Clinical Research

Cone-beam Computed Tomography Analysis of the Root

Canal Morphology of Maxillary First and Second Premolars
in a Spanish Population
o, DDS, MSc,* Shanon Patel, BDS, MSc,†
Francesc Abella, DDS, PhD,* Lu
ıs Miguel Teixid

Francisco Sosa, DDS, MSc,* Fernando Duran-Sindreu, DDS, PhD,* and Miguel Roig, DDS, PhD*

Abstract
Introduction: We investigated the root canal configu-
ration of maxillary premolars in a Spanish population
by using cone-beam computed tomography. Methods:
T he root canal system is complex, individual to each tooth, and can harbor a rich mi-
Images of 804 maxillary first and second premolars were
obtained from 620 patients who underwent cone-beam
computed tomography scanning during preoperative
assessment (before implant surgery, orthodontic treat-
ment, dentoalveolar trauma diagnosis, or difficult root
canal treatment). We determined tooth position, num-
ber of roots, root canal configuration (Vertucci’s classifi-
cation), number of root canals, and number of apical
foramina per root and used the c2 test to analyze the
correlation between root number and tooth position.
Results: In the maxillary first premolar group (n =
430), 46% (n = 198) had 1 root, 51.4% (n = 221)
had 2 roots, and 2.6% (n = 11) had 3 roots. Most ex-
hibited a type IV canal configuration (n = 227,
52.8%). Single-rooted teeth had a more variable canal
configuration, whereas most 2-rooted teeth showed a
type IV configuration (n = 215, 97.3%). In the maxillary
second premolar group (n = 374), 82.9% (n = 310) had
1 root, 15.5% (n = 58) had 2 roots, and 1.6% (n = 6)
had 3 roots. The majority of single-rooted second pre-
molars exhibited a type I configuration (n = 147,
47.2%). Overall, type VIII canals were only observed
in 3-rooted teeth. No statistical correlation was evident
between root number and gender and tooth position.
Conclusions: There was a high frequency of 2-rooted
and single-rooted teeth among maxillary first and sec-
ond premolars, respectively. The canal morphology of
single-rooted teeth was highly variable. (J Endod
2015;-:1–7)
crobial flora (1–3). A lack of knowledge of root canal anatomy and/or technical skill
may result in a failure to identify all root canals and/or inadequate instrumentation,
which can lead to endodontic treatment failure (4, 5). Therefore, a thorough
understanding of root canal anatomy and the use of diagnostic imaging are essential
before embarking on endodontic treatment (6).
Several studies (7–19) have reported that maxillary premolars have a highly
variable internal canal configuration, which can vary according to race and
geographic origin (8, 9, 12). The reported prevalence of maxillary first premolars
with 1 root ranges from 22% to 66%, with 2 roots from 33% to 84%, and with 3
roots from 0% to 6% (7, 8, 11, 12, 16, 17, 20). Maxillary second premolars usually
have 1 root, with either 1 or 2 root canals (10, 12, 20, 21). Significant anatomic
variation has also been observed among maxillary second premolars (22–24).
Hence, variability in root number and canal configuration in these teeth poses a
challenge to the clinician during root canal treatment.
Although intraoral periapical radiography is conventionally used to examine root
canal morphology in vivo (25), superimposition of structures and image distortion are
drawbacks to the use of this technique (26). Changing the horizontal angle of the x-ray
tube can sometimes highlight the complexities of the canal system in maxillary premo-
lars (27), but this is not always possible (for example, in patients with a shallow palatal
vault). Cone-beam computed tomography (CBCT) imaging allows a 3-dimensional
evaluation of teeth and their adjacent structures (26). CBCT has been successfully
used to identify second mesiobuccal canals in maxillary molars (28) and distolingual
root canals in mandibular first molars (29–31). Neelakantan et al (32) reported that
CBCT can detect the root canal system as accurately as the staining and clearing tech-
niques used to study extracted teeth and more accurately than intraoral periapical radi-
ography. Several other studies (33–35) have also concluded that CBCT is more accurate
in determining the root canal anatomy of teeth than intraoral periapical radiography.
To date, there has been no detailed examination of the roots and canal systems of
maxillary first and second premolars in a Spanish population. In this study, we evaluated
the root canal morphology of maxillary first and second premolars in this population by
using CBCT.

