Review Article
Root and Root Canal Morphology of Maxillary
First Premolars: A Literature Review and Clinical
Considerations
Ibrahim Ali Ahmad, BDS, MSc, JBE,* and Mohammad Ahmad Alenezi, BDS, MFDRCSI, MScD†‡
Abstract
Introduction: Sound knowledge of the external and
internal morphology of the different teeth groups is
essential to ensure a successful outcome of root canal
treatment. The aims of this study were to review the
available literature with respect to the root and root
canal morphology of maxillary first premolars and
discuss the clinical considerations of this morphology
on the various dental procedures. Methods: The
MEDLINE/PubMed and Scopus databases were searched
for relevant literature. The identified publications were
classified into anatomic studies and clinical case reports.
The data extracted from anatomic studies were tabu-
lated, and weighted averages for certain internal and
external morphologic features were calculated. The
anatomic and developmental variations in the clinical
case reports were summarized. Results: A total of 92
studies (45 anatomic studies and 47 case reports)
including a total of 11,299 teeth were identified.
The majority of maxillary first premolars had 1 root
(41.7%) or 2 roots (56.6%). Regardless of the number
of roots, the vast majority (86.6%) had 2 root canals,
with type IV (2-2) being the most common canal config-
uration (64.8%). The majority of the apical foramina
(66.6%) did not coincide with the apical root tip. About
38% of the teeth had lateral canals, 12.3% had apical
deltas, and 16.0% had isthmi. The clinical case reports
showed that the 3-rooted variant was the most common
anatomic variation, and developmental anomalies were
rarely reported. Conclusions: The maxillary first premo-
lars are predominantly 2-rooted teeth with 2 root canals.
However, the clinician should be aware about the
possible anatomic variations of these teeth and their
relationship with the adjacent anatomic structures
while planning and performing endodontic, restorative,
periodontal, and surgical procedures. (J Endod
2016;42:861–872)
From the *Dentistry Department, Al-Wakra Hospital, Hamad Medical Corporation, Al-Wakra, Qatar; †Ministry of Health, Kuwait City, Kuwait; and ‡Restorative
Dentistry Department, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia.
Address requests for reprints to Dr Ibrahim Ali Ahmad, Dentistry Department, Al-Wakra Hospital, Hamad Medical Corp, Postal Box 82228, Al-Wakra, Qatar. E-mail
address: ibrahimali79@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.02.017
JOE — Volume 42, Number 6, June 2016
Key Words
Anatomic variations, furcation grooves, maxillary first premolars, root canal
morphology, 3-rooted premolars
T he success of root canal treatment depends on complete chemomechanical prepa-
ration and 3-dimensional (3D) obturation of the root canal system. The inability
to locate, prepare, or obturate 1 or more of the root canals is a common cause
of post-treatment disease or failure of endodontic treatment (1, 2). Therefore,
clinicians should be familiar with the common root and root canal morphology and
its possible variations in the different teeth groups before commencing endodontic
treatment (3).
As a group, the maxillary premolars are common candidates for root canal
treatment and account for 15.8%–21.5% of all treated teeth (4, 5). Over the
years, the internal and external morphology of these teeth was investigated by
using different techniques. The maxillary first premolars typically have 2 roots
and 2 root canals, whereas the maxillary second premolars have 1 root with 1
or 2 root canals (5–20). In addition, both premolars may have 3 roots with 3
root canals (21, 22). Figure 1 illustrates 3 maxillary first premolars with different
root and root canal morphologies.
Variations in root and root canal morphology may be attributed to a number of
factors including ethnic background, gender and age of the study population, and
the evaluation technique (23). The objectives of this article were to do the following:
1. Review the anatomic studies and clinical cases that reported on the internal and
external anatomy of maxillary first premolars.
2. Determine the factors that may affect the morphology of these teeth.
3. Discuss the clinical considerations of morphology of these teeth on the various
dental procedures.
Materials and Methods
Literature Search Strategy
The MEDLINE/PubMed (http://www.ncbi.nlm.nih.gov/pubmed) and Scopus
(http://www.scopus.com) databases (last accessed January 15, 2016) were searched
to identify published manuscripts related to the morphology of maxillary first premolars
by using combinations of the following key words: maxillary first premolars, root
morphology, root canal morphology, anatomic variations, and dental anomalies. After
removal of duplicate articles, the title and abstract of the remaining articles were
Morphology of Maxillary First Premolars 861
Review Article
Figure 1. Maxillary first premolars with different root and canal morphol-
ogies. (A) Single-rooted premolar with type III (1-2-1) canal configuration.
(B) Two-rooted premolar with 2 buccal canals (2-2) and a single palatal
canal. (C) Three-rooted and 3-canalled premolar.
screened by the 2 authors for their relevance according to the below
inclusion criteria, and potential articles were retrieved in full text.
Then the reference list of each of these articles was manually checked
for additional studies.
Inclusion Criteria
Anatomic studies and clinical case reports that evaluated the root
and/or root canal morphology of maxillary first premolars and were
published in peer-reviewed journals were included in the current
review.
Data Extraction and Analysis
Overall, 45 anatomic studies (5–10, 12–20, 24–53) including
11,228 teeth and 47 clinical case reports (54–100) of anatomic and
developmental variations including 71 teeth met the inclusion criteria
and were subjected to further analysis (Table 1).
The data extracted from the anatomic studies were divided into
external and internal morphologic features. The external features
included the following:
1. The number of roots (Table 2). Some studies reported maxillary
first premolars with a single root that bifurcated in the middle or
apical thirds (9, 17, 18, 20, 49). These teeth were classified as
2-rooted premolars.
TABLE 1. Literature Search Strategy
No. of
Search terms publications
1 Maxillary first premolars AND root 269
morphology
2 Maxillary first premolars AND root canal 102
morphology
3 Maxillary first premolars AND anatomic 7
variations
4 Maxillary first premolars AND dental 114
anomalies
5 Total number of publications (1 + 2 + 3 + 4) 492
6 (5) after removal of duplicate publications 356
7 Publications remaining after title/abstract 68
screening
8 Articles retrieved through manual search 24
9 Total included publications (7 + 8) 92
862 Ahmad and Alenezi
2. The presence and type of roots fusion (RF) in multirooted teeth
(Table 2). The incidence of RF in 2-rooted and 3-rooted premolars
was calculated by dividing the number of teeth with RF by the
number of 2-rooted and 3-rooted teeth, respectively. The overall
incidence of RF was calculated by dividing the number of fused
2-rooted and 3-rooted teeth by the total number of multirooted teeth
in the sample (ie, total sample number minus the number of single-
rooted teeth). RF in 3-rooted teeth was classified into partial (fusion
of 2 roots) or complete (fusion of all 3 roots).
The internal features included the following:
1. Total number of root canals per tooth (Table 3).
2. Root canal configuration per tooth according to the 8 types of
Vertucci’s classifications (1). Additional canal configurations were
reported by some studies (13, 16, 17, 40, 43, 53) and were
categorized as ‘‘others’’ (Table 3).
3. Morphology of the apical region and included the following
(Table 4):

