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Root canal morphology of primary molars: a micro-computed tomography

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Article  in  European Archives of Paediatric Dentistry. Official Journal of the European Academy of Paediatric Dentistry · February 2014
DOI: 10.1007/s40368-014-0117-0 · Source: PubMed

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Eur Arch Paediatr Dent
DOI 10.1007/s40368-014-0117-0
ORIGINAL SCIENTIFIC ARTICLE
Root canal morphology of primary molars: a micro-computed
tomography study
A. C. Fumes • M. D. Sousa-Neto • G. B. Leoni •
M. A. Versiani • L. A. B. da Silva •
R. A. B. da Silva • A. Consolaro
Received: 18 September 2013 / Accepted: 23 January 2014
Ó European Academy of Paediatric Dentistry 2014
Abstract
Aim This was to investigate the root canal morphology of
primary molar teeth using micro-computed tomography.
Methods Primary maxillary (n = 20) and mandibular
(n = 20) molars were scanned at a resolution of 16.7 lm
and analysed regarding the number, location, volume, area,
structured model index (SMI), area, roundness, diameters,
and length of canals, as well as the thickness of dentine in
the apical third. Data were statistically compared by using
paired-sample t test, independent sample t test, and one-
way analysis of variance with significance level set as 5 %.
Results Overall, no statistical differences were found
between the canals with respect to length, SMI, dentine
thickness, area, roundness, and diameter (p [ 0.05). A
double canal system was observed in the mesial and mesio-
buccal roots of the mandibular and maxillary molars,
respectively. The thickness in the internal aspect of the
roots was lower than in the external aspect. Cross-sectional
evaluation of the roots in the apical third showed flat-
shaped canals in the mandibular molars and ribbon- and
oval-shaped canals in the maxillary molars.
A. C. Fumes
L. A. B. da Silva
R. A. B. da Silva

A. Consolaro
Department of Pediatric Dentistry, Dental School of Ribeirão
Preto, University of São Paulo, Av. do Café s/no, Bairro Monte
Alegre, São Paulo, Ribeirão Preto CEP 14049-904, Brazil
M. D. Sousa-Neto (&)
G. B. Leoni
M. A. Versiani
Department of Restorative Dentistry, Dental School of Ribeirão
Preto, University of São Paulo, Av. do Café s/no, Bairro Monte
Alegre, São Paulo, Ribeirão Preto CEP 14049-904, Brazil
e-mail: sousanet@forp.usp.br
M. D. Sousa-Neto
Rua Célia de Oliveira Meirelles 350, São Paulo,
Ribeirão Preto CEP 14024-070, Brazil
Conclusions External and internal anatomy of the pri-
mary first molars closely resemble the primary second
molars. The reported data may help clinicians to obtain a
thorough understanding of the morphological variations of
root canals in primary molars to overcome problems rela-
ted to shaping and cleaning procedures, allowing appro-
priate management strategies for root canal treatment.
Keywords Deciduous teeth
Dental pulp cavity
Micro-
computed tomography
Primary molars
Introduction
The premature loss of primary teeth may cause changes in
the chronology and sequence of eruption of permanent
teeth; thus, saving teeth in children is an important concept
and frequently involves endodontic treatment (Cleghorn
et al. 2012). Root canal treatment in primary teeth includes
the removal of the pulp tissue, debridement and prepara-
tion, irrigation, and filling of the canals. The main objective
of pulp therapy in primary teeth is to maintain the integrity
and health of the teeth and their supporting tissues (Cleg-
horn et al. 2012). To accomplish this goal, a comprehen-
sive understanding of the root and the root canal
morphology of primary teeth is of utmost importance
(Hibbard and Ireland 1957; Goodacre 2003; Zoremchhingi
et al. 2005; Aminabadi et al. 2008; Bagherian et al. 2010;
Cleghorn et al. 2012).
The external and internal morphology of primary teeth
are different in many aspects from permanent successors
(Kavanagh and O’Sullivan 1998; Goodacre 2003; Johnston
and Franklin 2006; Cleghorn et al. 2012). Generally, pri-
mary teeth with fully developed roots exhibit a less com-
plex root canal system compared to permanent teeth, with
123

