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doi:10.1111/iej.12380

Micro-CT evaluation of C-shaped mandibular first

premolars in a Brazilian subpopulation

R. Ordinola-Zapata1, C. Monteiro Bramante1, P. Gagliardi Minotti1, B. Cavalini Cavenago1,

J. L. Gutmann2, B. I. Moldauer3, M. A. Versiani4 & M. A. Hungaro Duarte1
1
ao Paulo, Bauru, Brazil; 2Department of Endodontics, Baylor
Department of Endodontics, Bauru Dental School, University of S~
College of Dentistry, Texas A&M University System Health Science Center, Dallas, TX; 3Advanced Education in General
Dentistry Program, Larkin Community Hospital, Miami, FL, USA; and 4Department of Endodontics, Ribeir~ ao Preto Dental
School, University of S~
ao Paulo, Ribeir~
ao Preto, Brazil

Abstract Results The more prevalent anatomical types

Ordinola-Zapata R, Monteiro Bramante C, Gagliardi
Minotti P, Cavalini Cavenago B, Gutmann JL,
Moldauer BI, Versiani MA, Hungaro Duarte MA.
Micro-CT Evaluation of C-Shaped mandibular first premolars
in a Brazilian subpopulation. International
Journal, 48, 807–813, 2015.
Aim To describe morphometric aspects of the inter-
nal anatomy of C-shaped mandibular premolars from
a Brazilian subpopulation using micro-CT analysis.
Methodology First mandibular premolars with
radicular grooves (n = 123) were scanned using a
micro-computed tomography system. After cross-
section analysis, 83 specimens were identified with a
C-shaped canal and selected for micro-CT analysis.
Number and location of canals according to Vertucci’s
classification, distances between anatomic landmarks,
occurrence of apical deltas, furcation canals, preva-
lence of C-shaped cross-sections at five levels as well
as 2-dimensional analysis (Area, perimeter, round-
ness, aspect ratio, major and minor diameters) were
performed for the more prevalent anatomical features.
Data were compared statistically using Kruskal–Wallis
tests (a = 0.05).
according to Vertucci’s classification were Type I
(13%), III (8%), V (37%) and VII (2%). Mean distances
from the furcation to the cemento-enamel junction
were in the range of 5.36–5.65 mm. Apical deltas and
furcation canals were present in 36 (43%) and 27
Endodontic
(33%) specimens, respectively. C-shaped cross-sections
were more prevalent at the middle (56%) and apical
middle levels (81%). Overall, significant differences
were found in the 2-dimensional analyses between sin-
gle canals at the apical third and buccal and lingual
canals of Vertucci’s V classification (P < 0.05).
Conclusions In this Brazilian subpopulation, C-
shaped canal configuration of the root canal system
was found in 67% of extracted first mandibular pre-
molars with radicular grooves. Vertucci’s types I and
V were the most prevalent anatomical variations. C-
shaped cross-sections were more prevalent in the mid-
dle third, and the presence of apical deltas was the
most common feature in the apical third.
Keywords: C-shaped canal system, dental anat-
omy, mandibular premolars, micro-computed tomog-
raphy.
Received 30 June 2014; accepted 17 September 2014

et al. 2007, Fan et al. 2008). This tooth is typically

Introduction
A wide morphological variation exists in the root
canal system of mandibular first premolars (Cleghorn
Correspondence: Ronald Ordinola-Zapata, Faculdade de
Odontologia de Bauru – USP, Al. Octavio Pinheiro Brisolla,
9-75, CEP 17012-901, Bauru - S~ ao Paulo, Brazil (e-mail:
ronaldordinola@usp.br).
described as single-rooted with a root canal wider
in the buccolingually plane in comparison with
mesiodistally (Wu et al. 2000); however, two- (Trope
et al. 1986), three- (Cleghorn et al. 2008), four-
(Farmakis 2008) and five root canals (Macri & Zmen-
er 2000) have also been reported in these teeth.
The C-shaped canal configuration was first reported
by Cooke & Cox (1979). Whilst most C-shaped canals

