mandibular first molars and subjected half to a
clearing technique and half to sectioning. Eight of
these teeth had four canals and two had three canals
present. Additionally, they found significant variability
in the root lengths of the teeth in the study.
Root number and form
Two roots are normally present (14,135,136)
(Table 15). Both roots are wider in the buccal-lingual
dimension, narrower mesiodistally, and often fluted.
The mesial and distal roots flare to accommodate the
developing permanent first premolar. From the proxi-
mal view, each root tapers a little toward the rounded
apex of each of the roots (6,9,10,13,15, 17,18).
Root canal system
Most studies found either one or two canals in each
of the mesial and distal roots of the mandibular first
molars (14,135,137) (Table 16). However, there is
generally a higher incidence of two canals in the
mesial root and one canal in the distal root.
 Primary human teeth and their root canal systems

Table 15: Number of roots in the primary mandibular first molar

Number of roots Number of teeth Two roots (mesial
(mandibular first molar) Reference (canal studies) One root and distal) Three roots Other variations

Bagherian et al., 2010 27 — 27 (100%) — —

(135)

Zoremchhingi et al., 15 — 15 (100%) — —

2005 (136)

Hibbard & Ireland, 1957 25 — 25 (100%) — —

(14)

Table 16: Root canal system—primary mandibular first molar

Number of canals Number of
and apices (mandibular teeth (canal Two canals Other
first molar) Reference studies) One canal B and L) Three canals variations*

Mesial root Bagherian et al., 2010 (135) 27 5 (18.5%) 22 (81.5%) — —

Aminabadi et al., 2008 (137) 46 — 46 (100%) — —
Zoremchhingi et al., 2005 (136) 15 1 (6.7%) 14 (93.3%) — —
Hibbard & Ireland, 1957 (14) 25 5 (20%) 6 (24%) — 14 (56%)

Distal root Bagherian et al., 2010 (135) 27 21 (77.8%) 6 (22.2%) — —

Aminabadi et al., 2008 (137) 46 37 (80.4%) 9 (19.6%) — —
Zoremchhingi et al., 2005 (136) 15 6 (40%) 9 (60%) — —
Hibbard & Ireland, 1957 (14) 25 17 (68%) — — 8 (32%)

*variations include apical ramifications, voids, connecting branches, and lateral fibrils

Table 17: Case studies of anomalies and ethnic variations of the primary mandibular first molars
Number of teeth Other key
Anomaly Reference in study information Type of study Comments

Supernumerary Winkler & 1 (USA; 3-year-old Clinical and radiographic 3-rooted primary
roots Ahmad, 1997 Navajo female) examination mandibular right first
(131) molar
1 (USA; 4-year-old Bilateral 3-rooted primary
Pueblo male) mandibular first and
second molars
Falk & Bowers, 1 (USA; 10-year-old male Clinical and radiographic Bilateral 3-rooted primary
1983 (148) of Western European examination mandibular first molars
descent)
Badger, 1982 1 (USA; 5-year-old Clinical and radiographic 3-rooted primary
(149) Caucasian male) examination mandibular right first
molar

root on an adjacent permanent molar was 94.3% when

Anomalies and ethnic variations
A study of 4050 Korean children by Song et al. (146)
found an incidence of 9.7% for an additional root in
the primary mandibular first molars. The study also
found that the probability of an additional distolingual
an additional distolingual root was present on a
primary mandibular molar. Tu et al. (147) studied 121
Taiwanese children with an age range from 2.4–10.4
years and found that 5% of the children exhibited a
three-rooted primary first molar and that 80% of those

25
Cleghorn et al.

Table 18: Number of roots in the primary mandibular second molar

Number of roots Number of Two roots
(mandibular teeth (canal (mesial and Other
second molar) Reference studies) One root distal) Three roots (extra root) variations

Liu & Dai, 2010 (151) 370 — 347 (93.8%) 23 (6.2%) extra distal —
root

Bagherian et al., 2010 22 — 21 (95.5%) 1 (4.5%) extra mesial root —

(135)

Zoremchhingi et al., 15 — 13 (86.7%) 2 (13.3%) extra mesial —

2005 (136) root

Hibbard & Ireland, 1957 22 — 22 (100%) — —

(14)

the primary mandibular first molar and smaller than

Fig. 11. Cross-sectional cuts of the root and buccal view
of the primary mandibular left second molar. Reprinted
with permission from Brown P, Herbranson E. Dental
Anatomy and 3D Tooth Atlas version 6.4, 6th edn. Portola
Valley, CA: eHuman Inc., 2010. Primary Teeth Rota-
tions and Slices.
the permanent mandibular first molar.
Three cusps are present on the buccal surface. The
MB cusp is larger than the DB cusp, which is larger
than the D cusp. The cusps are separated by the MB
and DB grooves, respectively. The cervical bulge, like
the other primary molars, is most prominent on the
mesial portion of the crown. The lingual surface of the
crown is convex and has two cusps present. The ML
and DB cusps, which are approximately the same size,
are separated by a shallow lingual groove. The mesial
and distal surfaces of the crown are convex and flatten
near the cervix. The mesial contact is broad and flat
while the distal contact (with the permanent mandibu-
lar first molar when it erupts) is small and round. The
occlusal view illustrates a lingual taper of the crown.
The three occlusal pits are the mesial, central, and
distal, with the central pit usually the deepest of the
three (6,9,10,13,15,17,18).

were unilateral. Other case studies of anomalies also Internal morphology

include supernumerary distolingual roots (131,148–
150) (Table 17).
Primary mandibular second molar
External morphology
The primary mandibular second molar closely resem-
bles the permanent mandibular first molar and is a
five-cusped tooth (Fig. 11). As in the maxillary arch,
the primary mandibular second molar is larger than
There are five prominent pulp horns present. The MB
and ML pulp horns are most prominent. The DB is
next in size followed by the smaller DL and D pulp
horns. Three or four pulp canals are usually present.
Two canals are usually present in the mesial root.
Initially it is a ribbon-shaped canal that separates into
two canals from the pulp chamber. The distal root
contains a single ribbon-shaped canal (wide buccolin-
gually and narrow mesiodistally), which is comparable
to the primary mandibular first molar (6,9,10,13,15,
17,18). With age and calcification, the distal root may
also present as a double canal system.