one canal per root. In primary molars, the complexity of
this system may increase over time due to the formation of
secondary dentine and narrowing of the canal system and
eventually the resorption process (Hibbard and Ireland
1957).
Traditionally, root canal anatomy of primary teeth has
been described in case reports (Badger 1982; Falk and
Bowers 1983; Caceda et al. 1994; Winkler and Ahmad
1997; Kavanagh and O’Sullivan 1998; Eden et al. 2002)
and in ex vivo studies using injection of materials (Simp-
son 1973), dye perfusion (Ringelstein and Seow 1989),
digital radiographs, longitudinal and transverse cross-sec-
tioning, histology (Poornima 2008), clearing technique
(Bagherian et al. 2010), scanning electron microscope
(Wrbas et al. 1997), and conventional computed tomogra-
phy (Zoremchhingi et al. 2005). These methodologies have
been successfully used for many years in the anatomical
study of the root canal system; however, most of them are
invasive or only provide a two-dimensional image of a
three-dimensional structure, and therefore may not accu-
rately reflect the morphology of the object being studied.
Thus, these inherent methodological limitations encour-
aged the search for new methods able to produce improved
results (Peters et al. 2000).
In recent years, significant technological advances for
imaging teeth have been introduced. Their non-invasive
nature allows the use of teeth for other purposes or as
controls for further treatment procedures. The development
of the high-resolution X-ray micro-computed tomography
(micro-CT) has gained increasing significance in the study
of dental tissues. Micro-CT offers a non-invasive repro-
ducible technique for three-dimensional assessment of the
root canal system and it can be applied both quantitatively
and qualitatively (Peters et al. 2000; Siqueira et al. 2010;
Versiani et al. 2011, 2012, 2013).
Even though there has been a growing body of research and
publications on the dental anatomy of primary teeth (Goodacre
2003; Cleghorn et al. 2012), a detailed quantitative description
of the anatomy of their root canal system is still lacking.
Therefore, the purpose of this study was to describe the mor-
phometric aspects of the external and internal anatomy of
primary mandibular and maxillary molars, using high-resolu-
tion three-dimensional micro-CT analysis.
Materials and methods
Sample selection
After approval from the local ethics in research committee
(CAAE #0072.0.130.000-09), primary mandibular (n = 20)
and maxillary (n = 20) molars, extracted for reasons not
related to this study and stored in 0.1 % thymol solution,
123
Eur Arch Paediatr Dent
were selected. For each group of teeth, ten first and ten
second primary molars were evaluated. The inclusion cri-
teria comprised only molars with no physiological root
resorption or at its initial stages, i.e. in which resorption did
not exceed 1/3 of root length.
Micro-CT scanning and reconstruction
Each tooth was slightly dried, mounted on a custom
attachment, and scanned in a micro-CT scanner (SkyScan
1174v2; Bruker-microCT, Kontich, Belgium) at an isotro-
pic resolution of 16.7 lm. The X-ray tube was operated at
50 kV and 800 mA, and the scanning was performed by
180° rotation around the vertical axis with a rotation step of
1°, using a 0.5-mm-thick aluminium filter. Images of each
specimen were reconstructed with dedicated software
(NRecon v.1.6.6; Bruker-microCT) providing axial cross
sections of the inner structure of the samples.
Quantitative analysis
DataViewer v.1.4.4 software (Bruker-microCT) was used
to evaluate the length (in millimetres) of the root from the
apex, and the length of the main root canals from the apical
foramen to the level of the cementoenamel junction. Three-
dimensional evaluation of the root canals (volume, surface
area, and structure model index) was performed from the
apex to the canal orifice using CTAn v.1.12 software
(Bruker-microCT). Volume was calculated as that of bi-
narised objects within the volume of interest. For the
measurement of the surface area of the 3D multilayer
dataset, two components to surface measured in 2D were
used: first, the perimeters of the binarised objects on each
cross-sectional level, and second, the vertical surfaces
exposed by pixel differences between adjacent cross sec-
tions. Structure model index (SMI) involves a measure-
ment of surface convexity in a 3D structure. SMI is derived
as 6.(S’.V)/S2), where S is the object surface area before
dilation and S’ is the change in surface area caused by
dilation. V is the initial, undilated object volume. An ideal
plate, cylinder and sphere have SMI values of 0, 3 and 4,
respectively (Peters et al. 2000).
The smallest thickness of dentine in the internal and
external aspects of the roots, at 1, 2 and 3 mm from the
apical resorption bevel, were also recorded. Measurements
of the dentine thickness were taken from the external limit
of the root canal to the surface of the root. At these same
levels, CTAn v.1.12 software (Bruker-microCT) was used
for the two-dimensional evaluation (area, roundness,
major diameter, and minor diameter) of the root canal.
Area was calculated using the Pratt algorithm (Pratt
1991). The cross-sectional appearance, round or more
ribbon shaped, was expressed as roundness. Roundness of
Eur Arch Paediatr Dent