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 807–813, 2015 807

C-shaped anatomy in mandibular first premolars Ordinola-Zapata et al.
occur in the mandibular second molar, they have also
been reported in the maxillary first and second molars
and in the mandibular first premolar (Baisden et al.
1992, Jafarzadeh & Wu 2007, Gu et al. 2013). The
main anatomic feature of the C-shaped canal system
is the presence of isthmuses connecting individual
canals, which would change the cross-sectional and
three-dimensional canal shape along the root (Fan
et al. 2008). Grooves in the proximal aspects of the
root are often associated with the presence of C-
shaped canals in mandibular premolars (Lu et al.
2006), but their prevalence varies amongst different
ethnic groups (Lu et al. 2006, Jafarzadeh & Wu
2007, Velmurugan & Sandhya 2009, Park et al.
2013). A detailed description of this anatomical varia-
tion in South American population is lacking. The
purpose of this study was to describe several morpho-
metric aspects of the internal anatomy of C-shaped
mandibular premolars from a Brazilian subpopulation,
using micro-CT analysis.
Material and methods
One hundred and twenty-three human mandibular
first premolars with radicular grooves and closed api-
ces, extracted for reasons not related to this study
were obtained from a pool of extracted teeth (Protocol
number 131-2010). The patient’s gender and age
were unknown. The samples were mounted on a cus-
tom attachment and scanned in a micro-CT system
(SkyScan 1174; Bruker-microCT, Kontich, Belgium)
using 50 kV, 800 mA and an isotropic resolution of
19.6 lm. Scanning was performed by 360° rotation
around the vertical axis with a rotation step of 0.8°,
camera exposure time of 5000 ms. X-rays were fil-
tered with a 0.5-mm aluminium filter. Images were
reconstructed with NRecon 1.6.3 software (Bruker-
microCT) using 20% beam hardening correction and
ring artefact correction of 1, resulting in the acquisi-
tion of transverse cross-sections in a bitmap (BMP)
format.
Three-dimensional models were reconstructed from
the source images by using automatic segmentation
and surface modelling with CTAn v.1.12 software (Bru-
ker-microCT). Dataviewer software (Bruker-microCT)
was used for visualization and qualitative evaluation of
the specimens regarding the presence of C-shaped con-
figuration of the root canal according to Fan et al.
(2008). Briefly, five levels were selected to determine the
morphology of the root canal according to the following
definitions (Fig. 1): (i) cemento-enamel junction plane
808 International Endodontic Journal, 48, 807–813, 2015
13652591, 2015, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.12380 by University Peruana Cayetano Heredia, Wiley Online Library on [04/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Figure 1 Levels for observation and classification of root
canal configuration: cemento-enamel junction (CEJ), apical
plane (AP), middle plane (M) and two equidistant planes,
one between the apical and the middle plane (AP-M) and
the another one between the middle and CEJ plane (CEJ-M).
(CEJ): the cross-sectional plane with enamel occupying
one half of the perimeter; (ii) apical plane: the plane
crossing the last 1 apical mm which is parallel to the
CEJ plane; and (iii) the middle plane of the root parallel
to the CEJ plane (4 and 5) two equidistant planes, one
between the apical and the middle plane and the
another one between the middle and CEJ plane. The
cross-sections were classified according to Fan et al.
(2008) as: continuous C-shaped canal (C1); incomplete
C-shaped canals, the canal shape is resembled a semico-
lon due to a discontinuation in the ‘C’ outline (C2); two
separate round, oval or flat canals (C3); only one canal
(C4) that was subdivided in round (C4a), oval (C4b) or
flat canal (C4c). The presence of three or more separate
canals was classified as (C5). The absence of root canal
was classified as (C6) (Fig. 2).
DataViewer v.1.4.4 and CTVol softwares (Bruker-
microCT) were used to evaluate the configuration of
root canals according to Vertucci’s classification
(Vertucci 2005), the presence of apical deltas and fur-
cation canals as well as the distances between several
anatomical landmarks such as the distance from the
cemento-enamel junction (CEJ) to the apex and to the
division level of the root canal. CTAn v.1.12 software
(Bruker-microCT) was used for the two-dimensional
analysis of the root canal up to 3 mm from the apical
foramen (area, perimeter, roundness, major diameter,
minor diameter and aspect ratio); definitions of these
parameters were taken from ASTM standard F1877-
05 (2010). Area and perimeter were calculated using
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Ordinola-Zapata et al. C-shaped anatomy in mandibular first premolars

Figure 2 Classification of root canal configuration of C-shaped mandibular first premolars.