Key Words Materials and Methods

Cone-beam computed tomography, maxillary premo- Sample Selection
lars, root morphology, Spanish population
Images of maxillary premolars were obtained between June 2013 and July 2014
from patients referred to Universitat Internacional de Catalunya (St Cugat del Vall
es,

From the *Department of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Sant Cugat del Valles, Barcelona, Spain; and †Conservative
Dentistry, King’s College London Dental Institute, London, United Kingdom.
Address requests for reprints to Dr Miguel Roig, Dentistry Faculty, Universitat Internacional de Catalunya, C/Josep Trueta s/n, 08195 Sant Cugat del Valles, Barcelona,
Spain. E-mail address: montserratmercade@gmail.com
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.03.026

JOE — Volume -, Number -, - 2015 Maxillary First, Second Premolars in Spanish Population 1
Clinical Research
Figure 1. Diagrammatic representation of Vertucci’s canal configuration.
Barcelona, Spain) who required CBCT scans as part of the treatment-
planning process. The indications for CBCT scanning included the
assessment of bone volume for dental implant planning, diagnosis of
dentoalveolar trauma, management of impacted teeth before orthodon-
tic treatment, and treatment planning before nonsurgical and surgical
endodontic treatment. The Institutional Ethics in Research Committee
(Universitat Internacional de Catalunya) approved the design of this
study, and all patients gave written informed consent to participate.
In accordance with data protection of minors, the Institutional Ethics
in Research Committee does not allow the use of CBCT data from per-
sons younger than 18. A total of 804 CBCT images of maxillary premo-
lars (430 first and 374 second premolars) from 620 patients (416 from
362 men and 388 from 258 women) were selected for this investigation,
according to the following criteria:
1. Availability of scans of the maxillary first and/or second premolars
2. Complete root formation
3. Absence of root resorption, calcification, or periapical lesions
4. Absence of root canal fillings, posts, or crown restorations
5. Availability of a clear and complete view of the relevant teeth
Image Acquisition
CBCT images were obtained by using a ProMax 3Ds (Planmeca OY,
Helsingfors, Finland). The operating parameters were 8 mA and 84 kV,
with an exposure time of 12 seconds. The smallest possible field of view
was used (5  8 cm), and the voxel size was 0.075 mm. All CBCT ex-
posures were performed with the minimum exposure necessary for
adequate image quality. The as low as reasonably achievable protocol
was strictly followed. Data were reconstructed with slices at 0.2-mm in-
tervals, positioned parallel to the horizontal axis of the alveolar process,
and the teeth under examination were placed in the center of the vol-
ume.
Image Evaluation
Images were assessed by 2 calibrated endodontists who were
trained by using example CBCT images. Before analyzing the experi-
mental material, the 2 examiners were asked to grade 50 sample
CBCT images. During the experiment, the examiners assessed the