Table 1 Mean (±SD) of the morphometric 3D data in each root of primary maxillary and mandibular molars
n Root canal Root length (mm) Canal length (mm) Volume (mm3) Surface area (mm2) SMI

Mandibular
First molar 10 M 7.3 ± 1.5 6.1 ± 1.5 5.4 ± 3.6 36.1 ± 12.7a 2.0 ± 0.4
a a
D 6.4 ± 1.9 4.7 ± 2.5 4.6 ± 4.4 28.0 ± 15.6b 1.9 ± 0.4
a
Second molar 10 M 8.5 ± 1.1 7.0 ± 1.8 6.6 ± 2.7 58.7 ± 20.3 1.7 ± 0.5
D 8.9 – 2.0b 6.7 – 2.3 9.6 ± 3.5b 65.9 ± 18.3b 1.6 ± 0.3
Maxillary
First molar 10 MB 7.9 – 1.1 6.5 – 2.3 2.8 ± 2.1 24.5 ± 7.9 2.1 ± 0.6
DB 6.7 ± 1.7 5.4 ± 1.5 1.3 ± 1.6 11.4 ± 6.9a 2.1 ± 0.5
P 5.9 ± 1.8 4.6 ± 1.9 2.9 ± 2.5a 17.9 ± 7.5a 2.7 ± 0.3
Second molar 10 MB 8.5 ± 1.4 6.3 ± 1.9 3.2 ± 1.6 31.0 ± 12.0 1.8 ± 0.6
DB 6.5 ± 1.6 5.7 ± 1.4 2.0 ± 1.0 22.2 ± 11.5b 2.0 ± 0.5
P 7.4 ± 1.4 5.9 ± 1.8 5.4 ± 2.6b 31.8 ± 11.6b 2.5 ± 0.4
Different superscript letters in the same column indicate statistical significant difference between root canals in the same group of teeth
(independent sample t test, p \ 0.05); within root, values with bold letters in the same line were statistically different (paired-sample t test,
p \ 0.05)
M mesial; D distal; MB mesio-buccal; DB disto-buccal; P palatal

a discreet 2D object is defined as 4A/(p.(dmax)2), where Results

‘‘A’’ is the area and ‘‘dmax’’ is the major diameter. The
value of roundness ranges from 0 to 1, with one signifying
a circle. The major diameter was defined as the distance
between the two most distant pixels in that object. The
minor diameter was defined as the longest chord through
the object that can be drawn in the direction orthogonal to
that of the major diameter.
Qualitative analysis
Three-dimensional models and cross sections of the root
canals were reconstructed based on micro-CT scans and
generated by the binarisation process using CTAn v.1.12
software (Bruker-microCT). CTVol v.2.2.1 (Bruker-mi-
croCT) and DataViewer v.1.4.4 (Bruker-microCT) soft-
ware were used for visualisation and qualitative evaluation
of the specimens.
Statistical analysis
Three-dimensional parameter results and the average
length of roots and root canals were statistically compared
using paired-sample t test within group and independent
sample t test between groups, respectively. Considering
that the data of dentine thickness and two-dimensional
parameters at 1, 2 and 3 mm from the resorption bevel
were normally distributed (Shapiro–Wilk test; p [ 0.05),
they were presented as means and standard deviations
(SD), and statistically compared using one-way analysis of
variance post hoc Tukey test. Statistical analysis was per-
formed using SPSS v.17.0 for Windows (SPSS Inc, Chi-
cago, IL, USA) with a significance level set at 5 %.
Quantitative analysis
Tables 1 and 2 show the mean (±SD) of the three- and
two-dimensional data, respectively, in each root of the
primary molars. Overall, in both groups of teeth no sta-
tistical differences were found between root canals of the
first and second molars with respect to length, SMI, and the
two-dimensional analysed parameters (area, roundness,
major diameter, and minor diameter) (p [ 0.05). Distal and
palatal canals of the mandibular and maxillary molars,
respectively, presented a significant higher volume than the
other canals in the same group of teeth (p \ 0.05). Gen-
erally, root canals of the second primary molar canals had
higher surface area than the first molars (p \ 0.05).
Table 3 summarises the mean dentine thickness in the
apical third of each molar root. No statistical difference
was observed in the comparison of the dentine thickness, in
either internal or external aspect of each root, between the
first and second molars (p [ 0.05). The lowest mean values
of dentine thickness were observed in the internal aspect of
the roots, in both molar groups. In general, the highest
mean thickness of dentine was observed in the distal and
palatal roots of the mandibular and maxillary molars,
respectively, in all evaluated levels.
Qualitative analysis
The analysis of the external anatomy of the mandibular first
and second molars showed that all specimens had two
roots, wider in the buccal–lingual dimension, narrower
mesio-distally, and often fluted. Deep caries with no pulp

