The Root Canal

Anatomy in
Permanent Dentition

Marco A. Versiani
Bettina Basrani
Manoel D. Sousa-Neto
Editors

123
The Root Canal Anatomy in Permanent
Dentition

pilararaya@ejercer.cl
Marco A. Versiani • Bettina Basrani
Manoel D. Sousa-Neto
Editors

The Root Canal

Anatomy in Permanent
Dentition

pilararaya@ejercer.cl
Editors
Marco A. Versiani Bettina Basrani
University of São Paulo University of Toronto
Ribeirão Preto Toronto
Brazil Canada

Manoel D. Sousa-Neto
University of São Paulo
Ribeirão Preto
Brazil

ISBN 978-3-319-73443-9    ISBN 978-3-319-73444-6 (eBook)

https://doi.org/10.1007/978-3-319-73444-6

Library of Congress Control Number: 2018942639

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pilararaya@ejercer.cl
Born in 1452 in the Tuscan village of Vinci, Leonardo was not
only a gifted artist but also one of the greatest geniuses who
has ever lived. According to him, “practice must always be
founded on sound theory, and to this perspective is the guide
and the gateway; and without this nothing can be done well.”
Obviously, this concept can be extended to innumerous human
activities, including dental practice. In other words, essential
practical and clinical experiences are very important for
managing complex cases, but they cannot be a substitute for
knowledge and theory. Dentistry was founded in empirical-
based research and clinical experience, which means that
clinicians often use empirical reasoning to make diagnoses and
treatment plans, based on thoughts and follow-up of cases over
the years. For several decades, the understanding of the
influence of canal anatomy on endodontic procedures was
based on empiric observation rather than on rigorous
experimentation. Consequently, several authors from the past
have stated the impossibility of succeeding in treating infected
teeth because of the complexity of the root canal system, which
was revealed at the end of the nineteenth century. With the
improvement and application of the scientific method in health
sciences, however, empirical approach started to be followed
by systematic observation, measurement, and experiment. At
this point, knowledge of the root and root canal anatomical
complexities started to be applied into clinical practice, root
canal therapy became more predictable, and endodontics, as a
respectful specialty, has born. As the Greek physician
Hippocrates postulated that the anatomy is the foundation of
medicine, root canal anatomy is undoubtedly the foundation of
endodontics!

pilararaya@ejercer.cl
This book is intended for students undergoing specialist
training, general practitioner with special interest in
endodontics, and specialists alike, being particularly dedicated
to the memory of the pioneers in the endodontic field who
overcame enormous obstacles to pave the way not only for
their own careers or personal wills, but also for giving us
inspiration to keep going with their outstanding work and write
this book.

pilararaya@ejercer.cl
Foreword I

Science is the father of knowledge, but opinion breeds ignorance.

—Hippocrates

Root canal anatomy is the foundation of the art and science of endodontic
therapy and succeeding post-treatment healing. Human dentition presents a
wide range of anatomical variations in each tooth type. The root and canal
morphology is learned to vary greatly between populations, within popula-
tions, and even within the same individual. The studies on root canal anatomy
from the first half of the nineteenth century highlighted the number of root
canals, their configurations, and complexities in teeth, while studies from the
second half of the nineteenth century and early twentieth century gained
insight on the apical terminus of the root canal anatomy and the periapical
tissues that surround it. The knowledge obtained from this cluster of studies
formed the bottom line for the biological basis in endodontic treatment. The
conception of pulp and periodontal tissue as a continuum, association between
endodontic disease and periapical host immune response, as well as the thera-
peutic significance of apical termination were all emphasized by these stud-
ies. Besides, leveraging on the current knowledge, it is recognized that
effective nonsurgical root canal treatment and endodontic surgery requires a
thorough knowledge of tooth morphology and root canal anatomy.
Unfortunately, some of the therapeutic issues associated with complex root
morphology and root canal anatomy still remain as challenges.
At the moment it is quite evident that the dental profession needs a broad
review of this complex topic—anatomy of the root canal systems and their
implications in root canal treatment. Drs. Versiani, Basrani, and Sousa-Neto
recognized this requirement and have put together a comprehensive body of
knowledge for endodontology. They have compiled some of the finest author-
ities from around the world to contribute knowledge and insights to this book.
The broad list of chapters covered in this book has left no stone unturned.
Drs. Versiani and Sousa-Neto as a team have studied root canal anatomy with
micro-CT for the last couple of decades. Dr. Sousa-Neto has also used the
method of diaphanization since the early 1980s to study root canal anatomy.
This team has studied more than 15,000 teeth through these years and pub-
lished many impactful articles. The experience of this group in this field is
obvious from the chapters covered in this book. This book is the most com-
prehensive overview of root canal anatomy and their clinical implications the
dental profession has had the opportunity to review.

vii

pilararaya@ejercer.cl
viii Foreword I

There are several reasons for me to be delighted to write the foreword for
this book. First, this book represents the maiden attempt to review the root
canal anatomy and their related topics using modern high resolution imaging
techniques. The dental profession must be updated about this important topic
in a structured manner. I am also very pleased because I have known Dr.
Versiani for almost 5 years and I am aware of his dedication to endodontol-
ogy. Dr. Basrani, my colleague at the University of Toronto, was one of the
very first internationally trained endodontists to move from Argentina to
Canada with great passion for endodontics. This book is a product of their
sacrifices, passion, and commitment. I am confident that this book will serve
our profession well.

 Anil Kishen, B.D.S., M.D.S., Ph.D.

Nanomaterial Guided Functional Tissue Engineering Lab
Dental Research Institute, Faculty of Dentistry
University of Toronto
Toronto, Canada

pilararaya@ejercer.cl
Foreword II

The ability to understand and to anticipate root canal anatomy prior to render-
ing endodontic therapy has remained a challenging issue. Indeed, this issue
confronts clinicians every day as they peer into access openings and search
for canal orifices. When we read the endodontic literature, we read from time-
to-time that a case failed because a second distal canal was overlooked, a
third mesial canal was not noticed, a second canal in a lateral incisor was
missed, etc. So, what can be done to significantly reduce these oversights?
Dr. Marco Versiani, Dr. Bettina Basrani, and Dr. Manoel Sousa-Neto took
up this challenge and engaged tooth anatomy experts from around the world
and combined their collective knowledge to prepare a textbook on internal
tooth anatomy that should be required reading for every dentist who aims to
provide the very finest endodontic therapy. As a reader would expect from a
textbook of this caliber, each chapter is enriched with high-quality images
and exhaustive citations from peer-reviewed literature.
This textbook is enhanced by also providing online videos and countless
photographs derived from some of the most current technologies enabling
researchers to even view the complexity of the root canal system in three
dimensions. Based on new discoveries, this textbook by Drs. Versiani,
Basrani, and Sousa-Neto provides a new nomenclature founded on expanded
knowledge that sophisticated technologies have revealed.

Stephen Cohen, M.A., D.D.S., F.I.C.D., F.A.C.D.

Department of Endodontics,
The Arthur A. Dugoni School of Dentistry
University of the Pacific
Stockton, CA, USA
Department of Preventive and Restorative Dental Sciences
School of Dentistry
University of California
San Francisco, CA, USA
Endodontic Postgraduate Program
Riyadh Colleges of Dentistry and Pharmacology
Riyadh, Saudi Arabia
American Board of Endodontics
Chicago, IL, USA

ix

pilararaya@ejercer.cl
…superstition and pseudoscience keep getting in the way, […] providing easy
answers, dodging sceptical scrutiny, casually pressing our awe buttons and cheap-
ening the experience, making us routine and comfortable practitioners as well as
victims of credulity. […] Pseudoscience is easier to contrive than science, because
distracting confrontations with reality - where we cannot control the outcome of the
comparison - are more readily avoided. […] Pseudoscience speaks to powerful
emotional needs that science often leaves unfulfilled. […] Science thrives on errors,
cutting them away one by one. False conclusions are drawn all the time, but they are
drawn tentatively. Hypotheses are framed so they are capable of being disproved.
[…] Proprietary feelings are of course offended when a scientific hypothesis is dis-
proved, but such disproofs are recognized as central to the scientific enterprise. […]
Science is far from a perfect instrument of knowledge. It's just the best we have.
Carl Sagan
The Demon-Haunted World: Science as a Candle in the Dark

xi

pilararaya@ejercer.cl
Acknowledgments

We would like to acknowledge Springer International Publishing for giving

us the opportunity to edit this textbook on root canal anatomy. A special
thanks goes to Andrei Berdichewsky, who was responsible for offering us this
project.
We are indebted to the following collaborators for their hard work and
invaluable contributions to make this book possible: Stephen Cohen, Anil
Kishen, Antonis Chaniotis, Arnaldo Castellucci, Carlos Murgel, Clóvis
Monteiro Bramante, Craig Barrington, Christos Boutsioukis, Diogo
Guerreiro, Domenico Ricucci, Elizeu A. Pascon, Francisco Balandrano,
Gustavo De-Deus, Hany M. A. Ahmed, Holm Reuver, Hugo Sousa, Isabela
N. Rôças, James L. Gutmann, Jesus D. Pécora, Jojo Kottoor, Jorge N. R.
Martins, José F. Siqueira Jr., Leo Tjäderhane, Mário R. Pereira, Nicola
Perrini, Nuno Pinto, Oscar von Stetten, Paul M. H. Dummer, Ronald
Ordinola-Zapata, Sergiu Nicola, and other colleagues who allow us the privi-
lege of sharing their images in courtesy. Thank you very much!
To our families, thanks for your encouragement, assistance, and support
that allow us to progress in our professional lives.

Marco A. Versiani
Bettina Basrani
Manoel D. Sousa-Neto

xiii

pilararaya@ejercer.cl
Contents

Part I Fundamentals of Root Canal Anatomy

1 Historical Overview of the Studies on Root

Canal Anatomy������������������������������������������������������������������������������    3
Nicola Perrini and Marco A. Versiani
2 Dentin Basic Structure, Composition, and Function������������������   17
Leo Tjäderhane

Part II Root Canal Components and Epidemiology

3 Root Canal Components����������������������������������������������������������������   31

Ronald Ordinola-Zapata, Marco A. Versiani, and Clóvis
Monteiro Bramante
4 New Proposal for Classifying Root and Root
Canal Morphology ������������������������������������������������������������������������   47
Hany M. A. Ahmed, Marco A. Versiani, Gustavo De-Deus,
and Paul M. H. Dummer
5 Diaphanization Techniques in the Study of Root
Canal Anatomy������������������������������������������������������������������������������   57
Craig Barrington and Francisco Balandrano
6 CBCT and Micro-CT on the Study of Root
Canal Anatomy������������������������������������������������������������������������������   89
Jorge N. R. Martins and Marco A. Versiani
7 Root Canal Anatomy of Maxillary
and Mandibular Teeth ������������������������������������������������������������������ 181
Marco A. Versiani, Mário R. Pereira, Jesus D. Pécora, and
Manoel D. Sousa-Neto
8 The Complexity of the Apical Anatomy�������������������������������������� 241
Domenico Ricucci, Elizeu A. Pascon, and José F. Siqueira Jr.
9 C-Shaped Root Canal System ������������������������������������������������������ 255
James L. Gutmann

xv

pilararaya@ejercer.cl
xvi Contents

Part III Influence of Root Canal Anatomy in Clinical Practice

10 Internal Tooth Anatomy and Root

Canal Instrumentation������������������������������������������������������������������ 277
José F. Siqueira Jr, Isabela N. Rôças, and Domenico Ricucci
11 Internal Tooth Anatomy and Root Canal Irrigation������������������ 303
Christos Boutsioukis
12 Internal Tooth Anatomy and Root Canal Obturation���������������� 323
Arnaldo Castellucci
13 Managing Complex Root Canal Anatomies�������������������������������� 343
Antonis Chaniotis, Diogo Guerreiro, Jojo Kottoor, Nuno
Pinto, Sergiu Nicola, Oscar von Stetten, Hugo Sousa, and
Carlos Murgel

Part IV Appendix

14 Contemporary Strategies for Teaching Internal

Anatomy of Teeth �������������������������������������������������������������������������� 375
Bettina Basrani and Marco A. Versiani
15 3D Visual Glossary of Terminology in Root
and Root Canal Anatomy�������������������������������������������������������������� 391
Marco A. Versiani, Jorge N. R. Martins, and Bettina Basrani

pilararaya@ejercer.cl
Contributors

Editors

Marco A. Versiani, D.D.S., M.Sc., Ph.D. Department of Restorative

Dentistry, Dental School of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, SP, Brazil
Bettina Basrani, D.D.S., M.Sc., Ph.D. Faculty of Dentistry, University of
Toronto, Toronto, ON, Canada
Manoel D. Sousa-Neto, D.D.S., M.Sc., Ph.D. Department of Restorative
Dentistry, Dental School of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, SP, Brazil

Collaborators

Hany M. A. Ahmed, B.D.S., H.D.D., Ph.D. Department of Restorative

Dentistry, Faculty of Dentistry, University Malaysia, Kuala Lumpur, Malaysia
Francisco Balandrano, D.D.S. Private Practice, Torreón, Coahuila, Mexico
Craig Barrington, D.D.S. Private Practice in the Waxahachie, Waxahachie,
TX, USA
Christos Boutsioukis, D.D.S., M.Sc., Ph.D. Department of Endodontology,
Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam
and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
Clóvis Monteiro Bramante, D.D.S., M.Sc., Ph.D. Dental School of Bauru,
University of São Paulo, Bauru, Brazil
Arnaldo Castellucci, M.D., D.D.S. Private Practice Limited to Endodontics,
Florence, Italy
University of Cagliari Dental School, University of Naples, Federico II
Antonis Chaniotis, D.D.S., M.Sc. Department of Endodontics, Athens
Dental School, University of Athens, Athens, Greece
University of Warwick, Coventry, UK
Private Practice Limited to Endodontics, Kalithea, Greece

xvii

pilararaya@ejercer.cl
xviii Contributors

Gustavo De-Deus, D.D.S., M.Sc., Ph.D. School of Dentistry, Fluminense

Federal University, Niterói, RJ, Brazil
Paul M. H. Dummer, D.D.S.c., M.Sc., Ph.D. School of Dentistry, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
Diogo Guerreiro, D.D.S., M.S. Resident ASE Endodontics, School of
Dentistry, University of Michigan, Ann Arbor, MI, USA
James L. Gutmann, D.D.S., Ph.D., F.I.C.D. Texas A&M University College
of Dentistry, Dallas, TX, USA
Jojo Kottoor, B.D.S., M.D.S. Department of Conservative Dentistry and
Endodontics, Indira Gandhi Institute of Dental Sciences, Ernakulam, India
Jorge N. R. Martins, D.D.S., M.Sc. Dental School of Lisbon, University of
Lisbon, Lisbon, Portugal
Carlos Murgel, D.D.S., M.Sc., Ph.D. Private Practice Limited to
Endodontics, Campinas, Brazil
Sergiu Nicola, D.D.S. Private Practice, Bucharest, Romania
Ronald Ordinola-Zapata, D.D.S., M.Sc., Ph.D. Dental School of Bauru,
University of São Paulo, Bauru, Brazil
Bender Division of Endodontics, Albert Einstein Medical Center, Philadelphia,
PA, USA
Elizeu A. Pascon, D.D.S., M.Sc., Ph.D. Private Practice, São Paulo, SP,
Brazil
Jesus D. Pécora, D.D.S., M.Sc., Ph.D. Department of Restorative Dentistry,
Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP,
Brazil
Mário R. Pereira, D.D.S., M.S. Department of Endodontics, University of
Lisbon, Lisbon, Portugal
Department of Endodontics, ISCSEM, Lisbon, Portugal
Nicola Perrini, M.D., D.D.S. Private Practice in the Centro di Odontoiatria
e Stomatologia at Pistoia, Pistoia, Italy
Nuno Pinto, D.D.S., M.Sc. Private Practice in the Mayo Clinic at Lisbon,
Lisbon, Portugal
Domenico Ricucci, M.D., D.D.S. Private Practice, Cetraro, Italy
Isabela N. Rôças, D.D.S., M.Sc., Ph.D. Molecular Microbiology Laboratory,
Faculty of Dentistry, Estácio de Sá University, Rio de Janeiro, RJ, Brazil
José F. Siqueira Jr., D.D.S., M.Sc., Ph.D. Department of Endodontics,
Faculty of Dentistry, Estácio de Sá University, Rio de Janeiro, RJ, Brazil

pilararaya@ejercer.cl
Contributors xix

Hugo Sousa, D.D.S., M.Sc. Clinical Residency, Foramen Dental Education,

Porto, Portugal
Private Practice Limited to Endodontics, Porto, Portugal
Oscar von Stetten Private Practice, Stuttgart, Germany
Leo Tjäderhane, D.D.S., Ph.D. Department of Oral and Maxillofacial
Diseases, University of Helsinki, Helsinki, Finland
Institute of Dentistry, University of Oulu, Oulu, Finland
Helsinki University Hospital, Helsinki, Finland
Research Unit of Oral Health Sciences, and Medical Research Center Oulu
(MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland

pilararaya@ejercer.cl
 Part I
Fundamentals of Root Canal Anatomy

pilararaya@ejercer.cl
 Historical Overview of the Studies
on Root Canal Anatomy
1
Nicola Perrini and Marco A. Versiani

Abstract study of the body, the determination of the regions

The fundamental basis of the endodontic spe-
cialty is the knowledge of root canal anatomy.
Thus, a thorough understanding of the canal
morphology and its variations in all groups of
teeth is a basic requirement to improve the out-
come of the endodontic therapy. In the past, a lot
of research work was done on this subject, and
the findings have had a noteworthy influence on
clinical practice as well as on dental education.
Therefore, it would be appropriate to take a brief
look to the past to understand contemporary
research approaches on the study of root canal
anatomy. Authors that preceded this new image-­
processing technological era, to whom endodon-
tics are greatly indebted, must be revisited.
in an organism that are to be considered its parts.
Writing about the historical aspects of the studies
on root canal anatomy does not simply mean to
place the stages that lead to the current knowledge
chronologically or compiling the biography of the
authors. In fact, the history of endodontic as a
dental specialty is relatively recent and was born
with the better understanding of the morphology
and biology of teeth, as well as the development
of endodontic techniques in the brief period of
30 years, from 1900 to 1930, after centuries of
immobility [1]. Consequently, this historical over-
view was carried out considering the result of a
long cultural and scientific evolution that simulta-
neously influenced medicine and its other biologi-
cal branches, including dentistry.

1.1 Introduction 1.2  rom Classical Antiquity

From the Latin anatomia, dissection, and from the
Greek anatome, where ana means “up” and tem-
nein means “to cut,” this word represents the
N. Perrini, M.D., D.D.S. (*)
Private Practice in the Centro di Odontoiatria e
Stomatologia at Pistoia, Pistoia, Italy
e-mail: n.perrini@cioesse.it
M. A. Versiani, D.D.S., M.Sc., Ph.D.
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil
F
to Thirteenth Century
The ancient Greek anatomist Herophilus (c.335–
c.280 B.C.), founder of the school of anatomy of
Alexandria, and his disciple Erasistratus (c.310–
c.250 B.C.) were the first physicians to perform
systematic dissection of human bodies. Herophilus
has been widely acknowledged as the “father of
anatomy” and hailed as one of the greatest anato-
mists that ever lived. His revolutionary discover-
ies represented an important step in the ancient
understanding of the human ­anatomy [2]. Some

© Springer International Publishing AG, part of Springer Nature 2019 3

M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_1

pilararaya@ejercer.cl
4 N. Perrini and M. A. Versiani
centuries later, the works of Claudius Galenus
(c.130–c.210 A.C.), usually known as Galen,
have influenced several generations of physicians
and the development of various scientific disci-
plines, including anatomy [3]. In his writings,
Galen did not just content to compile antique data
but also to observe and experience [1].
From the time of Galen’s death until
Renaissance, there was no substantial progress in
the understanding of human anatomy. In the
Middle Ages, the anatomical drawings of human
beings were completely devoid of realism, and
anatomical description of the teeth was limited to
their quantity, position in the oral cavity, and
number of roots [1]. Physicians suffered greatly
from stasis and intellectual stagnation, once med-
ical knowledge was limited to glossaries, com-
mentaries, encyclopedias, and compendia of
ancient works from Arabic writers such as
Avicenna [4], Rhazes [5] and Albucasis [6]. In the
anatomical field, the influence of Galen’s writ-
ings continued to prevail.
1.3 From Fourteenth
to the Seventeenth Century
The Renaissance, period that immediately fol-
lowed the High Middle Ages (eleventh to thir-
teenth century) in Europe, was the turning
point in which natural sciences and medicine
were under the general principle of critical
revisionism. At the end of the fourteenth cen-
tury, medical science slowly found noteworthy
progress because dissections became an
accepted and officially recognized procedure
in Bologna, Italy. This allowed Mondino de
Liucci (1270–1326) to write his book
Anathomia Corporis Humani [7], possibly the
first work exclusively devoted to anatomy. This
83-page book left a profound intellectual leg-
acy and renewed the way to understand and
teach human anatomy through direct observa-
tion of dissected corpses. Mondino dedicated
four pages to the anatomy of the mouth and
wrote about the number and function of teeth,
but nothing related to their internal anatomy
[1]. In 1363, Guy de Chauliac performed the
greatest synthesis of medical and surgical
pilararaya@ejercer.cl
knowledge of his time by writing the famous
book Chirurgia Magna [8]. Again, however,
description of teeth’s anatomy and physiology
was presented superficially [1].
At the end of fifteenth century, the realism
demanded by the aesthetic of the art in the
Renaissance age led various artists to undertake
in-depth studies of the human anatomy directly
on corpses, or indirectly by attending university
classes of anatomy, to elaborate artistic composi-
tions proportional to structures and shapes of the
human body. Circa 1510 Leonardo da Vinci
(1452–1519), working on human anatomy in col-
laboration with Marcantonio della Torre (1478–
1511), a renowned anatomist, compiled a series
of sheets with more than 240 individual drawings
and over 13,000 words of notes, in a work that is
considered one of the most significant achieve-
ments of Renaissance science [9]. Among these
drawings, Leonardo accurately depicted the max-
illary and frontal sinuses, the curvature of the
dental arches in centered occlusion, and the
external morphology of four teeth. It is interest-
ing to notice, however, that even with the innova-
tions of the anatomical studies with cadavers,
morphological description of the dental organs in
this period was practically ignored, not to men-
tion the internal anatomy that, according to
Galen’s dictates, did not exist [1].
In the first half of the sixteenth century, a set
of seven books written by Andreas Vesalius
(1514–1564) entitled De Humani Corporis
Fabrica were published [10]. This was the major
advance in the history of anatomy over the long-­
dominant works of Galen and Mondino and has
been recognized as the first complete treatise on
human body. Unlike Leonardo da Vinci, Vesalius
had a fruitful collaboration with the outstanding
painter Jan Steven van Calcar (1499–1546),
responsible for the anatomical plates conceived
for the book. Despite the anatomy of the teeth
was not treated so deeply as the other parts of
the body, description of the dental apparatus
was considerably more accurate than that of
Galen and represented a real progress in the
morphological knowledge of the mouth and
teeth. It is noteworthy that an important anatom-
ical aspect of teeth that had been ignored by pre-
vious authors, on which, centuries later, the
1 Historical Overview of the Studies on Root Canal Anatomy
endodontic specialty would be born, was high-
lighted for the first time in the literature. In
Chap. XI, there is the first registered drawing of
a sectioned two-rooted mandibular molar show-
ing its internal anatomy: the pulp chamber and
two root canals [1]. In 1563, Bartolomeo
Eustachi (c.1520–1574), in his treatise il
Libellus de dentibus, made very significant con-
tributions toward the anatomy and physiology
of the dentition, including the first descriptions
of the dental pulp, the periodontal membrane,
the dental follicles, the trigeminal nerve, and
other oral structures, based upon extensive dis-
sections of both human and animal material
[11]. In Chap. XVIII, Eustachi speaks about the
pulp cavity and its content, and shows accurate
tables in which he specified the number of roots
and the external morphological variations of all
groups of teeth. Eustachi’s book brought the
macroscopic anatomy of teeth to a high degree
of perfection that remained unsurpassed until
the nineteenth ­century [1].
In the seventeenth century, the first sign of
separation between oral sciences and medicine
emerged with the publication of several works
dedicated to the dental field, despite most of the
schematic images had been copied from Vesalius’
book. In 1675, Antonie van Leeuwenhoek (1632–
1723), using a compound microscope created by
himself, was the first author to describe the
microscopic anatomy of the dentinal tubules. It
led him to disagree with the predominant con-
cept according to which teeth were like bone
structures. He also published drawings of a sec-
tioned mandibular molar showing its pulp cham-
ber and the root canals [12]. Marcello Malpighi
(1628–1694) was also one of the greatest
microscopist of this century. In his manuscript
Observationes de dentibus, there are 27 sheets
richly depicted by drawings of sectioned and
non-sectioned human teeth in different angles
[13], some of which published in the posthu-
mous edition of his Opera Medica, et anatomica
varia [14], that remained unpublished until 1968
[15–17]. Undoubtedly, the works of Leeuwenhoek
and Malpighi were too advanced for their time
and lacked adequate practical application.
Therefore, they remained neglected for at least
another 150 years.
pilararaya@ejercer.cl
5
1.4 From the Eighteenth
to the Nineteenth Century
In 1728, the French dentist Pierre Fauchard
(1678–1761), also known as the “father of
modern dentistry,” published the first edition of
his two-volume treatise entitled Le Chirurgien
Dentiste ou Traité des dents [18], universally
acknowledged as the first scientific work of
conservative, surgical, and prosthetic dentistry
that reflected the state of the art of dental care at
that time. However, despite the external mor-
phology of teeth had been described in detail,
no information was provided about the root
canal anatomy. At the end of the eighteenth
century, John Hunter (1728–1793) published
two important books based on more than
15 years of observation and experimentation on
human dentition [19, 20]. In his former treatise,
Hunter performed a complete and original anal-
ysis of the human dentition that had never been
made. Regarding the canal anatomy, the avail-
able images are not numerous, but show root
canal changes with aging. In summary, several
works dedicated to teeth were published in this
century, but new anatomical knowledge of teeth
was scarce and remained unchanged since the
sixteenth century.
The nineteenth century witnessed the rise of
dentistry as a distinct profession, with its own
practitioners, techniques, standards, and specific
literature devoted to dental science [1]. But in the
first half of the century, only a few authors have
published new anatomical aspects regarding the
root canal morphology. Meyerus Fraenkel, a stu-
dent of the great anatomist Jan Evangelista
Purkinje (1787–1869), can be considered a
­precursor of the modern studies on root canal
anatomy because, in his thesis [21], there are
some drawings in which horizontal sections in
different root levels of a single-rooted incisor and
a double-­rooted premolar are shown. Some years
later, Georg Carabelli (1787–1842), in his post-
humous work [22], provided the most detailed
description of the number and direction of the
root canal until that moment. Unfortunately,
these remarkable studies, undeniably modern in
their conception, were completely disregarded
and considered unworthy of interest [1].
6 N. Perrini and M. A. Versiani
In the second half of the nineteenth century,
dentistry was overwhelming by the great para-
dox created between the microscopic and mac-
roscopic studies. While the former had already
characterized the tooth structure, the latter had
not yet defined the morphology of the root canal
system. In 1870 in Germany, Eduard Mühlreiter
(1839–1917) published the first complete study
on the root canal anatomy of human teeth in
which the external and internal morphologies of
teeth were compared through sagittal and hori-
zontal sections [23]. Even though it was a sim-
ple work in its essence, it proved to be extremely
important because it served as inspiration to
other researchers, such as Adolph Witzel (1847–
1906), to study the root canal anatomy. This
author showed, for the first time, the anatomical
variability of root canal system in maxillary pre-
molars and the morphological changes of the
pulp cavity of mandibular molars with aging
[24]. In the United States, Greene Vardiman
Black (1836–1915) examined the external and
internal morphology using images of sagittal
and horizontal sections of each group of teeth
[25]. A few years later, Alfred Gysi (1865–
1957), using histological sections, published the
first high-quality photomicrographs depicting
the internal morphology of a carious molar and
the pulp-dentin complex of another molar, in
which it is possible to observe details of the soft
connective tissue such as the vascular, lym-
phatic, and nervous elements [26].
Nevertheless, it was only at the end of nine-
teenth century that some researchers finally real-
ized the need for an in-depth research on the root
canal morphology. It happened mostly because of
the rise of misconceptions about root canal infec-
tion. At that time, Willoughby Dayton Miller
(1853–1907) proposed that oral microorganisms
or their products have a role in the development
of a variety of diseases in other parts of the body,
such as brain abscesses, pulmonary diseases, and
gastric problems [27]. Although Miller advocated
treating the root canals to eliminate the focus of
infection, teeth extraction was popularized at the
turn of the century because of further reports
from William Hunter [28, 29] and Frank Billings
[30, 31], which started the era of focal infection
theory. These evidences led many researchers to
pilararaya@ejercer.cl
consider that the main cause of root canal treat-
ment failure was the lack of knowledge regarding
the internal morphology of teeth [32, 33].
1.5 From Twentieth to Twenty-­
First Century
In 1903, Gustav Preiswerk (1866–1908) per-
formed a profound and comprehensive research
on the root canal anatomy. In his pioneering
study [34], Wood’s metal, an alloy that melts at a
low temperature, was molten and injected into
the canal space. After complete decalcification of
the teeth, three-dimensional metal models of the
internal anatomy were obtained. It is important to
point out that this method was developed by the
Dutch anatomist Govard Bidloo (1649–1713)
using melted bismuth [35], later improved by
Brunn, who employed Wood’s metal, and used by
Zuckerkandl in the study of pulp chamber [1].
This method, however, led to tooth overheating
and the replicas were obviously incomplete, as
the metal could not penetrate into the finer
branches of the root canal system. Despite these
methodological drawbacks, this innovative
method allowed Preiswerk [34] to observe that
canal anastomosis was not rare. Since then, the
classical descriptions of teeth with regular canal
anatomy and a single apical foramen that
appeared in almost all previous treatises started
to be questioned.
Guido Fischer (1877–1959) presented the
challenging nature of the apical root anatomy
for the first time in 1907 [36]. He obtained bet-
ter results than Preiswerk [34] by filling
approximately 700 teeth with a collodion solu-
tion. This solution could penetrate all the
branches of the root canal system and hardened
in 2 or 3 weeks, providing a full three-dimen-
sional replica of the canal. But the hardened
­collodion solution was fragile, and replicas of
the subtler ramifications fractured easily.
Fischer paid special attention to thin ramifica-
tions, little lateral branches, and apical termi-
nations and classified the morphological
variations of the root canal into simple ramifi-
cations or branches, lateral canals within the
radicular dentin, intercommunicating canal
1 Historical Overview of the Studies on Root Canal Anatomy
system, and islands of hard tissue within the
canal. The complexity and unpredictability of
the root canal morphology led him to coin the
nowadays widely used term “root canal sys-
tem” (Kanalsystem). In the next 2 years, Fisher
started to associate radiography [37] with his
macroscopic and microscopic observations
[38], highlighting the morphological complex-
ity of the root canal system. It may be said that
the innovative three-dimensional anatomical
studies of Preiswerk and Fisher resulted in
huge advancement adding new and significant
knowledge to dental literature, which stimu-
lated other researchers to undertake further
investigations on the anatomy of the root canal
system.
In 1911, the German anatomist Werner
Spalteholz (1861–1940) developed a process by
which organs could be made translucent and
stained using assorted colors [39]. This process
was based on dehydration of the removed organs
and the use of an optically transparent embed-
ding material that has the same refractive index
as the tissue of the organ itself. At this same year,
in Japan, T. Okumura used numerous grinding
sections to investigate the relation between the
external and internal structure of the teeth [40].
He measured several important root canal param-
eters including the position of the pulp chamber
floor, the thickness of the dentinal wall, the dis-
tance from the cervical line to the furcation area,
and the number, size, and shape of apical ramifi-
cations. However, this study was published in
Japanese and, therefore, did not have the expected
international recognition. In 1913, Spalteholz’s
method [39] was used for the first time by Fasoli
and Arlotta, from the University of Milan, in
Italy, to study the root canal anatomy [41]. In the
next years, this technique was modified and
employed for the study of the internal anatomy
by injecting fluid materials into the root canal
system [42, 43]. Since then, it has been referred
to as “clearing” or “diaphanization” technique.
In 1914, H. Moral reported another method in
which hard tissues were made transparent and
pulp cavity was filled with Indian ink [44]. Using
this approach, the author demonstrated, among
other findings, that the percentage frequency of a
fourth root canal in the mesiobuccal roots of 100
pilararaya@ejercer.cl
7
maxillary molars was 63% [45]. A few years
later, Walter Hess (1885–1980) published note-
worthy results on the root canal anatomy from a
sample comprising 2800 permanent human teeth
[46]. He succeeded in reconstructing the root
canal shape on such a large scale by using a novel
approach that involved filling the teeth with vul-
canized rubber followed by decalcification. Hess
complemented his findings by carrying out grind-
ing sections of selected teeth to illustrate the fine
structures of the root canal system at the apical
region, establishing a correlation between the fre-
quency of ramifications and the patient’s age,
which confirmed Fischer’s findings. This study
was followed by a second one conducted by
Ernst Zürcher, in 1922, under his supervision
[47]. These are undoubtedly the most important
and detailed studies on root canal anatomy, which
were later joined together and published in
English language [48]. In the following years, the
results obtained by the German school regarding
root canal [34, 36, 46] were finally confirmed by
several authors from different countries [49–53].
Wallace Clyde Davis (1866–1950) was the
first author to detail the internal morphology of
the root canal at the apical third and to address
the problem regarding the inability to remove
all pulp tissue from the root canal system. He
prepared and photographed, at 25× magnifica-
tion, 50 sectioning root apexes of different
teeth from patients ranging from 25 to 45 years
old [54]. Davis also introduced the terms pulp-
otomy and pulpectomy in dentistry. With the
publication of his book in 1920 [55], he con-
tributed to the endodontic knowledge of future
dentists by favoring the development of non-
empirical training techniques with scientific
foundations. In 1926, T. Okumura showed, at
the 16th International Dental Congress of
Philadelphia, the results of his study using the
Spalteholz’ method on the root canal anatomy
of 2146 teeth. Okumura’s work is undoubtedly
the most i­mportant anatomical study of the
root canal system using diaphanization method
because of the large sample and the conclu-
sions reached. As an unfolding of his work, he
categorized the canal anatomy into four types,
according to the root shape, the divisions of the
main root canal, and the presence of ramifica-
8 N. Perrini and M. A. Versiani
tions, being considered the first anatomical-
based classification of the root canal system. In
1928, the third and last work under Hess super-
vision was performed by Oskar Keller using
960 teeth [56], synthesizing all knowledge on
root canal morphology since Preiswerk [34]. In
this study, a new method combined the
Spalteholz technique [39] with modifications
[12, 41] and was virtually free of artifacts and
suitable for highlighting even the smallest
branches of the root canal system. Based on the
three studies of Hess, in which the internal
anatomy of almost 5000 teeth was studied, root
canals ceased to be only “a complex structure”
to become a well-defined structure in which
scientific-­based treatments could be developed
and applied [1].
In addition to the invasive techniques, X-ray
imaging was soon found to constitute a valuable
approach to understand variations in the internal
structure of the human tooth. Using this method,
Augustus Henry Mueller [57] investigated
extracted teeth filled with gutta-percha. It is
important to point out that, at this same period in
the Latin American, Pucci and Reig [58] also
­performed an extensive study on root canal anat-
omy using radiography, diaphanization, and sec-
tioning techniques. However, most of the in-depth
research studies on canal anatomy conducted by
them was not published in English, which
avoided this knowledge to be spread throughout
the world. In the years that followed, the advent
of the Second World War affected most of the
oral research centers around the world. As a con-
sequence, several authors kept reproducing in
their books the canal anatomy as previously
reported by Mühlreiter [1].
After the war, Balint W. Hermann, known for
introducing the calcium hydroxide in dentistry in
1920, published some images reproducing the
complexity of the root canal morphology at the
apical region [59]. Some years later, David Green
also studied the apical anatomy of all groups of
teeth using stereomicroscopy [60–62]. In a series
of anatomical studies, Wilhelm Meyer reported a
new protocol to reproduce three dimensionally
the internal anatomy of 800 teeth based on draw-
ings of sequential microscopic sections of the
root canal systems [63–67]. Quintiliano de Deus
pilararaya@ejercer.cl
was the first author in Brazil who studied system-
atically the root canal anatomy of all teeth using
diaphanization technique. He also evaluated the
percentage frequency of lateral canals in each
dental group [68]. Later, Vertucci and colleagues
[69–74] made a significant step forward docu-
menting a broad morphological variation in the
root canals of different teeth using clearing tech-
nique, which became a standard method in fur-
ther reports on root canal anatomy [75–82].
These works closed the series of major studies on
root canal morphology, accomplishing the results
of Preiswerk [34], Fisher [36], Hess [48], and
others.
In the twentieth century, technological
advancements allowed that a considerable range
of other techniques was also successfully
employed to visualize the anatomy of human
teeth including three-dimensional wax models
[65], digital radiography [83], resin injection
[84], radiographic methods with radiopaque con-
trast media [85], scanning electron microscopy
[86], and others. Undoubtedly, these techniques
have shown a great potential for endodontic
research; however, while most of these methods
required the partial or even full destruction of the
studied samples, rendering irreversible changes
in the specimens and many artifacts, others pro-
vided only a two-dimensional image of a three-­
dimensional structure [87]. These inherent
limitations have repeatedly been discussed in the
literature, encouraging the search for new meth-
ods with improved possibilities [88].
In 1986, Mayo and colleagues [89] intro-
duced computer-assisted imaging in the field of
endodontic research by injecting contrast
medium into the root canal and taking six radio-
graphs of each tooth from known angles. By
combining all six views, a mathematically deter-
mined three-­dimensional (3D) representation of
the canals was obtained. From this data, the vol-
ume and diameters of the root canals were
­determined using a computerized video image-
processing program. This radiographic volume
interpolation method was also used in fur-
ther studies to evaluate the root canal anatomy
[90–92]. The early to mid-1990s, the first appli-
cation of a computerized and digital approach
based on micrographs of grinding sections was
1 Historical Overview of the Studies on Root Canal Anatomy
proposed. Using diamond and silicon carbide
disks, Blašković-Šubat et al. [93] and Lyroudia
et al. [94, 95] cross-­sectioned extracted teeth and
photographed these sections using a camera
attached to a stereomicroscope. Each photograph
was then digitized, the shape was manually out-
lined, and the resulting stacks of labeled shapes
were rendered in 3D using dedicated software.
Although partly digital, this approach still
required the destruction of the samples under
study [96].
The invention of X-ray computed tomogra-
phy (CT) brought a significant step forward in
diagnostic medicine [97]. CT produces a two-­
dimensional map of X-ray absorption into a two-
dimensional slice of the subject. This is achieved
by taking a series of X-ray projections through
the slice at various angles around an axis perpen-
dicular to the slice. From this set of projections,
the X-ray absorption map is computed. By tak-
ing a number of slices, a three-dimensional map
is produced [98]. To maximize their effective-
ness in differentiating tissues while minimizing
patient exposure, medical CT systems need to
use a limited dose of relatively low-energy
X-rays (≤125 keV) and acquire data rapidly
because the patient should not move during
scanning. Besides, to obtain as much data as pos-
sible given these requirements, CT devices use
relatively large (mm scale) and high-efficiency
detectors [99].
In 1990, Tachibana and Matsumoto [100]
were the first authors to suggest and evaluate the
feasibility of CT imaging in endodontics.
Because of high costs, inadequate software, and
a low spatial resolution (0.6 mm), they con-
cluded that CT had only a limited usefulness in
endodontics as the acquired images were not
accurate for detailed analysis. Further improve-
ments in digital image systems have been used to
evaluate the root canal anatomy in either ex vivo
or in vivo conditions using nondestructive tools
such as conventional medical CT [101], mag-
netic resonance microscopy [102], tuned-aper-
ture computed tomography (TACT) [103],
optical coherence tomography [104], and volu-
metric or cone beam CT (CBCT) [105]. However,
these digital image systems were ­ hampered
mainly by insufficient spatial resolution and
pilararaya@ejercer.cl
9
slice thickness for the study of root canal anat-
omy [106, 107].
A decade after the CT scanner was created,
Elliott and Dover [108] developed the first high-­
resolution X-ray micro-computed tomographic
device, and, using a resolution of 12 μm, the
image of the shell of a Biomphalaria glabrata
snail was produced. The term “micro” in this
new device was used to indicate that the pixel
sizes of the cross sections were in the microm-
eter range. This also means that the machine
was smaller in design compared to the human
version and was indicated to model smaller
objects [109]. More recently, micro-CT has
gained increasing popularity in endodontics.
This noninvasive, nondestructive, high-resolu-
tion technology allows three-dimensional study
of the root canal system by reconstructing digi-
tal cross sections of the teeth, which can be
stacked to create 3D volumes. These volumes
can be used to generate computerized images of
specimens that can be manipulated, sectioned,
prepared, dissected, and measured to reveal
both internal and external morphology [110]. In
endodontics, Nielsen et al. [107] was the first
authors to apply micro-CT technology to recon-
struct the external and internal anatomy of four
maxillary molars. Then, Dowker et al. [106] and
Bjørndal et al. [111] used micro-CT to demon-
strate root canal anatomy and the feasibility of
using this methodological resource in different
stages of the root canal treatment. Nowadays,
despite the impossibility of employing micro-
CT for in vivo human imaging, it has been con-
sidered the most important and accurate research
tool for the study of root canal anatomy [87,
112–114].
As previously outlined, it is very important for
the clinician to develop a complete understanding
of the 3D morphologic features of root canal sys-
tems. The morphological studies of the last cen-
turies gave us a better understanding of the
internal anatomy of teeth (Figs. 1.1, 1.2, and 1.3)
and allowed the development of technological
resources aiming to overcome the treatment limi-
tations imposed by the anatomical complexities
of the root canal. From the present century, it
may be expected that this accumulated knowl-
edge provides improvements in the endodontic
10 N. Perrini and M. A. Versiani

Fig. 1.1 Timeline infographic of the studies on root canal anatomy (from classical antiquity to 1870) (images repro-
duced from Perrini [1] with permission)

pilararaya@ejercer.cl
1 Historical Overview of the Studies on Root Canal Anatomy 11

Fig. 1.2 Timeline infographic of the studies on root canal anatomy (from 1886 to 1928) (images reproduced from
Perrini [1] with permission)

pilararaya@ejercer.cl
12 N. Perrini and M. A. Versiani

Fig. 1.3 Timeline infographic of the studies on root canal Matsumoto [100], Blašković-Šubat et al. [93], Nielsen
anatomy (from 1931 to nowadays) (images reproduced et al. [107], Lyroudia et al. [94], Dowker et al. [106],
from Mueller [57], Pucci and Reig [58], Green [60], De Bjørndal et al. [111] and Perrini [1], with permission)
Deus [68], Vertucci [70], Mayo et al. [89], Tachibana and

pilararaya@ejercer.cl
1 Historical Overview of the Studies on Root Canal Anatomy
science, making root canal treatment more pre-
dictable and successful. Therefore, the main pur-
pose of this book is to focus on the complexity of
root canal anatomy and discuss its relationship
on the understanding of the principles and prob-
lems of shaping and cleaning procedures in order
to provide thorough in-depth background knowl-
edge of the internal anatomy of teeth.
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 Dentin Basic Structure,
Composition, and Function
Leo Tjäderhane
Abstract
Dentin is the largest structural component of
the human tooth. Dentin provides support to
enamel, preventing enamel fractures during
occlusal loading. It also protects the pulp from
microbial and other potentially harmful stim-
uli. As vital tissue, dentin is not only a passive
mechanical barrier between the oral environ-
ment and the pulp tissue but, in many ways,
participates in the overall protection of the
continuum of the hard and soft tissue often
referred as the dentin-pulp complex. For
example, dentin contains several growth fac-
tors that may be liberated during wear or car-
ies and participate in the regulation of the
defensive reaction at the dentin-pulp border or
the pulp proper. Odontoblasts project their cell
processes into dentinal tubules, and also there-
fore the division of the “vital” pulp and “dead”
mineralized dentin is artificial. Different parts
of the dentin in a particular tooth may also
L. Tjäderhane, D.D.S., Ph.D.
Department of Oral and Maxillofacial Diseases,
University of Helsinki, Helsinki, Finland
Institute of Dentistry, University of Oulu,
Oulu, Finland
Helsinki University Hospital, Helsinki, Finland
Research Unit of Oral Health Sciences, and Medical
Research Center Oulu (MRC Oulu), Oulu University
Hospital and University of Oulu, Oulu, Finland
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_2
pilararaya@ejercer.cl
2
qualitatively differ from each other, which
enables it to meet the requirements of that spe-
cific location.
2.1 Introduction
Dentin can be described in various ways, based on
the composition, structure, or type of dentin.
Usually, dentin is described as extracellular
organic matrix that has been mineralized, much
like the bone. As a matter of fact, dentin is
nanocrystalline-­ reinforced biocomposite, which
gives it its unique properties. About 70% (55% in
volume) and 20% (30% in volume) in weight are
minerals and organic components, respectively,
the rest being water. However, due to the tubular
nature of dentin and the occlusion of tubules by
peritubular (intratubular) dentin with age and as
defensive reaction, these values are only average.
The structure of dentin can also be divided into
intertubular and peritubular dentin. Vast majority
of the organic component is located in the intertu-
bular dentin formed by the odontoblasts at the
dentin-pulp border. Due to the tubular occlusion,
the amount of minerals and division between
inter- and peritubular dentin can vary significantly
between the different parts of the tooth, as the
peritubular dentin slowly occupies the tubular
lumen. At the same time, water content in these
areas is, respectively, reduced. And finally, dentin
17
18
is frequently classified by its phase of formation:
dentin-enamel junction, mantle dentin, primary
dentin, secondary dentin, and tertiary dentin.
Tertiary dentin formation is part of the dentin-
pulp complex defensive reaction aiming to protect
the pulp and can further be divided into reaction-
ary and reparative dentin, depending on the struc-
ture and cells forming the dentin (primary or
replacement odontoblasts, respectively) [1].
2.2 Dentin Formation
2.2.1 Odontoblasts
Dentin is almost exclusively formed by the odon-
toblasts that are derived from embryonic connec-
tive ectomesenchymal cells from the cranial
neural crest [2]. The differentiating odontoblasts
start the secretion of the predentinal proteins, fol-
lowed by the initiation of enamel matrix secre-
tion by the differentiating ameloblasts, at the site
where the dentin-enamel junction (DEJ) is
formed. During and right after the differentiation,
the odontoblasts organize into a distinguished
odontoblast cell layer, and the mineralization of
organic matrix completes the formation of the
first layer of dentin, mantle dentin [2].
In the coronal part of the tooth, odontoblasts
are tall cells, and their morphological and cell
Fig. 2.1 Drawing of the dentin-pulp border. Odontoblast
(OB) cell bodies with large nucleus at the pulpal
­terminus of the cell and cytoplasmic organelles form a
tight cell layer separated from the mineralized dentin by
predentin (PD) where the intertubular dentin organic
matrix is organized before mineralization. Odontoblast
pilararaya@ejercer.cl
L. Tjäderhane
membrane polarization [3] is unique in the group
of collagen-synthesizing cells. Odontoblasts
form a single layer of cells between dentin and
pulp, with the cell body located on a pulpal wall
of dentin and odontoblast processes inserted into
dentinal tubules (Figs. 2.1 and 2.2a). The cell
bodies are 20–40 μm tall, depending on dentino-
genic activity. The odontoblast process is a cyto-
plasmic process which penetrates into mineralized
dentin tubules. The process has the 0.5–1 μm
main trunk and thinner lateral branches [4].
One of the longest controversies in dentin-­
pulp complex research has been the extent of
odontoblast processes into dentinal tubules. This
is caused by the conflicting results obtained with
different research methods and by the possible
differences between the species [4]. In human
teeth, most studies indicate that the odontoblast
cell processes would not extend far from the
dentin-­pulp border (200–700 μm) (Fig. 2.2b).
2.2.2 Predentin and Mineralization
Front
The 10–30 μm layer of unmineralized predentin
is located between odontoblasts and mineralized
dentin (Figs. 2.1 and 2.2a). This is where the den-
tin organic matrix is organized before the con-
trolled mineralization at the mineralization front
p­ rocesses penetrate into mineralized intertubular dentin
in dentinal tubules. The cell processes are devoid of
cytoplasmic organelles. Peritubular dentin (PTD) for-
mation starts some distance from the mineralization
front (modified from Tjäderhane and Haapasalo [4],
with permission)
2 Dentin Basic Structure, Composition, and Function 19

structure than previously believed [1].