CBCT images independently and then compared readings. They were
able to scroll through the axial, coronal, and sagittal views of each tooth.
TABLE 1. Prevalence of Roots (% of teeth) According to Gender
Tooth position One root (%) Two roots (%)
Maxillary first premolars
Male 93 (43.9)
Female 105 (48.2)
Total 198 (46.0)
Maxillary second premolars
Male 170 (83.3)
Female 140 (82.4)
Total 310 (82.9)
2 Abella et al.
In the event of disagreement, the case was discussed until a consensus
was reached. A second session for the analysis of intraexaminer reli-
ability took place 4 weeks after the first assessment.
The following information was recorded and analyzed:
1. Tooth position relative to the left or right side
2. Root number and canal configuration, classified by using Vertucci’s
criteria (36) (Fig. 1)
3. The number of apical foramina per root
The number of roots detected in the axial plane of the CBCT images
was classified in accordance with P
ecora et al (9):
1. Single-rooted teeth: Teeth with a clear single root and teeth with 2
independent canals that seemed to have 2 roots, which were
actually fused
2. Multi-rooted teeth: 2-rooted teeth possessing bifurcated roots,
regardless of whether they were partial or complete, and 3-
rooted teeth, with 3 completely independent roots from the chamber
floor, or bifurcations at any position along the buccal or palatal
roots
Differences in tooth position (right or left) were determined by us-
ing the c2 test and were considered significant if the P value was <.05.
Intraexaminer and interexaminer agreements were calculated by using
the Cohen kappa coefficient.
Results
Table 1 shows the number of roots of maxillary first and second
premolars according to gender. Of the maxillary first premolars, the
majority (52.3%, n = 113) of the 212 teeth from male patients had
2 roots, and the remaining had 1 (43.9%, n = 93) or 3 roots (2.8%,
n = 6). The majority (50.5%, n = 108) of the 218 teeth from female
patients also had 2 roots, and the remaining presented 1 (48.2%, n
= 105) or 3 roots (2.3%, n = 5). Of the maxillary second premolars,
most (83.3%, n = 170) of the 204 teeth from male patients had 1 root,
and the remaining had 2 (15.2%, n = 31) or 3 roots (1.5%, n = 3).
Most (82.4%, n = 140) of the 170 teeth from female patients also
had 1 root, and the remaining presented 2 (15.8%, n = 27) or 3 roots
(1.8%, n = 3). No significant differences were observed between the
number of roots in both maxillary first and second premolars and
gender (P > .05).
Three roots (%) Total
113 (52.3) 6 (2.8) 212
108 (50.5) 5 (2.3) 218
221 (51.4) 11 (2.6) 430
31 (15.2) 3 (1.5) 204
27 (15.8) 3 (1.8) 170
58 (15.5) 6 (1.6) 374
JOE — Volume -, Number -, - 2015
 Clinical Research
TABLE 2. Frequency Distribution of Number of Roots According to Tooth Position
Tooth position One root (%) Two roots (%) Three roots (%) Total
Maxillary first premolars
Right 95 (47.9) 98 (49.5) 5 (2.5) 198
Left 103 (44.4) 123 (53.0) 6 (2.6) 232
Total 198 (46.0) 221 (51.4) 11 (2.6) 430
Maxillary second premolars
Right 147 (79.9) 33 (17.9) 4 (2.2) 184
Left 163 (85.8) 25 (13.2) 2 (1.1) 190
Total 310 (82.9) 58 (15.5) 6 (1.6) 374