Number and position of apical foramina

Presence of apical deltas

Presence and location of lateral canals and isthmi
The weighted average of the aforementioned morphologic features
was calculated by dividing the total number of teeth with that feature by
the total number of samples in all studies that evaluated it.
For each clinical case report, the following data were extracted
(Table 5):
1. Patient’s personal information (age, gender, and ethnicity if
mentioned)
2. Location of involved first premolar (#14 for right and #24 for left)
3. Management of the involved tooth (clinical examination, radio-
graphic examination, or clinical procedure)
4. Important anatomic variations and/or developmental anomalies
Results
Root Morphology
The root morphology was evaluated by 26 studies (5, 7–10,
13–15, 17, 18, 20, 24, 27, 31, 33, 37, 39, 40, 43, 44, 47–49,
51–53) that included a total of 6878 teeth (Table 2). The majority of
maxillary first premolars (56.6%) had 2 roots, 41.7% had 1 root,
and 1.7% had 3 roots. The 3-rooted premolars had either 2 buccal
roots and a single palatal root or 2 palatal roots and a single buccal
root. One anatomic study (43) reported eight 3-rooted premolars, of
which 6 had 2 palatal roots and 1 buccal root, and the other 2 teeth
had 2 buccal roots and 1 palatal root. All 3-rooted teeth in the clinical
case reports had 2 buccal roots and 1 palatal root (Table 5).
Eight studies (14, 37, 39, 43, 44, 47, 52, 53) with a total of 1779
teeth evaluated the presence of RF (Table 2). About one fourth of multi-
rooted teeth (24.9%) had RF, and 2-rooted premolars had a higher
incidence of RF than their 3-rooted counterparts (24.3% and 0.6%,
respectively). RF in 3-rooted premolars was reported by 2 studies
(37, 39), and it included either the buccal roots only (8 of 11 teeth)
or all roots (3 of 11 teeth).
Root Canal Morphology
The internal morphology was investigated by 41 studies including
10,013 teeth by using different techniques including tooth sectioning
(15, 24, 28, 30, 39, 47), tooth modeling (7, 25), tooth staining and
clearing (8, 10, 12, 13, 16–19, 26, 34, 35, 39, 40, 42–44, 53),
conventional radiography (5, 6, 9, 27, 28, 31, 32, 36–38, 46, 49),
and cone-beam computed tomography (20, 48, 50, 51).
JOE — Volume 42, Number 6, June 2016
JOE — Volume 42, Number 6, June 2016

TABLE 2. Number of Roots and Presence of Roots Fusion (RF) in Maxillary First Premolars
No. of roots (%) RF (%)
Reference Country (population) Sample no. 1 2 3 2-RPM 3-RPM Total
Barrett, 1925 (24) USA 32 24 (66.7) 8 (33.3) 0 (0.0)
Mueller, 1933 (27) USA 130 41 (31.5) 89 (68.5) 0 (0.0)
Carns and Skidmore, 1973 (7) USA 100 37 (37.0) 57 (57.0) 6 (6.0)
Hession, 1977 (31) Australia 12 1 (8.3) 11 (91.7) 0 (0.0)
Vertucci, 1984 (8) USA 400 158 (39.5) 226 (56.5) 16 (4.0)
De Deus, 1986 (33) Brazil (Brazilian) 108 38 (35.5) 66 (61.0) 4 (3.5)
Walker, 1987 (9) South China (Chinese) 100 60 (60.0) 40 (40.0) 0 (0.0)

cora et al, 1991 (10)
Pe Brazil (Brazilian) 240 134 (55.8) 100 (41.7) 6 (2.5)
Zaatar et al, 1997 (5) Kuwait (Kuwaiti) 79 34 (43.0) 42 (53.2) 3 (3.8)
Kartal et al, 1998 (13) Turkey (Turkish) 300 112 (37.3) 184 (61.3) 4 (1.3)
Loh, 1998 (14) Singapore (Singaporean) 957 473 (49.4) 484 (50.6) 0 (0.0) 155 (32.0) 0 (0.0) 155 (32.0)
Chaparro et al, 1999 (15) South Spain (Andalusian) 150 60 (40.0) 85 (56.7) 5 (3.3)
Lipski et al, 2005 (37) Poland (Polish) 142 22 (15.5) 107 (75.3) 13 (9.2) 37 (34.6) 8 (61.5) 45 (37.5)
Atieh, 2008 (39) Saudi Arabia (Saudi) 246 44 (17.9) 199 (80.9) 3 (1.2) 89 (44.7) 3 (100) 92 (45.5)
Awawdeh et al, 2008 (17) Jordan (Jordanian) 600 185 (30.8) 410 (68.4) 5 (0.8)
Cheng and Weng, 2008 (40) China (Chinese) 422 242 (57.4) 175 (41.5) 5 (1.2)
Peiris, 2008 (18) Japan (Sri Lankan) 153 82 (53.7) 71 (46.3) 0 (0.0)
Japan (Japanese) 81 62 (76.6) 18 (22.2) 1 (1.2)
Neelakantan et al, 2011 (43) India (Indian) 350 41 (11.7) 301 (86.0) 8 (2.3) 7 (2.3) 0 (0.0) 7 (2.3)
Rwenyonyi et al, 2011 (44) Uganda (Ugandan) 202 54 (26.7) 148 (73.3) 0 (0.0) 25 (16.9) 0 (0.0) 25 (16.9)
€
Ozcan et al, 2012 (47) Turkey (Turkish) 653 295 (45.2) 351 (55.7) 7 (1.1) 37 (10.5) 0 (0.0) 37 (10.3)
Tian et al, 2012 (20) China (Chinese) 300 198 (66.0) 100 (33.3) 2 (0.7)
Elkady and Allouba, 2013 (48) Saudi Arabia (Saudi) 120 34 (28.3) 86 (71.7) 0 (0.0)
Koçani et al, 2014 (49) Kosovo (Kosovar) 221 48 (21.7) 155 (70.1) 18 (8.1)
Abella et al, 2015 (51) Spain (Spanish) 430 198 (46.0) 221 (51.4) 11 (2.6)
Dashrath et al, 2015 (52) Nepal (Nepalese) 100 58 (58.0) 41 (41.0) 1 (1.0) 21 (51.2) 0 (0.0) 21 (50.0)
Morphology of Maxillary First Premolars

Gupta et al, 2015 (53) India (Indian) 250 134 (53.6) 115 (46.0) 1 (0.4) 61 (53.0) 0 (0.0) 61 (52.6)
No. of roots (26 studies) 6878 2869 (41.7) 3890 (56.6) 119 (1.7)
Incidence of RF (8 studies) 1779* 432 (24.3) 11 (0.6) 443 (24.9)
2-RPM, 2-rooted premolars; 3-RPM, 3-rooted premolars.
*Included only the number of 2-rooted and 3-rooted teeth.