a
Phylogenetic, developmental, structural, and
biological characteristics have led to the sugges-
tions that instead of the DEJ, this structure
should be termed the dentin-enamel junctional
complex [5].
The DEJ of human tooth is wavy, scalloped
line between two mineralized structures. Laser-­
induced autofluorescence and emission spec-
troscopy demonstrate the DEJ as 7–15-μm-wide
structure, which is distinct from both enamel
and dentin [6]. The “primary” scallop size var-
ies from 25 to 50 μm. They contain smaller
b (0.25–2 μm) “secondary scallops” and intermin-
gling sub-micrometer-sized ridges of dentin and
enamel [7, 8]. The scalloped form of the inter-
face is thought to improve the mechanical
attachment of enamel to dentin [1]. However,
human is among the very few species in which
the scalloping DEJ has been demonstrated,
questioning the role of this wavy structure to the
enamel-dentin attachment. Instead of the scal-
loped form of the DEJ—or in addition to it—
hydroxyapatite crystals extending through the
DEJ into both structure [9–11] and dentinal col-
Fig. 2.2 (a) Dentin-pulp complex interface, displaying lagen fibrils reaching into enamel [12] may con-
odontoblasts (OB), predentin (PD), tubular dentin (D), tribute to the durability and toughness of the
and pulp proper (P) beneath the odontoblasts. Note that DEJ under occlusal forces [1].
instead of being straight, the mineralization front is irreg-
ular, presenting the mineralization in the form of calco-
spherites. Demineralized section, toluidine blue.
Magnification 20×. (b) Odontoblast processes protruding 2.4 Mantle Dentin
from the dentin fracture site exposed at 0.4 mm from the
pulp. Magnification 2000× (from Goracci et al. [47], with
permission) The mantle dentin is 5–30-μm-thick layer of the
outermost dentin that in many aspects is different
from the rest of the dentin. This is due to the dif-
to form intertubular dentin. The backbone of the ferent process of formation. The mantle dentin
organic matrix is type I collagen, whereas non-­ organic matrix is laid down during and immedi-
collagenous proteins—glycoproteins, proteogly- ately after the terminal differentiation of the
cans, and enzymes—control the matrix odontoblasts and before their spatial organization
maturation and mineralization. The mineraliza- into distinct cell layer. It also contains the rem-
tion front is often considered to be linear, but nant components of dental papilla, and the mech-
actually mineralized globular protrusions called anisms of mineralization are different from what
calcospherites are common (Fig. 2.2a) [4]. occurs at the mineralization front [4]. It is devoid
of large tubules; instead, multiple small ramifica-
tions of each tubule are present in the mantle den-
2.3 Dentin-Enamel Junction tin. The organic matrix in mantle dentin is less
regular and contains so-called von Korff fibers
The dentin-enamel junction (DEJ) is not just an consisting mainly of type III collagen [13]. The
inactive interface between enamel and dentin but mineral content of mantle dentin has also been
seems to be much more complex and interactive thought to be lower than in circumpulpal dentin,

pilararaya@ejercer.cl
20
but the differences may be very minor [14], and
the change of the mineralization rate toward the
pulp may be more gradual [15, 16].
Although mantle dentin has traditionally been
considered to provide the elastic properties of
dentin necessary to withstand high occlusal
forces without enamel or dentin fractures, the
actual “resilience zone” may be much wider [1],
even up to 500 μm [17]. This may be contributed
to the changes in tubular direction [17], changes
in collagen fibril direction [18], and gradual
increase in mineralization from the DEJ toward
the pulp [15, 16].
2.5 Circumpulpal Dentin
2.5.1 Primary and Secondary
Dentin
Primary dentin is formed fast during the forma-
tion and growth of the tooth and forms the main
portion of dentin. After completion of primary
dentinogenesis, dentin formation continues as
secondary dentin at much slower rate (approxi-
mately 1/10) [1]. The exact timing of the “end” of
primary dentin formation has not been convinc-
ingly demonstrated, and animal experiments
have indicated that primary dentin formation
slows down gradually [19]. It is often difficult to
distinguish secondary dentin from primary dentin
even in histological or electron microscopy
images, and in clinical conditions it is not possi-
ble at all.
2.5.2 Composition of Dentin
Extracellular Matrix
Dentin organic matrix is in many ways similar to
that in bone; in other ways, it is quite unique. The
absence of type I collagen and high level of col-
lagen cross-linking is typical features to mineral-
ized tissue. About 90% of dentinal organic matrix
is type I collagen, the rest being non-collagenous
proteins such as proteoglycans and other pro-
teins, growth factors and enzymes, and small
amount of lipids [1]. However, mature human
pilararaya@ejercer.cl
L. Tjäderhane
odontoblasts produce type III collagen, and it is
present in dentinal tubules [20]. Type III collagen
is also found in dentinogenesis imperfecta [21]
and in reparative dentin under carious lesions
[22, 23].
2.5.3 Dentinal Tubules
Tubularity is an important characteristic of den-
tin, contributing, e.g., to the mechanical proper-
ties and behavior in dentin bonding. Although
the tubules are generally believed to extend
from the DEJ at right angles and run slightly
S-shaped course through the dentin, the direc-
tion may be different immediately beneath
enamel [17]. There may also be differences in
tubule orientation between the dental arches
[17], which may reflect the response to loading
of teeth under occlusal forces [1, 17]. Tubular
density is highest, and the direction is straighter
under the cuspal area [24], where the odonto-
blast processes and dense nerve innervation
have also been suggested to penetrate deeper
into the tubules [1]. These features may be
related to the sensing of external irritation and
regulation of dentin-pulp complex defensive
reactions, since the cusp tips are the first to be
worn in mastication [1].
2.5.4  eritubular Dentin and Dentin
P
Sclerosis
Peritubular dentin is highly mineralized circular
cuff forming to the inner walls of dentinal tubules
(Fig. 2.3). The name “peritubular” is, strictly
speaking, incorrect, since “peri” (“around,” “sur-
rounding,” “enclosing”) would indicate some-
thing that is formed around the tubules. A more
correct phrase would be intratubular, but since
“peritubular” has been and is still used exten-
sively, this phrase will also be used here.
Peritubular dentin formation causes an age-­
related reduction in tubular lumen even in intact
dentin, best seen in the increased dentinal trans-
parency advancing from the tip of the root toward
the crown with age [25]. In case of extensive
2 Dentin Basic Structure, Composition, and Function
a
b
Fig. 2.3 (a) Scanning electron micrograph of fractured
dentin about 1 mm from the dentin-pulp border.
Peritubular dentin (arrows) is present already this close to
the pulp. Magnification 2000× (from Goracci et al. [47],
with permission). (b) SEM image of dentin surface. In the
majority of tubules, peritubular dentin has fractured and
was lost during the polishing. Two tubules retain the peri-
tubular dentin (thick arrows) which appears non-fibrillar
and porous/perforated. The internal surfaces of tubule
walls exposed by the fragmentation of the peritubular den-
tin contain intertubular collagen fibrils (thin arrows) (from
Gotliv et al. [26], with permission)
wear or caries, the tubules may also be occluded
by mineral crystals formed due to reprecipitation
of minerals or from the mineral ions delivered
from the pulpal side via dentinal fluid. This phe-
nomenon is—confusingly—also called dentin
sclerosis, although “reactive (dentin) sclerosis”
might be the more appropriate term [1].
Peritubular dentin is a separate phase from
intertubular dentin, forming a distinct annulus
within each tubule instead of intertubular dentin
pilararaya@ejercer.cl
21
matrix-mediated crystallization (Fig. 2.3b).
However, peritubular dentin is often heteroge-
neous, and several separate or connected mecha-
nisms may occur at the same time [1, 4].
Peritubular dentin is perforated by tubular
branches but also by several small fenestrations
[26] (Fig. 2.3b), which allow tubular fluid and its
components pass back and forth across the peri-
tubular dentin. Peritubular dentin may thus not
act only as a passive blockage of dentinal tubules
but also contribute to the vitality and possibly
even remodeling of mineralized dentin as a
whole.
2.6 Tertiary Dentin
Tertiary dentin formation is a response to exter-
nal irritation, such as wear, erosion, trauma, car-
ies, or cavity preparation. The growth factors
present in mineralized dentin and liberated dur-
ing caries or wear are believed to initiate and con-
trol the tertiary dentin formation and structure
[27]. Tertiary dentin increases the mineralized
barrier thickness between oral microbes and
other irritants and pulp tissue, aiming to retain
the pulp tissue vital and noninfected. The form
and regularity of tertiary dentin depend on the
intensity and duration of the stimulus. There are
two kinds of tertiary dentin, namely, reactionary
dentin, formed by original odontoblasts, and
reparative dentin, formed by newly differentiated
replacement odontoblasts (Fig. 2.4) [2, 4].
Reactionary dentin is tubular and relatively simi-
lar to secondary dentin in structure, while repara-
tive dentin is usually atubular (or poorly
tubularized) and may present variable forms
(Fig. 2.5). Reparative dentin is believed to be
relatively impermeable, forming a barrier
between tubular dentin and pulp tissue.
2.7 Root Dentin
Root dentin bears strong resemblance but also
certain distinct differences to coronal dentin. The
outermost layer of root dentin, the granular layer
of Tomes, is located right beneath the root cemen-
22
Fig. 2.4 A model of the fate of odontoblasts under patho-
logical and physiological irritation. Intensive pathological
irritation (deep and/or active caries, extensive wear,
trauma), bacteria, and/or dentinal growth factors induce
local odontoblast death. At the same time, the pulp stem
cells migrate and differentiate into replacement odonto-
blasts and start the local synthesis of reparative dentin,
usually distinctly different from primary dentin (lack of
dentinal tubules, lamellar osteodentin-type calcification,
etc.). In teeth with physiological wear or other mild irrita-
tion, slow but continuous dentin formation (either physi-
ological or reactionary) by primary odontoblasts leads to
decrease in pulpal space (modified from Mitsiadis et al.
[2], and Tjäderhane and Haapasalo [4], with permissions)
tum. It is thought to represent the mantle dentin
with thin canaliculi and poorly fused globules
which perhaps represent the mineralization pat-
tern in the early stages of root dentin/cementum
formation [1]. The tubular density in root dentin
is at least moderately [24, 28] or even drastically
[29] lower than in coronal dentin, especially in
the most apical part [24, 28, 30, 31]. The apical
portion of human dentin has also other structural
variations, such as relatively large number of
accessory root canals, transient and repaired sur-
face resorption, and cementum-like lining the
apical root canal wall [1]. Interestingly, age-­
related root tubular sclerosis starts from the
pilararaya@ejercer.cl
L. Tjäderhane
Fig. 2.5 (a) Histological view at the dentin-pulp border
with physiological tubular dentin (TD) and reparative
dentin (RD) lacking tubular continuity. Also note the
poorly organized odontoblast-like cell layer. PT: pulp tis-
sue. Light microscopy, magnification 250×. (b) SEM
image of the borderline between normal tubular dentin
(TD) and atubular reparative dentin (RD). Magnification
1000× (both images from Goracci et al. [47] with
permission)
a­pical region and advances coronally [25, 32],
and it may be the main factor influencing perme-
ability of root dentin [33, 34] (Fig. 2.6a). Root
dentin has also other regional differences in per-
meability, as buccal/lingual root canal dentin has
patent tubules, while the mesial/distal dentin-
pulp borders may be completely occluded with
minerals [33, 34] (Fig. 2.6b). This kind of pat-
terns of tubule patency may correspond to local
stress distributions of the roots under occlusal
loading [1].
2 Dentin Basic Structure, Composition, and Function 23

Fig. 2.6 (a) Relative

mean dye penetration (in a
percentage of complete
dentin area) after
2-month methylene blue
incubation in
instrumented root canals
(data from Thaler et al.
[34]). (b) The patency of
tubules demonstrated in
lower molar roots with
the removal of
methylene blue stain
with 5.25% NaOCl
irrigation. Buccal and
lingual curvatures of
canals demonstrate clear
penetration, while in b
approximal and
especially furcal sides,
the effect is less
pronounced. At furcal
sites, the lack of tubular
patency is also seen with
the lack of methylene
blue staining. Reflective
light microscope, 10×
magnification

2.8 Physiological obliteration of the pulp chamber and root canals

and Pathological Changes even in intact teeth, due to physiological slow-­
in Dentin rate secondary dentin formation. In incisors,
canines, and premolars, the physiological age-­
2.8.1 Age-Related Changes related obliteration usually advances from the
coronal direction, while in molars the dentin in
The best known—and the most important in the pulp chamber floor may also grow toward the
terms of clinical endodontology—age-induced roof, contributing to the pulp chamber occlusion.
changes in human dentin-pulp complex are the The clinical relevance of these phenomena is

pilararaya@ejercer.cl
24 L. Tjäderhane

d­ iscussed in more details in other chapters of this
book.
The effects of aging on dentin mechanical
properties are less known and have been a sub-
ject of debate for decades. However, the more
recent studies strongly indicate that mineralized
dentin may not be as stable as previously indi-
cated, and the aging induces changes that should
be taken into consideration in clinical work.
Perhaps the most important aspect is the
increased mineralization—or more precisely,
increased mineral-to-­ collagen ratio—in aged
dentin that increases the hardness especially in
outer dentin [35]. This is mostly due to the peri-
tubular dentin occlusion of dentinal tubules [35,
36]. At the same time, the mechanical properties
of dentin change: the fatigue crack growth expo-
nent is about 40% lower [37], the endurance
strength about 48% lower [38], and the fatigue
crack propagation over 100 times faster [37] in
old than in young dentin. As a result, dentin flex-
ure strength has been calculated to reduce
approximately 20 MPa/decade [36, 38], and this
reduction correlates well with the occlusion of
tubules with age (Fig. 2.7). Reduction of the
lumen diameter and increase in mineral content
may not be the only factors contributing to the
changes in mechanical behavior of human dentin
with age, as changes in the organic components
have also been speculated to contribute to the
structural response [38]. While the potential age-
related changes in, e.g., dentin collagen cross-
link remain to be shown, loss of matrix-degrading
enzymes has already been demonstrated [39–41]
and may implicate also changes in their sub-
strates, including collagen and non-collagenous
proteins.
2.8.2 Caries-Affected Dentin
The concept of minimally invasive dentistry lim-
its the cavity preparation to the removal of
caries-­infected dentin, leaving the restoration to
be adhesive-bonded to caries-affected dentin.
The immediate bond strengths to caries-affected
dentin are commonly 20–50% lower than to
sound dentin and even lower with caries-infected
dentin [42]. Caries-affected dentin has lower
mineral content, increased porosity, and altered
structure and distribution of dentin collagen and
non-­collagenous proteins [43]. These changes
increase dentin wetness and significantly reduce
dentin mechanical properties, such as hardness,
stiffness, tensile strength, modulus of elasticity,
and shrinkage during drying [42] (Fig. 2.8),
which make the dentin in and under the hybrid
layer more prone to cohesive failures due to the
polymerization shrinkage (Fig. 2.9) and under
occlusal forces. In vitro experiments have shown

Fig. 2.7 The change in

average dentin tubular
lumen dimensions (red)
and the influence of age
on the strength of
coronal dentin (blue) in
adult human third
molars. “Cuff” indicates
peritubular dentin. The
average reduction in
strength over the adult
age span is 20 MPa per
decade at least until
approximately 50 years
of age (data adapted
from Arola et al. [36])

pilararaya@ejercer.cl
2 Dentin Basic Structure, Composition, and Function
Fig. 2.8 Shrinkage and stiffness of normal (intact) and
caries-affected dentin. Note the differences in both shrink-
age and stiffness scales (Y-axis) and water content (X-axis)
that even short exposure of dentin to lactic acid
(the acid produced by S. mutans and mainly
responsible for caries demineralization) at pH 5
significantly reduces dentin fatigue strength,
increases the rate of crack extension, and reduces
the fatigue crack growth resistance [44, 45] in a
way that is not prevented by sealing the tubular
lumens with adhesive resin [45]. Since fatigue
crack and its growth are precursors to unstable
fracture, lactic acid exposure, which has occurred
in caries-affected dentin and may again occur,
e.g., in secondary caries, substantially increases
the likelihood of restored tooth failure by­
fracture at lower mastication forces [45]. And
finally, deep restorations (typically present in
pilararaya@ejercer.cl
25
between the normal and caries-affected dentin (data
adapted from Ito et al. [48])
e­ ndodontically treated teeth) are more prone to
cracks and fractures, not only because of the
weaker structure due to loss of tooth tissue but
also because of the incremental crack extension
with significantly lower cyclic stresses in deep
vs. superficial dentin [46].
Taken together, the age- and caries-related
changes in dentin composition and structure that
may have deleterious effects on dentin mechani-
cal cannot be avoided. However, the dramatic
consequences, such as catastrophic tooth frac-
tures, can be avoided if the restorative procedures
are performed not only to repair and limit the
damage from caries but also to protect and pre-
serve the tooth structure.
26
a JC, Jonet L, Colin S, Tager F, Chaussain-Miller C,
b 243–50.
Fig. 2.9 (a) Dentin bonding over caries-affected dentin
that clinically appeared sound without apparent discolor-
ation. The interface between intact dentin and composite
resin is tight and intact, while over caries-affected dentin
the interface is clearly defective. Due to polymerization
shrinkage stress and shrinkage of the less mineralized
caries-affected dentin, cohesive fracture lines can be seen
on both sides of the caries-affected dentin. Reflected light
microscope, 20× magnification. (b) Higher magnification
of the interface at the caries-affected dentin site, clearly
demonstrating gap formation at the resin-dentin interface.
Reflected light microscope, 64× magnification
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C. Matrix metalloproteinases and other matrix pro-
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reduction in fatigue crack growth resistance of dentin
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48. Ito S, Saito T, Tay FR, Carvalho RM, Yoshiyama M,
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 Part II
Root Canal Components and Epidemiology

pilararaya@ejercer.cl
 Root Canal Components
Ronald Ordinola-Zapata, Marco A. Versiani,
and Clóvis Monteiro Bramante
Abstract
Essentially, the root canal system can be
divided into pulp chamber, located within the
anatomic dental crown, and the root canal
space, found inside the radicular portion of the
tooth. Other important components of the
internal anatomy of teeth include canal ori-
fices, apical foramina, apical ramifications,
and accessory, lateral, and furcation canals.
The purpose of this chapter is to describe
common features of the internal anatomy in
all groups of teeth, and, in addition, to provide
brief comments on its impact on diagnosis and
clinical procedures.
R. Ordinola-Zapata, D.D.S., M.Sc., Ph.D. (*)
Bender Division of Endodontics, Albert Einstein
Medical Center, Philadelphia, PA, USA
Dental School of Bauru, University of São Paulo,
Bauru, Brazil
M. A. Versiani, D.D.S., M.Sc., Ph.D.
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil
C. M. Bramante, D.D.S., M.Sc., Ph.D.
Dental School of Bauru, University of São Paulo,
Bauru, Brazil
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_3
pilararaya@ejercer.cl
3
3.1 Introduction
In 1919, Henry Morgan made an interesting anal-
ysis about what would be the object of dental
education [1]. From a formal point of view, the
answer was to make a dentist, a professional that
practices a healing art that aims to prevent or
relief human suffering. But, what would be the
foundation of every healing art? The answer is
the anatomy, one of the oldest branches of medi-
cine. Knowledge of root canal anatomy is essen-
tial in order to explain the treatment plan to a
patient, to properly examine radiological imag-
ing of teeth and surrounding structures, and, most
important, to perform invasive procedures. It is
also required to avoid iatrogenic injuries during
pulp chamber access, canal instrumentation, or
post-space preparation procedures. In addition, it
allows the detection of additional canals com-
monly correlated with persistent periapical dis-
ease. In summary, a deep understanding of the
canal morphology is an imperative requirement
for the success of the endodontic therapy.
Root canal treatment is indicated when the
pulp tissue of a tooth is damaged or infected
because of decay, trauma, iatrogenic operative
procedures, or deep fillings. Different bacteria
from the oral cavity can adhere to dentinal sur-
faces, invade the dentinal tubules and produce
pulpal inflammation that, lately, may spread
throughout the complexities of the root canal sys-
tem, compromising the periradicular tissues. This
31
32
statement is supported by several clinical and
laboratory studies which have demonstrated that
the main etiology of endodontic failure is intrara-
dicular infection [2, 3]. In this way, knowledge of
the common anatomy and its variations would
favor an effective reduction of bacterial popula-
tion from the main root canal, by using a proper
chemomechanical preparation and intracanal
dressing protocols, able to reach both transversal
and vertical extension of the root canal system [3,
4], followed by obturation and coronal restora-
tion, aiming to avoid future contamination or
repopulation of the cleaned canal space by
remaining bacteria [5].
3.2  natomy of the Root Canal
A • Law of concentricity: The walls of the pulp
System
The root canal system can be divided into two
parts: the pulp chamber, located within the ana-
tomic dental crown, and the root canal space,
found inside the radicular portion of the tooth.
3.2.1 Pulp Chamber
The pulp chamber is a cavity situated in the cen-
ter of the crown and, under no pathological con-
ditions, resembles the shape of the crown surface.
In anterior teeth, pulp chamber and root canal are
continuous, while, in posterior teeth, pulp cham-
ber floor separates these two components. In pre-
molars and molars, pulp chamber usually presents
a square shape with six sides: the floor, the roof,
and four axial walls identified as mesial, distal,
buccal, or lingual (palatal). The pulp chamber
roof usually presents projections or prominences
associated to the cusps, mamelons or incisal
edges, and denominated pulp horns [6]. As
pointed out in chapter 2, its morphology can be
modified by the odontoblasts present in the pulp
tissue. These cells produce secondary and tertiary
dentin through patient’s life. Thus, in teeth with
physiological wear or other irritation, continuous
dentin formation (either physiological or reac-
tionary) by primary odontoblasts may lead to a
decrease in the pulpal space dimensions which,
pilararaya@ejercer.cl
R. Ordinola-Zapata et al.
in some cases, can difficult root canal treatment.
Strictly speaking, access to the root canal system
in teeth with calcified pulp chamber is more chal-
lenging than in young permanent teeth. Based on
the anatomical study of 500 teeth, Krasner and
Rankow [7] demonstrated that specific and con-
sistent pulp chamber anatomy exists. Then, they
proposed some laws for aiding the determination
of the pulp chamber position as well as the loca-
tion and number of root canal entrances in each
group of teeth (Figs. 3.1 and 3.2):
• Law of centrality: The floor of the pulp cham-
ber is always located in the center of the tooth
at the level of the cementoenamel junction
(CEJ).
chamber are always concentric to the external
surface of the tooth at the level of the CEJ, i.e.,
the external root surface anatomy reflects the
internal pulp chamber anatomy.
• Law of the CEJ: The distance from the exter-
nal surface of the clinical crown to the wall of
the pulp chamber is the same throughout the
circumference of the tooth at the level of the
CEJ—the CEJ is the most consistent, repeat-
able landmark for locating the position of the
pulp chamber.
• Law of symmetry 1: Except for maxillary
molars, the orifices of the canals are equidis-
tant from a line drawn in a mesial-distal direc-
tion, through the pulp chamber floor.
• Law of symmetry 2: Except for the maxillary
molars, the orifices of the canals lie on a line
perpendicular to a line drawn in a mesial-­
distal direction across the center of the floor of
the pulp chamber.
• Law of color change: The color of the pulp-­
chamber floor is always darker than the walls.
• Law of orifice location 1: The orifices of the
root canals are always located at the junction
of the walls and the floor.
• Law of orifice location 2: The orifices of the
root canals are located at the angles in the
floor-wall junction.
• Law of orifice location 3: The orifices of the
root canals are located at the terminus of the
root developmental fusion lines.
3 Root Canal Components
a b
Fig. 3.1 Law of centrality, concentricity, and orifice loca-
tions observed through micro-CT sagittal and transverse
cross-sectional planes from a maxillary first molar. (a)
Detail of the pulp chamber; (b, c) projection of the root
In addition to knowing these laws, the use of
illumination and magnification associated with
special instruments, such as ultrasound tips,
would provide the best approach to explore all
anatomic variations of the pulp chamber in
order to locate all canal orifices and avoid
missed canals which has been considered one of
the main causes of endodontic failure (Fig. 3.3).
Amongst the most common missed canals asso-
ciated to cases with persistent periapical disease
are the second mesiobuccal canal of maxillary
molars (MB2 canal), lingual canals of mandibu-
lar incisors and premolars, and the middle
mesial and distolingual canals of mandibular
molars.
pilararaya@ejercer.cl
33
c
canal axis (white lines) converges to the center of the ana-
tomical crown; (d) the projection of the pulp chamber
floor into the coronal enamel dictates the ideal form of the
access (green area)
3.2.1.1 Minimally Invasive
Endodontics: Clinical
Considerations
In recent years, considerable attention has been
given to the anatomy of the pulp chamber. The
use of the operative microscope, three-­
dimensional imaging technology, ultra-flexible
files, and superior illumination has opened new
possibilities, allowing minimally invasive proce-
dures during endodontic treatment, mostly
related to changes in access preparation (Fig. 3.4).
This approach aimed to preserve tissue from
healthy tooth structure in order to avoid structural
failure in the future. This concept overlooks the
traditional requirements of straight-line access
34
a b
c d
Fig. 3.2 Micro-CT 3D reconstruction images of p­ osterior
teeth demonstrating the (a) laws of centrality and
­concentricity at CEJ level; (b) laws of color change and
and complete unroofing of the pulp chamber
emphasizing the importance of preserving the
pericervical dentin [8]. The pericervical dentin
has been defined as the dentin near the alveolar
crest extending 4 mm apical to the crestal bone
[9]. It has been quoted that the resistance to frac-
ture is closely related to the amount of residual
tooth structure at this level. Whereas there is no
agreement if this procedure will lead to a better
prognosis of the root canal treatment in clinics,
laboratory studies have shown that contracted
endodontic cavities are not deleterious for the
cleaning and shaping process in incisors, premo-
lars, and molars and conveyed a benefit of
increased fracture resistance in mandibular
pilararaya@ejercer.cl
R. Ordinola-Zapata et al.
orifice locations 1, 2, and 3 (arrow: developmental fusion
lines); and (c, d) laws of symmetry 1 and 2
molars and premolars [10]. Thus, efforts should
be made to identify pulp chamber components
without removing excessive dentin structure,
when using magnification, and there is no risk to
jeopardize the treatment outcome.
3.3 Root Canal
The root canal is the portion of the pulp canal
space within the root of the tooth limited by the
pulp chamber and the foramen that follows the
external outline of the root. The root canal can be
subdivided into two components, the main canal,
which is mostly cleaned by mechanical means,
3 Root Canal Components
Fig. 3.3 Root canal treatment of a maxillary first molar
with necrotic pulp and asymptomatic apical periodontitis.
The laws of color change and orifice locations can be
observed in the image of the pulp chamber. Observe how
different is the color of the pulp chamber compared to the
and lateral components composed by isthmuses,
accessory canals (furcation, lateral, and second-
ary canals) (Fig. 3.5), and some recesses of flat-
tened- and oval-shaped canals (Fig. 3.6).
In longitudinal section, canals are usually
broader buccolingually than in the mesiodistal
plane. The geometric cross-sectional shape of
root canals has been classified by calculating the
mean aspect ratio, defined as the ratio of the
major to the minor canal diameters. The major
diameter is the distance between the two most
distant points of the canal in the buccolingual
direction, while minor diameter is the longest
chord through the root canal that could be drawn
in the direction orthogonal to that of the major
diameter. Accordingly, an oval-shaped canal has
an aspect ratio between 1 and 2, a long oval canal
pilararaya@ejercer.cl
35
canal walls and location of the canal orifices. The con-
tracted access did not avoid the location and cleaning of
the second canal of the mesiobuccal root, the so-called
MB2 canal
higher than 2 but lower than 4, and a flattened
canal higher than 4 (Fig. 3.7). It is interesting to
point out that, in a same tooth, canal cross sec-
tions may show different shapes at different lev-
els of the root; but, at the apical third, it is more
round or slightly oval in shape in comparison
with the middle and cervical thirds [11, 12].
As mentioned, the anatomy of the root canal
systems is often complex and can vary greatly in
number and shape. Considering the large amount
of variations, different classification systems
have been proposed. These systems are based on
the number of root canals that begin at the pulp-­
chamber floor, arise along the course of the canal,
and open through an apical foramen. Recently,
Versiani and Ordinola-Zapata [6] reviewed the
literature and described the 37 most common
36
Fig. 3.4 Coronal view of micro-CT reconstruction images
of different teeth comparing the size of minimally invasive
(left) and the conventional (right) access preparations
canal configurations including almost all anatom-
ical configurations possible to be observed in a
single root (Fig. 3.8).
3.3.1 Isthmus
An isthmus, also called transverse anastomosis,
is a narrow, ribbon-shaped communication
between two root canals that may contain vital
pilararaya@ejercer.cl
R. Ordinola-Zapata et al.
tissue, necrotic pulp, biofilms, or residual filling
material [13, 14]. The presence of a partial isth-
mus, described as an incomplete communication
with one or more patent openings between two
main canals, has also been reported [13]. Isthmus
may present different configurations (Fig. 3.9),
and its prevalence is dependent on the type of
teeth, the root level, and the patient’s age. Hsu
and Kim [15] classified the isthmuses configura-
tion into five types:
• Type I: two canals with no notable
communication.
• Type II: a hair-thin connection between the
two main canals.
• Type III: differs from type II because of the
presence of three canals instead of two.
• Type IV: an isthmus with extended canals into
the connection.
• Type V: there is a true connection or wide cor-
ridor of tissue between two main canals.
A summary of the isthmuses prevalence in
mandibular and maxillary molars found in labo-
ratory studies is shown in Table 3.1. It is notewor-
thy that experimental studies demonstrated the
impossibility to obtain a complete mechanical
debridement or chemical disinfection of the isth-
mus with the current technology, mostly because
of the presence of hard tissue debris, packed into
these areas during the mechanical preparation of
the root canal system [5, 28]. Clinical studies
have also demonstrated that unfilled isthmuses
can be commonly observed after root-end resec-
tion in cases referred for apicoectomy treatment
[29, 30]. These limitations, however, can be sur-
passed in nonsurgical treatment by using chemi-
cal agents with the ability to dissolve organic
tissue at fins and isthmuses level associated with
ultrasonic activation [28]. Besides, with the
advent of operatory microscope, it is possible to
visualize, identify, and treat most of the isthmus
areas with thin ultrasonic tips in both surgical and
nonsurgical endodontic procedures, to ensure its
debridement and seal [13, 15, 28, 31].
3 Root Canal Components
Fig. 3.5 Micro-CT 3D reconstructions of the internal
anatomy of mandibular premolars showing the main com-
ponents of the root canal system. (a) Main canal; (b) lat-
eral canal (located at the coronal or middle thirds. When it
begins at the furcation level is denominated furcation
a b
Fig. 3.6 3D reconstructions of the root canal system of
2 mesiobuccal roots of maxillary molars showing how the
anatomical complexities of root canal components may
affect the mechanical debridement. Areas in red represent
the original anatomy, while areas in green are the dentin
removed during preparation of both mesiobuccal canals.
Root canals in (a) do not have significant lateral compo-
3.3.2 Accessory Canals
Accessory canal is any branch of the root canal
that communicates with the periodontal ligament,
while a lateral canal is defined as an accessory
canal located at the coronal or middle third of the
pilararaya@ejercer.cl
37
canal); (c) secondary canal (accessory canal located at the
apical third); (d) intercanal, transverse anastomosis, or
isthmus; (e) recurrent canal; and (f) apical ramifications or
apical delta
nents; thus, root canal preparation was able to remove
most of the dentinal surface of the original canal perime-
ter. Only minor areas were not touched by the instru-
ments; (b) in this case, there are significant lateral
components, including an isthmus extending from the
coronal to middle third (red areas) and an accessory canal
in the apical third
root (Fig. 3.9d) [32]. They are formed after a local-
ized fragmentation of the epithelial root sheath
develops, leaving a small gap, or when blood
­vessels running from the dental sac through the
dental papilla persist [33, 34]. Accessory canals
represent potential pathways through which
38 R. Ordinola-Zapata et al.

Fig. 3.7 Micro-CT transversal cross sections of the ana- lar. The canal is round-shape only at the coronal and apical
tomical crown, pulp chamber, middle third, and 3 mm thirds of the mandibular incisor, while both premolars have
from the apex (from left to right) of (a) a mandibular inci- long oval- and flattened-shaped canals. The mandibular
sor, (b) a mandibular premolar, and (c) a maxillary premo- incisor presents an oval canal at the middle third level

Fig. 3.8 Thirty-seven most common canal configurations including almost all anatomical configurations possible to be
observed in a single root [6] (published with permission)

pilararaya@ejercer.cl
3 Root Canal Components 39

a b c

d e f

Fig. 3.9 Micro-CT transversal cross section of poste-
rior teeth showing (a) a type II isthmus (hair connec-
tion), (b) a type III isthmus and the presence of a
middle canal, (c) a true connection or wide corridor
between the main canals, (d) an isthmus c­ ommunicating
the root canal system to the periodontal ligament
through a lateral canal, (e) an isthmus connecting sev-
eral canals in a fused root leading to the formation of a
C-shaped canal, and (f) an apical delta showing at least
six portals of exit

Table 3.1 Summary of laboratory studies on the prevalence and position of canal isthmuses in the mesial root of man-
dibular molars and mesiobuccal (MB) root of maxillary molars
Authors Methodology
Weller et al. [13] Transverse serial 1-mm-thick sections
from the apical 6 mm of 50 MB roots of
maxillary first molars were examined
under surgical operating microscope
Teixeira et al. [16] Transverse serial 1-mm-thick sections
from the apical 6 mm of 50 MB roots of
maxillary molars and 50 mesial roots of
mandibular first molars were examined
through a light microscope
Mannocci et al. [17] 800 cross sections from the apical 5 mm
of 20 mesial roots of mandibular first
molars were investigated by means of
micro-CT technology
Jung et al. [18] Transverse serial 1-mm-thick sections
from the apical 5 mm of 47 MB roots of
maxillary first molars and 50 mesial roots
of mandibular first molars were examined
through microscope
Degerness Transverse serial 0.44-mm-thick sections
and Bowles [19] from the apex of 153 MB roots of
maxillary first and second molars were
examined through stereomicroscope
Fan et al. [20] Cross-sectional images from the apical
5 mm of mesial roots of mandibular first
(n = 70) and second (n = 56) molars,
respectively, were investigated by means
of micro-CT technology
Conclusion
The mean frequency of isthmus was 30%,
65%, 90%, 100%, 82%, and 81% from 1 to
6 mm levels from the apex
Maxillary molars: the mean frequency of
isthmus was 11.4%, 20%, 31.5%, and 23.6%
from 3 to 6 mm from the apex. Mandibular
molars: the mean frequency of isthmus was
6.6%, 11.9%, 20.5%, 30.3%, 33.3%, and
32.4% from 1 to 6 mm from the apex
The mean frequency of isthmus was 17.2%,
36.7%, 50.2%, 33%, and 34.7% from 1 to
5 mm from the apex
Maxillary molars: the mean frequency of
isthmus was 52.7%, 52.6%, 63.2%, and
44.7% from 2 to 5 mm from the
apex. Mandibular molars: the mean frequency
of isthmus was 60%, 80%, 82.5%, and 70%
from 2 to 6 mm from the apex
The mean percentage of sections with isthmus
up to 5 mm from the apex was 8.5%
(0.64 mm), 35.3% (1.62 mm), 43.8%
(2.15 mm), 51.6% (3.12 mm), 60.2%
(3.64 mm), 66.7% (4.58 mm), and 76.5%
(5.1 mm)
The prevalence of isthmus in the apical 5 mm
of the mesial roots was 85%. Mandibular first
molars had more isthmuses with separate and
mixed types, whereas second molars had
more isthmuses with sheet connections
(continued)

pilararaya@ejercer.cl
40 R. Ordinola-Zapata et al.

Table 3.1 (continued)

Authors Methodology Conclusion
Villas-Boas et al. [21] 1.0 mm increment cross-sectional images The mean frequency of isthmus was 45%,
from the apical 4 mm of mesial roots of 55%, 71%, and 68% from 1 to 4 mm from the
60 mandibular molars were investigated apex
by means of micro-CT technology
Pécora et al. [22] 200 extracted maxillary and mandibular In maxillary molars, isthmuses were detected
molars, and consecutive 200 molars in 86% and 62% of the ex vivo and in vivo
selected from CBCT exams, were assay, respectively, whereas in mandibular
evaluated in axial slices of molars isthmuses were observed in 70% of
0.5 mm/0.5 mm from coronal to apical the ex vivo and 72% of the in vivo assay
level
Harris et al. [23] 0.5 mm increment cross-sectional images Isthmuses were found along the length of all
from the apical 6 mm of mesial roots of mesial roots. On average, they started at
22 mandibular molars were investigated 4-mm level and ended 8.1 mm from the apex
by means of micro-CT technology
Mehrvarzfar et al. [24] 60 extracted mandibular molars were 83% of molars had isthmus at the mesial root.
sectioned horizontally at 2, 4, and 6 mm This prevalence increased with distance from
levels from the apex and examined using the apex, i.e., 92% at 6 mm from the apex and
a stereomicroscope at ×30 70% at 2 mm from the apex
Lima et al. [25] 128 maxillary and mandibular molars The highest isthmus incidence was at 7.0 mm
were sectioned at different distances from from the apex with a low percentage in areas
the apex (1.0–2.5–4.0–5.5–7.0 mm) and close to the apex. Isthmus type V was
evaluated by stereomicroscopy observed in 28.8% of the sample, while type
IV was more frequent in the mesial root of
first (36%) and second (23.9%) mandibular
molars
Estrela et al. [26] 1400 teeth of 618 patients were evaluated The highest frequency of isthmus was found
on 0.1 mm/0.1 mm axial slices of CBCT in mandibular first molars (87.9%). Its
images of roots scanned from the pulp frequency, according to mean age and tooth
orifice to the apex group, was not significantly different, except
in mandibular central incisors. Isthmus was
less frequent among older patients
Tahmasbi et al. [27] In vivo evaluation of 122 mandibular first The frequency of isthmus in the mesial roots
and second molars with CTCB scan of mandibular molars was 64.7% being higher
in second molars

b­ acteria and/or their products from the necrotic
root canal might reach the periodontal ligament
and cause disease [33]. De Deus [35] studied the
frequency, location, and direction of the accessory
canals in 1140 teeth and showed that 27.4% of the
sample (n = 330) had accessory canals, especially
in the apical area (17%), followed by the middle
(8.8%) and coronal (1.6%) thirds. Similarly,
Vertucci [36] evaluated 2400 teeth and observed
lower occurrence of canal ramifications in the
middle (11.4%) and coronal (6.3%) thirds com-
pared to the apical level (73.5%).
Lateral canals are not usually visible in preop-
erative radiographs, but its presence can be sus-
pected when there is a localized thickening of the
periodontal ligament or a lesion on the lateral
surface of the root (Fig. 3.10). According to
Weine [37], lateral lesions can be radiographi-
cally classified into three types:
• Type I: lateral lesion with no apical lesion—as
the infection progresses apically, it might
reach a sufficiently large lateral canal to allow
a substantial amount of bacteria and bacterial
products to reach the lateral periodontium to
cause inflammation.
• Type II: separate lateral and apical lesions—if
the pathological process advances without
professional intervention, an apical periodon-
titis lesion can also be visible.

pilararaya@ejercer.cl
3 Root Canal Components
a b
Fig. 3.10 CBCT sagittal and transverse cross-sectional
planes of a mandibular first molar diagnosed with pulp
necrosis and apical periodontitis. (a) Presence of a
• Type III: coalescence of lateral and apical
lesions—in some cases, the type II condition
can progress to the so-called “wraparound”
lesion.
Actually, these types might represent different
stages of the disease progression within the root
canal space once the conditions of the tissue
within lateral canals and apical ramifications
reflect the conditions of the pulp in the main root
canal [33]. Clinically, it is also relevant that lat-
eral canals cannot be instrumented. In this way,
its content can only be neutralized by means of
effective irrigation with a suitable antimicrobial
solution or with an additional use of intracanal
medication.
Canals connecting the pulp chamber to the
periodontal ligament in the furcation region of a
multi-rooted tooth are called furcation canals
[32]. These canals derived from entrapment of
periodontal vessels during the fusion of the parts
of the diaphragm, which will become the floor of
the pulp chamber. In some cases, furcation canals
have been associated to primary endodontic
lesions in the interradicular region of multi-­
rooted teeth. Vertucci and Williams observed the
presence of furcation canals in 13% of mandibu-
lar first molars [38] and, in most of them (n = 7),
the canal extended from the center of the pulpal
floor, while in four and two specimens, respec-
tively, the canals arose from the mesial and distal
aspects of the floor. Later, Vertucci and Anthony
[39] observed the presence of foramina on both
the pulp chamber floor and the furcation surface
in 36% of maxillary first molars, 12% of m­ axillary
pilararaya@ejercer.cl
41
l­ateral root lesion with furcal involvement; (b) lateral
lesion was associated with a lateral canal in the mesial
root (arrows)
second molars, 32% of mandibular first molars,
and 24% of mandibular second molars. Recently,
micro-computed tomographic studies have also
demonstrated the presence of furcation canals in
two-rooted mandibular canines and three-rooted
mandibular premolars (Fig. 3.11).
3.3.3 Apical Canal
The main root canal ends at the apical foramen
(major foramen) which frequently opens laterally
on the root surface, at a mean distance between
0.2 and 3.8 mm from the anatomic apex [40],
despite larger distances having been also reported
[41]. The anatomic apex is the tip or the end of
the root as determined morphologically [32].
Depending on the type of teeth, the apical fora-
men can coincide with the anatomic apex in a
percentage frequency ranging from 6.7% to 46%
of the cases [36, 42–45]. Its diameter has been
described between 0.21 and 0.39 mm [46]. The
mesial roots of mandibular molars, the maxillary
premolars, and the mesiobuccal roots of maxil-
lary molars show the highest percentage of mul-
tiple apical foramina [46]. A previous study on
root apexes of all groups of permanent teeth
showed that the number of foramina on each root
may vary from 1 to 16 [40].
The apical portion of the root canal having the
narrowest diameter has been called “apical
constriction” (minor foramen) [32]. From the
­
apical constriction, the canal widens as it
approaches the apical foramen. The topography
of the apical constriction is not constant [12, 47]
42 R. Ordinola-Zapata et al.