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 Eur Arch Paediatr Dent

Table 2 Mean (±SD) of Root n Distance Area Roundness Major diameter Minor diameter
morphometric 2D data at 1, 2 canal (mm) (mm2) (mm) (mm)
and 3 mm from the apical
resorption bevel in each root of Mandibular
primary mandibular and
First molar M 10 1 0.4 ± 0.6 0.4 ± 0.2 1.0 ± 1.0 0.4 ± 0.3
maxillary molars
2 0.4 ± 0.6 0.4 ± 0.2 1.1 ± 0.9 0.4 ± 0.2
3 0.5 ± 0.6 0.4 ± 0.2 1.3 ± 0.9 0.4 ± 0.3
D 10 1 0.5 ± 0.4 0.3 ± 0.1 1.2 ± 0.6 0.4 ± 0.2
2 0.6 ± 0.4 0.3 ± 0.1 1.5 ± 0.4 0.5 ± 0.2
3 0.7 ± 0.4 0.4 ± 0.1 1.4 ± 0.6 0.6 ± 0.3
Second molar M 10 1 0.4 ± 0.6 0.4 ± 0.2 1.3 ± 1.6 0.3 ± 0.2
2 0.2 ± 0.4 0.4 ± 0.2 1.0 ± 1.0 0.3 ± 0.1
3 0.5 ± 0.9 0.3 ± 0.2 1.4 ± 1.1 0.4 ± 0.2
D 10 1 0.4 ± 0.5 0.2 ± 0.2 1.8 ± 1.4 0.3 ± 0.1
2 0.7 ± 0.7 0.2 ± 0.2 2.1 ± 1.5 0.4 ± 0.2
3 1.2 ± 1.0 0.2 ± 0.2 2.7 ± 1.4 0.5 ± 0.2
Maxillary
First molar MB 10 1 0.1 ± 0.1 0.4 ± 0.1 0.5 ± 0.3 0.3 ± 0.2
2 0.2 ± 0.2 0.3 ± 0.2 1.0 ± 0.6 0.3 ± 0.2
3 0.3 ± 0.2 0.3 ± 0.2 1.0 ± 0.6 0.4 ± 0.2
DB 10 1 0.1 ± 0.3 0.5 ± 0.2 0.5 ± 0.3 0.2 ± 0.2
2 0.2 ± 0.3 0.5 ± 0.2 0.6 ± 0.3 0.3 ± 0.2
3 0.2 ± 0.3 0.4 ± 0.2 0.6 ± 0.3 0.3 ± 0.2
P 10 1 0.4 ± 0.5 0.6 ± 0.1 0.8 ± 0.4 0.5 ± 0.3
2 0.6 ± 0.5 0.6 ± 0.1 1.0 ± 0.4 0.7 ± 0.4
3 0.9 ± 0.7 0.5 ± 0.1 1.3 ± 0.5 0.8 ± 0.4
Second molar MB 10 1 0.3 ± 0.2 0.3 ± 0.1 1.2 ± 0.9 0.3 ± 0.1
2 0.4 ± 0.2 0.2 ± 0.1 1.4 ± 0.9 0.4 ± 0.1
3 0.4 ± 0.3 0.2 ± 0.1 1.6 ± 1.0 0.4 ± 0.2
Asterisk (*) means statistically DB 10 1 0.2 ± 0.1 0.3 ± 0.2 0.9 ± 0.3 0.3 ± 0.1
significant difference within
2 0.3 ± 0.1 0.3 ± 0.2 1.3 ± 0.6 0.3 ± 0.1
root in the same group of teeth
(one-way ANOVA post hoc 3 0.4 ± 0.2 0.3 ± 0.2 1.6 ± 0.9 0.4 ± 0.1
Tukey test, p \ 0.05) P 10 1 0.7 ± 0.2 0.5 ± 0.1 1.3 ± 0.3 0.6 ± 0.1*
M mesial; D distal; MB mesio- 2 0.9 ± 0.4 0.5 ± 0.1 1.5 ± 0.4 0.7 ± 0.1
buccal; DB disto-buccal; 3 1.1 ± 0.4 0.5 ± 0.1 1.7 ± 0.5 0.8 ± 0.1*
P palatal