the Pratt algorithm (Versiani et al. 2012). The cross-

sectional appearance, round or more ribbon-shaped,
was expressed as roundness. Roundness of a discreet
two-dimensional object was defined as 4.A/(p.(dmax)2),
where ‘A’ is the area and ‘dmax’ is the major diameter.
The value of roundness ranges from 0 to 1, with 1
meaning a perfect circle. The major diameter was
defined as the distance between the two most distant
pixels in that object. The minor diameter was defined
as longest chord through the object that can be
drawn in the direction orthogonal to that of the
major diameter. The aspect ratio represents the ratio
between the major and minor diameter. These param-
eters were measured only in roots with 1 (Vertucci I
and III types) or 2 root canals in the apical third
(Vertucci V type).
Statistical analysis
Because normality assumptions could not be verified
(Shapiro–Wilk test; P < 0.05), the results of two-
dimensional analyses were described in terms of
median and range. The data were statistically com-
pared using Kruskal–Wallis post hoc Dunn test (SPSS
v17.0; SPSS Inc., Chicago, IL, USA) with a signifi-
cance level set at 5%.
Results
Three-dimensional reconstruction of the root canal
system of the evaluated samples revealed the presence
of 83 C-shaped mandibular first premolars (67.47%).
All specimens had one root except for 3 that had 2
roots. The number and percentage of more prevalent
anatomical types according to Vertucci’s classification
were Type I (11/13%), III (7/8%), V (31/37%)
and VII (2/2%). Other anatomical classifications were
1-2-3 (7/8%), 1-2-3-2 (6/7%), 1-2-3-2-3 (2/2%) and
1-2-1-2-4 (1/1%). In 16 samples, the presence of sev-
eral ramifications and anatomical complexities did not
permit to be classified. Thirty-six specimens (43%)
had apical delta, and furcal canals were present in 27
samples (33%). In all cases, the C-shaped canal was
restricted to the buccal canal or observed as an isth-
mus that joined buccal and lingual canals (Fig. 3).
The distribution of the transverse sections of sam-
ples is shown in Table 1. Overall, C4c was the more
prevalent cross-sections at the cervical third (84%), C1
and C2 C-shaped cross-sections were more prevalent
in the middle (30 and 26%) and apical middle levels
(24 and 57%). The apical third had a high incidence
of complex anatomy usually observed as an apical
delta and C5 anatomy followed by the C3 anatomy.

(a) (b)

Figure 3 (a–b) Roots of mandibular first premolars showing the relationship between the radicular groove and root canal con-
figuration. At the coronal level (C), the presence of an oval single canal is evident. At the middle third (M), the presence of the
C1 anatomy* is observed in (a), the other 3-dimensional reconstruction shows the presence of a C2 anatomy** in (b). In both
cases, an apical delta is evident in the apical middle and apical cross-sections (AM-AP).

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 807–813, 2015 809
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C-shaped anatomy in mandibular first premolars Ordinola-Zapata et al.

Table 1 Classification of transverse cross-sections of C-shaped canals in mandibular first premolars at five different levels
expressed in number and percentages

1 mm from apex Apical-middle Middle Middle-CEJ CEJ

C1 7 (8.43) 20 (24.09) 25 (30.12) 2 (2.40) 0

C2 10 (12.04) 48 (57.83) 22 (26.50) 1 (1.20) 0
C3 19 (22.89) 10 (12.04) 17 (20.48) 1 (1.20) 0
C4a 0 1 (1.20) 4 (4.81) 5 (5.61) 6 (7.22)
C4b 2 (2.40) 0 7 (8.43) 35 (42.16) 7 (8.43)
C4c 5 (5.61) 2 (2.40) 8 (9.63) 39 (46.98) 70 (84.33)
C5 36 (43.37) 2 (2.40) 0 0 0
C6 4 (4.81) 0 0 0 0

CEJ: cemento-enamel junction. N = 83.

Representative reconstructions of the different root
canal systems are shown in Fig. 4.
The length of the roots measured from the apex to
the cemento-enamel junction (CEJ) is shown in
Table 2. All the samples had an abrupt modification
of the transverse root canal anatomy due to the pres-
ence of the radicular groove usually 5 mm below the
CEJ (Table 2). At this level, Vertucci type III and V
anatomy revealed a clear bifurcation, whereas type I
anatomy had a rapid change from the cervical C4
anatomy to the C1 anatomy which corresponds to
the coronal portion of the radicular groove. The medi-
ans of the distances between the CEJ and the division
of the root canal in the evaluated anatomical features
are shown in Table 2.
Two-dimensional analysis
Morphometric measurements were performed in 49
specimens with a single canal or two canals in the

(a) (b) (c) (d) (e) (f) (g) (h) (i) (j)

(k) (l) (m) (n) (o) (p) (q) (r) (s) (t)

Figure 4 Three-dimensional reconstructions of mandibular first premolars with C-shaped canals. Vertucci configurations I, III,
VII and V can be observed from (a–h). Three Vertucci type V anatomies can be observed in detail from (e) to (h). Three root
canals can be observed in the specimens (i) to (l). The specimens 1-2-3-2-3 are shown in (i–j). The 1-2-3 anatomy is shown in
(k–l). In several cases, a complex configuration of the apical third is evident (m–t).