Fig. 3.11 Accessory canals connecting the pulp chamber to the periodontal ligament in the furcation region (arrows)
of multi-rooted mandibular (a) canine and (b) premolar teeth

and, when present, is usually located 0.5–1.5 mm
from the center of the apical foramen [14]. The
cementodentinal junction (CDJ) is the point at
which the cemental surface terminates at or near
the apex of a tooth and meets dentin [32]. At this
histological landmark, pulp tissue ends and peri-
odontal tissues begin [48] (Fig. 3.12).
Another relevant variation of the root canal at
or near the apex is the apical ramification or api-
cal delta, defined as a morphology in which the

pilararaya@ejercer.cl
3 Root Canal Components 43

a b

Fig. 3.12 (a) Single-rooted tooth with working length
determined in vitro at 1 mm from the apical foramen.
Observe that a significant portion of the apical canal will
be left without proper preparation if only radiography
is used as a reference; (b) Single-rooted tooth showing
the tip of the instrument at the foramen level. In this
specimen, constriction is less than 0.5 mm from the
­
r­ adiographic apex. The main root canal of the tooth on the
right has a higher chance to be mechanically ­prepared in
its apical portion than the tooth on the left. These images
show that the use of apex locators is mandatory for proper
working length determination (courtesy of Dr. Nole, Cajo,
Ccolcca y Oscco. Ica-Peru)

main canal divides into multiple accessory canals iatrogenic errors preoperative recognition of
(Figs. 3.5f and 3.9f) [32]. In maxillary teeth, the canal curvature is of utmost importance [49].
percentage frequency of apical delta ranges from Nearly all root canals are curved in the apical
1% (central incisors) to 15.1% (second premo- third, particularly in a buccolingual direction,
lars), while in mandibular teeth, its frequency which is not evident on standard radiography
varies from 5% (central incisors) to 14% (distal [14]. In general, the curvature may vary from
root of first molars) [36]. Clinically speaking, the gradual curvature of the entire canal, sharp curva-
infection of this tortuous and complex anatomi- ture of the canal near the apex, or a gradual curva-
cal configuration with several portals of exit can ture of the canal with a straight apical ending.
be related as an etiologic factor of nonsurgical Numerous methods have been proposed to deter-
failures. mine root canal curvature [37, 50–55], but the
Schneider’s method has been the most widely
used. Schneider [56] classified single-rooted per-
3.4 Root Canal Curvature manent teeth according to the degree of curvature
of the root, which was determined by firstly draw-
Knowledge of the root canal curvature is also an ing a line parallel to the long axis of the canal and
important factor for choosing the appropriate then a second line connecting the apical foramen
chemomechanical protocol to prepare the root to the point in the first line where the canal began
canal system. Before the introduction of nickel-­ to leave the long axis of the tooth. The angle
titanium (NiTi) instruments, several iatrogenic formed by these two lines was the angle of curva-
procedures were associated with the preparation ture, and its degree was classified as straight
of curved canals including zips, separate instru- (≤5°), moderate (10–20°), or severe (25–70°).
ments, ledges, and perforations. Nowadays, these Another method was introduced by Weine [57]
iatrogenic complications are no longer a prob- and also relies on the definition of two straight
lem, except for the instrument separation. lines, but it reflects the root canal curvature more
Therefore, this is one of the factors determining accurately than Schneider’s method, especially in
the difficulty of a treatment, and the likelihood of the apical part. A third ­proposal, geometrically

pilararaya@ejercer.cl
44
a b
Fig. 3.13 Radiographic images taken in different angles
of a mandibular molar demonstrating the tridimensional
aspect of the canal curvature. The instrument in the mesial
equivalent to Weine’s method, was introduced by
Pruett et al. [58], but its major innovation was the
concurrent measurement of the radius of curva-
ture by the superimposition of a circular arc on the
curved part of the root canal [59]. Therefore,
Schneider angle, when used in combination with
the radius and length of the curve, may provide a
more precise method for describing the apical
geometry of canal curvature.
Clinically, different angled views are neces-
sary to determine the presence, direction, and
severity of the root canal curvature. Schäfer et al.
[60] evaluated radiographically the curvature
degree of 1163 root canals from all groups of
teeth. The degree of curvature ranged from 0° to
75° and from 0° to 69° in clinical and proximal
views, respectively. The highest degree of curva-
ture was observed in the clinical view of the
mesiobuccal canal of maxillary molars and in the
mesial canals of mandibular molars. In several
cases, the angles of proximal curvatures were
higher than those of the clinical view (Fig. 3.13).
Additionally, a secondary curvature (S-shaped
canal) was observed in 12.3% and 23.3% of the
maxillary and mandibular teeth, respectively.
3.5 Concluding Remarks
It is noteworthy to point out that some factors can
modify the anatomy of the pulp chamber and root
canals such as aging, caries, periradicular
pilararaya@ejercer.cl
R. Ordinola-Zapata et al.
c d
canal is curved in both (a, b) proximal (mesial-to-distal
direction) and clinical (c, d) views (buccal-to-lingual
direction)
p­ athologies, and occlusion [34]. Thus, a careful
analysis of angled radiographs, the use of cone-
beam computed tomography, proper access prepa-
ration, and a detailed exploration of the root canal
system under magnification are essential require-
ments for successful treatment outcome [14].
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34. Nanci A, Ten Cate AR. Ten Cate’s oral histology:
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 New Proposal for Classifying Root
and Root Canal Morphology
4
Hany M. A. Ahmed, Marco A. Versiani,
Gustavo De-Deus, and Paul M. H. Dummer

Abstract 4.1 Introduction

Understanding the anatomy of roots and root
canals is fundamental for successful root canal
treatment and endodontic surgery. There are
numerous reports on anatomical variations of
teeth, and several classifications of canal con-
figurations have been proposed. Recently,
improved nondestructive digital imaging sys-
tems and the use of magnification in clinical
practice have further highlighted the complex-
ities of root canal anatomy. This chapter
reviews the existing classifications of root and
root canal morphology and introduces a new,
accurate, simple, and reliable system for
research, clinical, and training purposes.
H. M. A. Ahmed, B.D.S., H.D.D., Ph.D. (*)
Department of Restorative Dentistry, Faculty of
Dentistry, University Malaysia,
Kuala Lumpur, Malaysia
M. A. Versiani, D.D.S., M.Sc., Ph.D.
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil
G. De-Deus, D.D.S., M.Sc., Ph.D.
School of Dentistry, Fluminense Federal University,
Niterói, RJ, Brazil
P. M. H. Dummer, D.D.Sc., M.Sc., Ph.D.
School of Dentistry, College of Biomedical and Life
Sciences, Cardiff University, Cardiff, UK
Successful root canal treatment requires a thor-
ough knowledge of root canal morphology to
properly access the root canal system and remove
microorganisms and pulp tissue [1]. Human tooth
types have variations in terms of the number and
shape of roots and root canals [2–7]. For decades,
this topic has been the subject of numerous
experimental and clinical reports; evidently, root
and canal morphology varies significantly
between populations, within populations, and
within the same individual [2, 6, 8, 9].
Data from the classical work of Hess and
Zürcher [10] and those of recent investigations
have demonstrated that classification systems
that define root canal configurations are required.
Weine et al. [11], using sectioning and radio-
graphic methods, were the first to categorize root
canal configurations within a single root into
three types dependent on the division of the main
root canal along its course from the pulp chamber
to the root apex (Fig. 4.1a). Vertucci et al. [12]
developed a classification system based on the
evaluation of 200 cleared maxillary second pre-
molars, wherein the pulp cavities were stained
with dye; they found eight canal systems that
were more complex than those described by
Weine et al. [11] (Fig. 4.2b). Later, Weine [13]
added an additional category (Type IV) to his
original system (Fig. 4.1a).

© Springer International Publishing AG, part of Springer Nature 2019 47

M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_4

pilararaya@ejercer.cl
48
a Other classifications have been introduced for
b cally the diversity of canal configurations, addi-
Fig. 4.1 (a) Diagrammatic representations of Weine’s clas-
sification for root canal morphology (Weine et al. [11, 13]).
Type I, a single canal from pulp chamber to the apex (1-1
configuration); Type II, two separate canals leaving the
chamber but merging short of the apex to form a single canal
(2-1 configuration); Type III, two distinct canals from pulp
chamber to the apex (2 configuration); Type IV, a single canal
leaving the chamber and dividing into two separate canals at
the apex (1-2 configuration). (b) Diagrammatic representa-
tions of Vertucci’s classification for root canal morphology
(Vertucci et al. [12]). Type I, a single canal from pulp chamber
to the apex (1-1 configuration); Type II, two separate canals
leaving the chamber but merging short of the apex to form
a single canal (2-1 configuration); Type III, a single canal
that divides into two and subsequently merges to exit as one
(1-2-1 configuration); Type IV, two distinct canals from pulp
chamber to the apex (2 configuration); Type V, a single canal
leaving the chamber and dividing into two separate canals at
the apex (1-2 configuration); Type VI, two separate canals
leaving the pulp chamber, merging in the body of the root,
and dividing again into two distinct canals short from the apex
(2-1-2 configuration); Type VII, a single canal that divides,
merges, and exits into two distinct canals short from the apex
(1-2-1-2 configuration); Type VIII, three distinct canals from
pulp chamber to the apex (3-3 configuration) (modified from
Ahmed et al. [14] and published with permission)
pilararaya@ejercer.cl
H. M. A. Ahmed et al.
specific tooth types, such as maxillary molars
with four roots [5, 15–17], maxillary premolars
with three canals [8, 18], middle mesial canals
[19], and distolingual roots in mandibular molars
[20]. Recently, Kottoor et al. [21] and Albuquerque
et al. [22] proposed a nomenclature to classify
root canal anatomy in maxillary and mandibular
molars, respectively.
Despite these efforts to describe systemati-
tional types of root canal morphology within
different populations have been reported [6, 23–
26]. Based on a review of previous reports and
anatomical studies on root canal morphology
using micro-CT technology, Versiani and
Ordinola-Zapata [27] described 37 root canal
configurations that included the most common
anatomical configurations observable in a single
root (see Chap. 3). Notwithstanding these efforts,
a simple classification system that can be applied
for all root types and root canal configurations in
all groups of teeth has not been established.
4.2 Why a New Classification?
The systems by Weine et al. [11], Vertucci et al.
[12], and Weine [13] have been the most common
classifications and are beneficial when categoriz-
ing most canal configurations. Recent reports on
the identification of external and internal anatomi-
cal canal variations using advanced 3D imaging
technology revealed that the morphology of root
canal systems is highly complex, and many canal
configurations are non-classifiable using these
systems [28–31]. For example, one study [32]
reported that as many as 13% of specimens can-
not be fitted into the system by Vertucci et al. [12].
The literature has revealed inconsistencies in
the classification of the internal anatomy of sev-
eral tooth types, such as the maxillary premolar
with three canals. Vertucci et al. [12] categorized
this variation as Type VIII and defined it as three
separate, distinct root canals extending from the
pulp chamber to the apex. However, no informa-
tion in the classification was provided to describe
if these canals are encased in single-, double-, or
three-rooted teeth (Fig. 4.2). Therefore, in most
4 New Proposal for Classifying Root and Root Canal Morphology 49

Lateral view Apical view Internal view Root canal

Fig. 4.2 External and internal views of three maxillary with two root canals in fused buccal roots and a single
first premolars classified as Vertucci’s type VIII root canal canal in the palatal root; bottom, three-rooted premolar
configuration according to the literature. Top, premolar with three independent root canals (modified from Ahmed
with three root canals in fused roots; middle, premolar et al. [14] and published with permission)

pilararaya@ejercer.cl
50
studies, three-canalled single-, double-, or three-­
rooted maxillary premolars are referred to as
Type VIII configuration [12, 33–35]. During clin-
ical management of teeth undergoing root canal
treatment, the root number, and not just canals,
should be defined because of their implications
during access cavity preparation, canal instru-
mentation, and root filling procedures [8].
Briseño-Marroquin et al. [36] introduced a
four-digit classification of root canal configura-
tions, wherein each root is divided into thirds
(each third has a digit); the fourth digit denotes
the main foramina, which emerge from the same
canal at the apical terminus and have diameters
of no less than 0.2 mm. Nevertheless, in this
classification, no root component information is
given. Additionally, the clinical practicality of
this system is a concern, i.e. dividing the root
into thirds and defining the main apical foram-
ina based on their diameters.
Recently, Gupta and Saxena [37] introduced a
diagrammatic representation of the root canal.
The representation consists of five horizontal
lines dividing the tooth into four segments from a
reference point, and the root canal length is mea-
sured through the apical foramen. The diagram-
matic images of one anterior and one posterior
multi-rooted tooth are provided to clarify the
image orientation. Freehand vertical lines are
drawn to represent the major root canals. The
lines representing the canals are labeled where
the vertical lines start. The individual canal length
from the reference point to the apical foramen
can be written (in millimeters), depending on the
situation. Intercanal communications, isthmuses,
and accessory and lateral canals can be drawn as
well (that is, you draw what you see). Moreover,
images can be saved in portable network graphic
formats, imported to any word processing docu-
ment, and printed in a reporting sheet. However,
despite being useful in addressing canal configu-
rations in clinical practice, drawing root and
canal details of molars with more than three roots
and complex root canal configuration types will
make the diagram appear crowded and poten-
tially misleading. In addition, representing canal
configurations in a diagram is likely to be imprac-
tical in a research setting.
pilararaya@ejercer.cl
H. M. A. Ahmed et al.
4.3 Objectives of the New
Classification
Categorizing root canal configuration by type
using simple Roman numerals has been done for
more than 50 years. However, considerable data
on the morphological variations of root canals
have been generated [27], and current systems for
categorizing canal configurations into certain
types based on single numbers have become
insufficient, inaccurate, and misleading. The time
has now come to develop a coding system for
describing root and root canal configurations that
will aid clinicians, researchers, educators, and
students/trainees.
The new classification system proposed in this
chapter aims to be simple, accurate, and useful. It
provides information on root and root canal anat-
omy identified using any diagnostic method
regardless of their accuracy and reliability.
However, this system does not address the degree
of root and root canal curvature, degree of root/
canal separation, and exact levels of bifurcation
of canals/roots, accessory canals (lateral and fur-
cation canals), and apical ramifications. These
parameters were considered during the develop-
ment of the proposed classification, but they
added considerable complexity. Such additional
information could be useful and even improve
classification accuracy; however, the benefits of
any new system must be the simplicity in order to
achieve its universal adoption.
Many comprehensive classifications categorize
developmental anomalies related to the root or
root canal, such as dens invaginatus [38], C-shaped
canal [39–41], taurodontism [42, 43], and super-
numerary roots [15, 16, 20]. For simplicity, the
present classification will not reclassify abnormal-
ities already addressed in the literature.
4.4 Terminology
4.4.1 Root Canal System
The space within the tooth that contains pulp tis-
sue. The root canal system can be divided into
two portions: the pulp chamber, which is usually
4 New Proposal for Classifying Root and Root Canal Morphology
located in the anatomic crown of the tooth (or
may extend to the coronal third of the root in
double/multi-rooted teeth), and the root canal(s),
encased in the root(s).
4.4.2 Root Canal Orifice
The opening of the canal system at the base of
the chamber where the root canal begins.
Generally, it is located at or just apical to the cer-
vical line.
4.4.3 Root Canal Configuration
The course of the root canal system that begins at
the orifice and ends at the canal terminus.
4.4.4 Major Apical Foramen
The exit of the root canal onto the external root
surface, which is normally located within 3 mm
of the root apex.
4.4.5  inor Apical Foramen/Apical
M 4.5.3
Constriction
The apical part of the root canal with the narrow-
est diameter which is generally 0.5–1.5 mm from
the major apical foramen [2]. It is the reference
point often used as the apical termination of canal
instrumentation and filling procedures.
4.5  he Coding System
T which is subjective among different observers.
of the New Proposed
Classification
The new classification can be adapted for root
and root canal configurations. This system
includes codes for three separate components:
1. Tooth number
2. Number of roots and their configurations
3. Root canal configuration
pilararaya@ejercer.cl
51
4.5.1 Tooth Number (TN)
TN can be written using any numbering system
(i.e., Universal Numbering System, Palmer Notation
Numbering System, or FDI World Dental Federation
System). Moreover, when a tooth cannot be identi-
fied using one of the numbering systems (i.e.,
extracted teeth), a suitable abbreviation can be used,
for example, “MCI” for “maxillary central incisor.”
4.5.2  umber of Roots and Their
N
Configurations
The root number (R) is added as a superscript
before the TN (RTN). For instance, 1TN means
that tooth TN possesses one root. Any division of
a root, whether in the coronal, middle, or apical
third, will be coded as two or more roots.
Accordingly, a bifurcation is represented as 2TN,
and a trifurcation is represented as 3TN. Root
details in double- and multi-rooted teeth are added
on the right of the TN (RTN Rn), such as 2TN B P
(B: buccal, P: palatal) and 3TN MB DB P (MB:
mesiobuccal, DB: distobuccal, P: palatal).
Root Canal Configuration
The type of canal configuration in each root will
be identified using a superscript number(s) after
the TN starting from the orifice(s) (O) and
through the canal (C) to the foramen (or foram-
ina) (F) (Table 4.1).
Inevitably, the assessments of apical canal con-
figurations may vary depending on the identifica-
tion method, namely, experimental or clinical,
For example, according to certain experimental
Table 4.1 Summary of the codes allocated for single-,
double- and multi-rooted teeth
Tooth type Code
Single-rooted 1
TNO-C-F
Double-rooted 2
TN R1O-C-F R2O-C-F
Multi-rooted n
TN R1O-C-F R2O-C-F RnO-C-F
TN tooth number, R root, O orifice, C canal; F foramen.
One number is given if O = C = F
52 H. M. A. Ahmed et al.

measurements of canal dimensions or clinical
negotiability, apical bifurcations could be classified
either as an apical delta/ramification (i.e. a complex
ramification of the root canal branches located
near, and open on, the root apex) or a division from
the main canal (Type 1–2, for example). Evidently,
a standard consistent view of such anatomy cannot
be achieved. Therefore, the apical canal configura-
tion type should be classified according to the
method used and identification criteria.
rooted mandibular right central incisor having
one orifice and one canal initially, but then bifur-
cating into two independent canals and terminat-
ing in one canal (Fig. 4.4d), and 1441-2-3 refers to a
single-rooted mandibular right first premolar
having one orifice and one canal initially that
bifurcates into two independent canals and termi-
nating in three apical foramina (Fig. 4.3e).
4.7 Double-Rooted Teeth

4.6 Single-Rooted Teeth If a tooth is double-rooted, then the code 2TN

R1O-C-F R2O-C-F should be used where R1 and R2
For any canal, if the numbers of O, C, and F are describe the anatomy of the first and second roots.
the same, then a single code (1TNn) is used. Thus, As mentioned previously, only one code will be
1
111 describes a single-rooted maxillary right applied if the number of orifice(s), canal(s), and
central incisor having one orifice, one canal, and foramen (foramina) is the same, in the same root.
one foramen (Fig. 4.3a), while 1142 describes a For example, 214 B1 P1 refers to a double-rooted
single-rooted maxillary right first premolar hav- maxillary right first premolar in which each root
ing two orifices, two independent canals, and two (B, buccal; P, palatal) encases a single root canal
foramina (Fig. 4.3b). from the orifice to the main foramen (Fig. 4.4a).
If the root has a varying number of O, C, and/ 237 M2-1 D1 refers to a double-­rooted mandibular
or F, then the configuration of the canal will be left second molar in which the mesial root encases
written to provide this detail (1TNO-C-F) (Fig. 4.3c, two canals leaving the chamber that join into one
d). For instance, 1441-2 refers to a single-rooted canal until the apex, while the distal root encases
mandibular right first premolar having one orifice a single root canal from the orifice to the main
and one canal initially but then bifurcating into foramen (Fig. 4.4b).
two independent canals and having two apical If the root bifurcates in the middle or apical
foramina (Fig. 4.4c). 41 1 1-2-1
refers to a single-­ third, and the root canal configuration is different

a b c d e

Fig. 4.3 Micro-CT 3D models of single-rooted teeth with root and root canal morphologies classified according to the
new system

pilararaya@ejercer.cl
4 New Proposal for Classifying Root and Root Canal Morphology 53

a b c d e

Fig. 4.4 Micro-CT 3D models of double-rooted teeth with root and root canal morphologies classified according to the
new system. B buccal, P palatal, M mesial, D distal, L lingual

a b c d

Fig. 4.5 Micro-CT 3D models of multi-rooted teeth with root and root canal morphologies classified according to the
new system. MB mesiobuccal, DB distobuccal, P palatal, MP mesiopalatal, DP distopalatal, DL distolingual

below and above the level of bifurcation, then the
code will be 2TN O-CR1C-F R2C-F, where ‘O-C’ is the
root canal configuration coronal to the level of
bifurcation and R1C-F and R2C-F are the continua-
tion of the canal and number of foramina apical
to the level of the bifurcation in either first (R1)
or second (R2) roots, respectively (Fig. 4.4c–e).
Figure 4.4c shows a double-rooted maxillary left
first premolar coded as 224 1B1-2-1 P1 in which the
level of root bifurcation locates at the middle
third, and both roots have a common canal con-
figuration coronal to the level of root bifuca-
tion. Figure 4.4d shows a double-rooted maxillary
left central incisor coded as 221 1M1 D1 in which
the root bifurcates in the apical third and the root
canal configuration below and above the level of
bifurcation is different. Figure 4.4e shows similar
anatomical variation in a mandibular canine.
4.8 Multi-Rooted Teeth
If the tooth is multi-rooted, then the code nTN
R1O-C-F R2O-C-F RnO-C-F should be used.
Figures 4.5 and 4.6 show the application of the
new configuration system applied to several types
of root canal systems. As an example, 317 MB1
DB1 P1 means that the maxillary right second

pilararaya@ejercer.cl
54 H. M. A. Ahmed et al.

Fig. 4.6 Micro-CT 3D models of distinct groups of teeth with root and root canal morphologies classified according to
the new system

molar has three roots (MB, mesiobuccal; DB,
distobuccal; P, palatal) with a single orifice,
canal, and foramen in each root (Fig. 4.5a).
3
26 MB2-1 DP1 P1 means that the maxillary left
first molar has three roots in which the MB root
encases a type 2-1 canal, while the DP and P
roots encase a root canal with a single orifice,
canal, and foramen (Fig. 4.5b). Similarly,
4
27 MB2-1 DB1 MP1 DP1 means that the maxillary
left second molar has four roots (MB, mesiobuc-
cal; DB, distobuccal; MP, mesiopalatal; DP, dis-
topalatal) in which the MB root encases a type
2-1 canal, and the DB, MP, and DP roots each
encase a single orifice, canal and foramen

pilararaya@ejercer.cl
4 New Proposal for Classifying Root and Root Canal Morphology
(Fig. 4.5c). 347 M2 DB1 DL1 means that the man-
dibular right second molar has three roots (M, 9.
mesial; DB, distobuccal; DL, distolingual) in
which the mesial root has two independent 10.
canals, while DB and DL roots encase a single
orifice, canal, and foramen (Fig. 4.5d). Similar 11.
considerations will be applied if one of the roots
bifurcates in the middle or apical third, and the
root canal configuration is different below and
12.
above the level of bifurcation.
13.
4.9 Concluding Remarks
14.
This classification introduces a simple, accurate,
and practical system that allows students, dental 15.
practitioners, and researchers to classify root and
root canal configurations. It provides detailed 16.
information on the tooth number, root number,
and root canal configuration types but excludes
developmental defects and minor canal anatomy 17.
for simplicity and universal adoption.
18.
References
19.
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2. Vertucci FJ. Root canal morphology and its rela-
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3. Ahmed HMA, Abbott PV. Accessory roots in maxil-
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Bramante CM, Pécora JD, et al. Middle mesial canals
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 Diaphanization Techniques
in the Study of Root Canal
Anatomy
Craig Barrington and Francisco Balandrano
Abstract
The study of the root canal anatomy is very
important in endodontics. The introduction of
innovative technologies such as micro-CT or
CBCT has provided a great advance in the
field; however, due to their excessive costs, it
is still out of reach of most practitioners and
researchers. Dental diaphanization or trans-
parency methods, also known as dental clarifi-
cation, are economical in their implementation,
and the results are reliable. These features
make this technique a useful tool for under-
standing the internal anatomy of human teeth
while providing personal assessment of vari-
ous endodontic procedures using extracted
teeth. The mastery of advanced dental trans-
parency techniques can require a personal
learning curve where art and trial and error
play a key role. Practice, patience, and perse-
verance are essential elements in learning
these processes, but the basic elements and
fundamentals of tooth transparency can give
results that allow the teaching and learning
benefits that are offered herein. Therefore, this
chapter aimed to describe the foundation of
the dental diaphanization methodology and
C. Barrington, D.D.S. (*)
Private Practice, Waxahachie, TX, USA
e-mail: cmbdds@cbjb3.com
F. Balandrano, D.D.S.
Private Practice Limited to Endodontics,
Torreón, Coahuila, Mexico
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_5
pilararaya@ejercer.cl
5
provide details about the most used
techniques.
5.1 Introduction
Visualizing the internal anatomy of human teeth
has been a significant challenge particularly in
the field of endodontics. Many attempts have
been made to expose, analyze, and visualize the
internal anatomy of human teeth. Investigation
and analysis of the human anatomy has been
widely studied via dissection, autopsy, and
gross macroscopic observation. Alternatively,
microscopic examination allowed the under-
standing of human tissues in a molecular level.
These two-­ dimensional techniques provide
indispensable insights but are limited in their
ability to understand a tissue section or organ
three-dimensionally.
The German anatomist Werner Spalteholz
(1861–1940) was the first scientist who investi-
gated clearing of whole bodies, large tissue sec-
tions, and/or entire organs for three-dimensional
viewing of internal structures and their relative
positions within that volume [1]. On April 8 of
1909, Dr. Spalteholz applied for a US patent for
his process of manufacturing transparent and
translucent bodies, but it would not be until 1912
that he received a patent for his discovery [2]. In
the next year, Spalteholz’s method was published
57
58
in the Dental Cosmos journal by Dr. Hermann
Prinz in an article entitled The Spalteholz method
of preparing transparent animal bodies [3]. The
essential goal of Spalteholz’s proposal was to
view the true anatomy of whole bodies or organs
in their undisturbed three-dimensional arrange-
ment. Through the written disclosure of this
method [3], the ability to clear human teeth
entered dentistry. In 1913, Spalteholz’s method
was used for the first time by Fasoli and Arlota,
from the University of Milan, to study the root
canal anatomy [4]. Prior to the use of the
Spalteholz’s clearing method, dissection, X-rays,
and corrosion cavities were the most commonly
used methods, but they had several limitations.
The introduction of macroscopic histologic clear-
ing was a great step forward to view the root
canal anatomy of human teeth because for the
first time it was possible to observe it in its real
state. However, since publication of Spalteholz’s
work, dental transparency has been used as a very
effective tool for professionals interested in the
study of the different anatomical structures of the
root canals. This technique has been shown to be
very useful in revealing the complexity of the
root canal system and to classify anatomically
several root canal configuration types [5].
Dental diaphanization has been frequently
used to observe several anatomical features of
the root canal system including the presence and
amount of main canals (Fig. 5.1a), lateral canals
(Fig. 5.1b, c), additional canals such as MB2 in
mesiobuccal roots of maxillary molars (Fig. 5.1d,
e) or middle mesial canals in mesial roots of
mandibular molars (Fig. 5.1f, g), apical ramifica-
tions (Fig. 5.1h, i), loops (Fig. 5.1j, k), split
canals (Fig. 5.1l, m), connecting canals
(Fig. 5.1n, o), isthmuses (Fig. 5.1p, q), and so
on. Apart from the anatomical structures, dental
diaphanization can also be used to assess apical
diameters (Fig. 5.2a–c), thickness of the cement
at apical level (Fig. 5.2d, e), and location and
shape of the cement-dentin-canal (CDC) junc-
tion (Fig. 5.2f, g) and of the apical constriction,
which normally does not correspond to the CDC
junction (Fig. 5.2h, i). Dental diaphanization is
also suitable to appraise endodontic procedures
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
including the evaluation of electronic apex loca-
tors’ (EALs) accuracy [6] (Fig. 5.2j), sealing of
lateral canals [7] and different obturation tech-
niques [8–10] (Fig. 5.2k, l), and even vascular
distribution (Fig. 5.2m, n).
The clarification or diaphanization of teeth
has also other advantages including being a rela-
tively simple and economical method to perform
and a valuable educational tool. On the other
hand, it is a time-consuming procedure, and, in a
small number of teeth, it is not possible to obtain
predictable results. Dental diaphanization proce-
dures require specialized chemicals, but other-
wise no specialized equipment. The solutions
and/or materials necessary for their realization
are affordable and relatively inexpensive. It pro-
vides a great advantage for students and profes-
sionals in dentistry who wish to observe the
anatomy of root canals or the results of endodon-
tic procedures performed on extracted teeth aim-
ing to evaluate clinical skills or the shortcomings
and benefits of the steps involved in the root canal
treatment. Unfortunately, there is no standardiza-
tion regarding dental diaphanization pro-
cess. Table 5.1 shows that these procedures are
quite varied and, to a certain extent, empirical.
The authors of this chapter have spent much
time and efforts in improving dental diaphani-
zation technique in order to achieve some
degree of standardization supported on scien-
tific basis of trial and error. It is noteworthy that
each author uses different techniques. While
Dr. Barrington uses a patented technique of his
own [20], Dr. Balandrano uses a modification
of conventional techniques. At the end of this chap-
ter, both techniques are described in an attempt to
standardize dental diaphanization procedures.
5.2 Terminology
In the literature, current terminology for “clear-
ing” of human teeth presents discrepancy. This
section aims to provide some standardization and
understanding to the terms used.
Firstly, it is important to point out that the proper
terms for “clearing” teeth are “transparency” or
5 Diaphanization Techniques in the Study of Root Canal Anatomy 59

a b c

d e f g

h i j k

l m n

o p q

Fig. 5.1 Root canal anatomy through diaphanization
methods. (a) Maxillary premolar showing the pulp
chamber and a 2-1 configuration with lateral canals and
apical delta; (b) accessory canals in the apical third of a
maxillary canine; (c) palatal root of a maxillary first
molar with an accessory canal; (d) mesiobuccal root of
a maxillary first molar with a MB2 canal; (e) maxillary
first molar with MB2 canal; (f) mesial root of a man-
dibular molar with a middle mesial canal joining the
main canals; (g) mesial root of a mandibular molar
showing an independent middle mesial canal; (h) com-
plex apical ramification; (i) typical apical ramification;
(j) root canal loop in the apical third; (k) canal loop
(arrow) and transversal canal; (l) complex root canal
configuration in the mesial root of a mandibular molar;
(m) mesial root of a mandibular molar with three root
canals; (n) mesial root of a mandibular molar showing
two accessory canals and a transverse canal joining the
main canals (arrow); (o) transverse canal on the medium
third joining the main canals (arrow); (p) two main
canals joined by a wide isthmus; (q) two main canals
joined by a small isthmus

pilararaya@ejercer.cl
60
a b
d e
h i
m n
Fig. 5.2 Potential scientific applications of the diaphani-
zation methods. (a–c) Measurements of the main and lat-
eral canals; (d–g) measurement of the cement layer
thickness; (h–j) determination of the apical constriction
“diaphanization.” The latter has been employed
many times in the dental literature spelled as either
“diaphaniZation” or “diaphaniSation.” The use of
the letter “z” or “s” is nothing more than American
and British spelling differences, respectively. In the
current chapter, it was adopted the worldwide “ize”
as it tends to be accepted in scientific writing and
international organizations. The prefixes “dia,”
“phon,” and “phan” are Greek terms that mean “to
pass through,” “sound,” and “to appear,” respec-
tively. With the understanding of the root terms, it
is possible to conclude that the proper spelling is
“diaphanization” referring to “appearing through”
an object.
Diaphanization is a histologic term which
refers to the whole body, organ, or structure trans-
parency. Clearing, on the other hand, is used in tis-
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
c
f g
j k l
position; (j) assessment of the accuracy of electronic apex
locators; (k–l) evaluation of the quality of filling tech-
niques (m–n) observation of vascular distribution
sue section histology and is essentially a step in the
entire process, not the result. In histology, clearing
refers to the step following dehydration. It consists
of replacing the dehydrate agent with a substance
that can be miscible with the embedding medium
(paraffin). This term comes from the fact that the
clearing agents often have the same refractive
index as proteins. As a result, when the tissue is
completely infiltrated with the clearing agent, it
becomes translucent. This change in appearance is
often used as an indication of the effectiveness or
completeness of the clearing process. In turn,
diaphanization of human teeth essentially uses no
paraffin embedding; therefore, there is no sub-
stance to clear. Then, although the result of diaph-
anization is “clear,” a better term to use is
“transparency” or also “transparent.”
5 Diaphanization Techniques in the Study of Root Canal Anatomy 61

Table 5.1 Diaphanization techniques used by different authors

Author Decalcification Dehydration Clearing agent
Robertson et al. [11] 5% nitric acid 3 days Ethyl alcohol 80% overnight, Methyl salicylate
90% 1 h, 100% 1 h three times
Robertson et al. [12] 5% nitric acid 3 days Ethyl alcohol 70% overnight, Silicone 710
90% 1 h, 100% 1 h three times
Yamamoto et al. [13] 5% formic acid 14 days Ethyl alcohol time and Styrene monomer 24 h
concentrations were not polyester resin 24 h
described pure resin
Venturi et al. [7] 7% formic acid, 3% hydrochloric Ethyl alcohol 25%, 50%, 70%, Methyl salicylate
acid, 8% sodium citrate 14 days 90%, 95%, 100% 30 min each
one
Omer et al. [14] 10% hydrochloric acid 8 days 95% alcohol 36 h, 100% Methyl salicylate
alcohol 36 h
Weng et al. [15] 5% nitric acid 7 days Ethyl alcohol 75%, 85%, 95%, Methyl salicylate
and 100% 12 h each one
Neelakantan et al. [16] 10% nitric acid 28–30 h Ethyl alcohol 70%, 80%, 95%, Methyl salicylate
100% 24 h
Lee et al. [17] 5% nitric acid 5 days Ethyl alcohol 70% 12 h, 90% Methyl salicylate
6 h, 100% 6 h
Monika et al. [18] 5% nitric acid 4 days Ethyl alcohol 25%, 50%, 70%, Methyl salicylate
90%, 95%, 100% 30 min each
one
Rehman et al. [19] 5% nitric acid 3 days Isopropyl alcohol 70% 3 h, Xylene
80% 3 h, 90% 2 h, 100% 1 h

5.3 Diaphanization Techniques 6. Any material injected must be chemically and

(Transparency) of Dental
Pieces
The diaphanization procedure, regardless of
method, should always include three fundamental
steps: decalcification, dehydration, and clarifica-
tion. Some practitioners choose to fix teeth with
formalin or acetic acid before or during the diaph-
anization process [7]. The fixation is necessary in
soft tissues to avoid their decomposition; how-
ever, this procedure is not necessary as dental
pieces are hard tissues of difficult decomposition.
Diaphanization must also be based on the fol-
lowing criteria:
1. Dentin should not be destroyed.
2. The anatomical topography of the pulp, as
compared to the tooth, has to be highlighted.
3. Even the thinnest ramifications cannot be
overlooked.
4. The pulp cavity must be visible.
5. The material injected had to fill the root canal
space completely, and pulp residues, if any,
cannot represent any hindrance.
mechanically resistant.
7. The dye cannot be present within the dentinal
tissue.
5.3.1 Decalcification
Decalcification is known as the complete elimi-
nation of calcium and phosphorus salts present in
mineralized tissues. It is one of the most impor-
tant steps within dental diaphanization proce-
dures because if the tooth is not completely
decalcified, anatomical structures of the canal
system may not be revealed. The decalcification
process must produce the complete elimination
of the calcium deposits, but at the same time, it
must not cause undesirable effects or artifacts on
the treated tissues. Therefore, the acid agent
should be used at low concentrations to achieve
the complete demineralization of the tooth speci-
men. According to our experience, the use of
excessive concentrations can damage the root
surface without completely decalcifying the
deepest portions of the specimen (Fig. 5.3a–c).

pilararaya@ejercer.cl
62
a b
c d
Fig. 5.3 Inadequate decalcification process during the
diaphanization method. (a–c) Increased period of decalci-
fication time or an excessive concentration of the decalci-
fying agent may cause damages in the sample structure;
There are two main groups of decalcifying agents
that can be used for diaphanization purposes:
acids (organic and inorganic) and calcium
chelators.
5.3.1.1 Acids
The acids act by supplying hydrogen ions and
eliminating hydroxyl, calcium, and phosphate
ions. The result is an alteration of the ionic bal-
ance of the hydroxyapatite and its dissolution.
Any acid affects tissue stability, but it is depend-
ing on the solution’s acidity and duration of the
decalcification process. In addition, the faster the
action of the decalcifying agent, the greater the
damage to the tissue. There are two groups of
acids: the strong acids (inorganic) and the weak
acids (organic). Inorganic acids act very quickly
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
e
(d, e) diminished decalcification time or the use of a lower
concentration of the decalcifying solution may avoid
proper hard tissue decalcification
but are very aggressive, so if they are used at a
higher concentration and/or with too much expo-
sure time, they can damage the dental structures
and modify the morphology of the sample.
Organic acids act slowly and they preserve the
tissue in a better way. The most used acids for
dental diaphanization are hydrochloric (inor-
ganic), nitric (inorganic), and formic (organic)
acids. In the literature, authors have also sug-
gested different agents for decalcifying the dental
hard tissues. Venturi [7] proposed to use 7% for-
mic acid together with 3% hydrochloric acid and
8% sodium sulfate as buffering agent dissolved in
water for a period of 14 days. Greco-Machado
[21] demonstrated that this solution provides bet-
ter results than the nitric acid solutions proposed
by Okomura [22], Aprile [23], and Robertson
5 Diaphanization Techniques in the Study of Root Canal Anatomy
[11]; however, it is unknown if the results are due
to the use of hydrochloric acid at low concentra-
tion for 14 days or to the mixture of organic and
inorganic acids used in the solution.
Hydrochloric acid (HCl) is also called acidum
salis, muriatic acid, and spirits of salt. It is a very
effective decalcifying agent, but very aggressive
when in high concentrations. This inorganic acid
is commonly used during household cleaning
procedures, so it is possible to find it in stores in
the form of diluted commercial presentations.
During dental clarification process, the hydro-
chloric acid can be used in several concentra-
tions. Therefore, it is not advisable to use
commercial presentations because the precise
concentration is unknown. To achieve dental
decalcification, hydrochloric acid can be used
diluted in water in the concentrations of 3%, 5%,
7%, and 10% [7, 14, 20]. The higher the concen-
tration, the faster is the decalcification process,
but also higher may be tissue damage. In lower
concentration, the acid will take more time to
decalcify tissues, but this also decreases the risk
of damage. According to our experience, 3% HCl
usually takes 7–10 days to reach the endpoint of
decalcification, while 5% HCl takes 3–5 days and
10% from 1 to 3 days. Based on our results, the
use of 3% HCl for approximately 7–10 days, in
constant movement and changing the solution
every 24 h, produces an optimal result in the clar-
ification of the sample.
Nitric acid (HNO3) is one of the most effective
decalcifying inorganic agents. It should be used
in a maximum concentration of 5% (95% water)
because in higher concentrations it may cause
severe tissue damage. According to our experi-
ence, nitric acid diluted in ethyl alcohol in con-
centrations of 7.5% nitric acid to 92.5% absolute
alcohol is less aggressive as it decreases decalci-
fication time. But there are other two solutions
that can be prepared with nitric acid: (1) 10%
formaldehyde, 10% nitric acid, and 80% distilled
water [24] and (2) 10% nitric acid (40 mL) mixed
with 0.5% chromic acid (30 mL), which is also
known as Perenyi’s fluid [22].
Formic acid (CH2O2) can be used in concen-
trations of 5–10% dissolved in distilled or tap
water, and it is considered the acid of choice for
pilararaya@ejercer.cl
63
bone decalcification. This decalcifying organic
agent has the advantage of fixing and decalcify-
ing tissues simultaneously; however, it acts very
slowly. It has been suggested that a slow process
allowed for a greater cushion in the determina-
tion of endpoint of the procedure, helping against
over decalcification [25].
5.3.1.2 Chelating Agents
Chelates are substances capable of being com-
bined with metal ions in solution or stabilized in
the form of salts or in the preparation of new
compounds generally soluble in water [26].
EDTA (ethylenediaminetetraacetic acid) is the
most used chelator for decalcification of dental
specimens. The removal of calcium ions by 17%
EDTA is very slow, and, according to our obser-
vations, decalcification process usually takes
8–10 weeks to complete, depending on the thick-
ness of the tooth; however, it has the advantage of
avoiding considerable damage to the tooth
surface.
5.3.1.3 Endpoint of Decalcification
Accurate control of optimal decalcification time
of the tooth is important because a prolonged
time may cause damage to the tissues of the sam-
ple (Fig. 5.3a–c). If insufficient time is used, the
calcium deposits will prevent the detailed obser-
vation of the internal structures (Fig. 5.3d, e).
However, it is not possible to exactly determine
the time or agent concentration for decalcifying
teeth because differences in thickness and degree
of calcification may differ to a greater or lesser
extent from one tooth to the other interfering with
the required parameters. Consequently, physical,
chemical, and/or radiological methods can be
used to evaluate the decalcification process.
Physical Methods
The physical methods are inaccurate and can
damage the dental structure. The best physical
test is to carefully bend the tooth with the fingers.
This method is safer and not disruptive, but will
not conclusively determine if decalcification
process is completed [27]. Sound is another
­
method. If the tooth is dropped on a hollow metal
surface and it does not produce sound, it might be
64
considered decalcified; however, this evidence
continues to be inconclusive. Another two meth-
ods are the weight loss/weight gain procedure
and the “bubble” test. The weight loss/weight
gain test consists in accurately weighing the sam-
ple prior to the decalcification process. As the
sample loses calcium during the decalcification
process, it takes on water and gains weight. This
weight gain indicates the sample is decalcified.
The water is removed in later steps [28]. The
“bubble test” involves observing the formation of
carbon dioxide bubbles on the surface layer of
the sample. As the acids react with the calcium
carbonate of the samples, carbon dioxide is pro-
duced. Repeated agitation and shaking to release
the bubbles till they no longer form on the surface
is a subjective test but is considered somewhat
unreliable [29].
Chemical Methods
Chemical methods depend on the formation of
calcium oxalate. A sample of the decalcifying
solution is mixed with ammonium hydroxide and
ammonium oxalate. The solution is allowed to sit
for 30 min. Formation of calcium oxalate precipi-
tate indicates that calcium is being released from
the sample. In this methodology, use 5 mL of the
used decalcifying solution and mix with half
spoonful of concentrated ammonium hydroxide.
Subsequently, add 5 mL of aqueous ammonium
oxalate. The solution is then stirred and allowed to
stand for 30 min. After that, if opacity is observed
in the solution, decalcification is incomplete;
however, if the solution is transparent, decalcifica-
tion process has finished successfully [30, 31].
This test works with the aforementioned acids and
chelator, but the time frames and results may vary.
Although it is considered accurate, there are no
clear-cut directives as to when the test should be
started in the decalcification process or if succes-
sive tests can be performed. This test was derived
for the validation of decalcification in the bone
[25], and there is no information to authenticate
accuracy or challenges in using it for human teeth.
Radiographic Method
This is the most sensitive method to establish the
decalcification degree of the dental sample; how-
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
ever, shape irregularities and variations in thick-
ness of the sample can be a challenge. This
method consists of taking radiographs daily until
it is revealed, by means of radiolucency, that the
dental piece is completely decalcified. A prelimi-
nary radiography is recommended to allow fur-
ther comparisons and careful standardization of
the X-ray unit, and films must be considered [29].
Other Methods
In the literature, other methods have been sug-
gested to determine the endpoint of decalcifica-
tion process. These methods were empirically
established, but provide a general idea of the
degree of decalcification of the tooth. Robertson
[11] and Pécora [32] recommended finishing the
decalcification process when the enamel appeared
to be dissolved. Another technique is to rely only
on the time the tooth is submerged in a decalcify-
ing agent, usually 3–5 days, at the end of which
the process is finished; however, due to differ-
ences in thickness and degree of calcification of
dental structures, times may vary from tooth to
tooth.
5.3.1.4 Methods to Accelerate
the Decalcification Process
Chemical decalcification can be accelerated by
using several methods including the use of high
concentrations of warm decalcifying agent, but it
is more aggressive and can produce excessive
demineralization of the hard tissues and damage
to the organic components [11]. Another possi-
bility is the use of ultrasound. In this method, the
tooth is immersed into the decalcification solu-
tion and subject to the action of ultrasonic waves.
The molecular vibration of the solution on the
calcified material surface favors the formation of
salts between the released ions and the acids or
chelators used during the process.
5.3.2 Dehydration Process
Dehydration is the process that aims the complete
elimination of liquids contained in decalcified
hard tooth tissues so that they do not interfere
with the refractive index of the clarifying sub-
5 Diaphanization Techniques in the Study of Root Canal Anatomy
stance. During the dehydration process, it must be
considered that the time required for the removal
of the liquid from the tooth depends on the amount
of liquid contained therein and the moisture
absorption capacity possessed by the dehydrating
agent used. There are two basic requirements for
a good dehydrating agent: (1) it cannot alter the
tissue structure and (2) it cannot mix with the
clearing agent. The most used substance for den-
tal dehydration is ethyl alcohol, followed by iso-
propyl alcohol [33]. Other substances that can be
used are dioxane and chloroform, but they are not
recommendable because they are volatile and
have some degree of toxicity [34, 35].
5.3.2.1 Ethyl Alcohol
Ethyl alcohol is the most commonly used sub-
stance for tissue dehydration. It has a rapid
action, is nontoxic, is reliable, and provides an
effective dehydration, but it has the disadvantage
of causing tissue distortion because of its shrink-
age effect (Fig. 5.4a–c). To avoid distortion, ethyl
alcohol must be used with gradual concentrations
(Fig. 5.4d), and once the dental piece is placed
directly in absolute ethyl alcohol, the dehydration
a b
e f
Fig. 5.4 Variables involved in the quality of dehumidi-
fication process which must be gradual and progressive
to avoid sample distortion. (a, b) Samples placed
directly in 96° alcohol showing root fracture; (c) sample
placed directly 90° alcohol showing damage in the
cement structure; (d) gradual concentrations of alcohol
were used in this sample, and no damages can be
observed on the root surface; (e) particles adhered to the
pilararaya@ejercer.cl
65
process is fast and can modify its shape substan-
tially [36].
Absolute alcohol is difficult to obtain because
special processes are required for its preparation.
On the other hand, 96% alcohol concentration is
easily achieved, and its dissolution is simple
since the ethyl alcohol is miscible in distilled or
running water. To achieve the correct dissolution
of the alcohol, a simple cross multiplication can
be used. For example, to obtain a 70% alcohol
from a 96% alcohol in 100 mL, use the formula:
(70 × 100)/96. In Table 5.2, the approximate pro-
portions of water and alcohol to obtain different
concentrations are indicated.
There is no agreement in the literature on how
long the sample should remain in the different
concentrations of alcohol (Table 5.1); however,
despite the diversity in the decalcification and
dehydration times, clarification results are appar-
ently similar. This may be confusing for those
who start learning the diaphanization method,
since it seems to be a non-scientific-based pro-
cess. Therefore, everyone must follow the method
of trial and error and use the time deemed appro-
priate to achieve the best possible results.
c d
g h
root surface after the dehumidification process by direct
contact with the silica sand; (f) indirect exposure of
dental pieces to a desiccant agent (silica sand); (g) after
the dehydration process, the apexes must be semitrans-
parent which indicates that the sample is ready for oil
immersion; (h) the apex of this tooth is not semitrans-
parent which indicates an error in the decalcification or
dehydration process
66
Table 5.2 Proportions of water and alcohol to obtain dif-
ferent concentrations used in the dehydration process
of Dr. Balandrano
Alcohol 96° Water Time
52 mL 48 mL 24 h
62.5 mL 37.5 mL 24 h
73 mL 27 mL 24 h
83.5 mL 16.5 mL 24 h
94 mL 6 mL 24 h
100 mL 0 mL 24 h
Silica sand near to the sample 2h
Deformation caused by alcohol can be avoided
by using graduated concentrations. Besides, the
time the sample remains at each alcohol concen-
trations must be sufficient to remove the previous
chemicals from the sample allowing the adapta-
tion of the tissues to the current concentration. In
addition, it is advisable to increase the storage
period and shake the solution at least five times in
each of the different concentrations. It is worth
noting that 96° alcohol has a certain amount of
water that can interfere with the refractive index
of the clarifying substance; so, it is important to
leave the piece in a dry environment and near to a
desiccant for 1 or 2 h after dehydration process in
order to eliminate as much moisture as possible.
5.3.2.2 Isopropyl Alcohol
According to the National Institute for
Occupational Safety and Health (NIOSH), this
product is highly flammable and is necessary to
use gloves during its handling [37], so extreme
caution should be exercised if this substance is
used during the dehydration process. Like ethyl
alcohol, isopropyl alcohol should be used with
gradual concentrations to avoid deformation in
the sample.
5.3.2.3 Desiccation
Alcohols and other chemicals can affect the pulp
tissue and therefore are not used in some tech-
niques [20]. This was discovered by Dr. Craig
Barrington, and his patented technique includes
no alcohol-based drying agent but the exposure
of the sample to various desiccants, air, or simply
the environment in combination with or without
desiccants. Desiccant substances capable of
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
extracting moisture from dental tissues are
mainly silica, either in sand or gel, and desiccant
clay. The major problem in using these materials
is that they adhere sometimes to the moist sur-
faces. In this case, it can be difficult to completely
remove the desiccant from the dental surface
(Fig. 5.4e), and an attempt to their removal with
instruments may cause damage to the root sur-
face. To avoid this, it is recommended a very
quick rinse with a solution such as tap water,
deionized water, or even alcohol. This allows the
release of the drying agent, without affecting the
drying effect and the integrity of the sample. The
samples can also be dried in an airtight container
together but not in contact with the desiccant
agent (Fig. 5.4f).
5.3.2.4 Dehydration Through Exposure
to the Environment
It is possible to achieve complete dehydration of
the tooth without using alcohols or desiccants.
This reliable method consists of letting the tooth
dry overnight or for 24 h exposed to room
environment.
Whatever method is used, a good indicator of
an appropriate dehydration of teeth is when, at
the end of the procedure, it is semitransparent,
especially in the apical area (Fig. 5.4g). If the
tooth is not transparent after this procedure, it is
possible that some step in the decalcification or
dehydration processes has failed (Fig. 5.4h).
5.3.3 Techniques for Identifying
the Canal System in Dental
Diaphanization
Most of dental diaphanization techniques achieve
a degree of transparency that avoid the identifica-
tion of some root canal components, especially
narrow entities such as lateral canals or apical
ramifications (Fig. 5.5a). Therefore, it is
­necessary to use a contrast medium, unable to
become transparent by the clarification proce-
dures, to fill the pulp canal space. The most used
material to differentiate the root canals has been
the ink; however, there are other contrast sub-
stances that can also be used with this purpose.
5 Diaphanization Techniques in the Study of Root Canal Anatomy 67