exposure were observed in 20 % of the sample. Early
apical root resorption was observed in only one specimen
from each group of teeth. On the other hand, surface
resorption at the internal aspect of the roots was observed
in most of the teeth (n = 15). Bevelled resorption in the
apex of both roots resulted in a thinner thickness of the
dentine walls compared to the middle and cervical thirds.
Three-dimensional models of the mandibular molars con-
firm that the configuration of the root canal system was
consistent with the external morphology of the root
(Fig. 1a–c). A single root canal was observed in 10 % of
the mesial roots, while a single distal canal system was
detected in 60 and 50 % of the first and second molars,
respectively. In the mesial and distal roots, the maximum
number of orifices observed in the root canal cross sections
was 8 and 5, respectively. At the furcation level, the mesial
root of the mandibular first molars showed two orifices in
eight samples, whilst all other roots presented only one
orifice. Ribbon-shaped canal systems with one or two
canals in the mesial root and one in the distal root were
present in 40 and 30 % of the first and second molars,
respectively. In the latter, a ribbon-shaped canal that sep-
arates into two or more canals from below the cemento-
enamel junction was also observed.
Figure 2 shows exemplary 3D models of the external
(Fig. 2a) and internal anatomy (Fig. 2b–c) of three primary
maxillary molars. Generally, three canal systems were
present, one in each root. Two canals were observed in the
mesio-buccal (MB) root of two maxillary first molars. At
the furcation level, the MB root of the maxillary first
molars showed two orifices in two samples, whilst all other
roots presented only one orifice. The analysis of the