Table 2 Classification of C-shaped canals in mandibular first premolars according to Vertucci

Anatomical Type N % CEJ to apex (mm) CEJ–division (mm)

Type I (1) 11 13.25 14.70 (12.80–17.10) 5.50 (4.50–8.03)

Type V (1–2) 31 37.34 14.96 (13.30–21.71) 5.65 (2.90–10.20)
Type III (1–2–1) 7 8.43 15.25 (12.99–20.40) 5.36 (4.39–6.20)
Type VII (1–2–1–2) 2 2.40 14.4, 14.97 4.73, 5.2
Other C-shaped canals 32 38.55 14.22 (11.36–17.76) 5.65 (3.74–8.30)

N = 83. Median and range of anatomical landmarks studied are also presented.

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Ordinola-Zapata et al. C-shaped anatomy in mandibular first premolars

apical third and classified as Vertucci’s types I and III

1.43 (1.07–4.60)b
1.79 (1.03–3.20)b

1.66 (1.10–3.96)b
1.66 (1.04–5.40)b

2.00 (1.16–8.20)b
1.73 (1.11–4.28)b
Table 3 Morphological two-dimensional parameters found at the apical third of C-shaped mandibular premolars presenting a single canal at the apical third (Vertucci’s I and

2.99 (1.32–5.09)a

3.56 (1.25–4.86)a

3.44 (1.28–4.89)a
Aspect ratio
(n = 18) and V (n = 31). Data from two-dimensional
analysis of the more prevalent features are shown in

<0.0001

<0.0001

<0.0001
Table 3. In the apical 1-mm level, single canals (type
I and III anatomy) had significantly larger area,
perimeter and aspect ratio values than the root canals
of type V anatomy (P < 0.05). Roundness values of
buccal and lingual canals associated with type V

Minor Diameter (mm)

anatomy were significantly higher than the values

0.15 (0.04–0.36)b

0.17 (0.09–0.41)b

0.20 (0.03–0.42)b
0.33 (0.13–0.47)a
0.25 (0.07–0.55)a

0.35 (0.15–0.65)a
0.31 (0.06–0.67)a

0.42 (0.25–0.88)a
0.39 (0.19–0.77)a
found in single canals at all levels (P < 0.05). Lingual
canals of the Vertucci type V classification had signifi-
cantly smaller minor diameters in comparison with

<0.0001

<0.0001

<0.0001
the buccal canal and single canals at all levels. Single
canals in the apical third had a median of major api-
cal diameters of 0.98 mm. At the 2- and 3-mm level,
lingual canals of the Vertucci type V classification
had the lower values of major diameter in comparison
with the other root canals (P < 0.05).

Major Diameter (mm)

0.32 (0.03–1.01)b
0.25 (0.11–0.70)b

0.51 (0.12–1.62)b

0.80 (0.31–1.93)b
0.98 (0.30–1.70)a

1.24 (0.31–1.96)a

1.54 (0.54–2.40)a
0.33 (0.17–1.12)c

0.36 (0.12–1.63)c
Discussion

<0.0001

<0.0001

<0.0001
Anatomical variations of the root canal system can
be influenced by the ethnicity of the population stud-
ied. At least two anatomical variations are prevalent
in Asiatic countries: the C-shaped mandibular second
molar and the three-rooted first mandibular molar
0.58 (0.31–0.83)b

0.56 (0.06–0.81)b
0.53 (0.16–0.85)b

0.43 (0.10–0.74)b
0.57 (0.14–0.84)b
0.28 (0.14–0.77)a

0.22 (0.09–0.79)a

0.20 (0.12–0.66)a
(Fan et al. 2008). Mandibular first premolars also
0.64 (0.20–1.0)b
Roundness

have a high variability in the number of root canals

and in their transverse anatomy (Baisden et al.

B: buccal, L: lingual. Different letters in columns represent statistical differences.

<0.0001

<0.0001

<0.0001
1992). Previous studies have assessed the canal mor-
phology of mandibular premolars in populations from
China (Lu et al. 2006), United States (Baisden et al.
1992) and India (Sikri & Sikri 1994), where the prev-
alence of C-shaped canal anatomy was 18%, 14%,
0.97 (0.11–2.59)b
0.71 (0.28–1.79)b

1.48 (0.31–3.86)b

2.18 (0.83–5.08)b
2.51 (0.89–4.05)a

3.07 (0.94–5.17)a

3.82 (1.39–7.47)a
0.88 (0.49–2.67)c

0.90 (0.32–3.83)c
Perimeter (mm)

and 10.7% of the samples, respectively. The different

variations reported in the literature regarding the
prevalence of C-shaped premolars may be correlated
<0.0001

<0.0001

<0.0001

to the racial divergence of the samples (Trope et al.