Table 2 shows the frequency distribution of the number of roots
according to tooth position. Of 430 maxillary first premolars, 198
(46%) had 1 root, 221 (51.4%) had 2 roots, and 11 (2.6%) had
3 roots. Of the 2-rooted maxillary first premolars, 43% (n = 95)
bifurcated from the pulp chamber floor, forming 2 independent
roots, whereas the remaining 57% (n = 126) bifurcated at different
levels in the apical third. No correlation was found between root
number and tooth position in the maxillary first premolars (P =
.75). Of 374 maxillary second premolars, 310 (82.9%) had 1
root, 58 (15.5%) had 2 roots, and 6 (1.6%) had 3 roots. Of the
2-rooted second maxillary premolars, 36.2% (n = 21) bifurcated
from the pulp chamber floor, forming 2 independent roots, whereas
the remaining 63.8% (n = 37) had fused roots. No correlation was
found between root number and tooth position in the maxillary sec-
ond premolars (P = .28).
Table 3 shows the prevalence of different root canal types. The
most prevalent root canal type among maxillary first premolars was
type IV (n = 227, 52.8%), followed by type I (n = 108, 25.1%) and
type II (n = 44, 10.2%). Types III, V, VI, VII, and VIII were also found,
but more rarely. Single-rooted first premolars had a more variable ca-
nal configuration; 54.5% (n = 108) had a type I configuration, the fre-
quencies of types II (n = 44, 22.2%) and III (n = 19, 9.6%) were
lower, and types IV, V, VI, and VII together accounted for 13.6%.
Most 2-rooted first premolars exhibited a type IV canal configuration
(n = 215, 97.3%). Type VIII canals were only observed in 3-rooted
teeth. Type I (n = 147, 39.3%) was the most prevalent root canal
type in maxillary second premolars, followed by type II (n = 84,
22.5%) and type IV (n = 74, 19.8%). Types III (n = 27, 7.2%), V
n = 16, 4.3%), VI (n = 12, 3.2%), VII (n = 8, 2.1%), and VIII
(n = 6, 1.6%) occurred less often. The majority of single-rooted second
premolars had a type I canal configuration (n = 147, 47.4%), followed
by type II (n = 84, 27.1%) and type III (n = 27, 8.7%). Types IV, V, VI,
and VII together accounted for 16.8%. Type IV (n = 49, 84.5%) was the
predominant canal configuration among 2-rooted second premolars,
whereas a type VIII configuration was only found in 6 second premolars
(1.6%). Figures 2 and 3 show a selection of root canal types detected in
axial sections.
Maxillary first premolars with 1, 2, or 3 apical foramina accounted
for 39.8% (n = 171), 57.7% (n = 248), and 2.6% (n = 11), respec-
tively. Of the single-rooted maxillary first premolars, 86.4% (n = 171)
had 1 foramen per root, and 13.6% (n = 27) had 2, whereas all
2-rooted and 3-rooted teeth had only 1 foramen per root. Maxillary
second premolars with 1, 2, or 3 apical foramina accounted for 69%
(n = 258), 29.4% (n = 110), and 1.6% (n = 6), respectively. Of
the single-rooted maxillary second premolars, 83.2% (n = 258) had
1 foramen per root, and 16.7% (n = 52) had 2 foramina per root.
As observed for the maxillary first premolars, all 2-rooted and
3-rooted second premolars had only 1 foramen per root.
Regarding interexaminer agreement, the Cohen kappa values after
the training session were 0.993 and 0.995 for the first and second
assessments, respectively. The overall Cohen kappa value for intraexa-
miner agreement was 0.998. In summary, there was a very good
intraexaminer and interexaminer agreement.
Discussion
A sound knowledge of root canal morphology and its anatomic
variations is indispensable for successful root canal treatment. To
our knowledge, this is the first study to use CBCT in vivo to assess
the root and canal morphology of maxillary premolars in a Spanish
population.
In maxillary first premolars, the frequency of 1-rooted teeth (n =
198, 46%) was lower than that reported in Brazilian, Singaporean, and
different Chinese subpopulations (9, 11, 17, 37). These frequencies
were similar to those reported in some studies (25, 38, 39) but
much higher than findings reported elsewhere (7, 8, 12–16, 40)
(Table 4). These differences in root canal anatomy highlight the
influence of ethnic background on the root morphology of maxillary
premolars.
The frequencies of 2-rooted (n = 221, 51.4%) and 3-rooted (n =
11, 2.6%) teeth were similar to those reported by Pineda and Kuttler
(25), P
ecora et al (9), and Neelakantan et al (16). Many case reports
have described maxillary first premolars with 3 roots (40, 41), termed
radiculous premolars and generally considered a Caucasian trait (42).