Review Article
863
Review Article
TABLE 3. Number and Configurations of Root Canals (per tooth) in Maxillary First Premolars

Study Country (population) Type of study Sample no.

Barrett, 1925 (24) USA In vitro (LS) 32
Hess, 1925 (25) Switzerland In vitro (modeling) 260
Okumura, 1927 (26) Japan In vitro (clearing) 85
Mueller, 1933 (27) USA In vitro (radiography) 130
Green, 1955 (28) USA In vitro (radiography and LS) 10
Pineda and Kuttler, 1972 (6) Mexico In vitro (radiography) 259
Carns and Skidmore, 1973 (7) USA In vitro (modeling) 100
Green, 1973 (30) USA In vitro (LS) 50
Hession, 1977 (31) Australia In vitro (radiography) 12
Vertucci, 1984 (8) USA In vitro (clearing) 400
Bellizzi and Hartwell, 1985 (32) USA In vivo (radiography) 514
Walker, 1987 (9) South China (Chinese) In vitro (radiography) 100
Pe
cora et al, 1991 (10) Brazil (Brazilian) In vitro (clearing) 240
Çalişkan et al, 1995 (12) Turkey (Turkish) In vitro (clearing) 100
Wu et al, 1995 (34) China (Chinese) In vitro (clearing) 100
Zaatar et al, 1997 (5) Kuwait (Kuwaiti) In vivo (radiography) 79
Kartal et al, 1998 (13) Turkey (Turkish) In vitro (clearing) 300
Chaparro et al, 1999 (15) South Spain (Andalusian) In vitro (CS) 150
Deng et al, 2004 (35) China (Chinese) In vitro (clearing) 326
Oginni, 2004 (36) Nigeria (Nigerian) In vivo (radiography) 122
Sert and Bayirli, 2004 (16) Turkey (Turkish) In vitro (clearing) 100 (male)
100 (female)
Lipski et al, 2005 (37) Poland (Polish) In vitro (radiography) 142
Mattuella et al, 2005 (38) Brazil (Brazilian) In vitro (radiography) 39 (BRs)
Atieh, 2008 (39) Saudi Arabia (Saudi) In vitro (clearing and CS) 246
Awawdeh et al, 2008 (17) Jordan (Jordanian) In vitro (clearing) 600
Cheng and Weng, 2008 (40) China (Chinese) In vitro (clearing) 422
Peiris, 2008 (18) Japan (Sri Lankans) In vitro (clearing) 153
Japan (Japanese) In vitro (clearing) 81

zy1o
Ro _ et al, 2008 (41) Poland (Polish) In vitro (exploration with hand files) 83
Weng et al, 2009 (19) China (Chinese) In vitro (clearing) 95
Ng’ang’a et al, 2010 (42) Kenya (Kenyan) In vitro (clearing) 77 (male)
78 (female)
Neelakantan et al, 2011 (43) India (Indian) In vitro (clearing)
Single-rooted PM 41
2-rooted PM 301 BR
301 PR
3-rooted PM 2 MBR
2 DBR
2 PR
3-rooted PM 6 BR
6 MPR
6 DPR
Rwenyonyi et al, 2011 (44) Uganda (Ugandan) In vitro (clearing) 202
Sharma and Mathur, 2011 (45) India (Indian) In vitro (CT) 60
Al-Nazhan et al, 2012 (46) Saudi Arabia (Saudi) In vivo (radiography) 163 (male)
300 (female)
€
Ozcan et al, 2012 (47) Turkey (Turkish) In vitro (radiography and CS) 653
Tian et al, 2012 (20) China (Chinese) In vivo (CBCT) 300
Elkady and Allouba, 2013 (48) Saudi Arabia (Saudi) In vivo (CBCT) 120
Koçani et al, 2014 (49) Kosovo (Kosovar) In vitro (DOM and CDR) 221
Ok et al, 2014 (50) Turkey (Turkish) In vivo (CBCT) 1379
Abella et al, 2015 (51) Spain (Spanish) In vivo (CBCT) 430
Gupta et al, 2015 (53) India (Indian) In vitro (clearing) 250
No. of root canals (39 studies)# 9624
Root canal configurations (28 studies)# 7695
BR, buccal root; CBCT, cone-beam computed tomography; CDR, computed digital radiography; CS, cross-sectioning; CT, computed tomography; DBR, distobuccal root; DOM, dental operating microscope;
DPR, distopalatal root; LS, longitudinal sectioning; MBR, mesiobuccal root; MPR, mesiopalatal root; PM, premolar; PR, palatal root; RCT, root canal treatment.
* Type 2-3 (0.3%).
† Type 1-2-3-2 (3%).
‡ Types 3-2 (0.5%) and 2-3-2-3 (0.2%).
§ Type 1-3 (0.5%).
k Type 2-3 (0.7%) and 2-1-2-1 (1.0%).
¶ Type 2-1-2-1 (1.2%) and 1-2-1-3 (0.8%).
# Two studies were excluded from calculations of weighted averages. The first study (38) evaluated the root canal system in the buccal roots only, and the second one (43) studied the root canal morphology
of each root separately.