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Eur Arch Paediatr Dent

Table 3 Mean (±SD) of dentine thickness (in mm) at 1, 2 and 3 mm Surface resorption at the internal aspect of the roots was
from the apical resorption bevel in each root of primary mandibular observed in most of the specimens (n = 17).
and maxillary molars
Exemplary cross sections of the roots of the mandibular
Root n Distance Thickness Thickness and maxillary primary molars showed the complexity and
canal (mm) (internal) (external) the large dimensions of the root canal system in the apical
Mandibular third (Fig. 3). In the mandibular molars, mesial canal cross
First molar M 10 1 0.4 ± 0.1 0.7 ± 0.1 sections were significantly flatter and irregularly tapered in
2 0.5 ± 0.1 0.8 ± 0.2 the mesio-distal plane. The presence of thin isthmuses,
3 0.5 ± 0.1 0.9 ± 0.2 interconnecting branches, and multiples orifices were
D 10 1 0.4 ± 0.1 0.8 ± 0.3
observed. Round-shaped canals were observed when the
2 0.5 ± 0.2 0.8 ± 0.3
main canal split into multiple canals throughout the root,
which occurred in 60 and 70 % of the first and second
3 0.4 ± 0.1 0.8 ± 0.3
molars, respectively. In the maxillary molars, evaluation of
Second molar M 10 1 0.5 ± 0.1 0.6 ± 0.1*
the cross sections of the roots showed generally ribbon- or
2 0.6 ± 0.1 0.7 ± 0.1
oval-shaped canals with large dimensions. However, in
3 0.6 ± 0.1 0.8 ± 0.1*
both mandibular and maxillary molars, the cross-sectional
D 10 1 0.5 ± 0.1 0.7 ± 0.2
appearance of the canals varied in different levels of the
2 0.6 ± 0.1 0.8 ± 0.2
root. Table 4 summarises the percentage frequency of root
3 0.6 ± 0.1 0.9 ± 0.3
canal shape in each root of the primary maxillary and
Maxillary
mandibular molars.
First molar MB 10 1 0.3 ± 0.1 0.6 ± 0.3
2 0.4 ± 0.1 0.7 ± 0.3
3 0.5 ± 0.1 0.7 ± 0.3
Discussion
DB 10 1 0.4 ± 0.2 0.6 ± 0.2*
2 0.6 ± 0.2 0.7 ± 0.2 Although detailed descriptions of the external and internal
3 0.6 ± 0.3 0.9 ± 0.2* anatomical configuration of primary molars have been
P 10 1 0.8 ± 0.2 1.0 ± 0.2 already reported using conventional methodologies (Hib-
2 1.1 ± 0.3 1.1 ± 0.2 bard and Ireland 1957; Simpson 1973; Badger 1982; Falk
3 1.2 ± 0.4 1.2 ± 0.3 and Bowers 1983; Ringelstein and Seow 1989; Salama
Second molar MB 10 1 0.4 ± 0.1* 0.6 ± 0.1 et al. 1992; Caceda et al. 1994; Winkler and Ahmad 1997;
2 0.5 ± 0.1 0.8 ± 0.2 Wrbas et al. 1997; Kavanagh and O’Sullivan 1998; Fuks
3 0.6 ± 0.1* 0.8 ± 0.2 2000; Eden et al. 2002; Goodacre 2003; Zoremchhingi
DB 10 1 0.5 ± 0.2 0.7 ± 0.1 et al. 2005; Aminabadi et al. 2008; Poornima and Subba
2 0.6 ± 0.2 0.8 ± 0.2 Reddy 2008; Song et al. 2009; Bagherian et al. 2010; Liu
3 0.7 ± 0.2 0.9 ± 0.3 et al. 2010; Cleghorn et al. 2012), no study has been
P 10 1 0.6 ± 0.2 1.0 ± 0.3 undertaken to evaluate quantitatively their root canal sys-
2 0.8 ± 0.3 1.2 ± 0.4 tem using high-resolution micro-computed tomography.
3 0.8 ± 0.2 1.3 ± 0.5 Primary mandibular molars have been usually described
Asterisk (*) means statistically significant difference within root in
as having two grooved and divergent roots that flare to
the same group of teeth (one-way ANOVA post hoc Tukey test, accommodate the developing permanent premolars (Hib-
p \ 0.05) bard and Ireland 1957; Zoremchhingi et al. 2005; Baghe-
M mesial; D distal; MB mesio-buccal; DB disto-buccal; P palatal rian et al. 2010). In the literature, a considerable variation
in number and shape of canal systems has been described
external anatomy showed that six specimens from each in this group of teeth (Hibbard and Ireland 1957; Salama
group of teeth had three widely separated roots, while four et al. 1992; Zoremchhingi et al. 2005; Aminabadi et al.
presented fusion between the disto-buccal (DB) and palatal 2008; Bagherian et al. 2010; Cleghorn et al. 2012). Ana-
roots. Deep caries with no pulp exposure were observed in tomical anomalies, such as additional roots, dens invagin-
30 % of the sample. Early bevelled apical root resorption atus, and taurodontism, have also been reported, mostly in
was observed in two MB roots of the second molars, and mandibular second molars (Badger 1982; Falk and Bowers
three MB and two DB roots of the first molars. The apical 1983; Winkler and Ahmad 1997; Eden et al. 2002; Zor-
resorption of the roots resulted in a thinner thickness of the emchhingi et al. 2005; Johnston and Franklin 2006; Song
dentine walls compared to the middle and cervical thirds et al. 2009; Bagherian et al. 2010; Liu et al. 2010). Overall,
and, in some cases, exposure of the root canal (Fig. 2d). it may be inferred that the external and internal anatomy of

123
 Eur Arch Paediatr Dent

Fig. 1 Exemplary three-

dimensional models of three
primary mandibular molars
(a) showing the anatomical
configuration of the root canals
in frontal (b) and lateral
(c) views. Generally, ribbon-
shaped canal systems are
present, with one or two found
in the mesial root and one in the
distal root. A ribbon-shaped
canal that separates into two
canals from below the cemento-
enamel junction was also
observed in the distal root in
both molars

the primary mandibular first molar closely resembles the canals in each of the mesial and distal roots (Hibbard and
primary mandibular second molar (Goodacre 2003; Cleg- Ireland 1957; Zoremchhingi et al. 2005; Aminabadi et al.
horn et al. 2012). Most studies have found either one or two 2008; Bagherian et al. 2010). The incidence of double