a b c d

e f g h

i j k l

m n o p q

r s t u v

Fig. 5.5 Contrast medium in the diaphanization pro-
cess. (a) Without using a contrast medium, it is virtually
impossible to identify the root canal elements; (b) the
use of a contrast medium allows to observe anatomical
structures of the root canal; (c) India ink used as a con-
trast agent may cover the outer surface of the root pre-
venting correct visualization of the root canal; (d)
complete leaching out of contrast agent into the dentinal
tubules avoiding visualization of the canal system; (e)
contrast dye stained the canals and the dentin losing
overall contrast between dentin and canal system; (f)
India ink leaching into the dentinal tubules washing out
the appearance of the canal system; (g) penetration of
India ink into the dentinal tubules prevents visualization
of the lateral limits of the main canals; (h) the use of
diluted paint as a contrast medium can allow a correct
definition of the root canal boundaries (courtesy of Dr.
Holm Reuver); (i) paint as a contrast medium allows the
root canal to be clearly seen; (j) thickness of undiluted
paint did not allow full penetration into the canals; (k)
paint partially covering the outer surface of the root pre-
venting correct visualization of the root canal; (l) dye for
cakes used as a contrast medium; (m) neurovascular
entrapments as demonstrated here led Dr. Barrington to
use the existing pulpal tissue as a contrast medium; (n)
the first tooth made transparent by the patented
Barrington’s technique; (o, p) mandibular first premolar
cleared with the Barrington’s method using dental pulp
as a contrast medium; (q–s) air injection technique used
as a contrast medium; (t, u) unsatisfactory results from
air injection technique; (v) biofilm of microorganisms
used as a contrast medium

pilararaya@ejercer.cl
68
To place a contrast medium inside the tooth, root
canals must be previously accessed. Different
access openings, shapes, and sizes, from simply
making a pin hole to totally accessing the pulp
chamber, have been suggested. Some authors
have also considered soaking the sample in vari-
ous chemicals such as sodium hypochlorite
(NaOCl), which is effective in cleaning residual
pulp tissue, prior to the injection of the contrast
medium, while others recommended to use a
combination of soaking and actively forcing the
NaOCl through the pulp canal system. In our
opinion, there is no science to support these pro-
cedures, and it is a simply trial-and-error art form
of guess work combined with experience, prior to
the next step.
5.3.3.1 Contrast Medium
Ink
Indian or Chinese ink is the most widely used
material to differentiate root canal anatomy with
satisfactory results [11, 15] (Fig. 5.5b). In this
technique, it is recommended to introduce the ink
into the canal system before performing the
decalcification, dehydration, and clearing pro-
cesses. This allows one to remove the ink from
the outer surface of the dental piece in an effec-
tive manner prior to initiate the clarification pro-
cess. If the ink is placed after clarification, the
outer surface of the root is more likely to absorb
it due to the decalcification, making it difficult to
remove and leading to the disuse of the sample
[21] (Fig. 5.5c). In addition, the ink may invade
the dentinal tubules because of the decalcifica-
tion, making it difficult to define the lateral limits
of the canals (Fig. 5.5d–g).
Ink Mixed with Gelatin
Colorless gelatin can be dissolved in water mixed
with sufficient ink to achieve a good coloration
and then taken to the refrigerator. After gelation,
gelatin is placed in a syringe for its injection into
the canals. The syringe might be slightly heated
so that the gelatin is liquefied and, thus, can pass
through the needle without difficulty [38]. The
dissolution of the ink in gelatin facilitates its
removal from the outer root surface [21].
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
Paint
If paint is used to differentiate the canals, it is
recommended that it has adequate fluidity so it
can flow freely and fill the canal space in an
effective way (Fig. 5.5h–j). The acrylic paint,
used for various hobbies, has the proper consis-
tency and fluidity. However, it should be placed
with great care because it can be very difficult to
remove from the outer surface of tooth (Fig. 5.5k).
Dyes for Cakes
It exists as a gel or in liquid form. It is recom-
mended to use the liquid solution dissolved in
water because it is so concentrated that with only
an amount that fits in the tip of a toothpick can
achieve an intense color. Its main advantage is
that, after placing the dye, sample can be exposed
to the environment for a time before starting the
process of clarification. This environmental
exposition causes evaporation of the water, leav-
ing the dye particles inside the canal, allowing to
differentiate it in a very effective way (Fig. 5.5l).
5.3.3.2 Dental Pulp
According to Dr. Barrington [20], if a freshly
extracted tooth is allowed to dry for a period of
time with the blood and debris from the extrac-
tion on it, the remnants of dried blood and pulpal
tissue can provide a very detailed and semi-­
reliable contrast medium (Fig.5.5m–p). In this
technique, a freshly extracted tooth must be
firstly placed in an open or closed container and
allowed to dry. As alternative, sample can be left
on the tabletop exposing it to air and/or exposing
it to desiccants such as diatomaceous earth, silica
sand, silica gel, or even aluminum sulfate, which
can be found in certain animal litter-type prod-
ucts [39]. The results can be very detailed and
thorough, but problems such as overdrying the
samples can cause distortions to the point that it
no longer resembles the original specimen. Thus,
removal of water using this method is very sensi-
tive, but once accomplished, the sample can be
placed in the immersion oils for final clearing. It
is important to point out that the tooth cannot be
rinsed, treated, or wiped with any chemical treat-
ment or cleaning agent. Once the debris on the
outside surface of the tooth is dried, diaphaniza-
5 Diaphanization Techniques in the Study of Root Canal Anatomy
tion processes can start. Years of experimentation
have revealed that alcohol can also have a detri-
mental drying action (Fig. 5.4a–c). Using this
technique, alcohol should be avoided as a dehy-
dration agent because it breaks down the dried
blood and pulpal remnants, negatively affecting
the outcome.
5.3.3.3 Air
Based on Dr. Barrington’s findings [20], injecting
air into an accessed pulp canal system can reveal
the internal anatomy of teeth in a very predictable
way (Fig. 5.5q–s). This method is fast and gives a
perfect view of the internal anatomy. However,
sometimes air diffuses out fair quickly, which
makes a challenge to photograph the results
(Fig. 5.5t–u). Furthermore, repetitive attempts to
inject air may cause the tooth to be opaque and
lose its clarity for some time. An alternative to
overcome this limitation is to freeze the cleared
tooth and place it into a warm immersion oil. It
will cause the sample to expand and take in air
for a longer time than the simple injection
technique.
5.3.3.4 Biofilm
This technique from Dr. Balandrano consists in,
after access preparation, placing the dental pieces
in 1% NaOCl for 2 days, changing the solution
daily to dissolve remaining pulp tissue. The sam-
ples are then left in water for 2 or 3 days, chang-
ing it three times a day to remove as much NaOCl
as possible. The samples are subsequently dried
to the environment for 1 day, a liquid culture
medium (thioglycolate broth) is injected into the
canals through the access previously made, and
samples are immersed in the same culture
medium. The culture medium is then contami-
nated with bacteria taken from infected root
canals. The preparation must be stored at 37 °C
for at least 3 months feeding the culture every
week with new medium and new bacteria taken
from different patients aiming to allow colonies
to grow inside the root canal system. Once bacte-
rial growth is achieved, samples are carefully
taken from the culture medium and washed using
tap water and a disposable brush. The samples
are then left exposed to the environment for at
pilararaya@ejercer.cl
69
least 5 days after which the clarification process
can be initiated (Fig. 5.5v).
5.3.4 Clarification Process
5.3.4.1 Refractive Index
When light encounters an object, it can be
absorbed, reflected, or transmitted. If an object
transmits light, the light passes through that
object and this causes changes in their speed. As
light changes speed, it bends and this bending of
light is defined in terms of index of refraction.
The index refraction is the ratio of the speed of
light in a vacuum to the speed of light in a sub-
stance. It is represented by the letter “n” and can
be found through the equation n = c/v, where “c”
is the speed of light in a vacuum and “v” is the
speed of light in the material [40]. An example is
the refractive index of water which is expressed
as being 1.33 after calculation. This refractive
index implies that light travels 1.33 times faster
in a vacuum than in water. Teeth present a unique
problem in clearing compared to other tissues.
Teeth have dissimilar hard tissues with varied
mineral content. Consequently, the different
refractive indexes of enamel (n = 1.631), dentin
(n = 1.540), and cementum (n = 1.582) [41] will
affect the outcome of dental clarification
procedures.
In the field of optics, transparency is achieved
when light passes through an object without
scatter. It is very difficult to achieve transparency
in air so this is best managed by submerging
objects in liquids that share similar indexes of
refraction [9]. Scatter of light is reduced when
objects share the same or similar indices of
refraction. In histology, immersion oils are used
to achieve this “clearing.” This terminology
comes from the fact that the clearing agents
often have the same refractive index as proteins.
As a result, when the tissue is completely infil-
trated with the clearing agent, it becomes trans-
lucent to transparent. This change in appearance
of the object is often used as an indication of the
effectiveness or completeness of the clearing
method [10]. So, in light microscopy, oils are
defined as being index-­matching materials. In
70
optics, an index-matching material is a sub-
stance, usually a liquid, cement (adhesive), or
gel, which has an index of refraction that closely
approximates that of another object (such as a
lens, material, fiber optics, etc.). When two sub-
stances with the same index are next to each
other, light passes from one to the other with nei-
ther reflection nor refraction.
It is not easy to determine the index of refrac-
tion of a substance such as type 1 collagen; so,
definitive representative numbers are difficult to
find. It is estimated that its index of refraction,
depending on the level of hydration, may vary
from 1.43 to 1.53 [15–17]. The latter (1.53)
became an appropriate number in the diaphaniza-
tion of human teeth since this is the index of
refraction of the primary oil used in the clearing
process. Immersion oils are transparent and have
specific optical and viscosity characteristics nec-
essary for use in microscopy. Typical oils have an
index of refraction around 1.515 [20]. For exam-
ple, one of the most used oils in teeth clarification
is methyl salicylate, which has a refractive index
of 1.5369 [42]. This index of refraction values is
what allows the final object to be transparent.
5.3.4.2 Immersion Oils
Methyl Salicylate
Methyl salicylate is the most commonly used
immersion oil for transparency of human teeth. It
is an oil extracted from plants of the genus
Gaultheria. It can be found in many products of
daily use such as toothpaste, mouthwashes, and
creams to relieve muscle aches and even in some
perfumes, chewing gums, and soft drinks. Methyl
salicylate, either in its pure form or commercial
presentation, is referred to as “Winter Green Oil,”
which has 98% methyl salicylate, and is widely
used in microscopy because of its refractive index
of 1.5369 [42]. It must be point out that ingestion
of methyl salicylate is dangerous and can be
lethal. One teaspoon contains 7000 mg of salicy-
late, equivalent to 21.7 aspirin tablets of 325 mg
[43]. Besides, direct skin contact with methyl
salicylate may cause sufficient dermal absorption
to produce toxic serum salicylate levels [44].
Therefore, it is important to keep it out of reach
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
of children and use nitrile gloves and masks when
handling it.
Other Immersion Substances
Eugenol (oil clove) has a refractive index of 1.535
which is very close to the dentin (1.540) [45]. It is
a suitable alternative to methyl salicylate
(Fig. 5.6a, b); however, it must be fresh because it
may acquire a yellowish color with time and
affect the visualization of the sample (Fig. 5.6a).
Benzyl benzoate (benzyl ester of benzoic
acid; n = 1.568–1.570) and isosafrole (aro-
matic constituent of oil of sassafras; n = 1.577)
were also listed by Dr. Spalteholz as good
clearing agents [1, 2]. According to him, the
latter have better results when mixed with
methyl salicylate in a 5:3 proportion. Spalteholz
also recommended starting a sample with
either xylol or benzol and then slowly adding
isosafrole over a few days so as the xylol or
benzol can evaporate off a loosely covered
container. It is recommended to use a vent
hood as xylol and benzol are very volatile,
odorous, and flammable [3].
Bergamot, origanum, periwinkle oil, xylol,
toluol, and carbon disulfide are examples of other
clearing chemicals that have been tried in the
past. These substances are still available and
require to be mentioned due to their historic use
[3]. Some are dangerous in terms of being vola-
tile and flammable, but others still have experi-
mental value. Some practitioners may also find it
difficult to purchase certain chemicals in their
regions of residence. However, it is to be noted
that several high refractive index oils exist and
can be useful to attain results to an educational
level aiming to show the internal anatomy of
human teeth. Another product, like Canada bal-
sam, and honey with 10% water have a refraction
index of 1.52 and are also suitable as immersion
substances for making teeth transparent
(Fig. 5.6c).
Synthetic immersion oils are commonly used
in microscopy and are suitable for clarifying
teeth; however, according to the type of oil, it
may have a different refraction index. Hence, it is
important to look for an immersion oil that has a
similar index of refraction of the dentin.
5 Diaphanization Techniques in the Study of Root Canal Anatomy 71

Fig. 5.6 Immersion

agents in the a b
diaphanization process.
(a) When eugenol is
used as a clearing agent,
tooth is cleared but will
present a yellow
appearance; (b) the use
of methyl salicylate as a
clearing agent allows a
more transparent
appearance in
comparison with the
eugenol; (c) honey can
also be used as c
immersion agent with
acceptable result

5.3.5 Diaphanization Techniques 4. Neutralize with 5% sodium sulfate for

The basic concepts of decalcification, dehydra-
tion, and clarification for diaphanization of hard
tissues provided by Spalteholz [1, 2] have
remained immutable. Changes have been made
over time in the materials, proportions, and times
used to perform these procedures but without
changing the basic concepts. Therefore, these
changes must be considered as modifications of
original Spalteholz technique, as follows:
5.3.5.1 S
 palteholz Modification by
Lenhossék [45]
1. Remove teeth’s crowns.
2. Left roots in thermostat-controlled device at
37 °C for 1 month.
3. Decalcify samples in 5% HCl or HNO3,
changing solution every day for 2 weeks.
24 h.
5. Wash for 24 h with running water.
6. Place in thermostat-controlled device at
35–37 °C for 24 h in 10% gelatin.
7. Dissolve Prussian blue powder in water until
solution turns dark blue.
8. After gelatin is cold, take teeth out and
soak into 10% formalin solution for
2 days.
9. Wash in running water for 12 h.
10. Dehydrate for 1 day each in 30%, 50%, 80%,
and absolute alcohol, changing solution
three times per day.
11. Soak in benzene solution for 3 days, chang-
ing the solution every day.
12. Take out benzene solution and soak into
Spalteholz solution of wintergreen oil and
isopral for final transparency.

pilararaya@ejercer.cl
72
5.3.5.2 S palteholz Modification by
Vertucci [5]
1. Store extracted teeth in 10% formalin.
2. Prepare access cavities using no. 2 round bur.
3. Dissolve pulp tissue by immersing teeth in
2.5% NaOCl for 12 h, followed by 20 min of
immersion in an ultrasonic bath.
4. Rinse teeth under running tap water for 2 h
and dry them overnight.
5. Use a 27-G needle adapted to a syringe to
inject India ink into the root canal space cor-
onally, assisted by vacuum suction apically.
6. Dry teeth with air.
7. Decalcify teeth in 5% nitric acid for 4–5 days.
The acid solution must be changed daily and
the endpoint of decalcification determined
by radiographs.
8. Wash teeth under running water to remove
traces of acid.
9. Dry and dehydrate sample using increasing
concentrations of ethanol (70%, 95%, 100%)
for 24 h.
10. Render teeth transparent by immersing in
methyl salicylate.
5.3.5.3 S palteholz Modification by
Castellucci [46]
1. Dissolve soft tissues by immersing teeth
30 min in NaOCl.
2. Use gutta-percha as a contrast medium.
3. Left samples 3 days in 5% nitric acid at room
temperature.
4. Use radiographs to check demineralization
process.
5. Rinse sample in tap water for 4 h.
6. Dehydrate sample in 80% ethyl alcohol for
12 h, followed by 2 h in 90% and 2 h in over
proof.
7. Render teeth transparent after 2 h in methyl
salicylate.
5.3.5.4 S palteholz Modification by
Robertson: Canal Anatomy [12]
1. Left teeth 3 days in 5% nitric acid at room
temperature.
2. Dehydrate sample in 80% ethyl alcohol over-
night, then in 90% ethyl alcohol for 1 h fol-
lowed by 3-h rinse in 100% ethyl alcohol,
changed each 1 h.
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
3. Use methyl salicylate to render teeth
transparent.
4. Inject India ink into the pulp chamber with a
27-G needle. The ink can be drawn through
the canal system by applying negative pres-
sure to the apical end of the tooth with a suc-
tion system.
5.3.5.5 Spalteholz Modification
by Robertson: Canal
Obturation [12]
1. Gutta-percha and sealer are used as contrast
medium.
2. Left teeth in 5% nitric acid for 24 h at room
temperature.
3. Dehydrate sample in 80% ethyl alcohol over-
night, then in 90% and 100% ethyl alcohol for
1 h, respectively, followed by 3-h rinse with
acetone, changed each 1 h.
4. Use silicone 710 for 24 h to render teeth
transparent.
5.3.5.6 S palteholz Modification by
Pécora [32]
1. After access cavity preparation, store extracted
teeth in 5% NaOCl for 4 days changing the
solution every 24 h, followed by 6 h in tap
water.
2. Store teeth in 5% hydrochloric acid changing
the solution every 24 h until the enamel is dis-
solved, followed by 24 h in tap water.
3. Use 80% and 100% of alcohol for dehydration
(no time limit was reported).
4. Inject gelatin mixed with India ink into the
root canals.
5. Use methyl salicylate for clarification.
5.3.5.7 S palteholz Modification by
Venturi: Canal Obturation [7]
1. Gutta-percha and sealer are used as contrast
medium.
2. For decalcification, use 7% formic acid, 3%
hydrochloric acid, or 8% sodium citrate in
aqueous solution for 14 days changing the
solution every 3 days.
3. Wash teeth in tap water for 2 h.
4. For dehydration, use ethyl alcohol at 25%,
50%, 70%, 90%, 95%, and 100%, for 30 min
each.
5 Diaphanization Techniques in the Study of Root Canal Anatomy
5. Immerse teeth in methyl salicylate for
clarification.
5.3.5.8 S palteholz Modification by
Weng: No Contrast Medium [15]
1. Wash and store extracted teeth in 3% hydro-
gen peroxide (no time limit was reported).
2. Place samples in 3.25% NaOCl for 1 h.
3. Wash with tap water and allow to dry
overnight.
4. Without preparing access cavities, immerse
teeth in 50% India ink and place them in
hyperbaric oxygen chamber for 2 h at
6 MPa.
5. Wash with tap water and place into 5% nitric
acid for 7 days, changing solution daily.
6. Wash in running tap water for 3 h and dehy-
drate in ethyl alcohol (75%, 85%, 95%, and
100%) for 12 h in each concentration.
7. Place in methyl salicylate for 2 days.
5.3.5.9 S palteholz Modification by
Malentacca and Lajolo [47]
This protocol can be used for analysis of all teeth
no matter if root filled or untreated.
1. Freshly extracted teeth should be preserved
in water immediately after extraction, then
washed with a mild peroxide solution, scaled
and cleaned under running water, and finally
preserved in 2% glycerol-formalin solution.
2. Place teeth on a large Petri dish and dried
with absorbent paper to remove the excess
glycerol and then brushed with a 30% alco-
hol solution, and under running water, the
pulp cavity is opened removing the pulp
tissue.
3. Soak teeth into a solution of 0.5% blue ani-
line with 8% citric acid for 10 min.
4. Using microscope, wear roots and crown fol-
lowing the direction of the canal, taking
great care to include it well in the section.
Pay attention not to allow the teeth to dry out
and the cut to touch the canal in any way.
5. After this first rough-shaping, soak teeth in
distilled water and dye with one of the many
coloring methods for pulp tissue and root
cement (e.g., Mallory mix 1) for 2 or 3 days
according to the thickness of the section.
pilararaya@ejercer.cl
73
6. Wash under running water and finish first
with a fine-grain drill for turbine up to a
thickness of 2–3 mm, and then polish with
abrasive disks mounted on a contra-angle
under running water.
7. Wash with distilled water.
8. Soak in alcohol solutions at progressively
increasing concentrations (30%, 50%, 80%,
and 90%) and left in 100% alcohol until the
staining in the dentinal tubules is totally
removed, leaving dentinal tissue finally
transparent and pulp tissues a reddish-brown
color.
9. Transfer teeth to methyl benzoate for some
days until the dentin becomes totally trans-
parent and then to xylene working under the
hood to avoid highly toxic vapors.
Considering that xylene has a very fast evap-
oration of this solution, it must be quickly
removed with absorbent paper to avoid sec-
tion to dry in this phase.
10. Scout the canal with a size 08 or 10 K-file
and leave it there with the tip 1 or 2 mm out
of the apex. Cover pulp cavity and apex with
Vaseline, and immediately fix with resin for
inclusion, or attack glue on the slide for his-
tology covering with it all the section.
5.3.5.10  palteholz Modification by
S
Holm Reuver [48] (Figs. 5.7,
5.8, 5.9, 5.10, and 5.11)
This protocol can be used for analysis of all
teeth no matter if root filled or untreated. As
contrast media, aqueous suspensions of color
pigments are used. It is important that the pig-
ments used do not show chromatographic phe-
nomena when exposed to acid, alcohol, or
methyl salicylate. Besides, pigment particles
must on the one hand be small enough for good
penetration in the finest endodontic structures
and on the other hand large enough not to enter
dentinal tubules. The latter often is a problem
with India ink. Pulp tissue and other material
sometimes hinder color suspensions to cover all
inside dentin surfaces completely, or it might
block the inflow into certain areas of root canals.
This problem can be overcome or at least
reduced by dissolving organic material with
NaOCl, which is injected through a small coro-
74 C. Barrington and F. Balandrano

a b c d e

Fig. 5.7 Holm Reuver’s diaphanization technique applied to different teeth showing the complexity of the internal
anatomy of (a) one mandibular incisor and (b–f) five mandibular molars (http://www.transparentmacher.de)

nal access at the beginning of the whole proce-
dure. For analysis of root-filled teeth, it is
advisable to take photographs as soon as the
respective preparation has become transparent
and before diffusion of gutta-percha color into
dentin structures becomes too severe. Working
with lower temperatures helps to reduce color
diffusion of gutta-percha. This is especially a
problem of alpha gutta-percha. This method
works exclusively on previously treated teeth
and drastically cuts down on the time.
1. Tooth extraction is followed by gross removal
of soft tissue with hand instruments and ultra-
sonic bath with 3% NaOCl for 5 min.
2. Store teeth in containers with physiological
saline and a few thymol crystals.
3. Dry teeth overnight in normal room atmo-
sphere. By then water has evaporated from
pulp structures inside the teeth and is replaced
by air.
4. To install pigments into the pulp structures, a
low-pressure gradient is applied inside the

pilararaya@ejercer.cl
5 Diaphanization Techniques in the Study of Root Canal Anatomy 75

a b c d

e f g h

i j k l

Fig. 5.8 Holm Reuver’s diaphanization technique showing the complexity of the internal morphology of a maxillary
molar (a–l) (http://www.transparentmacher.de)

teeth and at the high end outside. Teeth are
immersed in a container with an aqueous sus-
pension of color pigments and evacuated (e.g.,
Power Mixer in the dental lab) for 2 min to
remove the air entrapped inside the teeth.
With removal of the vacuum, atmospheric
pressure presses the color suspension into all
pulp compartments. The gradient can be
raised by additional pressure, for example,
using a pressure pot for acrylic polymeriza-
tion, in which the container with the teeth is
transferred.
5. Teeth are taken out of the color suspension,
surfaces are cleaned with soft tissue, and

pilararaya@ejercer.cl
76 C. Barrington and F. Balandrano

a b c d

e f g h

i j k l

Fig. 5.9 Holm Reuver’s diaphanization technique applied to different teeth showing the apical complexity of the root
canal system (a–p) (http://www.transparentmacher.de)

pilararaya@ejercer.cl
5 Diaphanization Techniques in the Study of Root Canal Anatomy 77

m n o p

Fig. 5.9 (continued)

a b c d

e f

Fig. 5.10 Holm Reuver’s diaphanization technique applied to a maxillary molar tooth (a-j)highlighting a massive extra
canal invasive resorption (ECIR) on the buccal aspect of the palatal root (c-h) (http://www.transparentmacher.de)

pilararaya@ejercer.cl
78 C. Barrington and F. Balandrano

g h

i j

Fig. 5.10 (continued)

a b c d

Fig. 5.11 Holm Reuver’s diaphanization technique applied to a mandibular incisor (a, b) and mandibular molars (c–g)
depicting the presence of separated instruments in root-filled canals (d-h) (http://www.transparentmacher.de)

pilararaya@ejercer.cl
5 Diaphanization Techniques in the Study of Root Canal Anatomy 79

e f g

Fig. 5.11 (continued)

pilararaya@ejercer.cl
80
teeth are dried again at room atmosphere
for 1 h to let the pigments bind to the inside
dentin surfaces. Then pigment remnants on
the outside root surfaces are meticulously
removed from the dry teeth with moist tis-
sue and little brushes. Care must be taken
to not remove pigments out of any
foramina.
6. Place the sample in 5% HNO3 for 2–4 days,
depending on the thickness of the teeth,
changing solution every 6–12 h and shaking
the sample constantly.
7. Wash in tap water for 1 h.
8. Dehydrate in ethyl alcohol (50%, 80%, 96%)
for 3–6 h, depending on the thickness of the
tooth structure, shaking the solution
constantly.
9. Transfer teeth to methyl salicylate, which ren-
ders them transparent in 30–90 min.
5.3.5.11  palteholz Modification by
S 7–10 days shaking it at least five times every
Barrington: Technique A
(Fig. 5.12)
This method works exclusively on previously
treated teeth and drastically cuts down on the
time taken to expose the internal aspects of the
tooth.
1. Soak extracted teeth into NaOCl for 2–4 h to
remove the periodontal ligament and blood
debris.
2. Place into 5–7% hydrochloric acid for 12 h
(premolars/centrals) or 24 h (molars).
3. Do not rinse the sample.
4. Place them in full-strength alcohol for 2–4 h.
5. Use methyl salicylate for clarification.
5.3.5.12  palteholz Modification by
S
Barrington: Technique B
(Fig. 5.13)
This method (patent application #14/310,563)
uses no contrast medium and no access prepara-
tion. It is the fastest method to detail the internal
anatomy of human teeth, achieving results in
48–72 h. In some cases, results can be achieved
as soon as 18–24 h.
1. Do not clean the recently extracted tooth and
allow it to dry in a container for 24 h.
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
2. Place the specimen into 5–7% hydrochloric
acid for 12 h (premolars/centrals) or 24 h
(molars).
3. Clean the dried debris from the external por-
tion of the specimen with a razor blade.
4. Dry the sample in a nonalcohol drying agent
such as air, cat litter, silica sand, silica gel, and
diatomaceous earth, for approximately 2–4 h.
5. Place in methyl salicylate oil.
5.3.5.13  palteholz Modification by
S
Balandrano
In this technique, some of the following products
may be used as contrast media: India ink, cake
paint, recreational paint, and bacteria. The differ-
ence in the refractive index can also be used to
differentiate the canal system from the other den-
tal structures.
1. Keep sample in 3% hydrochloric acid for
24 h. The solution must be changed every
24 h.
2. Assess the demineralization process by
radiography.
3. Place sample in tap water for 1 h.
4. Dehydrate in ethyl alcohol (50%, 60%, 70%,
80%, 90%, and 96%, respectively) for 24 h
each, shaking the solution at least five times
every 24 h.
5. Place the sample in a hermetically sealed
container, containing silica sand in a small
opened container, for 1 h to complete
dehumidification.
6. Place the tooth in methyl salicylate oil for
clarification.
5.3.6 Photographic Techniques
The output quality of an image directly reflects
the reliability of the method used to evaluate root
canal anatomy using diaphanization technique
and, consequently, the accuracy of the acquired
results. It is important to point out that a close-to-­
ideal procedure for image analysis in a research
study for instance is that it should be performed
by an expertise technician, to guarantee image
with adequate quality aiming to acquire validate
5 Diaphanization Techniques in the Study of Root Canal Anatomy
a b
d e
g h
j k
Fig. 5.12 Barrington’s technique. (a–c) An endodonti-
cally treated maxillary second premolar was extracted and
made transparent revealing a complex apical anatomy; (d)
file separation and missed MB2 in the mesiobuccal root of
a maxillary left first molar; (e) root filled with silver point
technique obturation; (f) mesial root of a mandibular right
first molar filled with silver points; (g) root-filled maxil-
lary second molar showing a missed MB2 canal; (h) distal
root of a mandibular first molar filled with lateral conden-
sation technique; (i) mesiobuccal root of a maxillary right
pilararaya@ejercer.cl
81
c
f
i
l m
first molar with a long-term infection showing apical root
resorption and missed MB2 canal; (j) root canal of a man-
dibular right second premolar filled with classical
Schilder’s obturation technique; (k) root-filled mandibu-
lar first premolar with access closed with composite; (l)
root canal filled with carrier-based obturation showing
stripping of gutta-percha from carrier; (m) mesial root of
a mandibular right first molar filled with lateral condensa-
tion technique with master gutta-percha cones dipped in
eucalyptol
82
a
b lighting from a dental operating microscope
c because the results will change according to the
Fig. 5.13 Exposure of the internal anatomy of (a-b) two
maxillary second premolars and (c) a maxillary lateral
incisor using Barrington’s clearing method. Note
that Barrington's method does not involve an access open-
ing to inject dyes or contrast mediums (b-c). In the lateral
incisors it is possible to observe that pulpal reaction and
constriction of the canal occurred as a result of the irrita-
tion caused by the decay (c).
results. In this way, the photographic technique is
of utmost importance. All photographic tech-
niques used for registration of tooth transparency
must use some form of oil immersion and oblique
illumination light microscopy, which has been a
standard procedure in histology.
Three essential fundamentals are involved in
the documentation of the results:
1. The sample must be completely immersed in
an oil to maximally expose details.
2. Some form of perimeter lighting must be
used. It is rare and even sometimes detrimen-
tal to completely “backlight” a sample.
3. Magnification of some form is used from stan-
dard light microscopes and dental operating
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
microscopes to macrophotography. Many cre-
ative mechanisms, techniques, lighting, and
filters can also be used in the form of a scien-
tific to artistic approaches to portray the
results.
Dr. Barrington uses a total immersion of the
sample in methyl salicylate oil and perimeter
(magnification from 2× to 26×) coupled with a
digital camera mounted on a beam splitter. Dr.
Balandrano developed several photographic
techniques through which it is possible to dif-
ferentiate the dental structures such as cement,
dentin, and canals without the need of a con-
trast medium. Each technique includes differ-
ent cameras, backgrounds, filters, and special
lights in assorted colors and positions
(Figs. 5.14a–f, 5.15, and 5.16). The practitioner
must develop personal photographic techniques
camera, the background, the filter and the inten-
sity, and the arrangement and color of the
illumination.
The numerical aperture is key factor to the
performance of objective lens, including cameras
and microscopes, because it determines the
power, focal depth, and brightness provided by
lens [49]. So, it is suggested to obtain the opti-
mum numerical aperture at the moment of
observing or taking images of the clarified tooth.
However, because of different refractive index of
dental tissues, determination of the ideal aperture
of lens may be a problem for a clear picture of the
clarified samples. This situation can be solved if
the photograph is taken with the tooth submerged
in some substance that has similar index of
refraction of the dentin (n = 1.54). This immer-
sion also optimizes the numerical aperture, and
therefore it is possible to obtain a more accurate
image of the sample. Otherwise, the results can
be unreliable because some internal tooth struc-
tures could not be properly distinguished
(Fig. 5.14g, h).
In the literature, several substances have been
suggested to be used for observation of clarified
dental pieces, including xylene and epoxy res-
ins; however, xylene has a refractive index of
1.505 [42] which is different from dental struc-
5 Diaphanization Techniques in the Study of Root Canal Anatomy 83

a b

c d e f

g h

Fig. 5.14 Images of cleared teeth taken with different
photographic techniques developed by Dr. Balandrano.
(a, b) Mesial root of a mandibular molar photographed
using two different techniques clearly depicting the
cement layer, dentin, and root canal; (c, d) different pho-
tographic techniques showing cement layer and dentin
with distinct colors; (e, f) mandibular premolar submerged
in methyl salicylate and coated with acrylic resin showing
a wide canal with four ramifications at the apex level; (g,
h) same dental piece photographed submerged (left) and
not submerged (right) in oil

tures and could not allow for an accurate obser-
vation of the sample details. On the other hand,
epoxy resins can be very efficient for tooth trans-
parency, despite these materials have a refractive
index that varies according to their brand and
chemical composition [50]. Another problem is
that the refractive index may change after resin
polymerization [51]. Therefore, if epoxy resins
are used for tooth clarification, it is advisable to
ensure that they have similar refractive index as
the dentin at the time of polymerization
(Fig. 5.14e, f).

pilararaya@ejercer.cl
84
a b
d e
g h
Fig. 5.15 Complex canal anatomies observed in cleared
mesial roots of mandibular molars. (a–d) Middle mesial
canal dividing into two canals in the middle part of the
root. Each one of the divisions is confluent with the main
canals and has an independent foramen; (e) one of the
main canals is divided into two canals at apical level. A
middle mesial canal which ends in the division of the
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
c
f
i
main canals can be also observed; (f) it is common to
observe a widening of the middle mesial canals at the
coronal or middle thirds of the root; (g–i) a middle mesial
canal starts in one of the main canals and ends in the other.
There is also a recurrent canal at the level of the middle
third and a calculus at the apical third of the root
5 Diaphanization Techniques in the Study of Root Canal Anatomy 85

a b c

d e f

g h i

Fig. 5.16 Complex canal anatomies of cleared teeth. (a, b) canals in the mesial root of a mandibular molar connected by
Independent middle mesial canal showing multiple trans- multiple transverse canals; (h) a wide canal is divided into
verse connections with the main canals; (c, d) presence of a three canals with independent foramens at the apical third; (i)
calcification in the apical third of the canal; (e-g) main root magnification of image in (h) showing a canal calcification

pilararaya@ejercer.cl
86
5.3.7  oot Canal Preparation Using
R the other hand, in case of teeth stored for an
Transparent Teeth
It has been reported that teeth that have been
made transparent by diaphanization process can
be re-hardened for visualization of the effects of
different mechanical or irrigation techniques over
the anatomical components of the root canal sys-
tem. This procedure has been done mostly for
educational purposes [52]. Post-clearing treat-
ment of the teeth with xylene can restore some of
the overall loss of hardness that results from the
decalcification process, but the original hardness
cannot be restored [21]. Therefore, instrumenta-
tion and irrigant activation in straight canal sys-
tems can demonstrate some instructive value, but
curvatures and small ramifications in canals can
bring error and artifact. Even though treatment
with xylene of post-cleared teeth can gain some
hardness in comparison to untreated clear teeth,
the ease of over instrumentation and perforation
inherently exists. Therefore, this educational vec-
tor should be used with caution since the ease of
an error can result in much confusion and frustra-
tion in a classroom setting.
5.4 Conclusion Remarks
Dental diaphanization or dental transparency
technique is a valuable tool for teaching and
learning purposes. The ability to analyze instru-
mentation, irrigation protocols, and obturation
methods is unsurpassed in terms of thoroughness
and convenience [52]. Furthermore, this tech-
nique is particularly useful to study the anatomy
of the root canal system because it allows for a
three-dimensional visualization of the internal
structures of the tooth. In general, it is economic,
it does not need special devices, and, with some
experience, it is relatively easy to execute.
The authors of this chapter have thoroughly
studied and worked with the multitude of tech-
niques listed herein. This has brought them to
perform two basic methods, which are set accord-
ing to the conditions of the tooth. If the tooth is
recently extracted and pulp tissue is viable, it is
advisable to use the Barrington’s technique. On
pilararaya@ejercer.cl
C. Barrington and F. Balandrano
unknown period or previously exposure to differ-
ent chemicals such as NaOCl, saline, or formalin,
Balandrano’s technique is preferred.
This chapter describes the methodologies
involved in dental diaphanization procedures and
provides details of the most used techniques.
However, it is required a continuous practice for
mastering these techniques. Do not expect exem-
plary results from the beginning. Outcomes at
times can be varied and sometimes discouraging.
Differences in tooth size, root morphology, hard
tissue composition, and thicknesses throughout
the same tooth can also affect the outcome. Various
chemical treatments, prior to start the clearing pro-
cess, add variables that can also alter the results.
However, with a desire to learn and get better, nice
results can be achieved in a brief period. This will
provide years of education and learning which will
lead to improvements in endodontic outcomes for
all interested in achieving clinical treatment results
that eventually improve patient’s quality of life.
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 CBCT and Micro-CT on the Study
of Root Canal Anatomy
Jorge N. R. Martins and Marco A. Versiani
Abstract
A thorough understanding of the canal mor-
phology and its variations in all groups of
teeth is a basic requirement for the success of
the endodontic therapy. Over the last century,
the complexity of the root canal system was
well documented using several methods
including three-dimensional wax models, con-
ventional and digital radiography, resin
­injection, macroscopic and microscopic eval-
uations, tooth sectioning, clearing techniques,
radiographic methods with radiopaque con-
trast media, and scanning electron micros-
copy. These techniques have been used suc-
cessfully over many years, but their destructive
nature produced irreversible changes in the
specimens and many artifacts. Technological
advancements in three-dimensional computed
tomographic imaging have given rise to more
accurate methods for clinical and laboratory
evaluations of tooth anatomy. In the last
decades, cone beam computed tomography
(CBCT) and high-resolution micro-computed
J. N. R. Martins (*)
Dental School of Lisbon,
University of Lisbon, Lisbon, Portugal
e-mail: jnr_martins@yahoo.com.br
M. A. Versiani, D.D.S., M.Sc., Ph.D.
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_6
pilararaya@ejercer.cl
6
tomography (micro-CT) have gained increas-
ing significance in dental research allowing
the detailed study of canal anatomy because
they offered a nondestructive reproducible
technique that could be applied quantitatively
as well as qualitatively for two- and three-­
dimensional accurate assessment of the root
canal system. This chapter is focused on the
description of the main results obtained in the
in vivo and ex vivo research studies on the root
and root canal anatomy using CBCT and
micro-CT imaging technologies.
6.1  one Beam Computed
C
Tomography
6.1.1 Definition
Nowadays, imaging technology is the major
diagnostic aid used in dentistry. Among the most
used imaging resources are the conventional or
digital, panoramic and intraoral periapical, and
bitewing radiographs. While these user-friendly
techniques are quick to be performed and
assessed, present a low radiation dose, and have
relatively low cost worldwide, they are two-­
dimensional (2D) images associated with inher-
ent limitations such as geometric distortion,
superimposition of anatomic structures, and
dependency of observer interpretation [1].
89
90
Some clinical areas have surpassed some of
these limitations by accessing three-dimensional
(3D) examinations such as computed tomogra-
phy (CT) scans. In early years, a CT scan was a
3D imaging technique based on multiple 2D
slices separated by predefined distances. These
spaces between slices were blind areas, unavail-
able to be analyzed. Because of the multiple 2D
slices required to be taken, so a 3D interpretation
could be done, but multiple scans had to be per-
formed until the area of interest was completely
imaged. This highly increased the level of radia-
tion exposure of the patients. Moreover, the CT
machines had to be large enough, so the patient
could lay down and be moved through it while
being submitted to multiple scans. Although the
late versions of the CT devices reduced the
impact of some of these problems, it never
became a friendly imaging technology to be
incorporated into dental practice.
The wide acceptance of the 3D imaging tech-
nique in the dental community started with the
development of the cone beam computed tomog-
raphy (CBCT) during the 1990s. This technology
became so user-friendly that it was rapidly spread
worldwide. The most significant difference to the
earliest CT systems is the transition from multiple
scans to one single 180–360° scan with a cone-
shaped X-ray beam which allows to capture a 3D
image volume while reducing the blind spaces
between the slices. Another improvement is the
possibility to adjust the center of rotation aiming
to capture a smaller localized 3D volume related
to a specific area of interest and not a large slice of
the patient’s body as in conventional CT imaging.
The single scan and localized volume capturing
are the two main factors that significantly reduced
radiation exposure. CBCT imaging technique
also allowed the development of smaller machines.
Therefore, patients no longer must be moved
through the device but takes a standing or sitting
position with the head stabilized by a holder,
while the CBCT sensor moves around for a brief
time. The area of interest is captured in a cylindri-
cal or spherical volume, which is digitally recon-
structed, and then possibly to be observed and
submitted to several filters and setting changes,
allowing a better image interpretation in any per-
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
sonal computer. This 3D volume presents a sig-
nificant increase of resolution and image quality
when compared to the former CT scans based on
multiple 2D slices and also a greater diagnosis
accuracy in comparison with panoramic or intra-
oral radiography which, according to Bender [2],
requires at least an estimated 7.1% of mineral cor-
tical bone loss to produce a radiographically visi-
ble radiolucent area.
In summary, CBCT technology became a
faster, smaller, compact, and safer version of the
CT imaging technique to capture 3D images of a
specific area of interest. However, due to the radi-
ation dose, artifacts, and noise present on CBCT
images, conventional or digital panoramic and
intraoral radiographs are still the primary choice
for imaging diagnosis, balancing with CBCT
technique when a more advanced and detailed
examination is required.
6.1.2 CBCT Image Acquisition
Several technical dissimilarities exist among dif-
ferent CBCT devices; however, the basic con-
cepts are common to all of them. Normally, after
leaving the X-ray source, the CBCT beam takes a
cone-shaped form, which gives the name to this
imaging technique, and its electromagnetic wave
is projected to a detector plate while crossing, in
its way, the area of interest to be imaged. In other
words, the X-ray photons leave the source, tres-
pass the patient’s body, and will impress the
detector plate on the opposite side. From there, a
produced electric signal will be used for the
three-dimensional reconstruction of the patient’s
body. The X-ray source and detector plate are
connected to each other, and both rotate simulta-
neously around the patient in a 180–360° rotation
arc during the scan to produce multiple 2D pro-
jection images. A higher number of projections
are required to achieve a better resolution, and,
consequently, it also requires more time and a
higher frame rate, which increases the radiation
dose [3].
The 3D volume built by all these multiple 2D
projections is defined as field of view (FOV)
whose shape might be either a cylinder or a
6 CBCT and Micro-CT on the Study of Root Canal Anatomy
sphere. The FOV size can be adjusted to capture
only the area of interest. It can be a small field,
also designed as limited field, with only 5 cm3
size or smaller, to capture only two or three teeth,
or a large field to capture a maxillofacial view
with 10–15 cm3 [3]. These FOV volumes are dig-
ital reconstructions made up of smaller volumet-
ric particles designed as voxels. In 2D images,
the smallest image particle is designed as pixel,
which presents a specific height and width. The
smallest the pixel, the higher the number of pixel
per cm2 and the higher the image resolution. In
3D volumes, that smallest pixel has also a spe-
cific depth, giving it a 3D shape, and receives the
designation of voxel. The voxel is the 3D equiva-
lent of the 2D pixel. The CBCT voxels are isotro-
pic particles, meaning they present equal height,
width, and depth, giving accurate shape and mea-
sures to the 3D volume [4]. Each particle has also
an assigned gray-scale value according to the
density of the captured tissues. The global vision
of all these little combined voxel gray shades is
responsible for all different gray-scale transitions
(color transition) between tissues, giving shape to
a more clear and precise images in the 3D vol-
umes [5]. Nowadays, voxel size from CBCT
machines may vary from 400 μm to 76 μm [3].
Smaller voxel sizes allow higher resolutions but
will also require higher radiation doses. Some
devices allow the change of the voxel size, while
in others, voxel size is predefined. Several CBCT
machines use the smallest voxel size associated
with the smallest FOV, allowing a balance of the
radiation dose required since smaller FOV
requires also lower effective radiation dose [6].
Other important parameters of the CBCT
devices are the milliampere (mA) per second
and kilovoltage (kV). Changing the mA settings
to higher values will produce less noise and
increase the image quality; however, it will also
submit the patient to a higher radiation dose
since more electrons are released [7]. The reduc-
tion of the mA value is usually balanced with
the increasing in the kV parameter which will
give more energy to the released electrons,
increasing their tissue penetration capacity and
maintaining similar reception on detector plate
which, consequently, reduces the radiation dose.
pilararaya@ejercer.cl
91
One of the major concerns regarding the rou-
tine use of the CBCT imaging is the effective
radiation dose taken by the patient. The effective
dose is measured in sieverts (Sv) and takes into
account the radiosensitivity of the different body
tissues. Considering the estimated tissue weight-
ing factors, the full-mouth radiographs taken
with F-speed sensor films may reach 34.9 μSv
using a rectangular collimation, four F-speed
sensor posterior bitewings with rectangular col-
limation may reach 5.0 μSv, and panoramic
radiograph may reach 14.2 and 24.3 μSv with an
Orthophos XG (Sirona Group, Bensheim,
Germany) or ProMax (Planmeca, Helsinki,
Finland) devices [8], respectively. All these val-
ues may vary depending on the settings, sensors,
and equipment used. The CBCT imaging, having
as reference an i-Cat Classic (Imaging Sciences
International, Hatfield, USA), may reach 93.3
and 118.5 μSv for the maxilla or mandible,
respectively, using 6 cm3 FOV under high resolu-
tion, and 206.2 μSv using a 22 cm3 FOV under
standard resolution [5]. Therefore, the choice of
imaging technique must take into consideration
the amount of radiation, which must be as low as
possible to provide the required information,
avoiding duplicated exams.
6.1.3 CBCT Artifacts
Although the output of computed tomography is
visual in nature and thus lends itself to straight-
forward interpretation, subtle complications can
render the data more problematic for quantitative
use. Scanning artifacts can obscure details of
interest or cause the CT value of a single material
to change in different parts of an image. Besides
the radiation exposure, another significant draw-
back of the CBCT technology as an imaging
technique is the occurrence of artifacts. Schulze
et al. [9] defined artifact as a visualized structure
in the reconstructed data that is not present in the
object under investigation. These “phantom”
images arise as a result of device- or object-/
patient-related factors [10].
Double contour pattern and lack of sharpness
are the main features of the most common patient-
92 J. N. R. Martins and M. A. Versiani