864 Ahmad and Alenezi JOE — Volume 42, Number 6, June 2016
 Review Article

No. of canals (%) Canal configurations (%)

1 2 3 I II III IV V VI VII VIII Other
9 (28.1) 22 (68.8) 1 (3.1)
51 (19.5) 206 (79.3) 3 (1.2)
7 (8.2) 78 (91.8) 0 (0.0)
2 (1.5) 128 (98.5) 0 (0.0)
1 (10.0) 9 (90.0) 0 (0.0)
68 (26.2) 190 (73.3) 1 (0.5) 68 (26.2) 62 (23.9) 0 (0.0) 108 (41.7) 20 (7.7) 0 (0.0) 0 (0.0) 1 (0.5) 0 (0.0)
9 (9.0) 85 (85.0) 6 (6.0) 9 (9.0) 13 (13.0) 0 (0.0) 72 (72.0) 0 (0.0) 0 (0.0) 0 (0.0) 6 (6.0) 0 (0.0)
4 (8.0) 46 (92.0) 0 (0.0) 4 (8.0) 13 (26.0) 0 (0.0) 33 (66.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (8.3) 10 (83.3) 1 (8.3)
32 (8.0) 348 (87.0) 20 (5.0) 32 (8.0) 72 (18.0) 0 (0.0) 248 (62.0) 28 (7.0) 0 (0.0) 0 (0.0) 20 (5.0) 0 (0.0)
32 (6.2) 465 (90.5) 17 (3.3)
13 (13.0) 87 (87.0) 0 (0.0)
41 (17.1) 193 (80.4) 6 (2.5)
4 (3.9) 96 (96.1) 0 (0.0) 4 (3.9) 6 (5.9) 0 (0.0) 78 (78.4) 6 (5.9) 6 (5.9) 0 (0.0) 0 (0.0) 0 (0.0)
11 (11.0) 89 (89.0) 0 (0.0) 11 (11.0) 26 (26.0) 5 (5.0) 49 (49.0) 4 (4.0) 5 (5.0) 0 (0.0) 0 (0.0) 0 (0.0)
9 (11.4) 67 (84.8) 3 (3.8) 9 (11.4) 8 (10.1) 0 (0.0) 59 (74.7) 0 (0.0) 0 (0.0) 0 (0.0) 3 (3.8) 0 (0.0)
26 (8.7) 269 (89.6) 5 (1.7) 26 (8.7) 3 (1.0) 0 (0.0) 214 (71.3) 44 (14.7) 7 (2.3) 1 (0.3) 4 (1.3) 1 (0.3)*
2 (1.3) 143 (95.3) 5 (3.3) 2 (1.3) 56 (37.3) 0 (0.0) 87 (58.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (3.3) 0 (0.0)
159 (48.8) 165 (50.6) 2 (0.6) 159 (48.8) 32 (9.8) 8 (2.4) 118 (36.2) 0 (0.0) 7 (2.1) 0 (0.0) 2 (0.6) 0 (0.0)
18 (14.8) 104 (85.2) 0 (0.0) 18 (14.8) 36 (29.5) 0 (0.0) 68 (55.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
9 (9.0) 86 (86.0) 5 (5.0) 9 (9.0) 13 (13.0) 6 (6.0) 60 (60) 5 (5.0) 0 (0.0) 2 (2.0) 2 (2.0) 3 (3.0)†
12 (12.0) 84 (84.0) 4 (4.0) 12 (12.0) 12 (12.0) 5 (5.0) 63 (63.0) 2 (2.0) 2 (2.0) 0 (0.0) 4 (4.0) 0 (0.0)
3 (2.1) 126 (88.7) 13 (9.2) 3 (2.1) 9 (6.3) 0 (0.0) 117 (82.4) 0 (0.0) 0 (0.0) 0 (0.0) 13 (9.2) 0 (0.0)
7 (17.1) 32 (82.9) 0 (0.0)
22 (8.9) 221 (89.8) 3 (1.2) 22 (8.9) 66 (26.8) 0 (0.0) 155 (63.0) 0 (0.0) 0 (0.0) 0 (0.0) 3 (1.2) 0 (0.0)
20 (3.3) 567 (94.5) 13 (2.2) 20 (3.3) 61 (10.2) 2 (0.3) 478 (79.7) 12 (2.0) 14 (2.3) 0 (0.0) 9 (1.5) 4 (0.7)‡
43 (10.1) 371 (87.8) 8 (1.9) 43 (10.1) 45 (10.6) 25 (6.0) 239 (56.6) 51 (12.1) 8 (1.9) 3 (0.7) 6 (1.5) 2 (0.5)§
2 (1.3) 145 (94.8) 0 (0.0) 2 (1.3) 25 (16.3) 3 (2.0) 98 (64.0) 9 (5.9) 9 (5.9) 1 (0.7) 0 (0.0) 6 (3.9)
4 (4.9) 72 (88.9) 0 (0.0) 4 (4.9) 24 (29.6) 2 (2.5) 37 (45.7) 2 (2.5) 7 (8.6) 0 (0.0) 0 (0.0) 5 (6.2)
25 (30.1) 53 (63.9) 5 (6.0)
6 (6.3) 89 (93.7) 0 (0.0) 6 (6.3) 21 (22.1) 3 (3.2) 61 (64.2) 3 (3.2) 1 (1.0) 0 (0.0) 0 (0.0) 0 (0.0)
2 (2.6) 66 (85.7) 9 (11.7) 2 (2.6) 2 (2.6) 0 (0.0) 53 (68.8) 11 (14.3) 0 (0.0) 0 (0.0) 9 (11.7) 0 (0.0)
1 (1.3) 76 (97.4) 1 (1.3) 1 (1.3) 2 (2.6) 3 (3.8) 58 (74.4) 9 (11.5) 1 (1.3) 3 (3.8) 1 (1.3) 0 (0.0)