TABLE 3. Prevalence of Root Canal Types

Types of canal configuration*
No. of roots I (%) II (%) III (%) IV (%) V (%) VI (%) VII (%) VIII (%) Total
Maxillary first One 108 (54.5) 44 (22.2) 19 (9.6) 12 (6.1) 6 (3.0) 4 (2.0) 5 (2.5) — 198
premolars Two — — — 215 (97.3) 2 (0.9) 3 (1.4) 1 (0.5) — 221
Three — — — — — — — 11 (100) 11
Total 108 (25.1) 44 (10.2) 19 (4.4) 227 (52.8) 8 (1.9) 7 (1.6) 6 (1.4) 11 (2.6) 430
Maxillary second One 147 (47.4) 84 (27.1) 27 (8.7) 25 (8.1) 13 (4.2) 8 (2.6) 6 (1.9) — 310
premolars Two 49 (84.5) 3 (5.2) 4 (6.9) 2 (3.4) — 58
Three — — — — — — — 6 (100) 6
Total 147 (39.3) 84 (22.5) 27 (7.2) 74 (19.8) 16 (4.3) 12 (3.2) 8 (2.1) 6 (1.6) 374
*Vertucci’s classification of canal system.

JOE — Volume -, Number -, - 2015 Maxillary First, Second Premolars in Spanish Population 3
Clinical Research

Figure 2. CBCT in the axial plane revealed the different root forms of the maxillary first premolars (arrows indicate the examined teeth): (a and b) coronal; (c)
middle; and (d) apical thirds.

In other studies of the root canal morphology of maxillary second pre- (n = 310, 82.9%) had 1 root, whereas 15.5% had 2 roots, and 1.6%
molars, the percentages of 1-, 2-, and 3-rooted teeth range from 69% to had 3 roots (Table 4). The discrepancy in the distribution of root forms
90%, 13% to 30%, and 0% to 1%, respectively (10, 12, 19). between previous reports and this study may be due to differences in
The majority of maxillary second premolars examined in this study populations, evaluation techniques, and/or sample size.

4 Abella et al. JOE — Volume -, Number -, - 2015

 Clinical Research

Figure 3. CBCT scanning in the axial plane of the (a and b) coronal, (c) middle, and (d) apical thirds of the root demonstrated variations in canal morphology.
Arrows indicate canal morphology of maxillary second premolars.

The proportion of maxillary first premolars with different mon, followed by 1-root and then 3-root canals (Table 3). Among
numbers of root canals was consistent with the findings of previous single-rooted teeth, 39.4% (n = 78) had a complex root canal sys-
studies that used the clearing technique (12, 36), the radiologic tem with bifurcation and/or combination (types II, III, V, VI,
technique (37), or plastic casts (7); 2-root canals were most com- and VII). In contrast, most 2-rooted (n = 215, 97.3%) and all

JOE — Volume -, Number -, - 2015 Maxillary First, Second Premolars in Spanish Population 5
Clinical Research
TABLE 4. Comparison of Root Forms in Maxillary First and Second Premolars in Previous Studies and Those in This Study
Population One Two Three
Author (year) (sample size) root (%) roots (%) roots (%)
Maxillary first Ingle (1965) Not available 43.0 55.0 2.0
premolar Pineda and Kuttler (1972) USA (n = 259) 43.0 54.6 2.4
Carms and Skidmore (1973) USA (n = 100) 22.0 72.0 6.0
Vertucci and Gegayouff (1979) Not available (n = 400)
Walker (1987) Chinese (n = 100) 60.0 40.0 —
Pe
cora et al (1991) Brazilian (n = 240) 55.8 41.7 2.5
Loh (1998) Singaporean (n = 957) 49.4 50.6 —
Kartal et al (1998) Turkish (n = 300) 37.3 61.3 1.3
Chaparro et al (1999) Spanish (n = 150) 40.0 56.7 3.3
Lipski et al (2003) Polish (n = 142) 15.5 75.4 9.2
Atieh (2008) Saudi (n = 246) 17.9 80.9 1.2
Awawdeh (2008) Jordanian (n = 600) 30.8 68.4 0.8
Neelakantan (2011) Indian (n = 350) 11.7 86 2.3
€
Ozcan et al (2012) Turkish (n = 653) 45.2 55.7 1.1
Tian et al (2012) Chinese (n = 300) 66.0 33.0 1.0
Present study Spanish (n = 430) 46.0 51.4 2.6
Maxillary second Pe
cora et al (1992) Brazilian (n = 435) 90.3 9.7 —
premolar Kartal et al (1998) Turkish (n = 300) 69.6 29.7 0.7
Yang et al (2014) Chinese (n = 392) 86.5 13.5 —
Present study Spanish (n = 374) 82.9 15.5 1.6