related artifact, the so-called movement artifact
[9, 10] (Fig. 6.1a). It is difficult for a patient to
remain still during the scanning process due to
breathing, heart beating, unintentional move-
ments, or even ignored instructions, especially
considering that the examination may take
between 5 and 40 s [10]. Considering that around
20% of patients move during the scan procedure
[11, 12], it is important to minimize this occur-
rence by reducing the scanning time, improving
the stabilization of the head, and using software-­
based artifact corrections [10]. Other common
patient-related artifacts are beam hardening,
exponential edge-gradient effect, and metal arti-
facts. Beam hardening is characterized by the
emergence of dark bands adjacent to very dense
and radiopaque structures such as dental restora-
tions or root canal fillings (Fig. 6.1b, c). It hap-
pens because of differences in densities between
adjacent structures and the capacity of the dense
objects to absorb the X-ray beam photons which
will reflex on the energy received in the detector
and, consequently, in the 3D reconstructed vol-
ume [9, 13]. Exponential edge-gradient effect
usually causes dark streaks tangent to sharp edges
with high contrast to neighboring structures [9]

a b c

d e f

g h i

Fig. 6.1 Different types of CBCT artifacts. (a) Movement, (b, c) beam hardening, (d) exponential edge-gradient effect,
(e) metallic artifacts, (f, g) ring artifacts, (h) aliasing artifacts, and (i) noise

pilararaya@ejercer.cl
6 CBCT and Micro-CT on the Study of Root Canal Anatomy
(Fig. 6.1d), and metal artifacts are a mix of several
other artifacts, such as beam hardening or expo-
nential edge-gradient effect, and are characterized
by white and dark streaks or bands resulting in
blurred images and lack of sharpness (Fig. 6.1e).
Ring artifacts, aliasing artifacts, noise, volu-
metric distortion, and device motion are different
types of device-related artifacts [9, 10, 14]. Ring
artifacts are visible mainly in the axial slices and
are ring-like formations concentric to the axis of
rotation (Fig. 6.1f, g). These images are the result
of poor calibration or indicate a problem in the
detector plate [9, 13]. In these cases, a device
recalibration or maintenance servicing might be
required. Aliasing artifacts are line patterns, also
known as moiré pattern, divergent toward the
periphery and visible mostly in the peripheries of
the examination (Fig. 6.1h), usually not affecting
the central area where relevant information is
more often available. One reason for this event
might be the divergent and cone-shaped nature of
the CBCT X-ray beam [9]. Noise might be
described by a mottled gray fog which takes to a
lower contrast and sharpness [15] (Fig. 6.1i) and
is related with photon detection process and effi-
ciency of the detector plate [15]. Volumetric dis-
tortion is characterized by an imprecise object
volume and shape in the 3D volume when com-
pared to the object under evaluation. This might
be related to beam hardening [16] or larger voxel
size gray-scale assignment [15] which creates an
imprecise larger image of the real object.
Reducing the voxel size [15] or lowering the
FOV or mA may minimize this distortion [16].
Because of the artifacts produced in this imag-
ing technique, CBCT presents low accuracy on
the diagnosis of certain clinical conditions as the
detection of separated instruments on root-filled
teeth [17], for instance. Brito et al. [17] demon-
strated that in unfilled root canals, the accuracy of
both periapical radiographs and CBCT was
equally high, but in filled root canals, the accu-
racy of CBCT to detect separated instruments
was significantly lower when compared to peri-
apical radiographs. According to the authors, it
could be attributed to the presence of image arti-
facts generated by the high-density filling materi-
als. Consequently, the use of the CBCT as a
pilararaya@ejercer.cl
93
diagnostic aid should have taken into consider-
ation the potential artifacts that may emerge from
adjacent structures to the area of interest.
6.1.4 CBCT Method
on the Evaluation of the Roots
and Root Canal Anatomy
of Teeth
Several studies compared the use of CBCT imag-
ing to study root and canal anatomy with some
laboratory methods such as histological section-
ing and clearing technique and, more recently,
with the gold standard nondestructive high-­
resolution micro-computed tomography (micro-
­CT). Like CBCT, micro-CT uses X-rays to create
cross sections of a 3D object, but it employs sev-
eral optimizations including the use of high-­
energy X-rays, longer exposure times, smaller
X-ray focal spots, and finer and more densely
packed detectors. Consequently, there are an
effective X-ray penetration in dense materials
and an increased output resolution, which allows
it to be used for observing fine details of the inter-
nal anatomy of the teeth. On the other hand,
micro-CT procedures are time-consuming and
very expensive [18]. Therefore, it has been nor-
mally used for the study of a limited number of
extracted teeth. Considering that some anatomi-
cal features can make extraction difficult or even
impossible for a tooth to be removed intact, such
as multi-rooted teeth or tooth with root dilacera-
tions, and others that lead a tooth to be extracted
more frequently, such as the palatogingival
groove of maxillary lateral incisors [19], it may
be assumed that samples used for ex vivo ana-
tomical studies may be influenced by these fac-
tors, which are minimized when using CBCT
method in vivo.
One important parameter to support the reli-
ability of a method for the study of root and canal
anatomy is the voxel size. The lower the voxel
size, the more reliable is the outcome. CBCT
devices use larger voxel sizes which decrease the
resolution, when compared to micro-CT systems,
but it has been considered reliable for detecting
the number of root canals, or a particular canal
94
anatomy, in a specific root or tooth [20–22].
Sousa et al. [23] evaluated the canal configura-
tion of mandibular premolars and concluded that
the accuracy and sensibility of the CBCT for
detecting the correct morphological type were
0.89 and 0.79, respectively, when compared to
micro-­ CT. A similar study was performed by
Zhang et al. [24] that observed a kappa value of
0.886 for the agreement between CBCT and
micro-­ CT. Maret et al. [25] compared CBCT
images with different voxel sizes (76, 200, and
300 μm) with micro-CT technology (41 μm),
in vitro, and observed that geometric reconstruc-
tion discrepancies of hard tissue morphology
were significant only at 300 μm. According to
Scarfe et al. [3], the accuracy of CBCT to detect
secondary canals in maxillary first molars in
ex vivo conditions was 93% with 120 μm voxel
size, and it would decrease to 60% when using
400 μm resolution. CBCT method has been also
used to address several anatomic characteristics
of the teeth such as the presence of lateral canals
[26] and isthmuses [27]. While this method can
be considered reliable to identify isthmuses [27],
the same cannot be stated for lateral canals.
According to Sousa et al. [26], CBCT has low
accuracy on detecting lateral canals in non-­
treated roots and no accuracy when the tooth is
root filled. In summary, these studies have dem-
onstrated that although CBCT was accurate in
detecting major structures, such as number of
roots, or even the configuration of the main root
canal systems, it produced poorer image details
compared to micro-CT and its accuracy needed
to be improved specially in more complex canal
configurations.
On the other hand, the most important advan-
tage of using CBCT is the possibility of performing
in vivo anatomical studies using large populations,
addressing the influence of several variables such
as ethnicity, aging, gender, and side (left or right)
on the root canal anatomy, in private practices or
university clinics, with lower costs compared to
micro-CT technology. Generally, these epidemio-
logical data are not reported in laboratory studies
because these variables are unknown or impossible
to be acquired or compared using small sample
sizes. Consequently, CBCT method is more reli-
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
able to be used in observational studies that analyze
full dentition of several patients collected from a
specific population in a consecutive manner, espe-
cially using large FOV, to evaluate the proportion
of individuals presenting specific anatomical char-
acteristics. These features allow more reliable prev-
alence studies as the research is not the primary
purpose of the CBCT examination. Then, the out-
come is not influenced of the type of teeth needed
or more prone to be extracted.
In summary, it is important to point out that
CBCT imaging technology used on anatomical
studies present advantages, disadvantages, and
limitations. While micro-CT, clearing, and histol-
ogy techniques are adequate for the study of spe-
cific anatomical details of a particular group of
teeth, CBCT can be used to evaluate general ana-
tomical features in large populations. Therefore,
these differences make each one of these meth-
ods advisable to a particular type of study design.
As an example, if someone wants to study spe-
cific morphological aspects of the second canal
in the mesiobuccal root of maxillary first molars
(MB2 canal), such as cross-sectional shape,
taper, diameter, curvature, and position on the
pulp chamber floor, among others, the use of lab-
oratory methods would be advisable; however, if
the purpose of the study is to evaluate the influ-
ence of gender and age in the percentage fre-
quency of MB2 canal in a particular population
(prevalence study), CBCT imaging would be
more appropriate (Table 6.1).
6.1.5 Overview of the Literature
6.1.5.1 Anterior Teeth
Despite maxillary anterior teeth may display
variations regarding root length, apical curvature,
lateral canals, and cross-sectional root canal
shape and diameter, CBCT prevalence studies
typically present both maxillary incisors as
single-­rooted teeth with rare occurrence of two-­
rooted configuration. In most studies, canal is
described as Vertucci’s Type I configuration
(Fig. 6.2a–l), and several authors [45–47]
reported this configuration in 100% of the sample
(Tables 6.2 and 6.3). Rare occurrences of other
 6
Table 6.1 CBCT in vivo studies reporting the prevalence of MB2 root canal involving maxillary first and second molars according to age or gender
<20 20–30 30–40 40–50 50–60 >60
CBCT Number of Number of years years years years years years Male Female
Authors Country device Voxel size subjects teeth (%) (%) (%) (%) (%) (%) (%) (%)
Maxillary first molar
Aktan [28] Turkey Planmeca n/a 296 468 n/a 50.2 49.8
Altunsoy [29] Turkey i-Cat 300μ 827 1158 n/a 60.2 63.7
Betancourt [30] Chile Pax Zenith 120μ n/a 550 n/a 55.2b 44.8
Falcão [31] Brazil n/a n/a 80 80 76.9 53.9 51.9 68.3 43.6
Ghobashy [32] Egypt Cranex 133μ 657 605 12.0c 17.3c 18.4c 19.7c 17.7c 14.9c 47.5d 52.5d
Guo [33]a USA Galileos 300μ/150μ 317 634 67.6 72.4 60.0 74.6 60.8 80.0 69.4 67.0
Jing [34]a China NewTom 125μ n/a 630 26.9 37.3 30.1 36.2 22.1 66.9b 29.9
Kim [35] Korea Dinnova 167μ 415 814 58.4 65.6 68.1 51.8 69.4 68.4b 59.1
Lee [36]a Korea Volux 167μ 276 458 81.5 72.5 85.5 70.7 59.2 50.0 73.3 69.6
Martins [37] Portugal Planmeca 200μ 670 567 n/a 75.1 69.0
Naseri [38] Iran NewTom 200μ 149 149 n/a 86.0 87.0
Ratanajirasut Thailand Accuitomo 250μ 266 476 69.6 69.1 61.5 67.7 56.3 62.7 70.9b 58.7
[39]
Reis [40]c,e Brazil i-Cat 200μ 100 158 n/a 90.7 92.1 82.6 81.9 50.9d 49.1d
CBCT and Micro-CT on the Study of Root Canal Anatomy

Zhang [41]a China NewTom 150μ 548 1008 88.2f 82.9f 92.6f 76.9f 91.4f 89.0b 82.4
Zheng [42]a China Accuitomo 125μ 701 627 50.2 68.3 51.2 42.2 44.0 40.0 54.3 50.0

pilararaya@ejercer.cl
Maxillary second molar
Altunsoy [29] Turkey i-Cat 300μ 827 1329 n/a 39.4 34.8
Betancourt [43] Chile Pax Zenith 120μ n/a 225 n/a 63.0b,d 37.0d
Betancourt [30] Chile Pax Zenith 120μ n/a 550 n/a 59.3b,d 40.7d
Ghobashy [32] Egypt Cranex 133μ 657 610 9.0c 17.1c 19.0c 20.3c 19.7c 14.9c 46.1d 53.9d
Jing [34] China NewTom 125μ n/a 519 6.3 17.1 15.2 11.1 12.36 16.2 10.6
Kim [35] Korea Dinnova 167μ 415 821 31.7 30.8 38.8 29.9 41.4 36.7 32.0
Lee [36]a Korea Volux 167μ 276 467 71.2 48.0 46.9 28.4 24.6 22.2 48.7b 30.8
Martins [37] Portugal Planmeca 200μ 670 802 n/a 40.1 46.0
Ratanajirasut Thailand Accuitomo 250μ 266 457 20.0 27.0 31.2 32.8 34.6 23.5 31.3 28.0
[39]
(continued)
95
 Table 6.1 (continued)
96

<20 20–30 30–40 40–50 50–60 >60

CBCT Number of Number of years years years years years years Male Female
Authors Country device Voxel size subjects teeth (%) (%) (%) (%) (%) (%) (%) (%)
Reis [40]c,e Brazil i-Cat 200μ 100 158 n/a 90.7 92.1 82.6 81.9 50.9d 49.1d
Wu [44]1 China NewTom 160μ 1294 2412 n/a 30.8 36.2 31.0 18.3 33.7b 26.1
n/a not available
a
Study reporting a statistical difference in the age group distribution
b
Statistically higher when compared to the other gender (according to the authors)
c
MB2 ratio between age groups: {16–25} {26–35} {36–45} {46–55} {56–65} {66–75}
d
MB2 ratio between males and females
e
Study combines the results from maxillary first and second molars together
f
Age groups {16–25} {26–35} {36–45} {46–55} {>55}

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 97

a b c d e f

g h i j k l

m n o p q r

s t u v w x

y z a’ b’ c’ d’

Fig. 6.2 Representative CBCT images of different canal system configurations on maxillary teeth. (a–f) Central inci-
sors, (g–l) lateral incisors, (m–r) canines, (s–x) first premolars, and (y–d′) second premolars

pilararaya@ejercer.cl
 98

Table 6.2 CBCT studies on the root and root canal morphologies of maxillary central incisors
Number of
CBCT Voxel Number of Number root canals (%)
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [59] Turkey In vivo i-Cat 300μ 827 1543 n/a n/a n/a n/a n/a 99.6 – 0.2 01 0.1 – – – – –
Beshkenadze Georgia In vivo Gendex n/a 228 218 100 – – – – 100 – – – – – – – – –
[45]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 100 – – – – 100 – – – – – – – – –
Jain [60] India Ex vivo Galileos 300μ n/a 100 100 – – – – 100 – – – – – – – – –
Martins [47] Portugal In vivo Planmeca 200μ 646 872 100 – – – – 100 – – – – – – – – –

pilararaya@ejercer.cl
Monsarrat France In vivo Carestream 200μ 102 192 99.0 1.0 – – – 99.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.0
[61]
Silva [49] Brazil In vivo i-Cat 200μ 432 200 n/a n/a n/a n/a n/a 98.0 1.0 – – 1.0 – – – – –
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
J. N. R. Martins and M. A. Versiani
 6

Table 6.3 CBCT studies on the root and root canal morphologies of maxillary lateral incisors
Number of
CBCT Voxel Number of Number root canals (%)
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [59] Turkey In vivo i-Cat 300μ 827 1504 n/a n/a n/a n/a n/a 97.5 1.0 0.3 0.3 0.9 – – – – –
Beshkenadze Georgia In vivo Gendex n/a 228 171 100 – – – – 100 – – – – – – – – –
[45]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 100 – – – – 100 – – – – – – – – –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Jain [60] India Ex vivo Galileos 300μ n/a 85 100 – – – – 98.0 2.0 – – – – – – – –
Martins [47] Portugal In vivo Planmeca 200μ 646 902 100 – – – – 100 – – – – – – – – –

pilararaya@ejercer.cl
Monsarrat France In vivo Carestream 200μ 102 191 99.0 1.0 – – – 99.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.0
[61]
Silva [49] Brazil In vivo i-Cat 200μ 432 200 n/a n/a n/a n/a n/a 96.0 3.5 0.5 – – – – – – –
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
99
100
configuration types were also reported, mostly in
maxillary lateral incisors, considering the high
prevalence of dens invaginatus on that group of
teeth [48]. Maxillary canine has also been pre-
sented as a single-rooted tooth in almost 100% of
the cases, independently of the geographic
region. Vertucci’s Type I configuration preva-
lence has been reported to range from 97.0% [46]
to 100% [49] of the samples (Fig. 6.2m–r). Only
one study from India showed an atypical low fre-
quency of Type I configuration in maxillary
canines (81.6%) [50] (Table 6.4).
Mandibular incisors are usually single-rooted
teeth; however, root canal system on this group is
unpredictable not only regarding the Vertucci’s
configuration among the same population but also
when compared with different populations.
Vertucci’s Type I has been reported as the most
common configuration, mainly in Chinese studies
[51–55]. However, reports on the presence of a
second canal in central and lateral incisors varied
from 3.8% to 11.6% in China [55] and from
48.1% to 47.1% in Turkey [56], respectively
(Tables 6.5 and 6.6) (Fig. 6.3a–l). When a second
canal is present, Vertucci’s Type III is the most
common configuration for both incisors.
Mandibular canines are commonly presented as
having a single canal (Table 6.7), but the presence
of a second canal cannot be ignored (Fig. 6.3o–r).
Its prevalence in some studies has been shown to
vary from 10.3% [57] to 31.8% [45], while the
percentage frequency of a two-­rooted configura-
tion has been reported to range from 0.7% to
11.7% in the Chinese [54] and Iranian [58] sub-
populations, respectively (Fig. 6.3q, r).
6.1.5.2 Premolar Teeth
Except for the mandibular molar group, maxil-
lary first premolars are the teeth more prone to
display a two-rooted configuration, a clinical
condition that varies according to the geographic
region and may range from 33.3% in Chinese
[68] to 80.0% in French [61] populations
(Table 6.8). On the other hand, a two-rooted con-
figuration in maxillary second premolars is not so
common and varies from 5.6% in Portugal [47] to
37.8% in Georgia [45] (Table 6.9). Additionally,
three-rooted configuration was reported to be as
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
high as 6.0% [46] and 2.0% [61] for the first and
second maxillary premolars, respectively. These
multi-rooted configurations have a major influ-
ence in the morphology of the root canal system
in these teeth. Except for a Turkish study [69], in
which a single root canal system was observed in
62.6% of maxillary first premolars, all other stud-
ies reported Vertucci’s Type IV as the most com-
mon configuration (>50%), while mean
percentage frequencies of Type I configuration
were less than 26% (Fig. 6.2s–x) (Table 6.8). In
maxillary second premolar teeth, single root
canal system varied from 14.3% in Germany [16]
to 77.6% in Turkey [69], and Types II, IV, and V
were the most common configurations, depend-
ing on the geographic region under evaluation
(Table 6.9) (Fig. 6.2y–d′).
Mandibular premolars are more predictable
than maxillary premolars regarding the number
of roots. Prevalence of single-rooted configura-
tion in mandibular first premolars ranged from
82.0% in Taiwanese [70] to 99.9% in Korean [71]
populations (Table 6.10), while in second premo-
lars, it reached more than 95% of cases, except in
a study from Georgia (88.6%) [45] (Table 6.11).
Three-rooted configuration is a rare occurrence
for both teeth. A high prevalence of a single canal
system (Vertucci’s Type I) has been systemati-
cally associated with mandibular premolars,
varying from 62.4% in Georgia [45] to 94.2% in
Turkey [69], for the mandibular first premolar,
and from 56.6% in Georgia [45] to 99.7% in
India [72], for the mandibular second premolar
(Tables 6.10 and 6.11) (Fig. 6.3s–d’). Only one
study from Germany does not corroborate with
the general findings as it reported lower preva-
lence of single root canal systems for both teeth
(21.9% and 39%, respectively) [16]. Vertucci’s
Type V was reported as the most common con-
figuration in mandibular premolars with two root
canal systems, being also associated with a high
frequency of C-shaped anatomy [73].
6.1.5.3 Maxillary Molar Teeth
Maxillary first and second molar teeth are usually
described as three-rooted teeth with three or four
root canals; however, their anatomy may present
distinct morphological aspects. CBCT studies
 6

Table 6.4 CBCT studies on the root and root canal morphologies of maxillary canine
Number of
CBCT Voxel Number of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [59] Turkey In vivo i-Cat 300μ 827 1523 n/a n/a n/a n/a n/a 97.7 0.4 0.5 0.3 1.1 – – – – –
Amardeep India Ex vivo Galileos 300μ n/a 250 100 – – – – 81.6 2.8 11.6 0.8 2.0 – – – 1.2 –
[50]
Beshkenadze Georgia In vivo Gendex n/a 228 163 100 – – – – 100 – – – – – – – – –
[45]
CBCT and Micro-CT on the Study of Root Canal Anatomy

Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 100 – – – – 97.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 3.0
Jain [60] India Ex vivo Galileos 300μ n/a 100 100 – – – – 96.0 3.0 1.0 – – – – – – –

pilararaya@ejercer.cl
Martins [47] Portugal In vivo Planmeca 200μ 646 962 100 – – – – 98.6 1.1 0.2 0.1 – – – – – –
Monsarrat France In vivo Carestream 200μ 102 188 98.9 1.1 – – – 98.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.1
[61]
Silva [49] Brazil In vivo i-Cat 200μ 432 200 n/a n/a n/a n/a n/a 100 – – – – – – – – –
Torres [62] Brazil Ex vivo i-Cat n/a n/a 50 100 – – – – 100 – – – – – – – – –
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
101
 Table 6.5 CBCT studies on the root and root canal morphologies of mandibular central incisors
102

Number of
CBCT Voxel Number Number root canals
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [59] Turkey In vivo i-Cat 300μ 827 1582 n/a n/a n/a n/a n/a 84.5 0.4 0.8 4.2 10.1 – – – – –
Aminsobhani Iran In vivo Planmeca n/a 400 632 100 – – – – 72.7 11.3 4.7 7.7 3.6 – – – – –
[63]
Arslan [56] Turkey In vivo NewTom 150μ 101 185 100 – – – – 51.9 4.3 41.6 – 0.6 – – – 1.6 –
Beshkenadze Georgia In vivo Gendex n/a 228 207 100 – – – – 55.1 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 45.9
[45]b
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 100 – – – – 65.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc. 35.0
Han [51] China In vivo Galileos 125μ 648 1286 100 – – – – 84.3 3.4 6.5 1.2 3.9 – 0.3 – 0.4 –
Kamtane [64] Iran In vivo NewTom n/a n/a 52 100 – – – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kayaoglu [65] Turkey In vivo Planmeca 160μ 2828 1983 100 – – – – 85.1 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 14.9
Lin [52] China In vivo NewTom 200μ 353 706 100 – – – – 89.1 2.4 6.2 1.7 0.6 – – – – –
Liu [53] China In vivo i-Cat n/a 398 768 n/a n/a n/a n/a n/a 91.1 2.0 5.3 1.3 0.3 – – – – –
Martins [47] Portugal In vivo Planmeca 200μ 646 1160 100 – – – – 72.3 2.5 24.2 0.1 0.3 – 0.5 – 0.1 –
Monsarrat France In vivo Carestream 200μ 102 192 99.0 1.0 – – – 87.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 13.0
[61]
Shemesh [66] Israel In vivo Alioth 155μ 1026 1472 n/a n/a n/a n/a n/a 59.5 4.0 33.8 0.8 0.6 – – – 1.3 –
Silva [49] Brazil In vivo i-Cat 200μ 432 200 n/a n/a n/a n/a n/a 64.5 – 18.0 – 14.5 0.5 2.5 – – –

pilararaya@ejercer.cl
Verma [67] India In vivo Galileos n/a 200 400 100 – – – – 68.3 11.0 15.3 1.7 3.7 – – – – –
Zhao [54] China In vivo NewTom 150μ 866 1566 100 – – – – 93.3 – 5.7 – 1.0 – – – – –
Zhengyan China In vivo i-Cat 125μ 1725 3375 100 – – – – 96.2 0.1 2.7 0.1 0.8 – – – 0.1 –
[55]
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
b
Data is according to the original article although the sum of percentages was not 100%
J. N. R. Martins and M. A. Versiani
 6
Table 6.6 CBCT studies on the root and root canal morphologies of mandibular lateral incisors
Number Number of
CBCT Voxel of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [59] Turkey In vivo i-Cat 300μ 827 1603 n/a n/a n/a n/a n/a 80.2 1.3 1.0 5.4 12.1 – – – – –
Aminsobhani Iran In vivo Planmeca n/a 400 614 100 – – – – 70.6 7.1 3.7 15.4 3.2 – – – – –
[63]
Arslan [56] Turkey In vivo NewTom 150μ 101 189 100 – – – – 52.9 2.7 42.3 – 1.6 – – – 0.5 –
Beshkenadze Georgia In vivo Gendex n/a 228 219 100 – – – – 52.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 47.1
[45]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 100 – – – – 58.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 42.0
Han [51] China In vivo Galileos 125μ 648 1294 100 – – – – 72.6 4.0 15.5 2.3 5.1 0.2 0.2 – 0.1 –
Kamtane [64] Iran In vivo NewTom n/a n/a 50 100 – – – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kayaoglu Turkey In vivo Planmeca 160μ 2828 2077 99.9 0.1 – – – 82.8 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 17.2
[65]
Lin [52] China In vivo NewTom 200μ 353 706 100 – – – – 74.5 3.7 19.3 2.1 0.4 – – – – –
Liu [53] China In vivo i-Cat n/a 398 785 n/a n/a n/a n/a n/a 82.6 3.9 10.4 2.8 0.3 – – – – –
Martins [47] Portugal In vivo Planmeca 200μ 646 1191 100 – – – – 69.8 6.3 23.1 – 0.3 – 0.2 – 0.3 –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Monsarrat France In vivo Carestream 200μ 102 199 99.0 1.0 – – – 86.4 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 13.6
[61]
Shemesh [66] Israel In vivo Alioth 155μ 1026 1508 n/a n/a n/a n/a n/a 62.3 4.3 32.1 0.4 0.1 – – – 0.8 –

pilararaya@ejercer.cl
Silva [49] Brazil In vivo i-Cat 200μ 432 200 n/a n/a n/a n/a n/a 60.5 0.5 25.5 – 12.0 – 1.5 – – –
Verma [67] India In vivo Galileos n/a 200 400 100 – – – – 65.0 13.2 15.3 3.0 3.5 – – – – –
Zhao [54] China In vivo NewTom 150μ 866 1566 100 – – – – 82.5 – 15.4 – 1.9 – 0.1 – 0.1 –
Zhengyan China In vivo i-Cat 125μ 1725 3257 99.7 0.3 – – – 89.4 1.1 7.7 0.3 1.2 – – – 0.3 –
[55]
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
103
104 J. N. R. Martins and M. A. Versiani

a b c d e f

g h i j k l

m n o p q r

s t u v w x

y z a’ b’ c’ d’

Fig. 6.3 CBCT images of different root canal system configurations on mandibular teeth. (a–f) Central incisors, (g–l)
lateral incisors, (m–r) canines, (s–x) first premolars, and (y–d′) second premolars

pilararaya@ejercer.cl
 6
Table 6.7 CBCT studies on the root and root canal morphologies of mandibular canine
Number Number of
CBCT Voxel of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [59] Turkey In vivo i-Cat 300μ 827 1604 n/a n/a n/a n/a n/a 92.8 2.1 1.2 1.3 2.6 – – – – –
Amardeep India Ex vivo Galileos 300μ n/a 250 100 – – – – 79.6 3.2 13.6 – 2.0 – – – 1.6 –
[50]
Aminsobhani Iran In vivo Planmeca n/a 400 608 96.3 4.7 – – – 71.8 10.3 2.8 12.8 2.3 – – – – –
[63]b
Beshkenadze Georgia In vivo Gendex n/a 228 207 97.3 1.3 – – – 66.8 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 31.8
[45]b
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 97.0 3.0 – – – 78.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 22.0
Han [51] China In vivo Galileos 125μ 648 1291 98.7 1.3 – – – 93.7 0.6 3.8 – 0.6 – – – 1.3 –
Kayaoglu [65] Turkey In vivo Planmeca 160μ 2828 2193 96.9 3.1 – – – 93.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 6.1
Martins [47] Portugal In vivo Planmeca 200μ 646 1200 97.2 2.8 – – – 90.2 3.3 2.7 1.4 2.3 – – – 0.1 –
Monsarrat France In vivo Carestream 200μ 102 202 96.5 3.5 – – – 94.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 5.4
[61]
Shemesh [57] Israel In vivo Alioth 155μ 1020 1981 98.1 1.9 – – – 89.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 10.3
CBCT and Micro-CT on the Study of Root Canal Anatomy

Silva [49] Brazil In vivo i-Cat 200μ 432 200 n/a n/a n/a n/a n/a 90.5 1.0 4.0 2.5 2.0 – – – – –
Soleymani Iran In vivo NewTom 75μ 150 300 88.3 11.7 – – – 89.6 3.7 5.7 – 1.0 – – – – –
[58]

pilararaya@ejercer.cl
Zhao [54] China In vivo NewTom 150μ 866 1542 99.3 0.7 – – – 97.0 – 2.2 – 0.7 – 0.1 – – –
Zhengyan China In vivo i-Cat 125μ 1725 3014 99.2 0.8 – – – 95.8 0.7 2.1 0.1 0.4 – – – 0.9 –
[55]
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
b
Data is according to the original article although the sum of percentages was not 100%
105
 Table 6.8 CBCT studies on the root and root canal morphologies of maxillary first premolar
106

Number Number of
CBCT Voxel of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Abella [74] Spain In vivo Planmeca 75μ 620 430 46.0 51.4 2.6 – – 25.1 10.2 4.4 52.8 1.9 1.6 1.4 2.6 – –
Beshkenadze Georgia In vivo Gendex n/a 228 193 20.7 77.2 2.1 – – 11.8 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
[45]b 78.1/3rc, 2.1
Bulut [69] Turkey In vivo NewTom 250μ 440 511 28.2 70.8 1.0 – – 62.6 34.1 0.8 1.9 0.6 – – – – –
Bürklein Germany In vivo Planmeca 200μ 700 644 36.4 62.4 1.2 – – 3.9 6.5 – 68.5 7.9 12.3 0.2 2.0 – –
[16]b
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 32.0 66.0 2.0 – – 6.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
88.0/3rc, 6.0
Felsypremila India In vivo Kodak n/a 246 418 48.8 51.2 – – – 7.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 92.3
[72]
Martins [47] Portugal In vivo Planmeca 200μ 646 690 48.7 49.1 2.2 – – 3.1 17.3 0.3 68.0 0.9 4.8 – 0.7 4.9 3rc, 5.2
Monsarrat France In vivo Carestream 200μ 102 165 15,8 80.0 4.2 – – 13.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
[61] 80.6/3rc, 5.5
Ok [75] Turkey In vivo i-Cat 300μ 849 1379 n/a n/a n/a n/a n/a 9.6 6.4 1.4 76.9 4.6 0.1 – 1.0 – –
Tian [68] China In vivo Accuitomo 125μ 241 300 66.0 33.3 0.7 – – 14.3 23.4 4.3 51.0 3.3 2.3 0.7 0.7 – –
n/a not available, rc root canals
a
If no Vertucci’s classification was provided

pilararaya@ejercer.cl
b
Data is according to the original article although the sum of percentages was not 100%
J. N. R. Martins and M. A. Versiani
 6
Table 6.9 CBCT studies on the root and root canal morphologies of maxillary second premolar
Number Number of
CBCT Voxel of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Abella [74] Spain In vivo Planmeca 75μ 620 374 82.9 15.5 1.6 – – 39.3 22.5 7.2 19.8 4.3 3.2 2.1 1.6 – –
Beshkenadze Georgia In vivo Gendex n/a 228 185 61.1 37.8 1.1 – – 29.1 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
[45]b 61.0/3rc,
1.1
Bulut [69] Turkey In vivo NewTom 250μ 440 476 82.1 17.9 – – – 77.6 12.5 1.3 6.5 1.9 0.2 – – – –
Bürklein [16] Germany In vivo Planmeca 200μ 700 512 82.6 17.0 0.4 – – 14.3 11.1 0.6 25.0 28.7 19.1 0.6 0.6 – –
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 83.0 17.0 – – – 25.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
73.0/3rc,
2.0
Felsypremila India In vivo Kodak n/a 246 393 90.6 9.4 – – – 49.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 50.1
[72]
Martins [47] Portugal In vivo Planmeca 200μ 646 591 94.4 5.6 – – – 39.4 29.5 2.2 16.9 4.7 6.1 – – 1.2 3rc, 0.5
Monsarrat France In vivo Carestream 200μ 102 147 71.4 26.5 2.1 – – 66.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
[61] 31.3/3rc,
2.0
CBCT and Micro-CT on the Study of Root Canal Anatomy

Ok [75] Turkey In vivo i-Cat 300μ 849 1302 n/a n/a n/a n/a n/a 54.5 8.8 3.6 21.9 10.9 – – 0.3 – –
Yang [76] China In vivo Galileos 125μ 238 392 86.5 13.5 – – – 45.4 16.3 11.4 20.2 6.4 – – 0.3 – –

pilararaya@ejercer.cl
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
b
Data is according to the original article although the sum of percentages was not 100%
107
 Table 6.10 CBCT studies on the root and root canal morphologies of mandibular first premolar
108

Number Number of
CBCT Voxel of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Arslan [77] Turkey In vivo NewTom 150μ 88 154 87.7 12.3 – – – 71.4 1.3 2.6 – 20.1 – – – 4.6 –
Beshkenadze Georgia In vivo Gendex n/a 228 165 91.5 8.5 – – – 62.4 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 36.4/3rc,
[45] 1.2
Bulut [69] Turkey In vivo NewTom 250μ 440 604 96.2 3.8 – – – 94.2 0.7 1.1 0.8 3.2 – – – – –
Bürklein Germany In vivo Planmeca 200μ 700 1044 91.4 8.6 – – – 21.9 5.3 0.2 14.7 55.7 2.6 0.4 0.2 – –
[16]b
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 99.0 1.0 – – – 70.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 29.0/3rc,
1.0
Felsypremila India In vivo Kodak n/a 246 447 98.0 2.0 – – – 92.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 7.4
[72]
Huang [70] Taiwan In vivo i-Cat 250μ 150 300 82.0 17.0 1.0 – – 65.7 n/a n/a n/a n/a n/a n/a 1.0 n/a 2rc, 33.3
Khademi [78] Iran Ex vivo Scanora n/a n/a 182 n/a n/a n/a n/a n/a 81.3 3.3 1.1 5.5 8.8 – – – – –
Kazemipoor Iran In vivo Scanora 200μ 230 460 85.7 14.3 – – – 63.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 36.1
[79]
Kazemipoor Iran In vivo Scanora 200μ 457 914 86.4 13.6 – – – 68.1 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 31.9
[80]
Liao [81] China In vivo NewTom 240μ 97 194 n/a n/a n/a n/a n/a 83.5 – 3.6 – 8.8 – – – 4.1 –

pilararaya@ejercer.cl
Llena [82] Spain In vivo Kodak 76μ 70 73 100 – – – – 78.1 8.2 – – 10.9 1.4 – – 1.4 –
Martins [73] Portugal In vivo Planmeca 200μ 634 1123 99.8 0.2 – – – 77.8 2.3 5.4 1.4 12.3 – 0.2 – 0.6 –
Martins [47] Portugal In vivo Planmeca 200μ 646 1054 99.8 0.2 – – – 77.5 2.5 5.5 1.5 12.1 – 0.2 – 0.7 3rc, 0.6
Monsarrat France In vivo Carestream 200μ 102 187 94.1 5.9 – – – 87.2 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 12.8
[61]
Ok [75] Turkey In vivo i-Cat 300μ 849 1471 n/a n/a n/a n/a n/a 92.8 0.3 1.0 1.4 4.4 – – 0.1 – –
Park [71] Korea In vivo n/a n/a 430 797 99.9 0.1 – – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
SalarPour Iran Ex vivo Scanora n/a n/a 42 n/a n/a n/a n/a n/a 71.4 – – – 28.6 – – – – –
[83]
Shetty [84] India Ex vivo Kodak 76μ n/a 1186 100 – – – – 83.8 0.3 2.1 0.3 12.0 0.2 – 0.3 1.0 –
Yang [85] China In vivo Galileos 125μ 238 440 99.3 0.7 – – – 76.2 3.4 2.7 6.6 9.3 – – 0.7 1.1 –
Yu [86] China In vivo Accuitomo 125μ 149 178 97.8 2.2 – – – 86.8 – 1.7 – 9.8 – – – 1.7 –
Zhang [24] China Ex vivo Galileos 125μ n/a 136 n/a n/a n/a n/a n/a 72.7 – 4.9 – 17.5 – – – 4.9 –
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
J. N. R. Martins and M. A. Versiani

b
Data is according to the original article although the sum of percentages was not 100%
 6
Table 6.11 CBCT studies on the root and root canal morphologies of mandibular second premolar
Number of
CBCT Voxel Number of Number root canals
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classification (%) (%) (rc)a
1 2 3 4 >4 I II III IV V VI VII VIII Others
Arslan [77] Turkey In vivo NewTom 150μ 88 133 96.2 3.8 – – – 92.5 2.3 0.7 – 1.5 – – – 3.0 –
Beshkenadze Georgia In vivo Gendex n/a 228 181 88.6 8.3 – – – 56.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 39.7/3rc,
[45]b 0.5
Bulut [69] Turkey In vivo NewTom 250μ 440 549 98.9 1.1 – – – 98.9 0.2 0.4 – 0.5 – – – – –
Bürklein [16] Germany In vivo Planmeca 200μ 700 871 98.6 1.3 0.1 – – 39.0 1.1 0.1 1.4 57.3 0.5 0.3 0.3 – –
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 100 – – – – 97.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 3.0
Felsypremila India In vivo Kodak n/a 246 398 99.7 0.3 – – – 99.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 0.3
[72]
Khademi [78] Iran Ex vivo Scanora n/a n/a 182 n/a n/a n/a n/a n/a 92.3 – 2.2 2.2 3.3 – – – – –
Kazemipoor Iran In vivo Scanora 200μ 230 460 94.8 5.2 – – – 78.3 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 21.7
[79]
Kazemipoor Iran In vivo Scanora 200μ 457 914 95.0 5.0 – – – 80.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 19.4
[80]
Llena [82] Spain In vivo Kodak 76μ 70 53 100 – – – – 90.6 1.9 – – 7.5 – – – – –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Martins [73] Portugal In vivo Planmeca 200μ 634 889 99.9 0.1 – – – 95.9 0.8 1.2 0.5 1.3 – – – 0.3 –
Martins [47] Portugal In vivo Planmeca 200μ 646 832 99.9 0.1 – – – 95.7 0.9 1.3 0.5 1.4 – – – 0.2 3rc, 0.2
Monsarrat France In vivo Carestream 200μ 102 159 98.7 1.3 – – – 96.2 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 3.8

pilararaya@ejercer.cl
[61]
Ok [75] Turkey In vivo i-Cat 300μ 849 1345 n/a n/a n/a n/a n/a 98.5 0.1 0.1 0.6 0.5 – – 0.2 – –
Park [71] Korea In vivo n/a n/a 430 784 99.4 0.6 – – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
SalarPour Iran Ex vivo Scanora n/a n/a 41 n/a n/a n/a n/a n/a 75.6 – – – 22.0 – – – 2.4 –
[83]
Shetty [84] India Ex vivo Kodak 76μ n/a 814 100 – – – – 93.5 1.5 0.3 – 3.9 – – 0.1 0.7 –
Yu [86] China In vivo Accuitomo 125μ 149 178 100 – – – – 97.2 0.6 – – 1.6 – – – 0.6 –
n/a not available, rc root canals
a
If no Vertucci’s classification was provided
b
Data is according to the original article although the sum of percentages was not 100%
109
110
report three-rooted configuration in more than
95% of maxillary first molars, despite two-rooted
configurations can also be expected, mostly
because of fusion between distobuccal and pala-
tal roots [87]. In the second molars, external root
morphology is not so predictable. Prevalence
studies report three-rooted configuration ranging
from 57.8% in China [44] to 94.6% in Brazil
[40], while two- and single-rooted configurations
may reach 29.0% [46] and 17.7% [44] of this
tooth group, respectively. Four-rooted configura-
tion is an uncommon finding for both maxillary
molars. It is important to point out that the occur-
rence of root fusion in maxillary molars may
have a significant impact over the root canal sys-
tem with the development of atypical morpholo-
gies such as C-shaped configurations [88, 89],
isthmuses, or even fusion among the main root
canals of different roots. Martins et al. [87]
reported that 15.7% of the maxillary second
molars had fused roots with an unusual canal
configuration system. Therefore, differences in
the prevalence of root fusions between maxillary
first and second molars are reflected in the com-
plexity of their internal anatomy [35, 87, 90, 91],
which led some authors to exclude fused-rooted
teeth from the analysis [35, 47, 91].
Regarding canal configuration, the major dif-
ference between three-rooted maxillary first and
second molars is related to the mesiobuccal root.
Most of CBCT studies that compared both teeth
are consistent on reporting a higher prevalence of
a second root canal (MB2) in the mesiobuccal
root of maxillary first molar compared to the sec-
ond molar [30, 35, 47, 90, 91]. The prevalence of
MB2 canal ranged from 30.9% in China [34] to
88.5% in Brazil [40], for maxillary first molar,
and from 13.9% in China [34] to 83.4% in Brazil
[40], for the second molar (Tables 6.12, 6.13,
6.14, 6.15, 6.16, and 6.17). In mesiobuccal root,
Vertucci’s Types II and IV are the most frequent
configuration in multi-rooted canal systems for
both teeth. Type II configuration reached percent-
age frequencies as high as 69.1% in Iran [92] and
47.1% in Egypt [32], while the prevalence of
Type IV was 48.7% [29] and 29.8% [29] in
Turkey, for maxillary first and second molars,
respectively (Fig. 6.4a–f). Independent distobuc-
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
cal and palatal roots show Vertucci’s Type I con-
figuration (Fig. 6.4g–l) in more than 95% of the
teeth, although Naseri et al. [38], in Iran, and Li
et al. [93], in China, reported 89.9% and 90.9%
of Vertucci’s Type I in the distobuccal root of the
maxillary first and second molar, respectively.
Among other configuration types (Fig. 6.4m–v),
CBCT prevalence studies reported a third canal
in the mesiobuccal root of the maxillary first and
second molars as a rare occurrence [42, 47]
(Fig. 6.4u).
6.1.5.4 Mandibular Molar Teeth
Mandibular molars are usually described as two-­
rooted teeth; however, in Asian populations, there
is a high prevalence of a second distal root in
mandibular first molars (three-rooted configura-
tion) and fused roots (single-rooted configura-
tion) in mandibular second molars. These
anatomical variations have been reported as eth-
nic traits when analyzing the number of roots in
mandibular molars. CBCT studies from Korean
[71, 108], Chinese [109–111], and Taiwanese
[112, 113] populations reported a three-rooted
configuration of first molars in more than 22% of
the teeth. The highest percentage frequency on a
non-Asian country was identified in France
(7.7%) [61], while in some subpopulations from
Italy [104] and Brazil [114], this anatomical vari-
ation was not identified. Although these studies
did not compare Asian and non-Asian popula-
tions, the prevalence differences can be consid-
ered significant. Recently, a more robust evidence
of an ethnic trait was observed regarding the
highest prevalence of fused roots in mandibular
second molars in Asian population [115]. In this
study, the prevalence of mandibular second molar
with C-shaped morphology was evaluated in nine
different countries using CBCT method. Authors
observed the highest percentage of single-rooted
molars in China (46.5%), followed by Mexico
(16.3%). Three-rooted configuration in mandibu-
lar second molars and single-rooted morphology
in mandibular first molars are rare occurrences as
well as four-rooted configuration for both man-
dibular molars.
Regarding root canal configuration, both
molars are consistently presented as three-rooted
 6
Table 6.12 CBCT studies on the root and root canal morphologies of mesiobuccal root of maxillary first molar
Number
Number of root
of Number canalsa
Authors Country Method CBCT device Voxel size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Abuabara Brazil In vivo i-Cat 120μ 50 50 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 54.0
[94]
Aktan [28] Turkey In vivo Planmeca n/a 296 468 n/a n/a n/a n/a n/a 56.2 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 43.8
Alrahabi [95] Saudi Ex vivo Kodak 76μ n/a 100 – – 94.0 6.0 – 29.4 47.0 11.8 11.8 – – – – – –
Arabia
Altunsoy Turkey In vivo i-Cat 300μ 827 1158 0.1 0.3 99.0 0.6 – 38.0 12.9 0.1 48.7 0.3 – – – – –
[29]
BarattoFilho Brazil In vivo i-Cat 200μ n/a 54 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 37.1
[96]
Beshkenadze Georgia In vivo Gendex n/a 228 221 – – 100 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[45]
Betancourt Chile In vivo Pax Zenith 120μ n/a 550 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 69.8
[30]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 1.0 6.0 93.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Falcão [31] Brazil In vivo n/a n/a 80 80 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 56.3
Felsypremila India In vivo Kodak n/a 246 367 – 2.7 96.8 0.5 – 25.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 74.1

pilararaya@ejercer.cl
[72]
Ghobashy Egypt In vivo Cranex 133μ 657 605 – – 100 – – 25.5 45.7 1.0 27.3 0.5 – – – – –
[32]
Ghoncheh Iran In vivo NewTom 300μ 450 345 1.2 6.1 92.2 0.5 – 54.0 14.8 – 28.3 2.9 – – – – –
[97]
Gu [98] China In vivo Galileos 125μ 725 1365 0.1 2.2 97.6 0.1 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Guo [33] USA In vivo Galileos 300μ/150μ 317 634 – 0.9 99.1 – – 28.3 26.3 1.1 41.9 2.4 – – – – –
Hiebert [99] USA Ex vivo Veraviewepocs 125μ n/a 99 – – 100 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 68.7
Jing [34] China In vivo NewTom 125μ n/a 630 – 2.4 97.1 0.5 – 69.1 7.3 3.6 10.0 9.8 – 0.2 – – –
Jo [88]c Korea In vivo CB MercuRay 300μ 911 1786 0.4 2.7 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Khademi Iran In vivo Galileos 150μ 295 389 – 0.3 99.7 – – 29.8 69.1 – 0.8 0.3 – – – – –
[92]
Kim [35] Korea In vivo Dinnova 167μ 415 814 0.4 1.7 97.9 – – 36.4 20.4 0.3 40.7 2.0 0.1 – – 0.1 –
Lee [36] Korea In vivo Volux 167μ 276 458 n/a n/a n/a n/a n/a 28.2 33.2 – 34.9 2.4 – – – 1.3 –
(continued)
111
 Table 6.12 (continued)
112