9 (21.9) 32 (78.1) 0 (0.0) 9 (21.9) 14 (34.1) 3 (7.5) 11 (26.8) 4 (9.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
99 (32.9) 200 (66.4) 2 (0.7) 99 (32.9) 42 (13.9) 58 (19.3) 36 (12.0) 61 (20.3) 0 (0.0) 0 (0.0) 0 (0.0) 5 (1.7)k
252 (83.7) 49 (16.3) 0 (0.0) 252 (83.7) 32 (10.6) 0 (0.0) 2 (0.7) 15 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (50.0) 1 (50.0) 0 (0.0) 1 (50.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (50.0) 1 (50.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (50.0) 1 (50.0) 0 (0.0) 1 (50.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (16.6) 5 (83.4) 0 (0.0) 1 (16.6) 1 (16.6) 1 (16.6) 1 (16.6) 2 (33.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (16.6) 5 (83.4) 0 (0.0) 1 (16.6) 0 (0.0) 0 (0.0) 0 (0.0) 5 (83.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
1 (16.1) 5 (83.4) 0 (0.0) 1 (16.6) 0 (0.0) 1 (16.6) 0 (0.0) 4 (66.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
7 (3.5) 190 (94.0) 5 (2.5) 7 (3.5) 16 (7.9) 1 (0.5) 169 (83.6) 1 (0.5) 1 (0.5) 2 (1.0) 5 (2.5) 0 (0.0)
3 (5.0) 57 (95.0) 0 (0.0) 3 (5.0) 15 (25.0) 5 (8.3) 27 (45.0) 7 (11.7) 2 (3.3) 1 (1.7) 0 (0.0) 0 (0.0)
5 (3.1) 150 (92) 8 (4.9)
12 (4.0) 285 (95.0) 3 (1.0)
51 (7.8) 592 (90.7) 10 (1.5) 51 (7.8) 145 (22.2) 0 (0.0) 447 (68.5) 0 (0.0) 0 (0.0) 0 (0.0) 10 (1.5) 0 (0.0)
43 (14.3) 255 (85.0) 2 (0.7) 43 (14.3) 70 (23.3) 13 (4.3) 153 (51.0) 10 (3.3) 7 (2.3) 2 (0.7) 2 (0.7) 0 (0.0)
6 (5.0) 114 (95.0) 0 (0.0) 6 (5.0) 6 (5.0) 12 (10.0) 84 (70.0) 8 (6.7) 0 (0.0) 4 (3.3) 0 (0.0) 0 (0.0)
4 (1.8) 199 (90.0) 18 (8.1) 4 (1.8) 12 (5.4) 1 (0.4) 186 (84.2) 0 (0.0) 0 (0.0) 0 (0.0) 18 (8.1) 0 (0.0)
132 (9.6) 1233 (89.4) 14 (1.0) 132 (9.6) 89 (6.5) 19 (1.4) 1061 (76.9) 63 (4.6) 1 (0.1) 0 (0.0) 14 (1.0) 0 (0.0)
108 (25.1) 311 (72.3) 11 (2.6) 108 (25.1) 44 (10.2) 19 (4.4) 227 (52.8) 8 (1.9) 7 (1.6) 6 (1.4) 11 (2.6) 0 (0.0)
58 (23.2) 189 (75.6) 3 (1.2) 58 (23.2) 37 (14.8) 34 (13.6) 83 (33.2) 17 (6.8) 5 (2.0) 10 (4.0) 1 (0.4) 5 (2.0)¶
1077 (11.2) 8331 (86.6) 216 (2.2)
878 (11.4) 1041 (13.5) 166 (2.2) 4990 (64.8) 320 (4.2) 90 (1.2) 35 (0.5) 149 (1.9) 26 (0.3)

JOE — Volume 42, Number 6, June 2016 Morphology of Maxillary First Premolars 865
 866

Review Article
Ahmad and Alenezi

TABLE 4. Morphology of Apical Region

Apical foramina (%)
Number Location
Sample Apical Lateral
Study Study methodology (tooth) 1 2 $3 Centric Eccentric delta (%) canals (%) Isthmi (%)
Green, 1960 (29) In vitro (microscopy) 50 (R) 24 (47.0) 26 (53.0)
Pineda and Kuttler, 1972 (6) In vitro (radiography) 259 130 (50.1) 128 (49.4) 1 (0.5)
390 (RC) 43 (11.0) 347 (89.0) 7 (1.8) 161 (41.3)
Carns and Skidmore, 1973 (7) In vitro (modeling) 100 22 (22.0) 72 (72.0) 6 (6.0)
Green, 1973 (30) In vitro (LS) 50 17 (34.0) 33 (66.0) 0 (0.0)
Hession, 1977 (31) In vitro (radiography) 12 1 (8.3) 4 (33.3)
Vertucci, 1984 (8) In vitro (clearing) 400 104 (26.0) 276 (69.0) 20 (5.0) 48 (12.0) 352 (88.0) 13 (3.2) 198 (49.5) 137 (34.2)
Walker, 1987 (9) In vitro (radiography) 100 36 (36.0) 64 (64.0) 0 (0.0)
Çalişkan et al, 1995 (12) In vitro (clearing) 100 10 (9.8) 90 (90.2) 0 (0.0) 33 (33.3) 67 (66.7) 22 (21.6) 33 (33.3) 18 (17.6)
Wu et al, 1995 (34) In vitro (clearing) 100 42 (42.0) 58 (58.0) 0 (0.0) 9 (9.0)
Kartal et al, 1998 (13) In vitro (clearing) 300 29 (9.7) 266 (88.6) 5 (1.7) 46 (15.3) 254 (84.7) 69 (23.0) 234 (78.0) 63 (21.0)
Chaparro et al, 1999 (15) In vitro (CS) 150 58 (38.7) 87 (58.0) 5 (3.3)
Deng et al, 2004 (35) In vitro (clearing) 326 199 (61.0) 125 (38.3) 2 (0.6) 46 (14.1) 138 (42.5)
Sert and Bayirli, 2004 (16) In vitro (clearing) 200 57 (28.5) 137 (68.5) 6 (3) 47 (23.5) 153 (76.5) 61 (30.5) 66 (33.0) 24 (12.0)
Awawdeh et al, 2008 (17) In vitro (clearing) 600 83 (13.8) 507 (84.5) 10 (1.7) 360 (60.0) 240 (40.0) 26 (4.3) 116 (19.3) 42 (7.0)
Peiris, 2008 (18) In vitro (clearing) 153 (Sri Lanka) 30 (19.6) 122 (79.7) 1 (0.7)
81 (Japan) 30 (37.0) 48 (59.3) 3 (3.7)
Weng et al, 2009 (19) In vitro (clearing) 95 30 (31.6) 65 (68.4) 0 (0.0)
178 (RC) 52 (29.2) 92 (51.7)
Rwenyonyi et al, 2011 (44) In vitro (clearing) 202 24 (11.9) 173 (85.6) 5 (2.5) 57 (28.2) 5 (2.5)
Gupta et al, 2015 (53) In vitro (clearing) 250 121 (48.4) 127 (50.8) 2 (0.8) 87 (34.8) 40 (16.0)
No. of apical foramina (16 studies) 3466 1022 (29.5) 2378 (68.6) 66 (1.9)
Position of apical foramina (7 studies)* 1600 534 (33.4) 1066 (66.6)
Incidence of apical delta (9 studies)† 1938 238 (12.3)
Incidence of lateral canals (12 studies)† 2490 942 (37.8)
Incidence of isthmi (7 studies) 2052 329 (16.0)
JOE — Volume 42, Number 6, June 2016

CS, cross sectioning; LS, longitudinal sectioning; R, roots; RC, root canal.
*Two studies were excluded because they reported the position of apical foramina by the number of roots (29) or root canals (6).
†
Two studies (6, 19) were excluded because they reported the incidence of apical delta and lateral canals by the number of root canals.
JOE — Volume 42, Number 6, June 2016