26
 Primary human teeth and their root canal systems

Root number and form

variations*

8 (36%)

1 (5%)
Other
In Caucasian and Black populations, there is normally

—
—

—
—
two well-spread roots, mesial and distal, but many
studies have identified three-rooted specimens in Asian
Three canals
populations (14,135,136,151) (Table 18). Liu et al.
found three-rooted primary mandibular second molars

1 (6.7%)
in approximately 10% of patients and 6% of teeth in a
2 (9%)
radiographic study of 227 Chinese patients (151).
—
—

—
—

—
Song et al. (146) noted that in a study of 4,050
Korean children, there was a 27.8% incidence of a
third DL root on the primary mandibular second
(MB and ML)

molar. This was almost a three times more likely inci-

Two canals

(36.4%)

(53.3%)
(100%)
(100%)
(100%)

(100%)

dence than the primary mandibular first molar. The

(32%)

(14%)

presence of a third root in the primary mandibular

molar teeth was a good predictor (94.3%) of a third
22
38
15

38
7

8
3

root in the permanent mandibular first molar. They

suggest that the third distolingual root in mandibular
molars, primary or permanent, should be considered a
14 (63.6%)
One canal

18 (82%)
5 (23%)

6 (40%)

normal racial and morphologic variant of populations

of Mongoloid origin.
—
—
—

Root canal system

teeth (canal
Number of

Most studies found either one or two canals in each

*variations include apical ramifications, voids, connecting branches, and lateral fibrils
studies)

of the mesial and distal roots of the mandibular

second molars (Table 19). The majority reported a
22
38
15
22

22
38
15

higher incidence of two canals in the mesial roots

(14,135–137). Depending on the study, either one
Table 19: Root canal system—primary mandibular second molar

or two canals were predominant in the distal roots.

Zoremchhingi et al., 2005 (136)

Zoremchhingi et al., 2005 (136)

Hibbard & Ireland, 1957 (14)

Hibbard & Ireland, 1957 (14)

Aminabadi et al., 2008 (137)

Aminabadi et al., 2008 (137)

Bagherian et al., 2010 (135)

Bagherian et al., 2010 (135)

Anomalies and ethnic variations

A study of 4,050 Korean children by Song et al. (146)
found an incidence of 27.8% for an additional root in
the primary mandibular second molars. As mentioned
Reference

previously, the study also found that the probability of

an additional root on an adjacent permanent molar
was 94.3% when an additional root was present on a
primary mandibular molar. Due to the high incidence
of additional roots in ethnic Asian and aboriginal
Number of canals and apices

American populations, this characteristic is more

(mandibular second molar)

appropriately termed a variation in that population and

an anomaly with a lower incidence in non-Mongoloid
(European and Black) populations.
Anomalies associated with the primary mandibular
Mesial root

Distal root

second molars are rare (Table 20). Case reports of

anomalies include dens invaginatus (152), infraocclu-
sion (153), and supernumerary roots (131).

27
28
Table 20: Case studies of anomalies and ethnic variations of the primary mandibular second molars
Cleghorn et al.

Anomaly Reference Number of teeth in study Other key information Type of study Comments

Dens invaginatus Eden et al., 2002, (152) 1 (Turkey; 11-year-old Missing permanent Clinical and radiographic Dens invaginatus Type 3
(dens in dente) male) mandibular right examination associated with the
second premolar primary mandibular
right second molar

Infraocclusion Atwan & DesRosiers, 1 (Turkey; 3-year-old Primary mandibular right

1998 (153) Caucasian female) second molar was 3mm
below occlusal plane
and ankylosed

Supernumerary roots Winkler & Ahmad, 1997 1 (USA; 4-year-old Clinical and radiographic Bilateral 3-rooted primary
(131) Pueblo male) examination mandibular first and
second molars

Taurodontism* Johnston & Franklin, 1 (USA; 5-year-old Hypodontia Clinical and radiographic Fusion of mandibular
2006 (117) Caucasian female) Microdontia examination; genetic central and lateral
Late dental development confirmation of incisors; microdontia of
Taurdontism of primary syndrome primary dentition; late
molars dental development;
taurdontism of primary
molars

Retained primary 2nd Ith-Hansen & Kjaer, 26 (Denmark; 25 Clinical and radiographic Primary molars persisted
molars 2000 (142) patients, male and examination unaltered from a root
female, followed for 16 resorption up to 15
years) years after the normal
exfoliation time period;
infraocclusion was
obvious

*Ackerman et al. (150) seems to be the first publication citing a taurodontic primary molar, along with the family with multiple taurodontic permanent teeth.

Acknowledgements
Dr. Sigrid Coil’s assistance in editing the manuscript is
appreciated.
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