Number
Number of root
of Number canalsa
Authors Country Method CBCT device Voxel size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Lyra [100] Brazil Ex vivo i-Cat 200μ n/a 100 – – 100 – – 8.0 57.0 35.0 – – – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 961 0.7 6.4 92.8 0.1 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 542 0.6 8.3 91.1 – – 29.0 44.1 1.0 16.4 2.0 5.7 0.2 – 1.6 3rc, 0.4
Monsarrat France In vivo Carestream 200μ 102 149 – 2.0 96.6 1.4 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Naseri [38] Iran In vivo NewTom 200μ 149 149 – – 100 – – 13.4 32.9 1.3 11.4 5.4 35.6 – – – –
Neelakantan India Ex vivo Accuitomo n/a n/a 220 0.9 1.4 96.8 0.9 – 53.5 5.6 – 40.0 – – – – 0.9 –
[101]
Nikoloudaki Greece In vivo NewTom 125μ 273 410 3.9 5.6 89.3 1.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 53.0
[102]
PérezHeredia Spain In vivo Carestream 180μ 112 142 2.1 0.7 97.2 – – 13.8 56.5 – 23.2 – 4.3 – – 2.2 –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 161 – 4.3 95.7 – – 59.8 27.3 4.6 7.1 1.2 – – – – –
Ratanajirasut Thailand In vivo Accuitomo 250μ 266 476 – – 99.8 0.2 – 36.5 28.8 2.7 25.2 5.3 1.1 – – 0.4 –
[39]
Reis [40]c Brazil In vivo i-Cat 200μ 100 158 n/a n/a 99.4 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc,88.5

pilararaya@ejercer.cl
Rouhani Iran Ex vivo Planmeca 160μ n/a 125 – 0.8 97.6 1.6 – 47.1 14.6 9.8 3.3 1.6 17.9 5.7 – – –
[105]
Shenoi [106] India Ex vivo Kodak n/a n/a 30 – – 100 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 80.0
Silva [90] Brazil In vivo i-Cat 200μ 294 314 – 3.8 96.2 – – 55.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 44.4
Tian [91] China In vivo NewTom 160μ 844 1558 0.3 1.8 97.8 0.1 – 42.2 15.2 2.1 36.2 2.0 0.6 0.1 0.1 1.5 –
Zhang [107] China In vivo Accuitomo 125μ 269 299 – – 100 – – 48.0 7.3 – 36.4 8.3 – – – – –
Zhang [41] China In vivo NewTom 150μ 548 1008 0.2 0.8 99.0 – – 14.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
85.4/3rc,
0.6
Zheng [42] China In vivo Accuitomo 125μ 701 627 0.5 2.2 97.3 – – 47.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
51.9/3rc,
0.5
n/a not available, rc root canals
a
Data regarding maxillary molars with independent mesiobuccal root
b
If no Vertucci’s classification was provided
J. N. R. Martins and M. A. Versiani

c
Data is according to the original article although the sum of percentages was not 100%
 6
Table 6.13 CBCT studies on the root and root canal morphologies of distobuccal root of maxillary first molar
Number of
CBCT Voxel Number Number root canalsa
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Alrahabi [95] Saudi Ex vivo Kodak 76μ n/a 100 – – 94.0 6.0 – 100 – – – – – – – – –
Arabia
Altunsoy [29] Turkey In vivo i-Cat 300μ 827 1158 0.1 0.3 99.0 0.6 – 99.5 – – 0.5 – – – – – –
BarattoFilho Brazil In vivo i-Cat 200μ n/a 54 100 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[96]
Beshkenadze Georgia In vivo Gendex n/a 228 221 – – 100 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[45]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 1.0 6.0 93.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 367 – 2.7 96.8 0.5 – 100 – – – – – – – – –
[72]
Ghobashy Egypt In vivo Cranex 133μ 657 605 – – 100 – – 100 – – – – – – – – –
[32]
Ghoncheh Iran In vivo NewTom 300μ 450 345 1.2 6.1 92.2 0.5 – 97.3 0.9 0.3 1.2 0.3 – – – – –
[97]
Gu [98] China In vivo Galileos 125μ 725 1365 0.1 2.2 97.6 0.1 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Guo [33] USA In vivo Galileos n/a 317 634 – 0.9 99.1 – – 99.6 – 0.2 – 0.2 – – – – –
Jing [34] China In vivo NewTom 125μ n/a 630 – 2.4 97.1 0.5 – 99.8 – 0.2 – – – – – – –

pilararaya@ejercer.cl
Jo [88]c Korea In vivo CB 300μ 911 1786 0.4 2.7 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
MercuRay
Khademi [92] Iran In vivo Galileos 150μ 295 389 – 0.3 99.7 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kim [35] Korea In vivo Dinnova 167μ 415 814 0.4 1.7 97.9 – – 98.7 0.4 0.1 0.4 0.4 – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 961 0.7 6.4 92.8 0.1 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 542 0.6 8.3 91.1 – – 98.0 1.4 0.2 – 0.2 0.2 – – – –
Monsarrat France In vivo Carestream 200μ 102 149 – 2.0 96.6 1.4 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Naseri [38] Iran In vivo NewTom 200μ 149 149 – – 100 – – 89.9 – – – 10.1 – – – – –
Neelakantan India Ex vivo Accuitomo n/a n/a 220 0.9 1.4 96.8 0.9 – 93.4 2.8 1.9 1.9 – – – – – –
[101]
Nikoloudaki Greece In vivo NewTom 125μ 273 410 3.9 5.6 89.3 1.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 0.3
[102]
(continued)
113
 Table 6.13 (continued)
114

Number of
CBCT Voxel Number Number root canalsa
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
PérezHeredia Spain In vivo Carestream 180μ 112 142 2.1 0.7 97.2 – – 97.2 1.4 – – 1.4 – – – – –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 161 – 4.3 95.7 – – 100 – – – – – – – – –
Ratanajirasut Thailand In vivo Accuitomo 250μ 266 476 – – 99.8 0.2 – 99.0 – – 0.2 0.8 – – – – –
[39]
Rouhani [105] Iran Ex vivo Planmeca 160μ n/a 125 – 0.8 97.6 1.6 – 96.8 0.8 2.4 – – – – – – –
Silva [90] Brazil In vivo i-Cat 200μ 294 314 – 3.8 96.2 – – 100 – – – – – – – – –
Tian [91] China In vivo NewTom 160μ 844 1558 0.3 1.8 97.8 0.1 – 98.2 0.3 0.7 0.3 0.5 – – – – –
Zhang [107] China In vivo Accuitomo 125μ 269 299 – – 100 – – 100 – – – – – – – – –
Zhang [41] China In vivo NewTom 150μ 548 1008 0.2 0.8 99.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Zheng [42] China In vivo Accuitomo 125μ 701 627 0.5 2.2 97.3 – – 98.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.1
n/a not available, rc root canals
a
Data regarding maxillary molars with independent distobuccal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
 6
Table 6.14 CBCT studies on the root and root canal morphologies of palatal root of maxillary first molar
Number of
CBCT Voxel Number of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Alrahabi [95] Saudi Ex vivo Kodak 76μ n/a 100 – – 94.0 6.0 – 100 – – – – – – – – –
Arabia
Altunsoy [29] Turkey In vivo i-Cat 300μ 827 1158 0.1 0.3 99.0 0.6 – 99.8 – 0.1 0.1 – – – – – –
BarattoFilho Brazil In vivo i-Cat 200μ n/a 54 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.9
[96]
Beshkenadze Georgia In vivo Gendex n/a 228 221 – – 100 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[45]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 1.0 6.0 93.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 367 – 2.7 96.8 0.5 – 99.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 0.3
[72]
Ghobashy [32] Egypt In vivo Cranex 133μ 657 605 – – 100 – – 100 – – – – – – – – –
Ghoncheh Iran In vivo NewTom 300μ 450 345 1.2 6.1 92.2 0.5 – 100 – – – – – – – – –
[97]
Gu [98] China In vivo Galileos 125μ 725 1365 0.1 2.2 97.6 0.1 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Guo [33] USA In vivo Galileos n/a 317 634 – 0.9 99.1 – – 100 – – – – – – – – –
Jing [34] China In vivo NewTom 125μ n/a 630 – 2.4 97.1 0.5 – 99.8 0.2 – – – – – – – –
Jo [88]c Korea In vivo CB 300μ 911 1786 0.4 2.7 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –

pilararaya@ejercer.cl
MercuRay
Khademi [92] Iran In vivo Galileos 150μ 295 389 – 0.3 99.7 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kim [35] Korea In vivo Dinnova 167μ 415 814 0.4 1.7 97.9 – – 100 – – – – – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 961 0.7 6.4 92.8 0.1 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 542 0.6 8.3 91.1 – – 98.2 0.4 1.4 – – – – – – –
Monsarrat France In vivo Carestream 200μ 102 149 – 2.0 96.6 1.4 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Naseri [38] Iran In vivo NewTom 200μ 149 149 – – 100 – – 96.6 – – – 3.4 – – – – –
Neelakantan India Ex vivo Accuitomo n/a n/a 220 0.9 1.4 96.8 0.9 – 91.1 1.9 – 4.2 1.4 – – – 1.4 –
[101]
Nikoloudaki Greece In vivo NewTom 125μ 273 410 3.9 5.6 89.3 1.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[102]
PérezHeredia Spain In vivo Carestream 180μ 112 142 2.1 0.7 97.2 – – 100 – – – – – – – – –
[103]
(continued)
115
 Table 6.14 (continued)
116

Number of
CBCT Voxel Number of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Plotino [104] Italy In vivo NewTom n/a 201 161 – 4.3 95.7 – – 100 – – – – – – – – –
Ratanajirasut Thailand In vivo Accuitomo 250μ 266 476 – – 99.8 0.2 – 99.8 0.2 – – – – – – – –
[39]
Rouhani [105] Iran Ex vivo Planmeca 160μ n/a 125 – 0.8 97.6 1.6 – 98.4 0.8 – 0.8 – – – – – –
Silva [90] Brazil In vivo i-Cat 200μ 294 314 0 3.8 96.2 – – 99.3 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 0.7
Tian [91] China In vivo NewTom 160μ 844 1558 0.3 1.8 97.8 0.1 – 99.3 0.3 0.3 – 0.1 – – – – –
Zhang [107] China In vivo Accuitomo 125μ 269 299 – – 100 – – 100 – – – – – – – – –
Zhang [41] China In vivo NewTom 150μ 548 1008 0.2 0.8 99.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Zheng [42] China In vivo Accuitomo 125μ 701 627 0.5 2.2 97.3 – – 98.2 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.8
n/a not available, rc root canals
a
Data regarding maxillary molars with independent palatal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
 6
Table 6.15 CBCT studies on the root and root canal morphologies of mesiobuccal root of maxillary second molar
Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Other
Altunsoy [29] Turkey In vivo i-Cat 300μ 827 1329 2.2 4.8 92.5 0.5 – 62.9 6.9 – 29.8 0.4 – – – – –
Betancourt Chile In vivo Pax Zenith 120μ n/a 225 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 48.0
[43]
Betancourt Chile In vivo Pax Zenith 120μ n/a 550 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 46.9
[30]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 2.0 29.0 69.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 371 9.7 8.9 80.3 1.1 – 39.9 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 60.1
[72]
Ghobashy Egypt In vivo Cranex 133μ 657 610 1.6 10.7 87.7 – – 42.0 47.1 – 8.0 1.9 1.0 – – – –
[32]
Ghoncheh Iran In vivo NewTom 300μ 450 423 14.4 22.2 63.4 – – 86.2 2.5 – 11.3 – – – – – –
[97]
Gu [98] China In vivo Galileos 125μ 725 1226 14.1 21.9 63.0 1.0 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Jing [34] China In vivo NewTom 125μ n/a 519 10.4 15.2 73.6 0.8 – 86.0 4.1 2.3 2.9 4.1 – 0.3 0.3 – –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Jo [88]c Korea In vivo CB 300μ 911 1767 6.6 13.0 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
MercuRay
Khademi [92] Iran In vivo Galileos 150μ 295 460 4.8 6.3 88.2 0.7 – 57.6 39.4 – 1.7 1.3 – – – – –

pilararaya@ejercer.cl
Kim [35] Korea In vivo Dinnova 167μ 415 821 10.2 13.0 76.3 0.5 – 65.6 16.2 0.3 15.3 2.4 0.2 – – – –
Lee [36] Korea In vivo Volux 167μ 276 467 n/a n/a n/a n/a n/a 57.8 23.8 – 14.6 3.2 – – – 0.6 –
Li [93] China Ex vivo NewTom n/a n/a 46 2.2 23.9 71.7 2.2 – 57.6 18.2 – 18.2 3.0 3.0 – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 1335 13.0 12.3 74.2 0.5 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 778 13.4 13.2 72.9 0.5 – 56.2 27.1 0.7 7.6 3.4 4.2 0.2 – 0.6 3rc, 0.2
Monsarrat France In vivo Carestream 200μ 102 167 6.0 3.6 88.0 2.4 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Neelakantan India Ex vivo Accuitomo n/a n/a 205 1.0 5.9 93.1 – – 66.5 6.8 – 26.2 – – – – 0.5 –
[101]
Nikoloudaki Greece In vivo NewTom 125μ 273 402 5.5 8.2 85.1 1.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 40.3
[102]
PérezHeredia Spain In vivo Carestream 180μ 112 142 16.9 4.2 78.9 – – 52.7 33.0 – 9.8 – 2.7 – 0.9 0.9
[103]
(continued)
117
 Table 6.15 (continued)
118

Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Other
Plotino [104] Italy In vivo NewTom n/a 201 157 1.9 8.3 88.5 1.3 – 84.9 11.5 2.2 1.4 – – – – – –
Ratanajirasut Thailand In vivo Accuitomo 250μ 266 457 3.5 9.2 87.1 0.2 – 70.6 14.6 2.3 7.5 3.5 1.5 – – – –
[39]
Reis [40] Brazil In vivo i-Cat 200μ 100 185 n/a n/a 94.6 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 83.4
Rouhani [105] Iran Ex vivo Planmeca 160μ n/a 125 0.8 8.0 89.6 1.6 – 84.1 2.5 4.2 3.3 1.7 2.5 1.7 – – –
Silva [90] Brazil In vivo i-Cat 200μ 294 306 7.9 12.7 79.4 – – 56.8 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 43.2
Tian [91] China In vivo NewTom 160μ 844 1539 13.3 19.4 66.1 1.2 – 70.3 12.9 5.3 6.8 3.0 0.4 0.3 0.1 0.9 –
Wu [44] China In vivo NewTom 160μ 1294 2412 17.7 23.6 57.9 0.8 – 70.2 8.6 5.6 14.6 1.0 – – – – –
Zhang [107] China In vivo Accuitomo 125μ 269 210 10.5 8.1 81.4 – – 77.8 4.0 – 12.9 4.7 0.6 – – – –
n/a not available, rc root canals
a
Data regarding maxillary molars with independent mesiobuccal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
 6
Table 6.16 CBCT studies on the root and root canal morphologies of distobuccal root of maxillary second molar
Number of
CBCT Voxel Number Number root canalsa
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [29] Turkey In vivo i-Cat 300μ 827 1329 2.2 4.8 92.5 0.5 – 99.6 0.2 – 0.2 – – – – – –
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 2.0 29.0 69.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 371 9.7 8.9 80.3 1.1 – 100 – – – – – – – – –
[72]
Ghobashy Egypt In vivo Cranex 133μ 657 610 1.6 10.7 87.7 – – 100 – – – – – – – – –
[32]
Ghoncheh Iran In vivo NewTom 300μ 450 423 14.4 22.2 63.4 – – 100 – – – – – – – – –
[97]
Gu [98] China In vivo Galileos 125μ 725 1226 14.1 21.9 63.0 1.0 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Jing [34] China In vivo NewTom 125μ n/a 519 10.4 15.2 73.6 0.8 – 100 – – – – – – – – –
Jo [88]c Korea In vivo CB 300μ 911 1767 6.6 13.0 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
MercuRay
Khademi [92] Iran In vivo Galileos 150μ 295 460 4.8 6.3 88.2 0.7 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kim [35] Korea In vivo Dinnova 167μ 415 821 10.2 13.0 76.3 0.5 – 100 – – – – – – – – –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Li [93] China Ex vivo NewTom n/a n/a 46 2.2 23.9 71.7 2.2 – 90.9 9.1 – – – – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 1335 13.0 12.3 74.2 0.5 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 778 13.4 13.2 72.9 0.5 – 100 – – – – – – – – –

pilararaya@ejercer.cl
Monsarrat France In vivo Carestream 200μ 102 167 6.0 3.6 88.0 2.4 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Neelakantan India Ex vivo Accuitomo n/a n/a 205 1.0 5.9 93.1 – – 91.1 1.6 2.6 4.7 – – – – – –
[101]
Nikoloudaki Greece In vivo NewTom 125μ 273 402 5.5 8.2 85.1 1.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[102]
PérezHeredia Spain In vivo Carestream 180μ 112 142 16.9 4.2 78.9 – – 100 – – – – – – – – –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 157 1.9 8.3 88.5 1.3 – 100 – – – – – – – – –
(continued)
119
 Table 6.16 (continued)
120

Number of
CBCT Voxel Number Number root canalsa
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Ratanajirasut Thailand In vivo Accuitomo 250μ 266 457 3.5 9.2 87.1 0.2 – 100 – – – – – – – – –
[39]
Rouhani [105] Iran Ex vivo Planmeca 160μ n/a 125 0.8 8.0 89.6 1.6 – 99.2 – 0.8 – – – – – – –
Silva [90] Brazil In vivo i-Cat 200μ 294 306 7.9 12.7 79.4 – – 100 – – – – – – – – –
Tian [91] China In vivo NewTom 160μ 844 1539 13.3 19.4 66.1 1.2 – 99.5 0.2 – 0.1 0.2 – – – – –
Wu [44] China In vivo NewTom 160μ 1294 2412 17.7 23.6 57.9 0.8 – 100 – – – – – – – – –
Zhang [107] China In vivo Accuitomo 125μ 269 210 10.5 8.1 81.4 – – 99.4 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 0.6
n/a not available, rc root canals
a
Data regarding maxillary molars with independent distobuccal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
 6
Table 6.17 CBCT studies on the root and root canal morphologies of palatal root of maxillary second molar
Number of
CBCT Voxel Number Number root canalsa
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Altunsoy [29] Turkey In vivo i-Cat 300μ 827 1329 2.2 4.8 92.5 0.5 – 99.1 0.2 0.2 0.3 0.2 – – – – –
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 2.0 29.0 69.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 371 9.7 8.9 80.3 1.1 – 99.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 0.3
[72]
Ghobashy Egypt In vivo Cranex 133μ 657 610 1.6 10.7 87.7 – – 100 – – – – – – – – –
[32]
Ghoncheh Iran In vivo NewTom 300μ 450 423 14.4 22.2 63.4 – – 100 – – – – – – – – –
[97]
Gu [98] China In vivo Galileos 125μ 725 1226 14.1 21.9 63.0 1.0 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Jing [34] China In vivo NewTom 125μ n/a 519 10.4 15.2 73.6 0.8 – 100 – – – – – – – – –
Jo [88]c Korea In vivo CB 300μ 911 1767 6.6 13.0 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
MercuRay
Khademi [92] Iran In vivo Galileos 150μ 295 460 4.8 6.3 88.2 0.7 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kim [35] Korea In vivo Dinnova 167μ 415 821 10.2 13.0 76.3 0.5 – 100 – – – – – – – – –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Li [93] China Ex vivo NewTom n/a n/a 46 2.2 23.9 71.7 2.2 – 97.0 3.0 – – – – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 1335 13.0 12.3 74.2 0.5 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 778 13.4 13.2 72.9 0.5 – 98.9 0.4 0.7 – – – – – – –

pilararaya@ejercer.cl
Monsarrat France In vivo Carestream 200μ 102 167 6.0 3.6 88.0 2.4 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Neelakantan India Ex vivo Accuitomo n/a n/a 205 1.0 5.9 93.1 – – 94.2 – – 3.7 1.1 – – 0.5 0.5 –
[101]
Nikoloudaki Greece In vivo NewTom 125μ 273 402 5.5 8.2 85.1 1.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[102]
PérezHeredia Spain In vivo Carestream 180μ 112 142 16.9 4.2 78.9 – – 100 – – – – – – – – –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 157 1.9 8.3 88.5 1.3 – 100 – – – – – – – – –
Ratanajirasut Thailand In vivo Accuitomo 250μ 266 457 3.5 9.2 87.1 0.2 – 99.7 0.3 – – – – – – – –
[39]
(continued)
121
 Table 6.17 (continued)
122

Number of
CBCT Voxel Number Number root canalsa
Authors Country Method device size of subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Rouhani [105] Iran Ex vivo Planmeca 160μ n/a 125 0.8 8.0 89.6 1.6 – 100 – – – – – – – – –
Silva [90] Brazil In vivo i-Cat 200μ 294 306 7.9 12.7 79.4 – – 100 – – – – – – – – –
Tian [91] China In vivo NewTom 160μ 844 1539 13.3 19.4 66.1 1.2 – 99.7 0.2 0.1 – – – – – – –
Wu [44] China In vivo NewTom 160μ 1294 2412 17.7 23.6 57.9 0.8 – 100 – – – – – – – – –
Zhang [107] China In vivo Accuitomo 125μ 269 210 10.5 8.1 81.4 – – 100 – – – – – – – – –
n/a not available, rc root canals
a
Data regarding maxillary molars with independent palatal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 123

a b c

d e f

g h i

j k l

m n o p q

r s t u v

Fig. 6.4 Representative CBCT images of different root canal system morphologies on maxillary molars. (a–f)
Mesiobuccal root, (g–i) distobuccal root, (j–l) palatal root, and (m–v) different axial configurations

pilararaya@ejercer.cl
124
canal teeth in a two-rooted configuration, having
two root canals in the mesial root and one in the
distal root (Tables 6.18, 6.19, 6.20, and 6.21). In
the mesial root, prevalence of two canals ranged
from 88.5% [114] to 58.3% [110] and from 100%
to 97.0% [103], of the mandibular first and sec-
ond molars, respectively. In most studies,
Vertucci’s Type IV is the most predominant con-
figuration (>50%) in mandibular first molars,
with a prevalence varying from 16.4% in a
Belgium study [116] to 93.9% in Chinese popu-
lation [109], followed by Type II configuration
ranging from 1.0% in Turkey [117] to 51.3% in
Spain [103]. In mandibular second molars, Type
II and IV configurations had also a high preva-
lence, reaching as high as 78.2% [103] and 79.6%
[117], respectively (Fig. 6.5a–f). Among differ-
ent anatomical variations (Fig. 6.5m–v), the pres-
ence of a third root canal in the mesial root, the
so-called middle mesial canal (Fig. 6.5t, u), has
been reported in CBCT studies as an uncommon
finding in 5.5% [47] and 2.2% [47] of the man-
dibular first and second molars, respectively.
Reports on the prevalence of a single root canal
system in the distal root ranged from 59.5% [117]
to 99% [114], but this root may also have two
root canals (Fig. 6.5g–l). In this case, the most
common configuration is Vertucci’s Type II
(22.5%) [118], despite Types III, IV, and V are
also common findings.
6.1.5.5 Additional Morphologies
Different morphologies of roots and root canal
systems have been reported in CBCT studies, but
the most studied variation is the C-shaped canal
configuration. In some studies, C-shaped canal
anatomy has been studied in a particular tooth
group addressing several aspects including prev-
alence, configuration type, and influence of gen-
der, age, or tooth location [130–132]. Other
studies, in turn, have more loose criteria only
mentioning the prevalence of this configuration
in a specific tooth group [72, 114]. Using CBCT
method, the existence of C-shaped canal configu-
ration was reported in mandibular premolars and
maxillary and mandibular molars (Table 6.22),
being frequently associated with variations in the
external morphology of the roots. Therefore, con-
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
sidering the dissimilarities in the root morphol-
ogy, it would be also expected different C-shaped
canal configurations depending on the tooth
group.
C-shaped configuration in mandibular premo-
lars (Fig. 6.6m–r) is an uncommon finding in
CBCT studies, although it may reach 4.1% of the
Chinese [81] and 1.5% of the Turkish [77] popu-
lations, for the first and second premolars,
respectively. This morphology has been mostly
observed in mandibular premolars with
Vertucci’s Type V configuration [73], and its
prevalence was significantly higher for the first
premolar in a Portuguese study [73], while no
difference was detected between the first and
second premolars in a Turkish investigation [77].
In maxillary molars, C-shaped canal configura-
tion is an uncommon finding formed mostly due
to the fusion of buccal roots [80, 81], and, when
present, it may be displayed in several positions
depending on which roots are fused (Fig. 6.6a–
f). Its prevalence is reported to range from 0.3%
[72] to 1.1% [89] and from 0.5% [72] to 3.8%
[89] for maxillary first and second molars,
respectively. In mandibular first molars, reported
prevalence of C-shaped canals ranged from 0.1%
in China [111] to 1.7% in Brazil [114], while this
configuration in mandibular second molars
(Fig. 6.6g–l) varied from 1.9% in a Cypriote
population [121] to 44.0% in China [115]. In
second molars, its prevalence is significantly
higher [89] probably because of the common
occurrence of fused roots. The percentage fre-
quency of this anatomical variation has been
reported as having an ethnic influence, being
higher in Asian populations, such as in Korea
[71, 128] and China [115, 133]. Two studies
from Portugal [131] and Israel [132] stated that
the “C” concavity was more commonly turned
toward lingual, while a study from Brazil [115,
130] pointed to the opposite direction. Two
CBCT studies [131, 132] reported a high preva-
lence of Fan’s C1 Type at the coronal portion of
the root and Fan’s C3 Type at the middle canal
third. According to von Zuben et al. [115], Fan’s
C Type prevalence on each root canal third (cor-
onal, middle, and a­ pical) might not be consen-
sual in different populations.
 6
Table 6.18 CBCT studies on the root and root canal morphologies of mesial root of mandibular first molar
Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Akbarzadeh USA In vivo Carestream 300μ 210 210 – – – – – n/a n/a n/a n/a n/a n/a n/a n/a n/a 3rc, 14.8
[119]
Beshkenadze Georgia In vivo Gendex n/a 228 247 – 94.1 6.9 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[45]c
Caputo [120] Brazil In vivo Gendex 200μ 198 342 – 98.5 1.5 – – 0.6 38.5 14.9 40.4 4.1 0.6 – – 0.9 –
Celikten Cyprus In vivo NewTom n/a 272 384 0.8 95.6 3.6 – – 2.4 34.9 – 62.7 – – – – – –
[121]
Demirbuga Turkey In vivo NewTom n/a 605 823 1.8 95.9 2.1 0.2 – 2.2 27.6 1.7 67.7 0.8 – – – – –
[122]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 2.0 95.0 3.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 299 0.7 93.6 5.7 – – 1.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
[72] 94.6/3rc,
3.7
Huang [112] Taiwan In vivo i-Cat n/a 151 237 – 74.7 25.3 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kim [108] Korea In vivo Dinnova 167μ 976 1952 0.7 73.5 25.8 – – 1.8 20.2 0.3 76.8 0.5 – – – 0.4 –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Madani [123] Iran In vivo NewTom 300μ 110 154 1.2 96.8 2.0 – – 7.4 31.5 2.0 57.1 2.0 – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 709 0.7 97.3 2.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –

pilararaya@ejercer.cl
Martins [47] Portugal In vivo Planmeca 200μ 646 450 0.7 97.1 2.2 – – 1.1 46.5 – 41.9 – 4.1 – – 6.4 3rc, 5.5
Mokhtari Iran Ex vivo NewTom 150μ n/a 96 n/a n/a n/a n/a n/a 1.0 9.5 1.1 88.4 – – – – – –
[124]
Monsarrat France In vivo Carestream 200μ 102 130 1.5 90.0 7.7 0.8 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Mukhaimer Palestine Ex vivo MCT-1 n/a n/a 320 – 100 – – – 1.2 38.7 1.9 53.8 1.2 – – – 3.2 –
[118]
Nur [117] Turkey In vivo i-Cat 300μ 850 966 0.3 99.2 0.5 – – 5.4 1.0 0.1 91.6 1.8 – – 0.1 – –
Park [71] Korea In vivo n/a n/a 430 727 0.3 77.4 22.3 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
PérezHeredia Spain In vivo Carestream 180μ 112 121 1.7 94.2 4.1 – – – 51.3 – 37.8 0.8 1.7 – – 8.4 –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 117 – 100 – – – 9.4 27.4 – 62.3 – – – – 0.9 –
Rahimi [125]c Iran In vivo NewTom n/a 386 386 n/a n/a 3.1 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
(continued)
125
 Table 6.18 (continued)
126

Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Shemesh Israel In vivo Alioth 150μ 1020 1229 n/a n/a 2.6 – n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[126]c
Silva [114] Brazil In vivo i-Cat 200μ 154 234 3.4 96.6 – – – 11.5 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 88.5
Torres [116] Belgium In vivo Accuitomo 250μ 100 145 0.7 96.5 2.8 – – 1.4 5.0 33.6 16.4 42.9 – 0.7 – – –
Torres [116] Chile In vivo Accuitomo 250μ 170 146 – 93.8 6.2 – – 2.9 19.0 28.5 21.9 21.9 2.2 3.6 – – –
Tu [113]c Taiwan In vivo i-Cat 250μ 123 246 n/a n/a 25.6 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Wang [109] China In vivo Accuitomo 125μ 558 558 0.7 73.5 25.8 – – 1.5 1.7 – 93.9 0.2 – – 0.2 2.5 –
Zhang [110] China In vivo Accuitomo 125μ 211 232 – 70.3 29.3 0.4 – 3.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 96.3
Zhang [111] China In vivo Galileos 125μ 455 910 – 77.5 22.3 0.2 – 0.9 5.6 4.8 87.8 0.9 – – – – –
n/a not available, rc root canals
a
Data regarding mandibular molars with independent mesial root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
 6
Table 6.19 CBCT studies on the root and root canal morphologies of distal root of mandibular first molar
Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Beshkenadze Georgia In vivo Gendex n/a 228 247 – 94.1 6.9 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[45]c
Caputo [120] Brazil In vivo Gendex 200μ 198 342 – 98.5 1.5 – – 76.6 6.4 11.1 2.1 3.8 – – – – –
Celikten [121] Cyprus In vivo NewTom n/a 272 384 0.8 95.6 3.6 – – 83.9 11.8 0.3 3.4 0.3 0.3 – – – –
Demirbuga Turkey In vivo NewTom n/a 605 823 1.8 95.9 2.1 0.2 – 81.6 6.6 3.7 6.0 2.1 – – – – –
[122]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 2.0 95.0 3.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 299 0.7 93.6 5.7 – – 75.1 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 24.9
[72]
Huang [112] Taiwan In vivo i-Cat n/a 151 237 – 74.7 25.3 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Kim [108] Korea In vivo Dinnova 167μ 976 1952 0.7 73.5 25.8 – – 66.6 19.0 0.3 11.9 2.1 – – – 0.1 –
Kim [127] Korea In vivo Dinnova 167μ 979 1958 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 50.4
Madani [123] Iran In vivo NewTom 300μ 110 154 1.2 96.8 2.0 – – 79.9 10.7 4.7 3.4 1.3 – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 709 0.7 97.3 2.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Martins [47] Portugal In vivo Planmeca 200μ 646 450 0.7 97.1 2.2 – – 70.9 12.4 9.6 2.3 3.2 0.9 – – 0.7 –
Mokhtari Iran Ex vivo NewTom 150μ n/a 96 n/a n/a n/a n/a n/a 90.5 2.1 5.3 2.1 – – – – – –
[124]

pilararaya@ejercer.cl
Monsarrat France In vivo Carestream 200μ 102 130 1.5 90.0 7.7 0.8 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Mukhaimer Palestine Ex vivo MCT-1 n/a n/a 320 – 100 – – – 57.5 22.5 10.6 8.1 1.3 – – – – –
[118]
Nur [117] Turkey In vivo i-Cat 300μ 850 966 0.3 99.2 0.5 – – 59.5 12.6 2.0 19.3 6.6 – – – – –
Park [71] Korea In vivo n/a n/a 430 727 0.3 77.4 22.3 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
PérezHeredia Spain In vivo Carestream 180μ 112 121 1.7 94.2 4.1 – – 72.3 18.5 5.9 2.5 – – – – 0.8 –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 117 – 100 – – – 79.5 9.4 6.8 4.3 – – – – – –
Rahimi [125]c Iran In vivo NewTom n/a 386 386 n/a n/a 3.1 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
(continued)
127
 Table 6.19 (continued)
128

Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Shemesh Israel In vivo Alioth 150μ 1020 1229 n/a n/a 2.6 – n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[126]c
Silva [114] Brazil In vivo i-Cat 200μ 154 234 3.4 96.6 – – – 87.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 12.4
Torres [116] Belgium In vivo Accuitomo 250μ 100 145 0.7 96.5 2.8 – – 72.9 – 17.1 – 9.3 – 0.7 – – –
Torres [116] Chile In vivo Accuitomo 250μ 170 146 – 93.8 6.2 – – 78.8 – 12.4 – 5.9 – 2.9 – – –
Tu [113]c Taiwan In vivo i-Cat 250μ 123 246 n/a n/a 25.6 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Wang [109] China In vivo Accuitomo 125μ 558 558 0.7 73.5 25.8 – – 62.9 9.8 0.7 25.1 0.5 – – – 1.0 –
Zhang [110] China In vivo Accuitomo 125μ 211 232 – 70.3 29.3 0.4 – 77.3 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 22.7
Zhang [111] China In vivo Galileos 125μ 455 910 – 77.5 22.3 0.2 – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
n/a not available, rc root canals
a
Data regarding mandibular molars with independent distal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%

pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
 6

Table 6.20 CBCT studies on the root and root canal morphologies of mesial root of mandibular second molar
Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Celikten Cyprus In vivo NewTom n/a 272 421 3.6 95.7 0.5 0.2 – 7.1 32.3 0.3 60.3 – – – – – –
[121]
Demirbuga Turkey In vivo NewTom n/a 605 925 10.3 85.4 3.4 0.9 – 19.7 36.5 3.5 37.6 1.9 0.5 0.3 – – –
[122]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 7.0 91.0 2.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 322 8.7 88.8 2.5 – – 9.5 n/a n/a n/a n/a n/a n/a n/a n/a 2rc,
[72] 88.5/3rc,
2.0
Kim [128] Korea In vivo Dinnova 167μ 960 1920 41.2 58.1 0.7 – – 14.9 37.3 1.2 43.9 2.6 – – – 0.1 –
Madani [123] Iran In vivo NewTom 300μ 110 147 17.7 81.6 0.7 – – 18.3 28.4 5.8 43.4 3.3 0.8 – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 1115 12.6 85.2 2.2 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 667 14.2 83.1 2.7 – – 8.1 63.9 5.3 18.1 0.5 1.6 – – 2.5 3rc, 2.2
Monsarrat France In vivo Carestream 200μ 102 156 1.3 87.2 11.5 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
CBCT and Micro-CT on the Study of Root Canal Anatomy

[61]
Nur [117] Turkey In vivo i-Cat 300μ 850 1165 10.0 90.0 – – – 12.4 2.1 0.7 79.6 5.2 – – – – –

pilararaya@ejercer.cl
Park [71] Korea In vivo n/a n/a 430 710 43.1 54.5 2.4 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Pawar [129] India In vivo Planmeca 100μ 1120 983 13.1 79.4 7.5 – – 8.3 37.4 1.1 52.0 1.2 – – – – –
PérezHeredia Spain In vivo Carestream 180μ 112 121 16.5 83.5 – – – 3.0 78.2 – 14.8 1.0 – – – 3.0 –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 161 8.7 89.4 1.9 – – 12.5 23.6 2.1 61.8 – – – – – –
Shemesh Israel In vivo Alioth 150μ 1020 1465 n/a n/a 1.8 0.6 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[126]c
Silva [114] Brazil In vivo i-Cat 200μ 154 226 9.7 86.7 3.6 – – 36.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 63.3
Torres [116] Belgium In vivo Accuitomo 250μ 100 112 14.3 83.9 0.9 0.9 – 11.7 5.3 37.3 14.9 28.7 – 2.1 – – –
Torres [116] Chile In vivo Accuitomo 250μ 170 112 8.9 86.6 3.6 0.9 – 17.5 7.2 48.5 4.1 20.6 – 2.1 – – –
Zhang [110] China In vivo Accuitomo 125μ 211 157 22.3 76.4 1.3 – – 41.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 58.3
n/a not available, rc root canals
a
Data regarding mandibular molars with independent mesial root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%
129
 130

Table 6.21 CBCT studies on the root and root canal morphologies of distal root of mandibular second molar
Number Number of
CBCT Voxel of Number root canalsa
Authors Country Method device size subjects of teeth Number of roots (%) Vertucci’s classificationa (%) (%) (rc)b
1 2 3 4 >4 I II III IV V VI VII VIII Others
Celikten [121] Cyprus In vivo NewTom n/a 272 421 3.6 95.7 0.5 0.2 – 96.3 2.5 – 1.0 – 0.2 – – – –
Demirbuga Turkey In vivo NewTom n/a 605 925 10.3 85.4 3.4 0.9 – 96.6 0.5 0.7 1.0 1.0 0.2 – – – –
[122]
Estrela [46] Brazil In vivo PreXion3D 100μ 618 100 7.0 91.0 2.0 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Felsypremila India In vivo Kodak n/a 246 322 8.7 88.8 2.5 – – 96.6 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 3.4
[72]
Kim [128] Korea In vivo Dinnova 167μ 960 1920 41.2 58.1 0.7 – – 96.5 2.1 – 0.9 0.5 – – – – –
Madani [123] Iran In vivo NewTom 300μ 110 147 17.7 81.6 0.7 – – 92.5 3.3 0.8 1.7 1.7 – – – – –
Martins [87] Portugal In vivo Planmeca 200μ 1044 1115 12.6 85.2 2.2 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
Martins [47] Portugal In vivo Planmeca 200μ 646 667 14.2 83.1 2.7 – – 93.5 0.5 4.2 0.4 1.4 – – – – –
Monsarrat France In vivo Carestream 200μ 102 156 1.3 87.2 11.5 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[61]
Nur [117] Turkey In vivo i-Cat 300μ 850 1165 10.0 90.0 – – – 94.1 3.3 – 2.3 0.3 – – – – –
Park [71] Korea In vivo n/a n/a 430 710 43.1 54.5 2.4 – – n/a n/a n/a n/a n/a n/a n/a n/a n/a –

pilararaya@ejercer.cl
Pawar [129] India In vivo Planmeca 100μ 1120 983 13.1 79.4 7.5 – – 70.3 21.0 – 8.7 – – – – – –
PérezHeredia Spain In vivo Carestream 180μ 112 121 16.5 83.5 – – – 92.0 2.0 3.0 3.0 – – – – – –
[103]
Plotino [104] Italy In vivo NewTom n/a 201 161 8.7 89.4 1.9 – – 100 – – – – – – – – –
Shemesh Israel In vivo Alioth 150μ 1020 1465 n/a n/a 1.8 0.6 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a –
[126]c
Silva [114] Brazil In vivo i-Cat 200μ 154 226 9.7 86.7 3.6 – – 99.0 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 1.0
Torres [116] Belgium In vivo Accuitomo 250μ 100 112 14.3 83.9 0.9 0.9 – 98.9 – – – 1.1 – – – – –
Torres [116] Chile In vivo Accuitomo 250μ 170 112 8.9 86.6 3.6 0.9 – 99.0 – – – 1.0 – – – – –
Zhang [110] China In vivo Accuitomo 125μ 211 157 22.3 76.4 1.3 – – 96.7 n/a n/a n/a n/a n/a n/a n/a n/a 2rc, 3.3
n/a not available, rc root canals
a
Data regarding mandibular molars with independent distal root
b
If no Vertucci’s classification was provided
c
Data is according to the original article although the sum of percentages was not 100%
J. N. R. Martins and M. A. Versiani
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 131

a b c

d e f

g h i

j k l

m n o p q

r s t u v

Fig. 6.5 Representative CBCT images of different canal system configurations on mandibular molars. (a–f) Mesial
root, (g–l) distal root, and (m–v) different axial configurations

pilararaya@ejercer.cl
132 J. N. R. Martins and M. A. Versiani

Table 6.22 CBCT studies on the C-shaped root canal configuration

Number
CBCT of Number C-shaped canal
Tooth Authors Country Method device Voxel size subjects of teeth prevalence (%)
Maxillary Felsypremila India In vivo Kodak n/a 246 367 0.3
first molar [72]
Jo [88] Korean In vivo CB 300μ 911 1786 0.8
MercuRay
Martins [89] Portugal In vivo Planmeca 200μ 895 928 1.1
Maxillary Felsypremila India In vivo Kodak n/a 246 371 0.5
second [72]
molar Jo [88] Korean In vivo CB 300μ 911 1767 2.7
MercuRay
Martins [89] Portugal In vivo Planmeca 200μ 895 1299 3.8
Mandibular Celikten Cyprus In vivo NewTom n/a 272 384 0.5
first molar [121]
Demirbuga Turkey In vivo NewTom n/a 605 823 0.9
[122]
Felsypremila India In vivo Kodak n/a 246 299 0.7
[72]
Madani Iran In vivo NewTom 300μ 110 154 1.2
[123]
Martins Portugal In vivo Planmeca 200μ 792 695 0.6
[131]
Martins [87] Portugal In vivo Planmeca 200μ 1044 709 0.6
Shemesh Israel In vivo Alioth 155μ 1020 1229 0.2
[132]
Silva [114] Brazil In vivo i-Cat 200μ 154 234 1.7
Zhang [111] China In vivo Galileos 125μ 455 910 0.1
Mandibular Celikten Cyprus In vivo NewTom n/a 272 421 1.9
second [121]
molar Demirbuga Turkey In vivo NewTom n/a 605 925 4.1
[122]
Felsypremila India In vivo Kodak n/a 246 322 8.1
[72]
Helvacioglu-­ Turkey In vivo i-Cat 250μ 251 271 8.9
Yigit [135]
Kim [128] Korea In vivo Dinnova 167μ 960 1920 40.1
Ladeira Brazil In vivo i-Cat 250μ 214 406 15.3
[130]
Madani Iran In vivo NewTom 300μ 110 147 17.6
[123]
Martins Portugal In vivo Planmeca 200μ 792 1088 8.5
[131]
Martins [87] Portugal In vivo Planmeca 200μ 1044 1115 8.6
Park [71] Korea In vivo n/a n/a 430 710 41.3
Pawar [129] India In vivo Planmeca 100μ 1120 983 13.1
Plotino [104] Italy In vivo NewTom n/a 201 161 6.2
Shemesh Israel In vivo Alioth 155μ 1020 1465 4.6
[132]

pilararaya@ejercer.cl
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 133

Table 6.22 (continued)

Number
CBCT of Number C-shaped canal
Tooth Authors Country Method device Voxel size subjects of teeth prevalence (%)
Silva [114] Brazil In vivo i-Cat 200μ 154 226 3.5
Sinanoglu Turkey In vivo i-Cat 250μ 200 339 8.6
[136]
Torres [116] Belgium In vivo Accuitomo 250μ 100 112 10.71
Torres [116] Chile In vivo Accuitomo 250μ 170 112 8.93
von Zuben Brazil In vivo i-Cat 200μ 237 400 6.8
[115]
von Zuben China In vivo Kodak 200μ 214 400 44.0
[115]
von Zuben England In vivo Accuitomo 80μ 400 400 7.8
[115]
von Zuben India In vivo NewTom 75μ/150μ 232 400 12.3
[115]
von Zuben Mexico In vivo OP300 85μ/250μ 400 400 14.2
[115] Maxio
von Zuben Portugal In vivo Planmeca 200μ 259 400 8.3
[115]
von Zuben South In vivo Galileos 200μ 217 400 9.3
[115] Africa
von Zuben Spain In vivo Planmeca 200μ 362 400 11.0
[115]
von Zuben USA In vivo Kodak 76μ 400 400 11.3
[115]
Zhang [110] China In vivo Accuitomo 125μ 211 157 29.0
Zheng [133] China In vivo Accuitomo 125μ 608 528 38.6
Mandibular Arslan [77] Turkey In vivo NewTom 150μ 88 154 2.5
first Felsypremila India In vivo Kodak n/a 246 447 0.7
premolar [72]
Liao [81] China In vivo NewTom 240μ 97 194 4.1
Martins [73] Portugal In vivo Planmeca 200μ 634 1123 2.3
Shetty [84] India Ex vivo Kodak 76μ n/a 1186 0.9
Yang [85] China In vivo Galileos 125μ 238 440 1.1
Yu [86] China In vivo Accuitomo 125μ 149 178 1.1
Mandibular Arslan [77] Turkey In vivo NewTom 150μ 88 133 1.5
second Felsypremila India In vivo Kodak n/a 246 398 0.8
premolar [72]
Martins [73] Portugal In vivo Planmeca 200μ 634 889 0.6
Shetty [84] India Ex vivo Kodak 76μ n/a 814 0.7
Yu [86] China In vivo Accuitomo 125μ 149 178 0.6

Another anatomical variation that is usually
mentioned in mandibular molars is the presence
of an extra mesiobuccal root, the radix paramo-
laris (Fig. 6.6s), or an extra distolingual root, the
radix entomolaris (Fig. 6.6t–x). CBCT studies
usually report these extra roots as having
Vertucci’s Type I configuration [108]. Radix par-
amolaris is an uncommon finding with a preva-
lence that varied from 1.2% [103] to 1.6% [72]
for the mandibular first and second molars,
respectively. On the other hand, radix entomo-
laris is much more common, mainly in mandibu-
lar first molar from Asian population where its
prevalence is higher than 22% [91, 110, 111,
113], while in non-Asian population, it is usually
reported under 7%. In the mandibular second

pilararaya@ejercer.cl
134 J. N. R. Martins and M. A. Versiani

a b c d e f

g h i j k l

m n o p q r

s t u

v w x

y z a’ b’ c’ d’

Fig. 6.6 Representative CBCT images of different addi- molars, (g–l) mandibular C-shaped molars, (m–r) mandib-
tional root and root canal system morphologies on maxil- ular C-shaped premolars, (s) radix paramolaris, (t–x) radix
lary and mandibular teeth. (a–f) Maxillary C-shaped entomolaris, and (y–d′) maxillary molar root fusions

pilararaya@ejercer.cl
 6

Table 6.23 CBCT studies reporting the prevalence of an extra mesiobuccal or distolingual root
CBCT Voxel Number of Number of Extra mesiobuccal root Extra distolingual root
Tooth Authors Country Method device size subjects teeth (%) (%)
Mandibular first molar Beshkenadze [45] Georgia In vivo Gendex n/a 228 247 – 6.9
Demirbuga [122] Turkey In vivo NewTom n/a 605 823 – 2.1
Felsypremila [72] India In vivo Kodak n/a 246 299 0.7a 5.0b
Kim [108] Korea In vivo Dinnova 167μ 976 1952 0.1a n/a
Martins [47] Portugal In vivo Planmeca 200μ 646 450 – 2.2b
Nur [117] Turkey In vivo i-Cat 300μ 850 966 – 0.5
Park [71] Korea In vivo n/a n/a 430 727 – 22.3b
PérezHeredia Spain In vivo Carestream 180μ 112 121 1.2a 0.8b
[103]
Rahimi [125] Iran In vivo NewTom n/a 386 386 – 3.1b
CBCT and Micro-CT on the Study of Root Canal Anatomy