3-rooted teeth had 1 simple and independent canal in each root.
However, it is important to note that 57% (n = 126) of 2-rooted
teeth bifurcated at different levels in the apical third of the root;
hence, clinicians may believe there is only 1 root canal when using
a microscope, when in fact the roots are divided apically. Concerning
the internal root canal configuration of maxillary second premolars,
39.3% (n = 147) of the teeth studied had 1 root canal (type I),
whereas 19.8% had 2 separate root canals (type IV). These 2 canal
types are relatively easy to identify and treat. Conversely, teeth with a
complex root canal system (types II, III, V, VI, VII, and VIII) are
difficult to identify and treat with cleaning, shaping, and obturation.
In this study, 6 maxillary second premolars displayed 3 canals with a
complex internal anatomy. Awareness of the existence of this type of
root canal system is critical to successful root canal treatment.
Morfis et al (43) used scanning electron microscopy to demon-
strate that maxillary premolars exhibit a high frequency of multiple
apical foramina. As reported by Gutierrez and Aguayo (44) and
Tian et al (17), the number of foramina per root tended to be
more variable and multiple in single-rooted maxillary first premolar
teeth compared with 2-rooted teeth. Our study showed that 13.6%
(n = 27) of single-rooted maxillary first premolars had multiple
foramina, whereas 2-rooted and 3-rooted teeth had, on average, 1
apical foramen per root. These findings are similar to those of maxil-
lary second premolars, among which 83.23% (n = 258) of single-
rooted teeth had 1 foramen per root, and 16.77% (n = 52) had 2.
To ensure the integrity of the original morphology of the root canals,
teeth with filling materials with the potential to create artifacts and
teeth with resorptions and/or periapical lesions that can destroy
the root apices were excluded from this study (45).
Micro–computed tomography scanning (46) and the staining and
clearing technique (12, 21, 36) provide precise information on root
canal systems, but they can only be used on extracted teeth. CBCT
imaging is a noninvasive technique that is reportedly as accurate as
the modified canal staining and clearing technique for evaluating root
canal systems (32). Unlike conventional radiography, CBCT scanning
provides 3-dimensional images in axial, sagittal, and coronal sec-
tions, avoiding geometric distortion and anatomic superimposition at
a relatively low radiation dose when using a CBCT scanner with a small
field of view and appropriate exposure parameters (6). Previous inves-
tigations (17–19) on the root canal anatomy of maxillary premolars by
using CBCT scanning have yielded varied results. This may be explained
in part by differences in CBCT resolution, radiographic interpretation,
and sample size.
Several studies (17–19, 29, 31, 45, 47) have demonstrated the
quality of CBCT imaging and its clinical applications in the study of
root canal morphology before clinical endodontic treatment. When
abnormal findings are evident on traditional periapical films and/or
variations are detected with magnification in the clinical setting, it may
be impossible to evaluate the root canal system effectively (30, 31). In
these situations, it is sensible to use CBCT for further diagnosis.
Conclusions
Most maxillary first premolars in a Spanish population were 2-
rooted with 2 root canals, whereas maxillary second premolars tended
to be single-rooted with 1 root canal. In vivo CBCT analysis is a nonin-
vasive and clinically effective tool for examining root and canal
morphology that may ultimately improve the outcome of endodontic
treatment.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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