TABLE 5. Summary of Clinical Case Reports of Maxillary First Premolars Showing Anatomic Variations and Developmental Anomalies
Study Country Tooth Gender Age (y) Procedure Key anatomic features
Barry et al, 1975 (54) USA 14 Male 28 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Gazit and Lieberman, 1983 (55) USA 14 Male 13 Radiographic examination and inspection 2-rooted tooth with missing PR
of extracted tooth
Maibaum, 1989 (56) USA 24 Female 71 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Zaatar et al, 1990 (57) Kuwait 24 Male 34 Clinical RCT 3 canals (MB, DB, and P)
24 Male 29 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
14 Male 24 Clinical RCT 3 canals (MB, DB, and P)
Augsburger and Wong, 1996 (58) Guam 14, 24 Female 12 Apexification Dens evaginatus
Nahmias and Rampado, 2002 (59) Canada 24 Female 17 Clinical RCT Gemination with trifid crown and type
4-3-2 canal configuration
Stecker and DiAngelis, 2002 (60) USA 14, 24 Female 9 Clinical examination Dens evaginatus
Soares and Leonardo, 2003 (61) Brazil 24 NM 23 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Evans, 2004 (62) Australia 24 Female 65 Clinical RCT and apicectomy 2 BRs and 1 PR (each with 1 canal)
Segovi
c et al, 2004 (63) Croatia 14 NM NM Clinical RCT 2 BRs and 1 PR (each with 1 canal)
14 NM NM Clinical Re-RCT 2 BRs and 1 PR (each with 1 canal)
24 NM NM Clinical Re-RCT 2 BRs and 1 PR (each with 1 canal)
24 NM NM Clinical Re-RCT 2 BRs and 1 PR (each with 1 canal)
14 NM NM Clinical Re-RCT 2 BRs and 1 PR (each with 1 canal)
Oruçog lu and Çobankara, 2005 (64) Turkey 24 Male 51 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Rekha et al, 2005 (65) India 24 Female 21 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Woodmansey, 2006 (66) USA 24 Male 20 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Jafarzadeh, 2007 (67) Iran 14, 24 Male 17 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Parolia et al, 2007 (68) India 14 Male 37 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Javidi et al, 2008 (69) Iran 24 Male 23 Clinical RCT 3 canals (MB, DB. and P)
24 Male 35 Clinical Re-RCT 2 BRs and 1 PR (each with 1 canal)
14 Female 28 Clinical Re-RCT 2 BRs and 1 PR (each with 1 canal)
Arisu and Alacam, 2009 (70) Turkey 14 Male 24 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
24 Male 32 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Cardinali et al, 2009 (71) Italy 24 NM 53 Clinical RCT 3 canals (MB, DB, and P)
Dadresanfar et al, 2009 (72) Iran 24 Male 24 Clinical RCT 2 BRs (type 1-2 canal) and 1 PR (1 canal)
Al-Abdulwahhab et al, 2010 (73) Saudi Arabia 24 Female 32 Clinical Re-RCT 3 canals (MB, DB, and P)
Farooq et al, 2010 (74) India 24 Male 26 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
14 Male 16 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Abraham and Kumar, 2011 (75) India 24 Female 32 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Idris et al, 2011 (76) India 14 Male 27 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Karumaran et al, 2011 (77) India 24 Male 40 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
24 Male 21 Clinical RCT 2 BRs (type 1-2 canal) and 1 PR (1 canal)
Morphology of Maxillary First Premolars

14 Male 24 Clinical RCT 3 canals (MB, DB, and P)

Nica et al, 2011 (78) Romania 14 Female 51 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Aracena et al, 2012 (79) Chile 24 NM 22 Inspection of extracted tooth 2 BRs and 1 PR (each with 1 canal)
Chauhan and Chandra, 2012 (80) India 24 Male 43 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Çolak et al, 2012 (81) Turkey 14 Female 26 Clinical examination Dens evaginatus
Gandhi et al, 2012 (82) India 14, 24 Female 25 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Garapati et al, 2012 (83) India 24 Male 51 Clinical RCT 2 BRs and 1 PR (each with 1 canal)

Review Article
Gupta et al, 2012 (84) India 24 Male 45 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
14 Male 45 Radiographic examination 3 separate roots
Kamath et al, 2012 (85) India 24 Female 63 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
14 Male 32 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Nimigean et al, 2013 (86) Romania 14 Female 22 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Ocak and Ahmetog  lu, 2013 (87) Turkey 14 Male 28 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
Oporto et al, 2013 (88) Chile 14 Female 32 Clinical RCT 2 BRs and 1 PR (each with 1 canal)
867

(Continued )
Review Article
When the total number of canals per tooth was considered, 8331
(86.6%) had 2 canals, 1077 (11.2%) had 1 canal, and only 216

2 BRs and 1 PR (each with 1 canal)

2 BRs and 1 PR (each with 1 canal)

2 BRs and 1 PR (each with 1 canal)

2 BRs and 1 PR (each with 1 canal)
2 BRs and 1 PR (each with 1 canal)
2 BRs and 1 PR (each with 1 canal)
2 BRs and 1 PR (each with 1 canal)

2 BRs and 1 PR (each with 1 canal)

2 BRs and 1 PR (each with 1 canal)

2 BRs and 1 PR (each with 1 canal)
(2.2%) had 3 canals. Type IV was the most prevalent (64.8%) root
canal configuration, followed by types II (13.5%) and I (11.4%). In
3 canals (MB, DB, and P)
3 canals (MB, DB, and P)

3 canals (MB, DB, and P)

3 canals (MB, DB, and P)

3 canals (MB, DB, and P)

3 canals (MB, DB, and P)
Key anatomic features

addition, about 0.3% of the investigated teeth demonstrated additional

3 separate roots configurations such as 1-3, 2-3, 1-2-1-3, 1-2-3-2, 3-2, 2-3-2-3, and
2-1-2-1 (Table 3). The 3-rooted variant always had only 1 canal in
each root (5, 7, 8, 10, 13, 15, 17, 20, 37, 39, 40, 47, 49, 51). This

#14, maxillary right first premolar; #24, maxillary left first premolar; BR, buccal root; DB, distobuccal; MB, mesiobuccal; NM, not mentioned; P, palatal; PR, palatal root; Re-RCT, nonsurgical root canal retreatment; RCT, root canal treatment.
finding was also evident in the clinical cases that reported this variant
(Table 5).

Apical Region Morphology

The morphology of apical region was investigated by 18 studies
including 3528 teeth. The majority of the teeth had 1 foramen
(29.5%) or 2 foramina (68.6%), and the majority of these foramina
(66.6%) did not coincide with the apical root tip. About 38% of the teeth
had lateral canals that were found most frequently in the apical third of
the roots. Apical deltas and isthmi were found in 12.3% and 16.0% of
Inspection of extracted tooth
Radiographic examination

the teeth, respectively.