Shemesh [126] Israel In vivo Alioth 150μ 1020 1229 0.6a 2.0b
Tian [91] China In vivo NewTom 160μ 844 1558 – 25.8

pilararaya@ejercer.cl
Tu [113] Taiwan In vivo i-Cat 250μ 123 246 – 25.6
Zhang [110] China In vivo Accuitomo 125μ 211 232 – 29.7
Zhang [111] China In vivo Galileos 125μ 455 910 – 22.1
Mandibular second Demirbuga [122] Turkey In vivo NewTom n/a 605 925 – 3.5
molar Felsypremila [72] India In vivo Kodak n/a 246 322 1.6a 0.9b
Kim [128] Korea In vivo Dinnova 167μ 960 1920 – 0.4
Martins [47] Portugal In vivo Planmeca 200μ 646 667 0.4a 0.6b
Park [71] Korea In vivo n/a n/a 430 710 0.1a 2.3b
Shemesh [126] Israel In vivo Alioth 150μ 1020 1465 1.4a 0.4b
Silva [114] Brazil In vivo i-Cat 200μ 154 234 – 3.5b
Zhang [110] China In vivo Accuitomo 125μ 211 157 – 1.3
n/a not available
a
Study reporting the extra root as radix paramolaris
b
Study reporting the extra root as radix entomolaris
135
136
molars, this anatomic feature is not so common
(3.5%) [114, 122] and apparently is not influ-
enced by ethnic factor (Table 6.23).
Because of the complexity of root canal
anatomy in maxillary molars with fused roots
(Fig. 6.6y–d′), only a few CBCT studies have
addressed the prevalence of different root
fusion types (Table 6.24) following the classi-
fication proposed by Zhang et al. [134]. In
maxillary first molars, studies from Asian
population reported a prevalence of Type 1
fusion (between buccal roots) in 1.6% [88]
and 1.7% [42] of Korean and Chinese popula-
tion, while in an European Caucasian study
[87], it has been reported a higher prevalence
(6.0%) of Type III fusion (between distobuc-
cal and palatal roots). Regarding the maxillary
second molars, all studies are consensual pre-
senting Type II fusion (between mesiobuccal
and palatal roots) as the most common fusion
type with a prevalence varying from 6.8% [87]
to 8.3% [32].
6.2 Micro-computed
Tomography (Micro-CT)
6.2.1 Definition
A decade after the CT scanner was created, Elliott
and Dover [137] developed the first high-­resolution
X-ray micro-computed tomographic device, and,
using a resolution of 12 μm, the image of the shell of
a Biomphalaria glabrata snail was produced. The
term “micro” in this new device was used to indicate
that the pixel sizes of the cross sections were in the
micrometer range. This also means that the machine
was smaller in design compared to the human ver-
sion and was indicated to model smaller objects
[138]. X-ray micro-computed tomography has also
been denominated as microcomputed tomography,
microcomputer tomography, high-resolution X-ray
tomography, X-ray microtomography, micro-CT,
and similar terminologies. Nowadays, despite the
impossibility of employing micro-CT for in vivo
human imaging, it has been considered the most
important and accurate research tool for the study of
fine details of root canal anatomy [139–142].
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
Like conventional medical tomography,
micro-CT also uses X-rays to create cross sec-
tions of a 3D object that later can be used to rec-
reate a virtual model without destroying the
original model [138]. Therefore, whereas a typi-
cal digital image is composed of pixels (picture
elements), a CT slice image is composed of
­voxels (volume elements) [138, 143]. Because
micro-CT is mostly used in nonliving objects, the
scanners were designed to take advantage of the
fact that the items being studied do not move and
are not harmed by X-rays. Therefore, this imag-
ing technology employs four optimizations in
comparison with conventional CT [143]:
(a) Higher-energy X-rays which are more effec-
tive at penetrating dense materials
(b) Smaller X-ray focal spots providing
increased resolution at a cost in X-ray
output
(c) Finer and more densely packed X-ray detec-
tors which increase resolution at a cost in
detection efficiency
(d) Longer exposure times increasing the signal-­
to-­noise ratio to compensate for the loss in
signal from the diminished output and effi-
ciency of the source and detectors
In the last decades, micro-CT has gained
increasing significance in the detailed study of
canal anatomy in endodontics because it offers a
nondestructive, accurate, and reproducible tech-
nique that could be applied quantitatively as well
as qualitatively for two- and three-dimensional
assessment of the root canal system [139].
Conversely, given that scanning and reconstruc-
tion procedures take considerable time, the tech-
nique is not suitable for clinical use, the
equipment is expensive, and the complexity of
the technical procedures requires a high learning
curve and an in-depth knowledge of dedicated
software. The technical procedures related to the
micro-CT methodology with the aim to evaluate
aspects related to the morphological analysis of
the root canal anatomy are complex, and a
­thorough discussion is beyond the scope of this
chapter. However, an understanding of basic
principles is desirable to ensure a better compre-
 6

Table 6.24 CBCT studies reporting the prevalence of root fusion types in the maxillary first and second molars
Type I Type II Type III Type IV Type V Type VI Others
Authors Country Method CBCT device Voxel size Number of subjects Number of teeth (%) (%) (%) (%) (%) (%) (%)
Maxillary first molar
Jo [88] Korea In vivo CB MercuRay 300μ 911 1786 1.7 0.3 0.6 0.3 0.1 0.1 –
Martins [87] Portugal In vivo Planmeca 200μ 1044 709 0.1 0.2 6.0 0.1 0.3 0.1 0.2
Zheng [42] China In vivo Accuitomo 125μ 701 627 1.6 0.2 0.5 0.5 –
CBCT and Micro-CT on the Study of Root Canal Anatomy

Maxillary second molar

Ghobashy [32] Egypt In vivo Cranex 133μ 657 610 n/a 8.3 n/a n/a n/a n/a n/a

pilararaya@ejercer.cl
Jo [88] Korea In vivo CB MercuRay 300μ 911 1767 2.3 7.0 0.3 2.4 4.2 3.3 0.1
Martins [87] Portugal In vivo Planmeca 200μ 1044 1115 4.0 6.8 1.1 4.0 4.4 1.4 3.4
Wu [44] China In vivo NewTom 160μ 1294 2412 17.7 23.6 –
n/a not available
137
138
hension of its potential as a tool for endodontic
teaching and researching.
6.2.2 Micro-CT Image Acquisition
A typical micro-CT scanner consists of a micro-
focus X-ray source, a motorized high-precision
sample rotation stage, a detection array, a sys-
tem control mechanism, and computing soft-
ware resources for reconstruction, visualization,
and analysis [144]. For the study of root canal
anatomy, the source sends X-ray radiation
through a tooth attached to the sample stage,
and a detector array, coupled to a digital charge-
coupled device camera, records attenuated
intensities of the X-ray beam, while the object
rotates on its own axis (Fig. 6.7); in other words,
micro-CT involves gathering projection data of
the tooth from multiple directions. If many pro-
jections are recorded from different viewing
angles of the same tooth, each projection image
will contain different information about its
internal structure. At this stage, the only prepa-
ration that is absolutely necessary for scanning
is to ensure that the previously cleaned tooth fits
inside the field of view and does not move dur-
ing the scan [143]. The entire operation of the
scanner, including X-ray exposure, type of filter,
correction of flat field, resolution, rotation step,
a b
Fig. 6.7 (a) Internal chamber of the SkyScan 1174v2
micro-CT device (Bruker microCT, Kontich, Belgium)
showing the basic components of the system. (b) Upper
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
rotation angle, number of frames, data collec-
tion, etc., is controlled by a dedicated software
which allows setting up these parameters in
order to improve further the 3D reconstruction
of the tooth.
After recording the X-ray images, the pro-
jection data of the tooth from multiple direc-
tions (Fig. 6.8a, b) is used as input for a
reconstruction algorithm. This algorithm com-
putes a three-­dimensional image of the internal
anatomy of the tooth, based on the two-dimen-
sional projection images (Fig. 6.8c, d) [145].
The resulting volumetric images are then sub-
jected to image segmentation using dedicated
software. Image segmentation is a manual or
automatic procedure that can remove the
unwanted structures from the image based on
the object density. The goal of segmentation is
to simplify the representation of an image into
something that is more meaningful and easier
to analyze. More precisely, image segmenta-
tion is the process of assigning a label to every
pixel in an image such that pixels with the
same label share certain visual characteristics
[146]. Concerning the tooth, the different
radiodensities of the enamel, dentin, and root
canal make segmentation easier. The result of
image segmentation is a set of segments that
collectively cover the entire image. When
applied to a stack of images, as in the study of
view of the specimen fixed to the sample stage, showing
the direction of rotation (arrow) during the image acquisi-
tion process
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 139

Fig. 6.8 Scanning procedure

and 3D reconstruction with
a
micro-CT technology. (a)
Projections are obtained by
rotating and/or translating the
object in front of the system
formed by the X-ray source and
detectors; (b) by repeating this
procedure at different angles
from the same plane, different
projections of the sample are
obtained; (c) based on the
acquired projections,
reconstruction of the inner
object is possible by creation of
serial transversal “slices”
(sections) using specific
algorithms; (d) finally, slices
can be assembled sequentially
through appropriate techniques,
forming three-­dimensional b
images of the object

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140 J. N. R. Martins and M. A. Versiani

the internal anatomy of the teeth, the resulting uate the morphological characteristics of the root
contours after image segmentation can be used canal before and after different stages of root
to create 3D models with the help of interpola- canal treatment. Authors concluded that micro-
tion algorithms, which can be visualized or CT technology would offer the possibility of
­
analyzed using other software. learning tooth morphology by interactive study
of surface-rendered images and slices, contribut-
ing to the development of virtual reality tech-
6.2.3 Micro-CT Artifacts niques for endodontic teaching. But the first
attempt to use micro-CT tools for quantitative
Considering that the principles of exposure for analysis of root canal anatomy was done by
acquiring micro-CT images are the same as for Bjørndal et al. [150]. Authors correlated the
CBCT, the overall aspects involved in the pro- shape of the root canals to the corresponding root
cesses of acquiring and reconstructing images surface of five maxillary molars scanned at a res-
will produce similar artifacts, as previously olution of 33 μm. In the following year, Peters
explained in this chapter. et al. [139] studied the potential and accuracy of
micro-CT for detailing the root canal geometry
of 12 maxillary molars regarding several other
6.2.4 Micro-CT Method quantitative parameters including volume, sur-
on the Evaluation of the Roots face area, diameter, and structured model index.
and Root Canal Anatomy The quantitative morphological data of the first
of Teeth studies [151, 152] on root canal anatomy using
conventional methods were taken by measuring
Application of micro-CT technology to endodon- some parameters such as area, diameter, and
tic research was recognized 13 years after its perimeter, acquired from a few cross sections of
development and described in a paper entitled the root. In contrast, using micro-CT technology,
Microcomputed Tomography: An Advanced these same parameters can be measured and plot-
System for Detailed Endodontic Research [147]. ted on graphs using automatic computer tools in
In this article, Nielsen et al. [147] evaluated the hundreds or thousands of slices at once (Fig. 6.9a,
reliability of micro-CT in the reconstruction of b). In the past, based on sectioned roots, the canal
the external and internal anatomy of four maxil- shape was qualitatively classified as round-, flat-,
lary first molars, assessing the morphological oval-, flat-oval, or irregular-shaped [153]. Despite
changes in the root canal after instrumentation its applicability, a qualitative evaluation is always
and obturation, using an isotropic resolution of subjective and may lead to inaccurate results.
127 μm. Authors concluded that micro-CT had Algorithms used in micro-CT allow a mathemati-
“potential as an advanced system for research, cal description of these cross-sectional appear-
but also provides the foundation as an exciting ances using two morphometric parameters: form
interactive educational tool.” In this study, three-­ factor and roundness (Fig. 6.9c). Roundness is
dimensional images of the internal and external defined as 4·A/(p·[dmax]2), where “A” is the area
structures of the teeth were also presented in a and “dmax” is the major diameter. The value of
format previously unattainable [147]. roundness ranges from 0 to 1, with 1 signifying a
With further developments of the micro-CT circle. The form factor is calculated by the equa-
scanners, improvements in the speed of data col- tion (4·p·A)/P2, where “A” and “P” are object area
lection, resolution, and image quality yielded and perimeter, respectively. Elongation of indi-
greater accuracy compared with the first studies vidual objects results in smaller values of form
using computational methods, with voxel sizes factor. Previous results using these parameters in
decreasing to less than 40 μm [148, 149]. Dowker single-rooted canines have demonstrated different
et al. [149] demonstrated the feasibility of this cross-sectional forms throughout the root canal
technology using a resolution of 38.7 μm to eval- [142]. This is an important data as different canal

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 141

Fig. 6.9 Quantitative 2D morphological parameters obtained calculating major (blue curve) and minor (orange curve)
from hundreds of cross sections of a mandibular incisor diameters; (c) quantitative cross-sectional appearance of the
scanned in a micro-CT device and plotted on graphs. (a) Area root canal in different root levels (roundness)
and perimeter; (b) aspect ratio (graphic below) obtained by

pilararaya@ejercer.cl
142
shapes in the same root may have an impact on the
selected chemomechanical protocol on root canal
treatment. Form factor was also used to describe
that the shape of the accessory foramen was more
round than that of the main foramen in C-shaped
canals of mandibular second molars [154].
Nowadays, 3D analysis using micro-CT algo-
rithms allows also for the calculation of volume
and surface area [139]. The clinical significance
of such parameters has been emphasized by stud-
ies demonstrating that variations in canal geom-
etry before cleaning and shaping had a greater
effect on the changes that occurred during prepa-
ration than that of the instrumentation techniques
[155]. Besides, considering that the main role of
laboratory-based studies is to develop well-­
controlled condition, these morphological data
should be taken into account in the sample selec-
tion, as the results of such studies might demon-
strate the effect of canal anatomy rather than the
variable of interest [140, 142, 155–157]. Another
3D parameter possible to be acquired using
micro-CT technology is the so-called structure
model index (SMI). SMI is derived as
6·[(S′·V)/S2], where S is the object surface area
before dilation, S′ is the change in surface area
caused by dilation, and V is the initial, undilated
object volume. An ideal plate, cylinder, and
sphere have SMI values of 0, 3, and 4, respec-
tively. SMI parameter is impossible to be acquired
using conventional techniques such as radio-
graphs or grinding, as it describes the 3D geom-
etry of an object by an infinitesimal enlargement
of its surface. This parameter has been used to
assess root canal 3D geometry in anatomical
studies of different groups of the teeth [139–142].
A study has shown a large discrepancy between
the minimum and maximum values of SMI in the
comparison of the root canal thirds in the same
tooth [142]. These dissimilarities should be taken
into consideration during the root canal prepara-
tion as it might compromise the treatment
outcome.
6.2.5 Overview of the Literature
Most of the micro-CT studies on root canal
anatomy evaluated anatomical variations p­ resent
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
in specific groups of the teeth, such as the sec-
ond canal in the mesiobuccal root of maxillary
first molars [21, 158–165], three-rooted man-
dibular premolars [166–168] and molars [169–
171], four-rooted maxillary second molar [141],
two-­rooted mandibular canines [140] and pre-
molars [172], C-shaped canals in mandibular
premolars [173–175] and molars [154, 176–
182], radicular grooves [168, 173, 183–185],
and isthmuses [186–190]. Other authors evalu-
ated the anatomical configuration of conven-
tional mandibular incisors [191, 192],
mandibular canines [142], mandibular first pre-
molars [193], and maxillary molars [194]. It is
important to point out that, because of its high
resolution, studies on root canal anatomy using
micro-CT technology have been evaluating spe-
cific anatomical features of a tooth group, as
opposed to CBCT studies which are focused
mostly on epidemiological information about
the number of roots and canal configuration of
all groups of teeth from a certain population.
Summarized data extracted from articles using
micro-CT technology to evaluate root canal
anatomy are displayed in Tables 6.25, 6.26,
6.27, 6.28, 6.29, 6.30, and 6.31.
6.2.5.1 Anterior Teeth
Only a few studies have focused on anterior teeth
using micro-CT technology (Tables 6.25 to 6.27).
Gu et al. [174] evaluated maxillary lateral inci-
sors with radicular grooves from a Chinese popu-
lation, an uncommon but important anatomic
feature which is prone to be present on this tooth
group. Authors concluded that this morphologi-
cal variation was found more frequently in the
distal portion of the palatal root surface. Almeida
et al. [183] and Leoni et al. [182] evaluated root
canal configuration of mandibular incisors and
confirmed results from the CBCT studies, report-
ing a high combined percentage of Vertucci’s
Types I and III. Accessory canals were found
mostly at the apical third, but its frequency was
considered low. Several two- and three-­
dimensional morphological aspects of the root
canal systems of single- and two-rooted mandib-
ular canines were also evaluated by Versiani et al.
[131, 133]. In two-rooted canines, bifurcation
was observed at the middle and apical thirds, and
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 143

Table 6.25 Micro-CT studies on the root and root canal morphologies of maxillary incisors
Voxel
Micro-CT size
Authors Country device (μm) Aim/sample/conclusions
Gu [183] China Siemens 15 To investigate the anatomical features of radicular grooves (RG) in
Inveon maxillary lateral incisors (n = 11). RGs were classified into Type I
(n = 3), short RG at the coronal third; Type II (n = 5), long and shallow
RG extended beyond the coronal third of the root (in one specimen, a
cross-sectional teardrop-like canal was observed); and Type III (n = 3):
long and deep RG associated with a complex root canal system
(C-shaped, invagination, and additional root/canal). RGs were located at
mesial (n = 3), at distal (n = 6), and in both (n = 1) aspects of the root

Table 6.26 Micro-CT studies on the root and root canal morphologies of mandibular incisors
Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Almeida et al. Brazil SkyScan 19.6 To investigate the root canal anatomy of 340
[192] 1174v2 mandibular incisors. Vertucci’s Type I and
III configuration represented 92% of the
sample. Oval-shaped canals in the apical
third were not uncommon and were more
prevalent in the Type III anatomy. The
incidence of two or more root canals at the
apical third was 3.2%
Leoni et al. [191] Brazil SkyScan 22.9 To investigate the root canal anatomy of
1174v2 mandibular central (n = 100) and lateral
(n = 100) incisors. Vertucci’s Types I and III
were the most prevalent canal
configurations; however, eight new types
were described. Accessory canals were
observed only at the apical third; however,
most of the incisors had no accessory canals.
No difference was observed in the
comparison of the morphometric parameter
analyzed between central and lateral
incisors. The area of the root canal in both
teeth increased gradually in the coronal
direction. The average roundness
represented a flat- or oval-shaped
configuration of the canal in the apical third
of both groups of teeth

S-shaped roots were found in 21% of the speci-
mens [131], while single-rooted canines showed
variations in the two-dimensional configuration
of the root canal throughout the root [133].
6.2.5.2 Premolar Teeth
Maxillary premolars have been evaluated regard-
ing different aspects of the root and root canal
anatomy (Tables 6.28 and 6.29). Elnour et al.
[186] observed that the most common canal con-
figurations of maxillary second premolars were
Vertucci’s Types IV and V, while Li et al. [176]
showed a high prevalence (85.7%) of furcation
grooves on the palatal aspect of the buccal root of
bifurcated maxillary first premolars. Regarding
three-rooted maxillary premolars, Hartmann
et al. [187] concluded that the thickness of root
canal walls in the apical portion of buccal and
palatal roots could be as thin as 0.4–0.6 mm,
respectively, while Marca et al. [158] observed
that the area of the mesiobuccal canal was higher
than the distobuccal canal. Johnsen et al. [188]

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144 J. N. R. Martins and M. A. Versiani

Table 6.27 Micro-CT studies on the root and root canal morphologies of canines
Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Versiani Brazil SkyScan 16.7 To investigate the root canal anatomy of mandibular
et al. [140] 1174v2 canines (n = 14) with two roots and two distinct
canals. Bifurcation was located in both apical (42%)
and middle (58%) thirds of the root. From a buccal
view, no curvature toward the lingual or buccal
direction occurred in either roots. From a proximal
view, no straight lingual root occurred. In both views,
S-shaped roots were found in 21% of the specimens.
Location of the apical foramen tended to the
mesiobuccal aspect of both roots. Lateral and furcation
canals were observed mostly in the cervical third. SMI
ranged from 1.87 to 3.86. Mean volume and area of
the canals were 11.52 ± 3.44 mm3 and
71.16 ± 11.83 mm2, respectively
Versiani Brazil SkyScan 19.6 To investigate the root canal anatomy of single-rooted
et al. [142] 1174v2 mandibular canines (n = 100). 31% of the sample had
no accessory canals. The location of the apical
foramen varied considerably, and its major diameter
ranged from 0.16 to 0.72 mm. The mean distance from
the root apex to the major apical foramen was
0.27 ± 0.25 mm. Mean major and minor diameters of
the canal 1 mm short of the foramen were 0.43 and
0.31 mm, respectively. The mean area, perimeter, form
factor, roundness, major and minor diameters, volume,
surface area, and SMI were 0.85 ± 0.31 mm2,
3.69 ± 0.88 mm, 0.70 ± 0.09, 0.59 ± 0.11,
1.36 ± 0.36 mm and 0.72 ± 0.14 mm,
13.33 ± 4.98 mm3, 63.5 ± 16.4 mm2, and 3.35 ± 0.64,
respectively

Table 6.28 Micro-CT studies on the root and root canal morphologies of maxillary premolars
Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Elnour et al. [195] Saudi SkyScan 27.4 To investigate the root canal morphology of maxillary
Arabia 1172 second premolars in a Saudi Arabian subpopulation
(n = 100). The most common morphology was a
single root (67%), followed by two roots (30%) and
three roots (3%). Regarding the canal morphology,
most teeth (65%) contained two canals, followed by
30% with one canal and 5% with three canals. One
orifice was observed in 55% of the teeth, and two
orifices were detected in 45% of the teeth. According
to Vertucci’s classification, the most common canal
types were IV and V (both found in 23% of the
teeth), followed by Type I (17%), Type III (9%), Type
II (7%), and Type VII (2%). Additional types that
were inconsistent with Vertucci’s classification were
recorded in 19% of the teeth

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 145

Table 6.28 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Hartmann et al. Brazil SkyScan 34 × 34 × 42 To anatomically characterize of three-rooted
[196] 1072 maxillary premolars considering measures of clinical
interest for root canal treatment (n = 15). Root wall
thickness as thin as 0.4 and 0.6 mm was detected in
the apical portion of buccal and palatal roots,
respectively. In the cervical portion, buccal roots had
narrower root walls (0.817–1.670 mm) compared
with palatal roots (1.361–2.720 mm). In all thirds, the
palatal canal was wider compared with the
mesiobuccal and distobuccal canals. In the
buccopalatal direction, all roots had thicker root walls
toward the furcation, whereas in the mesiodistal
direction, the mesiobuccal and distobuccal roots had
the thinnest walls along their distal and mesial
aspects, respectively. Both buccal canals revealed
dentin apposition 2 mm from the canal orifice,
resulting in cervical constriction. Generally, the
distance between the root apex and the foramen was
greater in distobuccal roots in comparison with the
others with a tendency for foramina to be eccentric
Johnsen et al. Norway SkyScan 13.59 To compare the internal and external morphologies of
[197] 1172 contralateral premolars (n = 82). Contralateral
premolar pairs demonstrated a high degree of
similarity within this sample population’s age span in
terms of simple morphometric measurements such as
length, width, and thickness. The apical portion
(foramina, C-shapes, and accessory canals) did not
demonstrate bilateral symmetry. There are variations
between contralateral pairs in the apical portion as
well as instances of anatomic differences.
Contralateral premolars should undergo screening by
high-­resolution micro-CT before inclusion in any
endodontic comparison studies
Li et al. [185] China Scanco 36 To investigate the furcation grooves (FG) in the
μCT-80 buccal root of bifurcated maxillary first premolars
(n = 42). The prevalence of FG was 85.7%. Most of
them (69.4%) were located in the coronal and middle
thirds of the buccal roots. The mean groove length
was 3.94 mm. The wall thickness of the buccal roots
was buccopalatally asymmetric
Marca et al. [167] Brazil SkyScan 42 To evaluate the applicability of micro-CT and i-Cat
1072 CBCT system to study the anatomy of three-­rooted
maxillary premolars (n = 16). Mesiobuccal (MB)
canal area was greater than distobuccal (DB) canal.
Micro-CT images revealed more details than CBCT
including the presence of three and two canals in the
middle third of the MB and DB root of one specimen,
lateral canals, canal trifurcation in the apical third,
and differences in cross-sectional canal shapes in
different levels of the root

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146 J. N. R. Martins and M. A. Versiani

Table 6.29 Micro-CT studies on the root and root canal morphologies of mandibular premolars
Voxel
Authors Country Micro-CT device size (μm) Aim/sample/conclusions
Alkaabi et al. United Arab SkyScan 11.94 To investigate variations in the root canal morphology
[198] Emirates 1172 of mandibular first premolars in a population from the
United Arab Emirates (n = 50). Variable root canal
configurations based on Vertucci’s classification were
observed (i.e., Types I, III, IV, V, and VII). The
examined teeth exhibited the following two additional
root canal configurations, which did not fit Vertucci’s
classification: type 1-2-3 and type 1-3. A C-shaped
canal configuration was present in 14 (28%) cases,
and lateral canals were present in 22 (44%) cases.
Apical deltas were found in 25 (50%) cases, intercanal
communications were seen in 6 (12%) cases, and
apical loops were seen in 2 (4%) samples. Micro-CT
and X-ray imaging identified 39 (78%) and 34 (68%)
apical foramina, respectively. A single apical foramen
was detected in 33 (66%) samples, and 2 or 3 apical
foramina were detected in 14 (28%) and 3 (6%)
samples, respectively. In 18 (37%) samples, the apical
foramina were located centrally, and in 31 (62%), they
were located laterally
Chen et al. China Siemens 14.97 To explore the correlation between radicular grooves
[199] Inveon CT and root canal types by quantitatively detecting the
radicular groove in mandibular first premolars
(n = 127). Teeth with multiple and complex canals had
a higher incidence of radicular grooves and more
complicated root morphology than single and simple
canals. A total of 40.9% of the teeth had radicular
grooves. Most of the grooves (69.5%) were located on
the mesial surface of the root. The prevalence of
radicular grooves in single canals (17.4%, 15/86) was
lower than that in multiple and complex canals
(90.2%, 37/41). The mean length and depth of
radicular groove in Type V (7.7 ± 2.16 and
0.87 ± 0.39 mm, respectively) and other types of
canals (6.91 ± 2.67 and 0.63 ± 0.27 mm, respectively)
were significantly longer and deeper than Type I
canals (6.06 ± 2.12 and 0.43 ± 0.14 mm, respectively)
Cleghorn Canada FeinFocus 30 To investigate unusual variations in the root and canal
et al. [166] 160 morphology of mandibular first (n = 1) and second
(n = 1) premolars. Mandibular first premolar exhibited
three distinct, separate roots. Corresponding canals
divided in the middle to apical third of the root. A
prominent furcation canal was present. The
mandibular second premolar exhibited a single root, a
single apical foramen, and a prominent vertical root
groove on buccal surface. Canal system had a
C-shaped morphology through most of the mid-canal
system, which terminated in a single apical foramen

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 147

Table 6.29 (continued)

Voxel
Authors Country Micro-CT device size (μm) Aim/sample/conclusions
Dou et al. China Siemens 15 To investigate root anatomy and root canal
[200] Inveon CT morphology of mandibular first premolars in a
Chinese population (n = 178). Almost all samples
were single-rooted (99.4%). 64.04% of teeth showed
Type I canal configuration, while 34.27% had two
canals, and 1.69% had three canals. According to
ASUDAS system, the scores of radicular grooves
were 56.74%, 16.85%, 12.36%, 10.11%, 3.37%, and
0.56%, respectively, from grade 0 to grade 5. The
roots with radicular grooves (grade 3 or 4) were
defined as Tome’s anomalous root, and these roots
have a high incidence of C-shaped configurations
(66.67%) and multiple-canal systems (100%)
Fan et al. China Scanco 37 To investigate the root and canal morphology of
[173] μCT-80 C-shaped mandibular first premolars with (n = 86)
and without (n = 54) radicular groove (RG) by
accessing the morphology of canal orifices. Two
canals and bifurcations were dominant at the middle
and apical third. It was not possible to define the
canal configurations in the middle and apical canal
third by just assessing the morphology of coronal
canal. Detection and instrumentation of a second
canal of a bifurcation located further apically may
be a challenging task
Fan et al. China Scanco To investigate the root and canal morphology of
[174] μCT-20 38 C-shaped mandibular first premolars with (n = 146)
μCT-80 30 and without (n = 181) radicular groove (RG). No
C-shaped canals were found in the teeth without
RG. C-shaped canals were identified in 66.2% of
premolars with RG. C-shaped mandibular first
premolars had a groove on the external root surface.
The morphology of C-shaped canals was classified
as continuous, semilunar, continuous combined with
semilunar, and interrupted by non-C-shaped canal.
70 furcation canals were observed, and 57 were
located in C-shaped premolars
Gu et al. China Siemens 15 To investigate the wall thickness and groove
[175] Inveon configuration in C-shaped mandibular first premolars
(n = 148) with radicular groove (RG). C-shaped canals
were observed in 29 teeth (19.6%) and 107 cross
sections. 102 sections exhibited a mesial groove. The
root length ranged from 9.7 to 14.9 mm. The wall
thickness decreased at increasing distances from the
CEJ. Buccal and lingual walls were thicker than the
distal and mesial walls. Overall, the minimum
thickness occurred at the lingual aspect of the mesial
(67.3%) and distal (69.2%) root walls
(continued)

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Table 6.29 (continued)

Voxel
Authors Country Micro-CT device size (μm) Aim/sample/conclusions
Gu et al. China Siemens 15 To investigate the relation between the root canal and
[184] Inveon radicular grooves (RGs) in C-shaped mandibular first
premolars (n = 148). Mean root length was
12.98 ± 1.36 mm. Shallow and deep RGs were found
on 37.5% and 18.5% of the specimens, respectively.
155 RGs were observed on 140 premolars. If one RG
was present (n = 125), the location was mostly on the
mesiolingual side of the root; if two RGs were present
(n = 15), another groove was located on the
distobuccal side. C-shaped canals were found in 29
specimens (19.6%) and 107 cross sections. The
complexity of canal systems in mandibular premolars
may be determined by the severity of the RGs
Johnsen et al. Norway SkyScan 13.59 To qualitatively and quantitatively compare the
[197] 1172 morphology of contralateral premolars (n = 82).
Contralateral premolar pairs demonstrated a high
degree of similarity within this sample population’s
age span in terms of simple morphometric
measurements such as length, width, and thickness.
The apical portion (foramina, C-shapes, and accessory
canals) did not demonstrate bilateral symmetry. There
are variations between contralateral pairs in the apical
portion. Contralateral premolars should undergo
screening by high-resolution micro-CT before
inclusion in any endodontic comparison studies
Li et al. [172] China Siemens 14.97 To evaluate the anatomical aspects of the lingual canal
Inveon in mandibular first premolars with Vertucci’s Type V
canal configuration (n = 26). The lingual canal orifice
was located at the middle/apical third with severe
angle. 69% of lingual canals begin at the middle third
and remain at the apical third. The greatest angles “a”
[curvature at the beginning of the lingual canal] and
“b” [lingual canal curvature] were 65.24° and 43.39°,
respectively
Liu et al. China Siemens 14.97 To investigate the canal morphology of mandibular
[193] Inveon first premolars (n = 115). The shape of the canal
orifice was classified as oval (84.3%), flattened
ribbon-shaped (7.0%), eight-shaped (7.0%), and
triangular (1.7%). Root canal configuration was
identified as Types I (65.2%), V (22.6%), III (2.6%),
and VII (0.9%). Ten specimens did not fit Vertucci’s
classification. Accessory canals were present in 35.7%
of the teeth, and most of them (92.7%) were located in
the apical third. The presence of one (50.4%), two
(28.7%), three (14.8%), or four (6.1%) apical
foramens was observed mostly laterally (77.4%).
Apical delta and intercanal communications were
present in 6.1% and 3.5% of the sample, respectively.
Mesial invagination of the root was observed in 27.8%
of the teeth

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Table 6.29 (continued)

Voxel
Authors Country Micro-CT device size (μm) Aim/sample/conclusions
Ordinola- Brazil SkyScan 18 To describe the morphometric aspects of the external
Zapata et al. 1174v2 and internal anatomy of mandibular premolars with
[168] Vertucci’s Type IX canal configuration (n = 16). Type
IX configuration was found in 15.2% of mandibular
premolars with radicular grooves. Most of them had a
triangle-shaped pulp chamber in which the distance
between the MB and L canals was the largest.
Complexities of the root canal systems such as the
presence of furcation canals, fusion of canals,
oval-shaped canals at the apical level, small orifices at
the pulp chamber level, and apical delta were
observed
Ordinola- Brazil SkyScan 19.6 To describe morphometric aspects of the internal
Zapata et al. 1174v2 anatomy of C-shaped mandibular premolars from a
[201] Brazilian subpopulation (n = 83). The most prevalent
anatomical configurations, according to Vertucci’s
classification, were Types I (13%), III (8%), V (37%),
and VII (2%). Mean distances from the furcation to
the cementoenamel junction ranged from 5.36 to 5.65
mm. Apical deltas and furcation canals were present
in 36 (43%) and 27 (33%) specimens, respectively.
C-shaped cross sections were more prevalent at the
middle (56%) and apical levels (81%). Overall,
significant differences were found in the two-
dimensional analyses between single canals at the
apical third and buccal and lingual canals of Vertucci’s
Type V classification

Table 6.30 Micro-CT studies on the root and root canal morphologies of maxillary molars
Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Bjørndal et al. Denmark THX1430GKV 33 To analyze the correlation between the
[150] shapes of the outer surface of the root and
the canal morphology in maxillary molars
(n = 5). There was a strong correlation
between the shape of the canals and the root
components. Authors suggested that 3D
volumes generated by micro-CT technology
would constitute a platform for preclinical
training in fundamental endodontic
procedures
(continued)

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Table 6.30 (continued)

Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Briseño- Germany Scanco 20 To propose a root canal configuration
Marroquin et al. μCT-40 description method and to investigate the
[202] root canal system morphology of the
maxillary first molar (n = 179). The root
canal configuration of maxillary first molars
was quite diversified. The most frequent
root canal configurations were 1-1-1/1
(45.8%), 2-2-2/2 (25.1%), and 2-2-1/1
(10.1%) in mesiobuccal roots and 1-1-1/1 in
distobuccal (97.2%) and palatal (98.9%)
roots. The first mesiobuccal (MB1) root
canal had one accessory canal in 26.3% of
the teeth, the distobuccal root canal had
12.3%, and the palatal root canal had 9.5%;
in the second mesiobuccal root canal, there
was rarely one accessory canal. There was
one accessory canal in 26.3%, 12.3%, and
9.5% in the MB1, distobuccal, and palatal
root canals, respectively. The MB1,
distobuccal, and palatal root canals had one
main foramen. The MB2 had one main
foramen in 39.0% of the teeth and no
foramen in 61.0%
Domark et al. USA Scanco 20 To evaluate the reliability of radiography,
[21] VivaCT 40 CBCT, and micro-CT in determining the
number of canals in the MB root of
maxillary first (n = 13) and second (n = 14)
molars. Using human cadavers, it was
verified that the number of canals observed
with micro-CT was different compared to
digital radiography but similar from those
acquired using CBCT system (Kodak 9000).
In all maxillary first molars, MB roots had
two canals, of which 69% (9 out of 13)
exited as 2 or more foramina. Fifty-seven
percent (8 out of 14) of the MB roots of
maxillary second molar had two canals
exiting as two or more foramina
ElAyouti et al. Germany Siemens 27 To validate the existence of the apical
[203] Inveon CT constriction (AC) and determine its location
and dimensions in molars (n = 90). The
apical constriction was found to be located
at or close to the foramen. The mean
distance of AC-foramen was 0.2 mm (99%
confidence interval, 0.15–0.24; range,
0–0.6 mm), and of AC-apex, it was 0.9 mm
(99% confidence interval, 0.86–1.0; range,
0.1–1.7 mm). The type of canal had no
influence on AC-foramen and AC-apex
distances. In 76% of all canals, the apical
constriction was parallel. The mean size of
constriction in molars was instrument size
30. Patients aged 30 or younger had
significantly wider constrictions

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Table 6.30 (continued)

Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Gu et al. [158] South Korea SkyScan 1172 31.8 To evaluate the use of minimum intensity
projection technique as an adjunct to
evaluate the morphology of the MB root of
maxillary first molars (n = 110). 24 roots
had a single canal. Multiple canals were
observed in 76.2% of the MB roots. 15 MB
roots had a completely independent second
canal, while 9 had three canals. 53 roots had
two canals that joined into 1 or had 1 canal
that divided into 2. Eleven roots showed six
new configuration types. 82.2% of roots had
multiple apical foramina. Intercanal
communications were found in all roots
having multiple canals. The incidence of
intercanal communication in the coronal,
middle, or apical third was 40.6%, 49.5%,
and 44.6%, respectively
Hosoya et al. Japan Hitachi n.r. To evaluate the reliability of different
[159] MCT100-MFZ methods in detecting a second canal in the
MB root of maxillary first molars (n = 86).
A second canal in the MB root was
observed in 60.5% of the sample. Types I,
II, III, and IV (Weine’s configuration) were
observed in 39.5%, 15.1%, 27.9%, and
17.5% of the sample, respectively. Detection
of the second canal was higher for micro-CT
and dental CT than other tested diagnostic
tools
Kim et al. [160] South Korea SkyScan 1172 15.9 To investigate the canal configuration in the
MB roots of maxillary first molars
(n = 154). 73.4 % roots presented additional
canals. 94 roots had 2 canals, and 19 roots
had 3 or more canals. The most prevalent
configurations were Weine’s Types III
(32.8%), II (23%), and IV (15%). Using
Vertucci’s classification, the most common
configurations were Types II (23%), IV
(19.5%), VI (13.3%), III (10.6%), V (9.7%),
VII (5.3%), and VIII (0.9%). 20 (17.7%)
roots had 12 new configuration types
Lee et al. [161] South Korea SkyScan 1072 39 To evaluate the root canal curvature in
maxillary first molars (n = 46). Curvatures
were most pronounced in the MB canals,
moderate in the DB canals, and least in the
P canals. Accessory canals within the apical
third were present in almost half of the MB
canals and nearly a quarter of the DB
canals. The curvature increased in the apical
third when accessory canals are present,
particularly in MB and DB canals
(continued)

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Table 6.30 (continued)

Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Lee et al. [204] South Korea SkyScan 31.8 To compare alternative image reformatting
1172 techniques on the mesiobuccal (MB) root of
maxillary first molars (n = 18). All image
reformatting techniques in micro-CT
showed detailed configurations and
numerous fine structures, non-classifiable,
because of their complexity as simple Type I
or II canals; several were classified as Types
III and IV according to Weine or Types IV,
V, and VI according to Vertucci. The
combination of 2D MinIP and 3D volume-
rendered images showed the most detailed
canal morphology and fine anatomic
structures
Marceliano- Brazil SkyScan 60 To evaluate the internal anatomy of the
Alves et al. 1174v2 palatal roots of maxillary first molars
[205] (n = 169). All canals were classified as
Vertucci’s Type I. The cross sections were
oval in 61% of the canals. Lateral canals
were found in 25% of the samples. The
main foramen did not coincide with the root
apex in 95% of the cases. Only 8% of the
canals were classified as straight. Apical
constriction was identified in 38% of the
roots. The minor and major canal diameters
and minor dentin thickness decreased near
the apex. The minor dentin thickness 1 mm
from the foramen was 0.82 mm. The palatal
canals exhibited a volume of 6.91 mm3 and
surface area of 55.31 mm2 and were
rod-shaped
Meder-Cowherd USA Siemens n.r. To evaluate the apical morphology of the
et al.[194] Micro-CAT II palatal canal of maxillary first and second
molars (n = 40). 65% of the specimens had
no constriction in the apical 1–3 mm, while
35% had a constriction. The morphology
frequencies of the apical constriction were
parallel (35%), single (19%), flaring (18%),
tapered (15%), and delta (12%)
Ordinola-Zapata Brazil SkyScan 19.6 To evaluate the internal and external
et al. [206] 1174v2 morphologies of fused-rooted maxillary
second molars (n = 100). The most prevalent
root canal fusions were Type I, MB root
fused with DB root (32%), followed by
Type III, DB root fused with P root (27%),
and Type IV, MB root fused with DB root
and P root fused with MB or DB roots
(21%). The prevalence of C-shaped root
canal system was observed in 22% of the
evaluated molars. Depending on the type of
root fusion, the percentage frequency of
isthmuses at the apical level varied from
9.3% to 42.8%, while the presence of apical
delta ranged from 18.5% to 57.1% of the
teeth

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Table 6.30 (continued)

Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Park et al. [162] South Korea SkyScan 1072 19.1 × 19.1 × 38 To investigate the canal configuration of the
MB root of maxillary first molars (n = 30).
80% of the roots had two canals. An
independent canal was observed in 42% of
roots. Communications between canals were
found mostly at the coronal and middle
thirds, while accessory canals and loops
were mainly found at the apical third. In five
teeth (21%), a second canal had its origin
some distance down the orifice. Isthmus and
intercanal connection were observed in
different regions of the same root. A single
apical foramen was found in 37% of the
sample, while two foramina were present in
23% of the sample. Three separated apical
foramina and apical delta were present in
20% of the sample
Tomaszewska Poland SkyScan 13.68 To analyze the root canal morphology of
et al. [207] 1172 maxillary third molars (n = 78). Maxillary
third molars possessed one or three roots,
curved mostly to the buccal or palatal
directions (75.9%), and had 1–4 root canals
typically with no apical constriction
(84.4%). The average root length was
11.89 ± 1.53 mm, while root canal length
was 10.18 ± 0.35 mm. The root canal
diameter 1 mm from the apex was
0.37 ± 0.23 mm and negatively correlated
with donor’s age, while pulp chamber
thickness positively correlated with age.
Significantly, furcation canals, canal loops,
and root canal calcifications were sporadic
findings
Verma and Love New SkyScan 1172 11.6 To investigate the canal configuration of the
[164] Zealand MB root of maxillary first molars (n = 20).
Multiple foramina and accessory canals
were found in 17 roots. Types II and III
(Weine’s classification) were the most
prevalent configuration; however, 40% and
30% of the roots had configurations that
could not be classified by Weine’s or
Vertucci’s classification systems. Intercanal
communications were found in 55% of the
roots in all levels. In 18 roots with multiple
canals, 2 had completely independent MB
canals. 2 roots had three canals with
separate orifices, while 14 roots had two
canals that either joined into one canal, or
one canal divided into two or multiple
canals, or showed multiple intercanal
communications
(continued)

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Table 6.30 (continued)

Authors Country Micro-CT device Voxel size (μm) Aim/sample/conclusions
Versiani et al. Brazil SkyScan 22.6 To investigate the canal morphology of
[141] 1174v2 four-rooted maxillary second molars
(n = 25). Most of the roots presented
straight with one main canal, except the MB
root, which presented two canals in 24% of
the samples. No furcation canals were
observed. Accessory canals were located
mostly at the apical third of the roots, and
apical delta was observed in 12% of the
roots. 56% of the samples presented an
irregular quadrilateral-shaped orifice
configuration. The mean distance from the
pulp chamber floor to the furcation was
2.15 ± 0.57 mm. No difference was
observed between roots by considering their
length, canal configuration at the apical
third, SMI, volume, and surface area of the
root canals
Yamada et al. Japan HMX225 ACTIS4 n.r. To investigate the anatomy of the MB root
[165] of maxillary first molars (n=90). Single root
canals were observed in 44.5% of the
sample, incomplete separation of root canals
in 22.3%, and completely separated canals
in 33.3%. Accessory canals were observed
in 76.6% of the sample
Zhang et al. China Scanco 30 To investigate the relationship between
[134] μCT-50 features of fused roots and root canal
anatomy in maxillary second molars
(n = 187). Maxillary second molars with
fused roots may present a complicated root
canal system as a result of canal merging.
108 (57.75%) specimens had 3 separate
roots, and 79 (42.25%) had fused roots. Of
the 79 fused roots, 22 showed partial canal
merging, and 6 had complete canal merging.
Canal merging was found with the teeth
with three-root fusion more often than in
those with two-root fusion. Of 28 merged
canals, 16 occurred between mesiobuccal
and distobuccal canals and 9 among
mesiobuccal, distobuccal, and palatal canals
n.r. not reported

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 155

Table 6.31 Micro-CT studies on the root and root canal morphologies of mandibular molars
Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Amoroso-Silva Brazil SkyScan 19.6 To evaluate the morphometric aspects of the
et al. [208] 1174v2 internal anatomy of the root canal system of
mandibular second molars with fused roots
and C-shaped canals (n = 52). The
three-dimensional reconstruction images of
the C-shaped roots exhibited an even
distribution in terms of Gao’s classification
(i.e., Type I [n = 19], Type II [n = 16], and
Type III [n = 17]). All of the evaluated
molars exhibited at least one level of the
roots that was classified as C1, C2, or C3.
Overall, the C-shaped molars
predominantly exhibited C3 and C4
configurations 1 mm from the apex. At the
2 and 3 mm levels, the C1 and C3
configurations were most prevalent. In the
middle third of the root, the C3
configuration was the most prevalent, and
the C1 and C2 were the second and third
most prevalent configurations. In the
cervical third C1 and C2 configurations
were most common
Barsness et al. USA X-Tech XT 11.41 × 12.21 × 17.53 To describe the root canal morphology of
[209] H 225 mandibular second molars (n = 18). The
most frequently found mesial root canal
configuration was Vertucci’s Type VII
(1-2-1-2), which was seen in 33.3% of
samples. Distal canals were most frequently
Vertucci’s Type I (one canal), with 61.1%
of samples showing this configuration.
11.1% of samples had two canals, 44.4% of
samples had three canals, 33.3% of samples
had four canals, and 11.1% of samples had
five canals at some point along the length
of the roots. Average root wall thickness
between the mesiobuccal canal and the
furcation was 1.23 mm. Mesiolingual root
canal wall thickness was on average
1.29 mm, and the distal root furcation wall
thickness averaged 1.41 mm. 77.8% of
samples had calcifications present in both
the pulp chamber and within the canals
Cheung et al. China Scanco 30 To investigate the apical canal morphology
[154] μCT-20 of C-shaped mandibular second molars
(n = 44). Most of sample had two (i.e., Type
II, IV, V, or VI) or three (i.e., Type VIII)
root canals. 1/5 of specimens showed four
or more canals. Prevalence of accessory and
lateral canals ranged from 11% to 41%. A
total of 115 main and 41 accessory
foramina were observed. The diameters of
the main and accessory foramina ranged
from 0.19 to 0.32 mm and from 0.07 to
0.10 mm, with a mean form factor of 0.73
and 0.82, respectively
(continued)

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Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
ElAyouti et al. Germany Siemens 27 To validate the existence of the apical
[203] Inveon CT constriction (AC) and determine its location
and dimensions in molars (n = 90). The
apical constriction was found to be located
at or close to the foramen. The mean
distance of AC-foramen was 0.2 mm (99%
confidence interval, 0.15–0.24; range,
0–0.6 mm), and of AC-apex, it was 0.9 mm
(99% confidence interval, 0.86–1.0; range,
0.1–1.7 mm). The type of canal had no
influence on AC-foramen and AC-apex
distance. In 76% of all canals, the apical
constriction was parallel. The mean size of
constriction in molars was instrument size
30. Patients aged 30 or younger had
significantly wider constrictions
Fan et al. [178] China Scanco n.r. To investigate effective ways to negotiate
μCT-20 the root canal system of C-shaped
mandibular second molars (n = 44). 8 teeth
had a continuous C-shaped orifice (Type I),
16 a Type II configuration, 14 a Type III
configuration, and 6 a Type IV
configuration. The total number of the
orifices was 83 including 8 continuous
C-shaped, 14 mesiobuccal-distal, 14 flat, 41
oval, and 6 round orifices
Fan et al. [186] China Scanco 37 To investigate the morphology of the
μCT-80 isthmuses in the mesial root of mandibular
first (n = 70) and second (n = 56) molars.
107 molars (85%) had isthmuses in the
apical 5 mm of mesial roots. The total
number of isthmuses was 120, in which 94
samples had only 1 isthmus and 13 samples
had 2. Mandibular first molars had more
isthmuses with separate and mixed
morphological types, while second molars
had more isthmuses with sheet connections
Fan et al. [176] China Scanco n.r. To investigate the canal morphology of
μCT-20 C-shaped mandibular second molars
(n = 54). C-shaped canals varied in shape at
different levels. None of the orifices was
found at the level of the CEJ. 1/4 of the
orifices were found 1 mm below CEJ, while
98.1% were located within 3 mm below the
CEJ. Canal bifurcation was observed in the
apical 4 mm of 17 teeth, with most of them
occurring within 2 mm from the apex