1986, Baisden et al. 1992, Lu et al. 2006) as well as
the methodologies involved to analyze the specimens
(Lee et al. 2014).
III) and Vertucci’s type V anatomy

One of the anatomical characteristics of mandibular

0.05 (0.01–0.31)b

0.04 (0.01–0.20)b

0.04 (0.02–0.30)b
0.20 (0.04–0.56)a

0.23 (0.06–0.72)a
0.11 (0.04–0.48)a

0.32 (0.10–1.02)a
0.19 (0.04–0.67)a
0.03 (0.01–0.17)c
Area (mm2)

premolars is the presence of a radicular groove. The

prevalence of C-shaped canals in mandibular premo-
<0.0001

<0.0001

<0.0001

lars with radicular grooves found in this study (67%)

was similar to that reported previously (66%) in a
1-mm apical level

2-mm apical level

3-mm apical level

Chinese population (Fan et al. 2012). This character-

istic has also been reported as bifurcations or trifurca-
tions when two or three root canals were found
V (B)

V (B)

V (B)
V (L)

V (L)

V (L)

(Ordinola-Zapata et al. 2013). Similar to other man-

I-III

I-III

I-III
P

dibular premolars variations, the C-shaped canals are

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 807–813, 2015 811

C-shaped anatomy in mandibular first premolars Ordinola-Zapata et al.
characterized by the presence of an oval canal in the
cervical third (C4c variation) that changes abruptly
approximately 5 mm below the cemento-enamel
junction. This value is similar to previous results that
addressed the cementoenamel to bifurcation distance
(Fan et al. 2012) or trifurcations (Ordinola-Zapata
et al. 2013) in mandibular premolars. These land-
marks are important for proper negotiation of addi-
tional canals and may be measured using several cone
beam computed tomography software programs.
Despite the presence of several anatomical varia-
tions, the presence of a bifurcation in the root canal
system in the middle third, defined as Vertucci’s type
V configuration, is the most common anatomical vari-
ation described in the literature, confirming the
results of this study (Vertucci 2005). Two-dimen-
sional data of the apical third such as area, perimeter,
roundness and major and minor diameters provides
data that can help clinicians to develop techniques
that enable effective root canal debridement. Round-
ness values found in the apical 3 mm showed that
Vertucci V variation had higher values between 0.43
and 0.64 in comparison with Vertucci I and III vari-
ants. Thus, a single root canal in the apical level is
likely to be more long oval shaped with more pulp tis-
sue when compared to the presence of two root
canals as in Vertucci type V variation.
Large apical diameters were found to be more pre-
valent in anatomical variations ending in one root
canal such as Type I and III variations. These varia-
tions had medians of 0.98 and 0.33 mm for major
and minor diameters 1 mm from apex. This difference
between major and minor diameters of Type I and III
variations is reflected when the aspect ratio and
roundness values were analyzed. These values were
between 2.9 and 3.5 and can be considered as long
oval canals. These results are higher than the values
found in type V canals. These data highlight the diffi-
culty in canal enlargement, shaping and cleaning
that the clinician faces in the presence of extreme
complexity found in the apical third of C-shaped
canals from Vertucci type I and III variations.
Furcation canals in first mandibular premolars with
radicular grooves extending from the pulp chamber to
the radicular groove were observed in 27 of 83
samples (32%). This finding is consistent with previ-
ous reports on two-rooted mandibular canines and
premolars with radicular grooves (Versiani et al.
2011, Fan et al. 2012). Another important anatomic
aspect observed in a high percentage of samples is
the presence of apical deltas and the relative high
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prevalence of canal systems that did not fit within
Vertucci’s classification (38%).
In summary, data from this study will help clinicians
to have a more thorough understanding of the varia-
tions in root canal morphology of mandibular premo-
lars with C-shaped root canals to overcome problems
related to canal identification and preparation.
Conclusions
C-shaped canal configuration of the root canal system
was found in 83 (67%) of 123 extracted first mandib-
ular premolars with radicular grooves. Vertucci’s
types I and V were the most prevalent anatomical
variations. C-shaped cross-sections (C1, C2) were
more prevalent in the middle third, and the presence
of apical deltas was the most common feature found
in the apical third.
Acknowledgements
This work was supported by FAPESP (2013/03695-0,
2010/16072-2).
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