123
Eur Arch Paediatr Dent
Fig. 2 Exemplary three-dimensional models of three primary
maxillary molars (a) showing the anatomical configuration of the
root canals in frontal (b–c) and apical (d) views. Generally, ribbon- or
oval-shaped canal systems were present, with one or two canals in the
ribbon-shaped canal system has been reported to range
from 24 to 100 % in the mesial root, and from 22.2 to 60 %
in the distal root (Zoremchhingi et al. 2005; Aminabadi
et al. 2008; Bagherian et al. 2010); however, two canals in
the mesial root and one canal in the distal root comprised
the most commonly reported anatomical configuration in
primary mandibular molars (Cleghorn et al. 2012). In the
present study, this configuration was observed in 50 and
40 % of the first and second mandibular molars, respec-
tively. The lowest length of the distal roots was not
reflected in the volume and surface area of the canal, which
showed higher values than the mesial canal. An
mesio-buccal root and one in the disto-buccal and palatal roots. The
presence of a bevelled resorption in the apex of the roots resulted in a
thinner thickness of the dentine walls and exposure of the root canal
(arrows in d)
explanation can be found in the analysis of the 2D
parameters, which showed the highest mean values of area,
major and minor diameters in the distal canals of both
molar types. Goodacre (2003) calculated the mean
dimensions of primary teeth based on several studies and
found that the mean lengths of the mesial and distal roots of
the first and second molars were 10.5 and 8.9 mm, and 11.4
and 10.5 mm, which were higher than the present results.
Primary maxillary molars have been described as having
three divergent and separated roots that flare to accom-
modate the developing permanent premolars (Hibbard and
Ireland 1957; Goodacre 2003; Zoremchhingi et al. 2005;
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 Eur Arch Paediatr Dent

Fig. 3 Exemplary cross

sections of the M mesial,
D distal, MB mesio-buccal, DB
disto-buccal, and P palatal roots
of the mandibular (a) and
maxillary (b) primary molars,
showing the complexity and the
large dimensions of the root
canal system in the apical third

Table 4 Percentage frequency of root canal shape in each root of the primary maxillary and mandibular molars
n Root canal Round Oval Flat-oval Ribbon Irregular

Mandibular
First molar 10 M 30 – 10 50 10
D 30 10 10 40 10
Second molar 10 M 30 – – 60 10
D 40 – 20 40 –
Maxillary
First molar 10 MB 10 10 20 50 10
DB – 50 50 – –
P 20 80 – – –
Second molar 10 MB 20 10 20 40 10
DB – 40 60 – –
P 30 70 – – –
M mesial; D distal; MB mesio-buccal; DB disto-buccal; P palatal

Bagherian et al. 2010). Overall, it may be inferred that the
external and internal anatomy of the primary maxillary first
molar roots closely resembles the primary maxillary sec-
ond molar roots (Hibbard and Ireland 1957; Goodacre
2003; Cleghorn et al. 2012). Despite the fact that ana-
tomical anomalies have been also reported in this group of
teeth, such as additional roots and taurodontism (Caceda
et al. 1994; Kavanagh and O’Sullivan 1998; Johnston and
Franklin 2006), they were not observed in this sample. The
incidence of fusion between palatal and DB roots was
observed in 40 % of the teeth, while in the literature it was
reported as being 77.7 % (Bagherian et al. 2010), 53.5 %
(Zoremchhingi et al. 2005), and 29 % (Hibbard and Ireland
1957) of the sample. Some variations in the number and
shape of canal systems have also been described in the
primary maxillary molars (Hibbard and Ireland 1957;
Goodacre 2003; Zoremchhingi et al. 2005; Bagherian et al.
2010; Cleghorn et al. 2012). Most studies have found only
one root canal in each root of both molar types (Hibbard
and Ireland 1957; Zoremchhingi et al. 2005; Aminabadi
et al. 2008; Bagherian et al. 2010). However, the incidence
of a double canal system in the MB root was reported in