Clinical Re-RCT

Anatomic Variations and Developmental Anomalies

Clinical RCT
Clinical RCT
Clinical RCT
Clinical RCT

Clinical RCT

Clinical RCT
Clinical RCT
Clinical RCT
Clinical RCT
Clinical RCT

Clinical RCT
Clinical RCT
Clinical RCT
Clinical RCT
Procedure

The most common anatomic variation reported in the clinical case

reports was the presence of 3 roots with 3 root canals (54, 56, 57,
61–70, 72, 74–80, 82–88, 91–96, 99, 100). Some cases (57, 69,
71, 73, 77, 89, 90, 95, 97, 98) reported the presence of 3 root
canals without specifying the number of roots (Table 5). Developmental
anomalies in maxillary first premolars are very rare. Hamasha and
Alomari (101) studied the presence of dens invaginatus in the Jorda-
nian population and found that only 0.4% of the maxillary first premo-
lars had dens invaginatus. Darwazeh et al (102) and Pillai et al (103)
reported that the incidence of taurodontism in maxillary first premolars
Age (y)

is rare, ranging from 0.1% to 0.4%. Few developmental anomalies were

NM
NM
NM

NM
16
50
32
38
38
34
13

21

24
45
40
25
50

also documented in clinical case reports including the presence

of dens evaginatus (58, 60, 81), gemination (59), and congenitally
missing palatal root (55).
Gender
Female
Female

Female
Female
Female

Female
Male

Male

Male

Male
Male
Male
NM
NM
NM
NM
NM

Discussion
The objectives of this article were to review the available literature
on the root and root canal morphology of the maxillary first premolars
14
14
14
24
14
14, 24
14
14
24
14
24
24
24
24
24
14
14
Tooth

and to discuss the clinical implications of their internal and external

morphology on the various dental procedures. The data analyzed in
the current review are secondary data that have been extracted from
previously published studies that had variations in their methodology,
Bulgaria
Country
Brazil

Brazil
India

India
India

India
India

India
India

sample number, and study population. Therefore, although the

Iran

Iran

weighted averages in the current review represent the most common

anatomic features of maxillary first premolars, clinicians should always
expect morphologic variations in these teeth and use their knowledge
and available tools to detect and manage them. There are several clinical
Victorino and Men-Martins, 2013 (91)

guidelines and tools that may be used to locate and negotiate root canals
including careful radiographic interpretation, proper access cavity
Davoudi and Akhavan, 2015 (98)
Chandra and Mathew, 2014 (92)

design, careful inspection of the pulp floor to locate canal orifices,

enhance the vision in the operating field by using magnifying tools
Sulaiman et al, 2013 (90)

Praveen et al, 2015 (100)

such as eye loupes and dental operating microscope, use of advanced

Mathew et al, 2015 (99)
Theruvil et al, 2014 (97)
Kirilova et al, 2014 (95)

Mantri et al, 2014 (96)

Jayesh et al, 2014 (94)
Study
Relvas et al, 2013 (89)

Gopal et al, 2014 (93)

imaging techniques such as cone-beam computed tomography, and

TABLE 5. (Continued )

allocating sufficient time for treatment (1, 2).

The current review showed that the maxillary first premolars are
predominantly 2-rooted teeth with 2 root canals and that the most com-
mon anatomic variation in these teeth is the presence of 3 roots with
3 root canals. Three-rooted premolars are also known as radiculous
premolars, miniature 3-canalled molars, small molars, or mini-
molars (21, 22, 56) and have an overall incidence of 1.7% (range,