123
Eur Arch Paediatr Dent
6.7 % (Zoremchhingi et al. 2005), 7.4 % (Bagherian et al.
2010), and 35 % (Hibbard and Ireland 1957) of the sample
and, in the DB root, in 3.7 % of the specimens (Bagherian
et al. 2010). In the present study, a double canal system
was observed only in the MB root of two maxillary first
molars. A previous study has found that the mean lengths
of the MB, DB and palatal roots of the primary maxillary
first molar were 8.8, 8.2 and 7.8 mm, respectively, and in
the maxillary second molars 10.8, 9.7 and 10.8 mm,
respectively (Goodacre 2003), which were higher than the
present results. The lowest dimension of the palatal root in
the maxillary first molar (5.96 mm) reflected the volume
and surface area of the canal, which were significantly
lower than the palatal canal of the second molar. The
surface area of the DB canal in the second molar showed
significantly higher values than in the first molar, despite
the similar mean length between them. An explanation can
be found in the analysis of the 2D parameters, which
showed higher values of area, major and minor diameters
in the DB canal of the second molar.
The SMI describes the plate- or cylinder-like geometry
of an object. If a perfect plate is enlarged, the surface area
does not change, yielding an SMI of zero. However, if a
rod is expanded, the surface area increases with the volume
and the SMI is normed, so that perfect rods are assigned an
SMI score of 3 (Peters et al. 2000). In the mandibular
molars, the mean SMI values varied from 1.69 to 2.06
indicating that the root canal system of the mesial and
distal canals, in both molars, had flat cone-shaped geom-
etry. In the maxillary molars, the mean SMI values of the
canals in most of the specimens were higher than 2.08
indicating a conical shape geometry. The cross-sectional
appearance of the root canal in the apical third was eval-
uated using the so-called morphometric parameter of
roundness. In mandibular molars, mean roundness ranged
from 0.31 to 0.49, which means that the root canal was
more flat shaped. In the maxillary molars, the lowest range
of values observed in the MB root of the second molar
(0.26–0.33) indicated a ribbon-shaped canal and reflected
its SMI data (1.81 ± 0.61). On the other hand, DB and P
root canals, as well as MB canal of the first molar, were
more oval shaped considering that the roundness ranged
from 0.38 to 0.63.
The wide range of variations reported in the literature
regarding the anatomy of the root canal system of primary
molars, in comparison to the present results, has been
mostly related to the diversity in sample origin, racial
factors, the relatively small number of teeth in each group,
the presence of initial apical root resorption in some
specimens and, of course, to the methodological approach
(Cleghorn et al. 2012). On the other hand, the micro-CT
experimental model presented here overcomes several
limitations displayed by the aforementioned conventional
methods, as it provides useful 2D and 3D information
related to the root canal space without changing the ori-
ginal sample. Unfortunately, these morphometric analyses
cannot be compared to others because of the lack of similar
reports in the literature to date.
Effective root canal debridement relies on accurate
determination of the working length and adequate apical
canal enlargement, which allow for better irrigation in the
apical area, optimising root canal disinfection (Fornari
et al. 2010). In the present study, major and minor diam-
eters of the root canals in the apical third indicated that the
debridement at this level could be improved with instru-
ments up to an ISO size 100. However, considering the
shape of the root canals, the reduced thickness of the
dentine walls, and the difficulty in predicting the location
of the canal terminus accurately in primary teeth (Beltrame
et al. 2011), using instruments of this size would definitely
lead to stripping or perforations of the roots. Clinically, 2D
data results have definite implications for shaping and
cleaning procedures, because only the minor diameter is
evident on radiographs. Thus, clinicians must be aware of
the anatomical configuration of the canals which, combined
with the presence of thin isthmuses in the apical region,
would compromise adequate cleaning and shaping, leaving
untouched fins on the buccal and/or lingual aspects of the
canal.
The introduction of nickel–titanium rotary file systems
has resulted in a marked progress in the mechanical prep-
aration of the root canal space (Hülsmann et al. 2005).
However, shaping root canals with these systems has failed
in debriding flat- and oval-shaped canals, leaving untou-
ched fins or recesses on the buccal and/or lingual exten-
sions (Versiani et al. 2011, 2013). Besides, large tapered
rotary files should be avoided in primary mandibular
molars considering their internal anatomical configuration.
Recently, Self-Adjusting File (SAF; ReDent-Nova, Ra’a-
nana, Israel) cleaning–shaping–irrigation system was
introduced. This innovative instrument consists of a hollow
and lightly abrasive nickel–titanium file composed of a
metal lattice, which adapts itself to round, oval, or even
long-oval cross sections of root canals. During its opera-
tion, which lasts 4 min, SAF removes dentine with a back-
and-forth grinding motion by scrubbing the canal walls
with a continuous irrigation provided by a peristaltic pump,
i.e. it simultaneously performs the mechanical and chem-
ical preparation of the root canal space (Metzger et al.
2010). Previous reports have shown that the SAF system
was advantageous in promoting cleaning, shaping, and
disinfection of oval-shaped canals in permanent teeth
compared to rotary files (Siqueira et al. 2010; Versiani
et al. 2011, 2013; Ribeiro et al. 2013), and may be an
alternative for shaping procedures in primary molar teeth to
be evaluated in further studies.
123

Conclusion
Under the limitations of this ex vivo study, it was possible
to conclude that external and internal anatomy of the pri-
mary first molars closely resembles the primary second
molars. Considering the morphology of the canals in the
apical third, a careful selection of instruments including the
use of additional disinfection supplements such as passive
ultrasonic irrigation or negative apical pressure is advis-
able. The reported data may help clinicians to obtain a
thorough understanding of the variations in root canal
morphology of primary molars to overcome problems
related to shaping and cleaning procedures.
Conflict of interest The authors declare that they have no conflict
of interest.
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