868 Ahmad and Alenezi JOE — Volume 42, Number 6, June 2016

0.4%–9.2%) (5, 7, 8, 10, 13, 15, 17, 18, 20, 33, 37, 39, 40, 43, 47,
51–53). These teeth usually have 2 buccal roots and 1 palatal root
or less commonly 1 buccal root and 2 palatal roots, and each root
usually has only 1 root canal (Tables 3 and 5). The detection and
management of these premolars begin with careful clinical and
radiographic examination. A wide mesiodistal dimension of the
crown compared with its buccolingual dimension may indicate the
presence of extra roots or root canals. Whenever the mesiodistal
width of the mid root region on the preoperative radiograph is equal
to or greater than the mesiodistal width of the crown, the tooth is
likely to have an extra root (21, 22). Angulated periapical radiographs
and 3D imaging techniques can be also used to confirm the presence
of extra roots or root canals. When 3 canals are present, the outline
form of the access cavity is changed from the traditional oval shape to
become triangular with the base on the buccal side while apex on
palatal side (or vice versa in teeth with 2 palatal roots and 1 buccal
root), resulting in a cavity with a T-shaped outline (22).
Clinicians should pay attention to morphology of the apical
region during surgical and nonsurgical root canal treatment. The cur-
rent review showed the majority of apical foramina did not coincide
with the apical root tips. It has been reported that deviation of the
foramen is not easily detected radiographically, particularly when
the opening occurs on the buccal or lingual root surfaces (6). There-
fore, it is recommended to confirm the radiographic working length
with electronic apex locators, which have been reported to be highly
accurate in determining the location of apical foramen (104). The
lateral canals may be found at any level of the root but are more com-
mon in the apical third. They are rarely d
ebrided during cleaning and
shaping but may occasionally be filled with obturating materials during
canal obturation. These canals may act as avenues for the extension of
inflammatory breakdown products from the dental pulp to the peri-
odontal tissues or vice versa, affecting the outcome of endodontic
treatment and the maintenance of periodontal health (105). The pres-
ence of apical deltas and isthmi may also be of clinical significance
because it may be difficult to d
ebride and fill these areas adequately,
and this may predispose to endodontic failure. Adequate irrigation
during nonsurgical treatment and activation of the irrigant with ultra-
sonics may help to reach these uninstrumented parts of the root canal
system (106). Surgical root canal treatment involves resecting the api-
cal third of the root, thus removing the majority of canal irregularities
including lateral canals and apical deltas. All apical foramina and
isthmi on the resected root surface should be prepared and filled to
seal the apical end of the root (107).
Certain external anatomic features including furcation grooves
and root curvature should also be taken into consideration during
dental procedures involving maxillary premolars. The furcation groove
(also known as furcal concavity, buccal furcation groove, or develop-
mental depression) is a depression that is found on the palatal aspect
of the buccal root in 2-rooted premolars, and its incidence in maxillary
first premolars ranges from 62% (108) to 100% (17, 109–113)
(Fig. 2). The existence of furcation grooves has clinical implications
on endodontic, restorative, and periodontal procedures. Most of these
grooves are located in the coronal two thirds of the buccal root, and
their length varies from 1.1 to 9.0 mm (112, 113). In the area of the
deepest invagination, the average dentin thickness of the palatal wall
ranges from 0.78 to 1.18 mm (109–114). It is generally
recommended that the post should be surrounded by a minimum
of 1 mm of sound dentin (110, 115). Endodontic treatment and
post space preparation may jeopardize root integrity in this ‘‘danger
zone’’ and lead to root perforation. Therefore, clinicians should
avoid overpreparation of this area during root canal treatment and
place the post, if needed, in the palatal root canal (110, 115).
JOE — Volume 42, Number 6, June 2016
Review Article
Figure 2. Furcation groove. (A) Proximal view showing presence of the
groove (arrow) on palatal aspect of buccal root. (B) Cross section of sample
tooth showing the groove on the buccal root (arrow).
Furthermore, these grooves are potential sites for plaque and
calculus and may predispose these teeth to periodontal disease (108).
The presence of root curvature is another important parameter
that should be considered during endodontic and restorative treat-
ments. Sch€afer et al (116) investigated the frequency and degree of
canal curvatures in extracted permanent teeth by using a standardized
radiographic technique from the buccal and proximal views. The
majority of buccal (85%) and palatal (87%) root canals in maxillary
first premolars had at least 1 curve along their length. Depending on
the radiographic view and canal type, the median angle of curvature
ranged from 10 to 13 , the median radius of curvature ranged from
5.9 to 8.8 mm, and the median length of curvature ranged from 2.5
to 4.2 mm. Willershausen et al (117) studied the location of root cur-
vature in maxillary premolars radiographically and reported that the
median distance from cementoenamel junction to the first curvature
in these teeth ranged from 8.4 to 9.1 mm. Careful analysis of these pa-
rameters (angle, radius, length, and location of curvature) is essential
to decrease the risk of procedural errors such as instrument separation,
ledge formation, or root perforation during root canal instrumentation
or post space preparation.
The relationship between the maxillary posterior teeth and the sur-
rounding anatomic structures such as the maxillary sinus and overlying
bone plates should also be considered during dental procedures. The
relationship between the maxillary posterior teeth and the maxillary
sinus has been a constant challenge in dentistry, particularly for non-
surgical and surgical endodontic procedures (118, 119) or during
extraction of these teeth (120). Furthermore, periradicular and peri-
odontal pathosis originating from posterior maxillary teeth may spread
into the maxillary sinus (121–123). Fortunately, the buccal and palatal
roots of the maxillary first premolars have the farthest distance from the
maxillary sinus compared with the roots of other maxillary posterior
teeth, with a mean distance of 6.18–8.28 mm and 7.05–7.17 mm,
respectively (124, 125). One study (126) evaluated the complications
that occurred during apicectomy of maxillary posterior teeth and found
that maxillary first premolars had the least incidence of sinus perfora-
tions (2.0%) compared with maxillary second premolars (10.4%) and
molars (23.0%).
On the other hand, Eberhardt et al (124) found that the mean
thickness of bone covering the buccal roots of maxillary posterior teeth
Morphology of Maxillary First Premolars 869
Review Article
was the least over the maxillary first premolars (1.63  0.44 mm),
whereas the palatal roots of these teeth were covered by the highest
thickness of palatal bone (5.42  0.86 mm). The thin thickness of
buccal bone plate is one of the risk factors for developing a clinical con-
dition known as mucosal fenestration, which describes the situation
where the apex of a tooth is exposed to the oral environment after
breakdown of the overlying bone and alveolar mucosa (127, 128).
The presence of this fenestration may give rise to some problems
during root canal treatment including difficulty in determining the
working length, chronic post-treatment sensitivity to palpation over
the apex, and increased risk of an irrigation accident (129). Many treat-
ment modalities have been proposed alone or in combination to
manage mucosal fenestrations including root-end resection, blind
root surface instrumentation and mouth rinsing with chlorhexidine,
full-thickness mucogingival flap with primary or secondary healing,
full-thickness mucogingival flaps with guided tissue regeneration and
bone grafting, and pedicle flap operations (127–129).
Some of the anatomic studies investigated the effect of patient’s
gender (16, 40, 42, 46, 50–52) and tooth location (48, 50, 51) on
the morphology of maxillary first premolars. Although the tooth
location had no effect on root and canal morphology, significant
differences related to gender were reported in 2 studies (40, 42).
Cheng and Weng (40) found that men had a significantly higher number
of roots than women (66.4% of men had 2-rooted and 3-rooted premo-
lars, and 62.7% of women had single-rooted teeth). Ng’ang’a et al (42)
reported that men had a significantly higher incidence of 3 root canals
compared with women (11.7% and 1.3%, respectively). None of the
previous studies compared the morphologic features of maxillary first
premolars in patients with different ethnic backgrounds. Nevertheless, it
is interesting to note that the majority of studies that evaluated the Asian
populations (9, 18, 20, 40, 52, 53) reported a higher incidence of
single-rooted premolars (53.6%–76.6%) than those studies conducted
on other populations (31.5%–39.5% in North America, 15.5%–46.0%
in Europe, 17.9%–45.2% in the Middle East, 8.3% in Australia, and
26.7% in Africa). More research is warranted to arrive at definite con-
clusions regarding the influence of ethnicity, age, and gender on the
morphology of maxillary first premolars. The use of advanced imaging
techniques such as cone-beam computed tomography and micro–
computed tomography associated with evaluation of wider populations
by using larger study samples will provide a better insight regarding
morphology of maxillary first premolars and their inherent variations.
Conclusions
1. The majority of maxillary first premolars have 1 (41.7%) or 2
(56.6%) roots, and the 3-rooted variant is rare (1.7%).
2. Regardless of the number of roots, the majority of maxillary first pre-
molars (86.6%) have 2 root canals.
3. The most common root canal configuration in these teeth is type IV
(64.8%), followed by types II and I (13.5% and 11.4%, respectively).
4. The clinical case reports showed that the presence of a third root is
the most common anatomic variation in these teeth, whereas devel-
opmental anomalies are rare.
5. The clinician should have sound knowledge about the internal and
external morphology of maxillary first premolars and their relation-
ship with adjacent anatomic structures to improve the treatment
outcome of surgical and nonsurgical dental procedures.
Acknowledgments
The authors thank Dr Ziad D. Baghdadi from University
of Saskatchewan, Saskatchewan, Canada and Professor Saad
870 Ahmad and Alenezi
Al-Nazhan from King Saud University, Riyadh, Saudi Arabia for
their valuable advice and assistance in collecting the literature
used in this study. The authors also thank Engineer Abdullah Bug-
shan, Research Chair for Growth Factors and Bone Regeneration
(GFBR), Vice Deanship of Research Chairs, at King Saud
University for conducting the micro-computed tomographic scan
of the teeth in Figures 1 and 2.
The authors deny any conflicts of interest related to this study.
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