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Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Fan et al. [177] China Scanco n.r. To investigate the predictability of the
μCT-20 radiography in detecting C-shaped canals in
mandibular second molars (n = 54). C1
(uninterrupted “C”) and C2 (shape
resembled a semicolon) configurations
always have a narrow isthmus close to the
groove. C1 and C2 configurations were
prevalent in Types I (mesial and distal
canals merge into one before exiting) and
III (separated canals) teeth, suggesting that
the debridement of these canals would be
more demanding than Type II (canals
continue on their own pathway to the apex).
C-shaped canal system in mandibular
molars might be predicted according to the
radiographic appearance
Fan et al. [179] China Scanco n.r. To investigate the predictability of the
μCT-20 radiography in detecting C-shaped canals in
mandibular second molars (n = 30), using a
contrast medium. The contrast medium
helped to discern the C-shaped canal
anatomy in mandibular second molars. The
development of a device for contrast
medium introduction into anatomically
complex root canal systems might lead to a
useful clinical diagnostic tool
Fan et al. [180] China Scanco n.r. To investigate the predictability of the
μCT-20 digital subtraction radiography (DSR) in
detecting C-shaped canals in mandibular
second molars (n = 30) using a contrast
medium. It was observed that some factors,
such as the X-ray projecting angulation and
the degree to which the contrast medium is
distributed within the canal system, could
change the shape and size of canal images,
affecting the classification of the canal
anatomy. This discrepancy could be the
result of incomplete cleaning in the apical
canal merging area, which would prevent
contrast media from entering this area
Filpo-Perez Brazil SkyScan 19.6 To evaluate the morphological aspects of
et al. [210] 1174v2 the root canal anatomy of the distal root of
a mandibular first molar (n = 100). 76% of
the distal roots had a single root canal. Two,
three, and four canals were found in 13%,
8%, and 3% of the sample, respectively. In
13 specimens, the configuration of the root
canal did not fit into Vertucci’s
classification. Overall, two-dimensional
parameter values significantly increased at
the 3 mm level. The prevalence of oval
canals was higher at the 1 mm level and
decreased at the 5 mm level in which long
oval and flattened canals were more
prevalent
(continued)

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Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Gao et al. [181] China Scanco 11 To investigate the morphology and canal
μCT-20 30 wall thickness at different levels of
C-shaped mandibular second molars
(n = 98). C-shaped canals were assigned as
Types I (n = 32), canals merged into one
major canal before exiting at the apical
foramen; II (n = 38), separated mesial canal
and distal canal located at the mesial part
and distal part of the root, respectively
(symmetry of the mesial canal and distal
canal was present along the root); and III
(n = 28), separate mesial and distal canals
were evident. The distal canal may have a
large isthmus across the furcation area,
which commonly made the mesial and
distal canals asymmetrical. Differences in
the minimum canal wall thickness were
observed in the apical and middle levels,
but not in the coronal third
Gu et al. [187] China GE eXplore 15 To investigate the isthmuses in mesial roots
Locus SP of mandibular first molars (n = 36). The
morphology of the isthmuses includes the
presence of fin, web, or ribbon connecting
the individual canals. In the apical third, 32
teeth had isthmus somewhere along its
length. 7 out of 32 roots had a continuous
isthmus from coronal to the apical end,
while 25 roots showed a pattern of sections
with and without isthmus. The prevalence
of an isthmus was higher at the apical 4 to
6 mm level in the 20- to 39-year-old age
group (up to 81%)
Gu et al. [169] China GE eXplore 21 To investigate the root canal configuration
Locus SP in three- (n = 20) and two-rooted (n = 25)
mandibular first molars. Pulp floors with
two mesial and two distal orifices were
frequent (n = 16). The third root usually
curved severely in the proximal view. The
lingual edge of the orifice might form a
dentinal shelf, which blocks the view of the
canal. Grooves could be observed between
adjacent orifices. In 65% of the three-­rooted
teeth, mesial root contained a type 2-2
configuration. Type 1-1 canal occurred
more frequently in the DL and DB roots. In
mesial and distal roots of three-rooted
molars, the incidence of lateral canals was
65% and 40%, respectively. Furcation
canals were not observed

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 159

Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Gu et al. [170] China GE eXplore 21 To investigate the root canal curvature in
Locus SP three- (n = 20) and two-rooted (n = 25)
mandibular first molars. In the three-rooted
molars, the mean degrees of curvature in
the MB and ML canals were 24.34° and
22.39°, respectively (Schneider method).
Secondary curvature was rare in the mesial
root. The frequency of S-shaped canals was
60% of the DB canals. The mean angle of
the second curvature was approximately
twice that of the primary one. In proximal
view, the DL canal exhibited the greatest
degree of curvature (32.06°). Using Pruett
method, the mean angle and radius of the
DL canals were 59.04° and 6.17 mm in
proximal view and 26.17° and 20.99 mm in
central view, respectively. The curvature in
the DL canals had a more severe angle and
smaller radius in the proximal view
Gu et al. [171] China GE eXplore 21 To investigate the root canal morphology in
Locus SP three- (n = 20) and two-rooted (n = 25)
mandibular first molars. The length of DL
roots was shorter than the DB and mesial
roots. The buccal and lingual canal walls
were thicker than the distal and mesial for
MB, ML, and DB canals. The distal wall of
the MB/ML canal and the mesial wall of
the DB and DL canals were the thinnest
zones. It was suggested that the initial
apical file for a DL canal should be two
sizes smaller than that for a DB canal; DB,
DL, and MB/ML canals should be
instrumented to a mean ISO size of 55, 40,
and 45, respectively. The MB, ML, and DB
canals were more oval, while the DL canals
were relatively rounder
Harris et al. USA n.r. 11.41 × 12.21 × 17.53 To investigate the canal morphology of the
[188] mandibular first molars (n = 22). Mean
distance from the mesial to distal orifices
on the pulpal floor was 4.35 mm. In the
apical third of the distal root, the mean
thickness of dentin on the furcation side
ranged from 0.25 to 1.47 mm. Types V and
I were the most common configurations of
the canal in the mesial and distal roots,
respectively. Isthmuses were found along
the length of all mesial roots (100%) and
within 9.1% of the distal roots. In the
mesial and distal roots, an average of 3.73
and 3.36 portals of exit was observed in the
apical 0.5 mm of the roots
(continued)

pilararaya@ejercer.cl
160 J. N. R. Martins and M. A. Versiani

Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Keleş and Turkey SkyScan 10 To perform a quantitative and qualitative
Keskin [211] 1172 analysis of the band-shaped isthmus area,
the floor of which was located in the apical
third of the mesial roots of mandibular first
molars (n = 269). The percentage of roots
with a band-shaped isthmus, where the
floor was in their apical third, was 15% of
the total 269 specimens. Of these, 75% had
two canal orifices, while 15% and 10% had
three and one orifice, respectively. The
number of orifices was not affected by the
minor diameter, the major diameter, and the
roundness values of the isthmuses. No
difference was detected between the
isthmus roof and floor regarding roundness
values. The isthmus roof had significantly
higher values for the minor and major
diameters and area and perimeter values
than the isthmus floor
Keleş and Turkey SkyScan 10 To assess the features of the apical root
Keskin [212] 1172 canal anatomy and its relation to the level at
which two separate root canals merge in the
mesial roots of mandibular first molars with
Vertucci’s Type II canal configuration
(n = 83). The mean value and standard
deviation for the distance of the level at
which two separate root canals merge from
the 0 level were 4.20 ± 1.64 mm. In each
millimeter within 3 mm from the 0 level,
the percentages of long oval cross sections
were 46.9%, 50.9%, 75.9%, and 80.5%,
respectively. Specimens for which root
canals join 3–9 mm from the foramen
displayed significantly higher roundness
values in each millimeter compared with
specimens in which root canals rejoin
0–3 mm from the foramen. In the latter,
major diameter values of the root canal
cross sections were significantly higher
than former specimens
Keleş and Turkey SkyScan 10 To measure the orifice depth of middle
Keskin [213] 1172 mesial canals (MMCs) and evaluate the
detectability of orifices using troughing
preparation (n = 85). 77.41% of the MMC
orifices were at the CEJ level, whereas
5.38% and 9.69% of the MMC orifices
were detectable within 1 and 2 mm depths
from the CEJ, respectively. 7.52% of the
sample had MMC orifices deeper than
2 mm from the CEJ. Confluent anatomy
was the most frequent configuration. No
significant relationship was detected
between the orifice depth and MMC
configuration

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 161

Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Kim et al. [214] South Korea SkyScan 15.91 To compare 2D and 3D micro-CT images
1172 with tooth clearing for the study of mesial
root canal morphology of mandibular first
molar (n = 31). Canal configurations and
fine anatomic structures were more clearly
observed in the combined 2D and 3D
images than the clearing technique. The
frequency of non-classifiable configurations
demonstrated the complexity of the mesial
root canal anatomy of mandibular first
molars
Lamia and USA Scanco 18 To evaluate the frequency in which mesial
McDonald [215] μCT-100 canals conjoined in one common portal of
exit, record the interorifice distance for both
conjoined and separated mesial canals, and
determine the location at which the mesial
canals joined in mandibular molars
(n = 206). 62.6% of the sample displayed
conjoined mesial canals with a single portal
of exit, while 37.4% displayed Vertucci’s
Type IV anatomy. From the teeth with
conjoined mesial canals, 71 (55.0%) were
second molars, and 58 (45.0%) were first
molars. Considering the first and second
molars, respectively, 67.2% and 46.5%
joined in the apical third, 22.4% and 31%
joined in the middle third, and 10.3% and
22.5% joined in the coronal third.
Accessory canals were observed in 9 and 6
mesial canals of the first and second molars,
respectively. The mean interorifice
distances in conjoined canals of mandibular
first and second molars were 2.34 and
2.37 mm, respectively
Lee et al. [216] South Korea SkyScan 31.8 To evaluate 3D curvatures and dentin
1172 thickness in mesiobuccal (MB) and
mesiolingual (ML) root canals of
mandibular molars (n = 37). Lateral dentin
thicknesses were significantly higher than
mesial and distal thicknesses at all the
levels. Mesial thicknesses were
significantly higher than distal thicknesses
in the coronal third of both canals. The
thinnest dentin thicknesses were mostly
located on the distal aspect of both canals.
The narrowest canal widths were
0.24 ± 0.10 and 0.22 ± 0.09 mm in the MB
and ML canals, respectively. Canal
curvatures were greatest in the apical third
of both canals, and they were greater in the
MB canals than in the ML canals
(continued)

pilararaya@ejercer.cl
162 J. N. R. Martins and M. A. Versiani

Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Mannocci et al. UK GE 12.5 × 12.5 × 25.0 To investigate isthmuses located at the
[189] Testing Lab apical third of the mesial roots of
mandibular first molars (n = 20). Seventeen
roots had isthmus in one or more sections
in the apical third. Only 4 out of 17 roots
had a continuous isthmus from coronal to
the apical end. The other three roots
showed sections with and without isthmus.
The percentage of sections showing
isthmus ranged from 17.25% to 50.25% in
the apical 5 mm of the root canals. The
morphology of the isthmus varied between
teeth and within the same tooth
Min et al. [182] China Scanco n.r. To investigate the morphology of the pulp
μCT-20 chamber floor of C-shaped mandibular
second molars (n = 44). 90.91% of the pulp
chamber floors were within 3 mm below
the CEJ. The location of grooves was
usually 4 mm below the CEJ. Eight teeth
had a continuous C-shaped orifice and
canal shape (Type I). Types II and III were
observed in 16 and 14 teeth, respectively.
Six teeth with a C-shaped canal system
demonstrated non-C-­shaped chamber
floors. In Type II teeth, the canal
configuration was like those present in
conventional mandibular molars with
separated roots. In Type III teeth, there
were a large MB-D orifice and a small ML
orifice
Min et al. [217] China Scanco 30 To investigate the clinical negotiation of
μCT-50 various apical anatomic features of
mandibular first molars in a Chinese
population (n = 152). Most of the sample
had two separated roots (94.1%); about 6%
had a third root. 62% of the sample had 3
main root canals, 32.2% with four canals,
and 5.9% with five canals. The most
frequent anatomy was Type I (68.5%), and
Type II (13%). The relationship between
the apical anatomy and the negotiability
was examined, and a significant association
was confirmed suggesting that there was a
high consistency between negotiability and
anatomical classification

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6 CBCT and Micro-CT on the Study of Root Canal Anatomy 163

Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Ordinola-Zapata Brazil SkyScan 19.6 To compare the accuracy of the clearing
et al. [218] 1174v2 technique and cone beam computed
tomography (CBCT) in the assessment of
the canal configuration of mesial roots of
mandibular molars (n = 32). Accuracy was
greatly influenced by the evaluation method
and the type of anatomy. Detection of Type
I configuration in cleared teeth was
significantly lower, while Type II
configuration was detected in all specimens
by both methods. In mesial roots with
variable anatomical configurations, neither
CBCT nor clearing methods were accurate
for detecting the real canal anatomy
Rodrigues et al. Brazil SkyScan 19.6 To evaluate the anatomy of mandibular first
[219] 1174v2 molars with three roots (n = 55). The
prevalence of three-rooted mandibular
molars in a Brazilian subpopulation was
2.58%. Distolingual roots had short length,
severe curvature, and a low apical diameter
in comparison with the distobuccal and
mesial canals. Single canals were highly
prevalent in both distal roots in comparison
with the mesial root which showed a more
complex anatomical configuration
Souza-Flamini Brazil SkyScan 22.9 To evaluate the morphology of the
et al. [220] 1174v2 supernumerary third root (radix) in
mandibular first molars (n = 19). The mean
length of the mesial, distal, and radix roots
was 20.36 ± 1.73, 20.0 ± 1.83, and
18.09 ± 1.68 mm, respectively. The radix
was located distolingually (n = 16),
mesiolingually (n = 1), and distobuccally
(n = 2). In a proximal view, most radix had
a severe curvature with buccal orientation
and a buccally displaced apical foramen.
The spatial configuration of the canal
orifices on the pulp chamber floor was
mostly trapezoidal in shape. The radix root
canal orifice was usually covered by a
dentinal projection. The radix differed
significantly from the mesial and distal
roots for all evaluated three-dimensional
parameters. The radix canal had a more
circular shape in the apical third, and the
mean size of the minor diameter 1 mm
short of the foramen was 0.25 ± 0.10 mm

(continued)

pilararaya@ejercer.cl
164 J. N. R. Martins and M. A. Versiani

Table 6.31 (continued)

Micro-CT
Authors Country device Voxel size (μm) Aim/sample/conclusions
Versiani et al. Brazil SkyScan 9.9 To describe the morphological aspects of
[221] 1172 middle mesial canals (MMCs) in
mandibular first molars collected from
Brazilian and Turkish population (n = 48).
Incidence of MMC was 18.6% (48 out of
258 molars) and was significantly higher in
the Brazilian (n = 30, 22.1%) than in the
Turkish (n = 18, 14.8%) population. In both
populations, confluent configuration of the
MMC was the most frequent anatomy.
Most of the specimens with MMC had
three independent orifices (n = 26, 54.2%)
and three apical foramina (n = 21, 43.8%).
The mean minor diameter of the MMC
orifice (0.16 mm) was three times less than
the other orifices (0.50 mm). In mesial roots
with independent configuration (n = 3,
6.3%), the mean volumes (mm3) of the
MMC, mesiobuccal (MBC), and
mesiolingual (MLC) were 0.20 ± 0.10,
0.75 ± 0.28, and 0.88 ± 0.19, respectively.
In the specimens with canal confluence
(n = 26, 54.2%), MMC merged to the MBC
(n = 8, 16.7%), to MLC (n = 4, 8.3%), or to
both MBC and MLC (n = 14, 29.2%).
Double mesial canal was observed in only
one specimen. MMC with an independent
foramen was observed mostly in Brazilian
specimens
Villas-Boas Brazil SkyScan 18 To evaluate the morphology of the canal
et al. [190] 1076 and the presence of isthmus at the apical
third of the mesial root of mandibular first
and second molars (n = 60). The median
mesiodistal diameters (in mm) at the 1, 2, 3,
and 4 mm levels were 0.22, 0.23, 0.27, and
0.27 in the MB canal and 0.3, 0.3, 0.36, and
0.35 in the ML canal, while the
buccolingual diameters were 0.37, 0.55,
0.54, and 0.54 in the MB canal and 0.35,
0.41, 0.49, and 0.6 in the ML canal.
Isthmus was more prevalent at the 3 to
4 mm level. Twenty-­seven teeth had a
complete or incomplete isthmus at the
1 mm apical level. The volume of the apical
third ranged from 0.02 to 2.4 mm3

pilararaya@ejercer.cl
6 CBCT and Micro-CT on the Study of Root Canal Anatomy
Table 6.31 (continued)
Micro-CT
Authors Country device Voxel size (μm)
Wolf et al. [222] Germany Scanco 20
μCT-40
n.r. not reported
performed a morphometric analysis on the root
canal system of contralateral maxillary premo-
lars and observed a high similarity, except in the
apical area.
The most studied morphological characteris-
tics of mandibular premolars were the incidence
of radicular grooves [166, 175, 190] and C-shaped
canal configuration [157, 164–166, 175, 192].
Overall, these studies concluded that the com-
plexity of the internal morphology of mandibular
premolars may be determined by the severity of
the radicular grooves, which includes the pres-
ence of multiple and complex canal systems,
accessory canals at the furcation area, as well as
a high incidence of C-shaped configuration
(66.2%). Additionally, Ordilona-Zapata et al.
pilararaya@ejercer.cl
165
Aim/sample/conclusions
To investigate the root canal system
morphology of the mandibular first molar
(n = 118). The root canal configuration of
mandibular first molars varies strongly. The
most frequent configurations of the mesial
root were 2-2-2/2 (31.4%), 2-2-1/1
(15.3%), and 2-2-2/3 (11.9%); another 24
different configurations were observed in
this root. 1-1-1/1 (58.5%), 1-1-1/2 (10.2%),
and 16 other root canal configurations were
observed in the distal root. The mesiobuccal
root canal showed 1–4 foramina in 24.6%,
and the mesiolingual showed 1–3 foramina
in 28.0%. One connecting canal between
the mesial root canals was observed in
30.5% and two in 3.4%. The distolingual
canal showed 1–4 foramina in 23.7%,
whereas a foramen in the distobuccal canal
was rarely detected (3.4%). The
mesiobuccal, mesiolingual, and distolingual
root canals showed at least one accessory
canal (14.3%, 10.2%, and 4.2%,
respectively), but the distobuccal had none
[192] reported that the root canal system of man-
dibular premolars with C-shaped morphology
was more prone to have a Vertucci’s Type V con-
figuration. Studies evaluating root and root canal
configuration of mandibular premolars [189,
191] showed that Vertucci’s Type I was the most
common anatomy, while three-rooted configura-
tion was an uncommon occurrence. Li et al. [163]
evaluated the anatomical aspects of the lingual
canal in mandibular first premolars with
Vertucci’s Type V configuration and concluded
that this canal splits from the main buccal canal
mostly at the middle third with an abrupt curva-
ture. Johnsen et al. [188] performed a morpho-
metric analysis on the root canal system of
contralateral mandibular premolars and observed
166
differences between them, recommending cau-
tion when using these teeth for research studies in
endodontics.
6.2.5.3 Maxillary Molar Teeth
Most of micro-CT studies on maxillary first
molars have addressed the internal and external
morphologies of the mesiobuccal root [21, 149–
151, 153, 155, 156, 193, 195] (Table 6.30). This
root normally presents a pronounced curvature
[152] with multiple canals, intercanal communi-
cations [149, 155], and several portals of exit
[153, 193], in percentage frequencies higher than
70% [149, 151, 153, 155], except for two studies
in which the presence of a single canal system in
this root was observed in 45% of the sample [156,
193]. On the other hand, distobuccal and palatal
roots generally present slight to moderate curva-
ture [152] and a single canal with one main fora-
men in a frequency of 97.2% and 98.9%,
respectively [193]. In the palatal root, the canal
normally has an oval-shaped cross section with
lateral canals, no defined apical constriction [185,
194, 196], and an eccentric foramen [196].
Maxillary second molars with fused roots
were studied by Ordinola-Zapata et al. [197]
and Zhang et al. [125]. These authors showed
that these teeth might present a root canal sys-
tem with complex configurations, isthmuses,
apical ramifications, and a high frequency of
C-shaped configuration (22%) [197]. Four-
rooted maxillary second molars were also inves-
tigated, and, except for the mesiobuccal root, all
other three roots always showed a single root
canal system [132]. Two additional studies [21,
150] compared the accuracy of radiography and
CBCT in detecting the presence/absence of a
second root canal in the mesiobuccal root of
maxillary molars, using micro-CT as a gold
standard. Detection of the second canal was
higher for micro-CT and CBCT than the other
diagnostic tool.
pilararaya@ejercer.cl
J. N. R. Martins and M. A. Versiani
6.2.5.4 Mandibular Molar Teeth
Micro-CT studies on mandibular molars focused
mostly on the evaluation of roots and configura-
tion of the root canals [160–162, 179, 200, 206,
208, 213] (Table 6.31). In the mesial and distal
roots, Vertucci’s Types V and I were the most
common canal configurations observed in man-
dibular first molars [179], while a high fre-
quency of Vertucci’s Types VII and I was found
in mandibular second molars [200], respec-
tively. Min et al. [208] reported a high percent-
age frequency of three (62%) and four (32.2%)
root canals in mandibular first molars, while
Wolf et al. [213] demonstrated a high variability
in the canal morphology in this group of teeth.
At the apical third, canal curvature was more
severe in mesial canals [161, 207], while the
presence of isthmuses was found to be as high
as 85% for both mandibular first and second
molars [177, 178, 180, 181, 202]. The incidence
of a third root canal in the mesial root, named
middle mesial canal, was reported to be as high
as 18.6%, and the confluent c­ onfiguration was
the most common anatomy [212, 214]. In the
distal root, a high incidence of single oval-­
shaped canal was demonstrated (76%), but it
was also observed the presence of two (13%),
three (8%), and four (3%) root canals [201]. The
internal and external morphologies of a third
root in mandibular first molars, named radix,
were also evaluated in three studies [160, 210,
211]. Authors stated that, in the proximal view,
radix usually presented a severe curvature.
Because of the high incidence of C-shaped
canal morphology, this was the most studied
configuration in the mandibular second molars
using micro-CT technology [145, 167–173,
199]. Several authors attempted to classify this
unusual anatomical finding into distinct catego-
ries, according to its axial appearance [145,
167–169, 172]: a Type C1 presenting an unin-
terrupted “C” with no separation, a Type C2
6 CBCT and Micro-CT on the Study of Root Canal Anatomy
with the canal shape resembling a semicolon
resulting from a discontinuation of the “C” out-
line, and a Type C3 with two or three separated
canals [167]. Overall, Type C1 is mostly present
at the coronal portion of the root canal, and, as
the canals neared the middle and apical portions
of the root, it turns into C2 and C3 types, respec-
tively [169, 199]. However, it was reported that
“C” shape often varies along the root length, so
the crown morphology, the orifice shape, or the
radiographic appearance of the root may not be
good predictors of the actual canal anatomy
[168, 170, 171]. In summary, studies indicated
that mandibular second molars presenting
C-shaped canals may exhibit a very complex
canal system with a deep pulp chamber floor
[173], a high incidence of accessory canals and
isthmuses [145, 172], as well as many canals
ending in multiple foramens [145].
6.3 Influence of Aging
in the Root Canal System
Configuration
The root canal anatomy is susceptible to changes
over the years because of physiological or patho-
logical events. Natural physiological aging tends
to modify the root canal system morphology due
to the deposition of secondary dentine, which
starts to form once the tooth erupts and is in
occlusion [223]. Consequently, young patients
tend to present large single canals and pulp cham-
bers [224, 225], while older patients tend to pres-
ent more sharply defined and narrow root canals
[224]. Other pathological or iatrogenic factors
can also modify the deposition of dentine includ-
ing occlusal trauma, periodontal disease, carious
lesions, or deep restorative procedures [36].
pilararaya@ejercer.cl
167
Gani et al. [224] addressed the changes in
the mesial root of mandibular first molars and
concluded that, in children (under 13 years),
root canals tend to be single, large, and trian-
gular shaped with a vertex ending in a single
apical foramen and presenting a ribbon-shaped
axial section. In young adults (20–39 years),
root canals become more complex due to cal-
cification and dentine deposition, while in
older adults (over 40 years), canals become
more sharply defined and narrow. Peiris et al.
[226] found similar results. Other authors
evaluated clinically the identification of mid-
dle mesial root canal in mandibular molars
[227] and the second mesiobuccal root canal
(MB2) in maxillary first molars [228] and con-
cluded that these extra root canals were more
prone to be found in patients under 20 years
old and between 20 and 40 years old,
respectively.
In the literature, CBCT imaging technology
has been also used to address in vivo root canal
morphological changes due to aging [31, 33, 35,
36, 38, 40, 42, 55, 65] (Tables 6.32, 6.33, 6.34,
and 6.35). Overall, results showed no significant
difference between maxillary and mandibular
anterior teeth groups regarding age, despite con-
tradictory information can be found. While in
mandibular anterior teeth most of the studies
reported a lower prevalence of multiple canals
in older patients [55, 65], in maxillary and man-
dibular premolars [34], as well as in mandibular
molars [225, 229], it was observed a progressive
decrease of Vertucci’s Type I configuration with
age. The prevalence of MB2 canal in maxillary
first and second molars was also evaluated, and
most of the studies reported a low prevalence of
this root canal in older patients [31, 36, 38–40,
42, 44].
 168

Table 6.32 Root canal configurations on maxillary anterior teeth and premolars in each age group

Age Teeth groups

group Maxillary central incisor Maxillary lateral incisor Maxillary canine Maxillary first premolar Maxillary second premolar
sample ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61
(n) (230) (407) (270) (265) (408) (264) (292) (440) (255) (266) (298) (150) (227) (270) (121)
Root canal configuration
Type I 230 407 270 265 408 264 290 440 255 11 9 4 107 98 41
(1-1) 100% 100% 100% 100% 100% 100% 99.3% 98.0% 98.8% 4.1% 3.0% 2.6% 47.1% 36.3% 33.9%
Type II – – – – – – 2 6 3 53 40 29 58 75 44
(2-1) 0.7% 1.3% 1.2% 19.9% 13.4% 19.3% 25.6% 27.8% 36.3%
Type III – – – – – – – 2 – – 2 – 4 8 1
(1-2-1) 0.5% 0.7% 1.8% 3.0% 0.8%
Type IV – – – – – – – 1 – 171 216 100 32 56 18
(2-2) 0.2% 64.3% 72.5% 66.7% 14.1% 20.7% 14.9%
Type V – – – – – – – – – 6 1 – 11 12 6
(1-2) 2.3% 0.3% 4.8% 4.4% 5.0%
Type VI – – – – – – – – – 13 14 6 9 20 11
(2-1-2) 4.8% 4.7% 4.0% 4.0% 7.4% 9.1%
Type VII – – – – – – – – – – – – – – –
(1-2-1-2)

pilararaya@ejercer.cl
Type VIII – – – – – – – – – 1 4 – – – –
(3-3) 0.4% 1.4%
Others – – – – – – – – – – 2 1 3 1 –
(2-1-2-1) 0.7% 0.7% 1.3% 0.4%
Others – – – – – – – – – 6 – – – – –
(1-3) 2.3%
Other – – – – – – – – – 1 3 6 1 – –
(2-3) 0.4% 1.0% 4.0% 0.4%
Others – – – – – – – – – – 1 – – – –
(2-1-3) 0.3%
Others – – – – – – – – – 4 5 4 2 – –
(2-3-2) 1.5% 1.7% 2.7 0.9%
Others – – – – – – – – – – 1 – – – –
(2-3-2-1) 0.3%
Adapted from Martins et al. [229]
J. N. R. Martins and M. A. Versiani
 6

Table 6.33 Root canal configurations on maxillary first and second molars in each age group
a
Age Maxillary first molar Maxillary second molara
group Mesiobuccal Distobuccal Palatal Mesiobuccal Distobuccal Palatal
sample ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61
(n) (202) (214) (100) (202) (214) (100) (202) (214) (100) (205) (262) (131) (205) (262) (131) (205) (262) (131)
Root canal configuration
Type I 58 59 31 198 209 99 197 211 99 126 138 67 205 253 131 202 249 130
(1-1) 28.7% 27.5% 31.0% 98.0% 97.6% 99.0% 97.5% 98.6% 99.0% 61.5% 54.6% 51.1% 100% 100% 100% 98.5% 98.4% 99.2%
Type II 86 97 47 3 4 – – 2 – 41 77 39 – – – – 1 1
(2-1) 42.6% 45.3% 47.0% 1.5% 1.9% 0.9% 20.0% 30.4% 29.8% 0.4% 0.8%
Type III 1 4 – – 1 – 5 1 1 1 3 1 – – – 3 3 –
(1-2-1) 0.5% 1.9% 0.5% 2.5% 0.5% 1.0% 0.5% 1.2% 0.8% 1.5% 1.2%
Type IV 44 28 11 – – – – – – 23 11 11 – – – – – –
(2-2) 21.8% 13.1% 11.0% 11.2% 4.3% 8.4%
Type V 1 7 2 1 – – – – – 6 11 5 – – – – – –
(1-2) 0.5% 3.3% 2.0% 0.5% 2.9% 4.3% 3.8%
Type VI 9 15 7 – – 1 – – – 7 12 6 – – – – – –
CBCT and Micro-CT on the Study of Root Canal Anatomy

(2-1-2) 4.5% 7.0% 7.0% 1.0% 3.4% 4.8% 4.6%

Type – – 1 – – – – – – 1 – – – – – – – –
VII 1.0% 0.5%

pilararaya@ejercer.cl
(1-2-1-­
2)
Type – – – – – – – – – – – – – – – – – –
VIII
(3-3)
Others 3 3 – – – – – – – – 1 1 – – – – – –
(2-1-2-­ 1.4% 1.4% 0.4% 0.8%
1)
Others – 1 1 – – – – – – – – – – – – – – –
(3-1-2) 0.5% 1.0%
Others – – – – – – – – – – – 1 – – – – – –
(3-2-1) 0.8%
Adapted from Martins et al. [229]
a
Only maxillary molars with three independent roots
169
 170

Table 6.34 Root canal configurations on mandibular anterior teeth and premolars in each age group

Age Teeth groups

group Mandibular central incisor Mandibular lateral incisor Mandibular canine Mandibular first premolar Mandibular second premolar
sample ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61
(n) (316) (562) (325) (315) (582) (337) (317) (581) (346) (299) (500) (290) (264) (395) (199)
Root canal configuration
Type I 215 413 245 222 408 235 291 522 309 241 377 228 257 380 184
(1-1) 68.0% 73.5% 75.4% 70.5% 70.1% 69.7% 91.8% 89.9% 89.3% 80.6% 75.4% 78.6% 97.3% 96.2% 92.5%
Type II 9 13 7 16 34 25 7 19 15 5 12 10 – 5 2
(2-1) 2.9% 2.3% 2.2% 5.1% 5.9% 7.4% 2.2% 3.3% 4.4% 1.7% 2.4% 3.5% 1.3% 1.0%
Type III 89 131 69 76 134 75 7 20 5 9 31 18 2 5 4
(1-2-1) 28.2% 23.3% 21.2% 24.1% 23.0% 22.3% 2.2% 3.4% 1.4% 3.0% 6.2% 6.2% 0.8% 1.3% 2.0%
Type IV 1 – – – – – 6 6 5 2 7 7 – 1 3
(2-2) 0.3% 1.9% 1.0% 1.4% 0.7% 1.4% 2.4% 0.2% 1.5%
Type V 1 3 – 1 2 – 6 13 12 39 68 26 3 3 6
(1-2) 0.3% 0.5% 0.3% 0.3% 1.9% 2.2% 3.5% 13.0% 13.6% 9.0% 1.1% 0.8% 3.0%
Type VI – – – – – – – – – – – – – – –
(2-1-2)
Type VII – 2 4 – 1 2 – – – – 1 1 – – –
(1-2-1-2) 0.4% 1.2% 0.2% 0.6% 0.2% 0.3%

pilararaya@ejercer.cl
Type VIII – – – – – – – – – – – – – – –
(3-3)
Others 1 – – – – – – – – – – – – – –
(1-2-1-2- 0.3%
1)
Others – – – – 2 – – 1 – – 1 – – – –
(2-1-2-1) 0.3% 0.2% 0.2%
Other – – – – – – – – – – 3 – – – –
(1-3) 0.6%
Others – – – – 1 – – – – 2 – – 2 1 –
(1-3-1) 0.2% 0.7% 0.8% 0.2%
Others – – – – – – – – – 1 – – – – –
(1-3-2) 0.3%
Adapted from Martins et al. [229]
J. N. R. Martins and M. A. Versiani
6 CBCT and Micro-CT on the Study of Root Canal Anatomy 171

Table 6.35 Root canal configurations on mandibular first and second molars in each age group
Teeth groups
Age Mandibular first molara Mandibular second molara
group Mesial Distal Mesial Distal
sample ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61 ≤40 41–60 ≥61
(n) (176) (188) (99) (176) (188) (99) (217) (268) (104) (217) (268) (104)
Root canal configuration
Type I 1 3 1 126 143 59 17 21 9 204 248 95
(1-1) 0.6% 1.6% 1.0% 71.6% 76.0% 59.6% 7.8% 7.8% 8.6% 94.0% 92.6% 91.3%
Type II 81 95 41 16 16 23 131 173 66 2 2 1
(2-1) 46.0% 50.5% 41.4% 9.1% 8.5% 23.2% 60.4% 64.5% 63.4% 0.9% 0.7% 1.0%
Type III – – – 17 19 8 8 14 8 5 11 7
(1-2-1) 9.6% 10.1% 8.1%% 3.7% 5.2% 7.7% 2.3% 4.1% 6.7%
Type 76 72 46 3 5 5 52 46 16 1 2 –
IV 43.2% 38.3% 46.6% 1.7% 2.7% 5.1% 23.9% 17.2% 15.4% 0.5% 0.7%
(2-2)
Type V – – – 11 2 1 1 1 1 5 5 1
(1-2) 6.2% 1.1% 1.0% 0.5% 0.4% 1.0% 2.3% 1.9% 1.0%
Type VI 8 7 3 1 2 2 4 6 – – – –
(2-1-2) 4.5% 3.7% 3.0% 0.6% 1.1% 2.0% 1.8% 2.2%
Type – – – 1 – – – – – – – –
VII 0.6%
(1-2-1-­
2)
Type – – – – – – – – – – – –
VIII
(3-3)
Others – – – – – 1 – – – – – –
(1-2-1-­ 1.0%
2-1)
Others 1 2 1 1 1 – – 1 1 – – –
(2-1-2-­ 0.6% 1.1% 1.0% 0.6% 0.5% 0.4% 1.0%
1)
Others – 5 4 – – – 1 1 – – – –
(3-2) 2.7% 4.0% 0.5% 0.4%
Others – 1 – – – – – – – – – –
(2-3-2) 0.5%
Others 9 3 3 – – – 2 4 2 – – –
(3-2-1) 5.1% 1.6% 3.0% 0.9% 1.5% 1.9%
Others – – – – – – 1 1 – – – –
(2-3-2-­ 0.5% 0.4%
1)
Others – – – – – – – – 1 – – –
(3-2-3-­ 1.0%
2-1)
Adapted from Martins et al. [229]
a
Only mandibular molars with two independent roots

3. Scarfe WC, Levin MD, Gane D, Farman AG. Use of

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 Root Canal Anatomy of Maxillary
and Mandibular Teeth
7
Marco A. Versiani, Mário R. Pereira,
Jesus D. Pécora, and Manoel D. Sousa-Neto

Abstract influence of several variables such as ethnicity,

It is a common knowledge that a comprehensive
understanding of the complexity of the internal
anatomy of teeth is imperative to ensure suc-
cessful root canal treatment. The significance of
canal anatomy has been emphasized by studies
demonstrating that variations in canal geometry
before cleaning, shaping, and obturation proce-
dures had a greater effect on the outcome than
the techniques themselves. In recent years, sig-
nificant technological advances for imaging
teeth, such as CBCT and micro-CT, respec-
tively, have been introduced. Their noninvasive
nature allows to perform in vivo anatomical
studies using large populations to address the
Electronic supplementary material The online version
of this chapter (https://doi.org/10.1007/978-3-319-73444-
6_7) contains supplementary material, which is available
to authorized users.
M. A. Versiani, D.D.S., M.Sc., Ph.D. (*) J. D.
Pécora, D.D.S., M.Sc., Ph.D. · M. D. Sousa-Neto,
D.D.S., M.Sc., Ph.D.
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
São Paulo, Brazil
e-mail: marcoversiani@yahoo.com
M. R. Pereira, D.D.S., M.S.
Faculty of Dental Medicine, Department of
Endodontics, University of Lisbon, Lisbon, Portugal
Department of Endodontics, ISCSEM,
Almada, Portugal
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_7
aging, gender, and others, on the root canal
anatomy, as well as to evaluate, quantitatively
and/or qualitatively, specific and fine anatomi-
cal features of a tooth group. The purpose of this
chapter is to summarize the morphological
aspects of the root canal anatomy published in
the literature of all groups of teeth and illustrate
with three-dimensional images acquired from
micro-CT technology.
7.1 Introduction
Guido Fischer demonstrated the challenging
nature of the apical root anatomy for the first time
in 1907 by filling approximately 700 teeth with a
collodion solution [1]. The complexity and unpre-
dictability of the root canal morphology led him
to coin the widely used terminology kanalsystem,
which was translated to English as “root canal
system.” So, the concept of a “single” root canal
with a “single” apical foramen is mistaken [2].
The root canal space is often complex, with canals
that divide and rejoin, isthmuses, fins, anastomo-
sis, accessory canals, and apical deltas. For this
reason, it has been referred as a system, and its
complexity has been demonstrated by several
authors. Considering that the goal of endodontic
therapy is the removal of all vital or necrotic tis-
sue, microorganisms, and microbial by-products
from the root canal space [2], a thorough under-
181

pilararaya@ejercer.cl
182 M. A. Versiani et al.

standing of the canal morphology and its varia-
tions in all groups of teeth is a basic requirement
for the success of the endodontic therapy.
The first step in understanding dental anatomy
and to apply it for recording data in clinical prac-
tice is to learn some system of tooth notation. In
this chapter, Universal Numbering, Palmer
Notation, and International Numbering systems
were used to identify each tooth group [3].
Additionally, for a better comprehension and
detailed study of root and root canal anatomy, sev-
eral landmarks of importance were selected, and
proper information acquired from the literature
cited accordingly, including general description of
the teeth [3], overall and root lengths [4], chronol-
ogy of root formation [5], tooth axes angulation [6,
7], number of roots [8], apical root curvature [6],
root grooves [4], number and canal configuration
[8, 9], canal cross-sectional shape [4, 6], canal
taper [10], percentage frequency of transversal
anastomosis and furcation canal [9], position of
the apical foramen [9], accessory canals and apical
ramifications [8, 9, 11], degree of canal curvature
[12], and canal diameter 1 mm from the apical
foramen [10]. Occurrence of anatomical anoma-
lies and important clinical remarks associated with
the external and internal anatomy of each group
tooth were also pointed out (Tables 7.1, 7.2, 7.3,

Table 7.1 Morphological aspects of the root and root canal anatomy of maxillary central incisors
Tooth notation (right/left)
Overall length
Root length
Complete root formation
Tooth axes angulation
Number of roots
Apical root curvature
Root grooves
Number of canals
Canal configuration
Canal cross section
Canal taper
Transverse anastomosis
Furcation canals
Apical foramen position
Accessory canals
Apical ramification
Canal curvature
Canal diameter
Anomalies
Clinical remarksc
BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Clinical remarks [2, 20]
(8 and 9), (1| and |1), or (11 and 21)
23.6 mm (16.5–32.6 mm)
13.0 mm (6.3–20.3 mm)
9.3–10.6 years (male-female)
3–5° (orthoradial) and 15–20° (proximal)
1 (100%)a
1 (99.94%), 2 (0.06%)b
Straight (75%), buccal (9.3%), distal (7.8%), mesial (4.3%), palatal (3.6%)
No prominent groove
1 (100%)a
1 (99.2%), 2 (0.8%)b
Type I (100%)a
Types I (99.2%), IV (0.5%), II (0.1%), III (0.1%), and V (0.1%)b
Coronal, triangular with the mesial side longer than the distal side; middle, oval; apical,
round
BL, 0.11 mm/mm; MD, 0.06 mm/mm
–
–
Central, 12%; lateral, 88%
18.9–42.6% (coronal, 1%; middle, 6%; apical, 93%)
8.1–27.9%
Clinical view, 0–26°; proximal view, 0–18°
BL: 0.34 mm (0.15–0.69 mm)
MD: 0.30 mm (0.14–0.59 mm)
Two canals [13–15]; three canals [16]; four canals [17]; two roots [13–15]; radicular
groove [18]; fusion/gemination [19]
If a great amount of irritation-­induced dentin is produced, pulp chamber may be
partially or completely obliterated; a total of 79.7% of all foramina are located
approximately 0.5 mm or less from the apex and 94.9% are approximately 1.0 mm or
less away; 56.4% of the lateral canals have a mean diameter less than a size 10 K-file;
lingual shoulder should be removed as it prevents direct access to the root canal,
deflecting files and often resulting in ledge or perforation. In older patients, the roof of
the pulp chamber is often first encountered in the region of the tooth cervix. For this
reason, the access cavity must often be made near to the incisal edge to achieve the
necessary straight-line access to the root canal

pilararaya@ejercer.cl
7 Root Canal Anatomy of Maxillary and Mandibular Teeth 183

Table 7.2 Morphological aspects of the root and root canal anatomy of maxillary lateral incisors
Tooth notation (right/left)
Overall length
Root length
Complete root formation
Tooth axes angulation
Number of roots
Apical root curvature
Root grooves
Number of canals
Canal configuration
Canal cross section
Canal taper
Transverse anastomosis
Furcation canals
Apical foramen position
Accessory canals
Apical ramification
Canal curvature
Canal diameter
Anomalies
Clinical remarksc
BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Clinical remarks [2, 20]
(7 and 10), (2| and |2), or (12 and 22)
22.5 mm (17.7–28.9 mm)
13.4 mm (9.6–19.4 mm)
9.7–11.1 years (male-female)
5–6° (orthoradial) and 17–20° (proximal)
1 (100%)a
1 (99.94%) 2 (0.06%)b
Distal (49.2%), straight (29.7%), palatal (3.9%), buccal (3.9%), mesial (3.1%),
S-shaped (1.6%), others (8.6%)
Shallow depression on the middle of mesial root surface
1 (97%), 2 (3%)a
1 (98.5%), 2 (1.5%)b
Type I (100%)a
Types I (98.5%), II (0.8%), V (0.4%), III (0.2%), IV (0.1%)b
Coronal, “egg-shaped” or ovoid; middle, oval; apical, round
BL, 0.08 mm/mm; MD, 0.04 mm/mm
–
–
Central, 22%; lateral, 78%
5.5–26% (coronal, 1%; middle, 8%; apical, 91%)
3.9–23.6%
Clinical view, 0–74°; proximal view, 0–55°
BL: 0.45 mm (0.27–0.83 mm)
MD: 0.33 mm (0.19–0.54 mm)
Two canals [21–23]; three canals [24, 25]; four canals [26]; two roots [27]; radicular
groove [18]; fusion/gemination [28]; dens invaginatus [29]; dens evaginatus [30];
C-shaped canal [31]; talon cusp [32]; abrupt apical curvature [33]
This tooth often has anomalies and presents a high frequency of apical root
curvature to the distopalatal direction; lingual shoulder must be removed as it
prevents direct access to the root canal and often results in ledge or perforation; the
root canal is generally oval-shaped, and the root is frequently bent either buccally or
distally; therefore, on the radiograph, the canal may appear shorter than it actually is

7.4, 7.5, 7.6, 7.7, 7.8, 7.9, 7.10, 7.11, 7.12, and
7.13). Finally, information regarding the number
of roots and root canals, as well as the most fre-
quently observed root canal configurations, were
depicted from recent epidemiological studies
using CBCT technology (Chap. 6) and compiled
in Tables 7.14 and 7.15. Considering that the
anatomy of the maxillary and mandibular third
molars varies greatly and is unpredictable, this
group of teeth was not included in this chapter.
In accordance with information provided
herein, a great deal of variation has been reported
in the literature regarding the root and root canal
morphologies of all groups of teeth, and these
dissimilarities have been explained by method-
ological differences, sample size, as well as eth-
nicity, race, and gender of the studied population.
Therefore, based on the mentioned criteria, this
chapter aimed to summarize the most relevant
morphological aspects of the root and root canal
anatomy of all groups of teeth, depicting in
tables data extracted from current and classical
studies, illustrated by images acquired from non-
destructive micro-CT technology.

pilararaya@ejercer.cl
184 M. A. Versiani et al.

Table 7.3 Morphological aspects of the root and root canal anatomy of maxillary canines
Tooth notation (6 and 11), (3| and |3), or (13 and 23)
(right/left)
Overall length 26.4 mm (20.0–38.4 mm)
Root length 16.5 mm (10.8–28.5 mm)
Complete root 11.9–13.7 years (male-female)
formation
Tooth axes 6° (orthoradial) and 17° (proximal)
angulation
Number of roots 1 (100%)a,b
Apical root Straight (38.5%), distal (19.5%), buccal (12.8%), mesial (12%), palatal (6.5%), others (10.7%)
curvature
Root grooves Developmental grooves on both mesial and distal sides
Number of canals 1 (100%)a
1 (97%) 2 (3%)b
Canal Type I (100%)a
configuration Types I (98.5%), III (1.2%), II (0.8%), V (0.7%), IV (0.2%), others (0.1%)b
Canal cross Coronal, broad buccolingually and appears ovoid; middle, oval; apical, round
section
Canal taper BL, 0.08 mm/mm; MD, 0.05 mm/mm
Transverse –
anastomosis
Furcation canals –
Apical foramen Central, 14%; lateral, 86%
position
Accessory canals 3.4–30% (coronal, 0%; middle, 10%; apical, 90%)
Apical 15–33.8%
ramification
Canal curvature Clinical view, 0–29°; proximal view, 0–33°
Canal diameter BL: 0.31 mm (0.16–0.58 mm)
MD: 0.29 mm (0.11–0.50 mm)
Anomalies Two canals [34–36]; dens invaginatus [37]
Clinical remarksc Large mid-root canal diameter becoming much narrower only in the final third near the apex;
root canal cross section is usually oval-shaped, and clinician must take care to circumferentially
file labially and palatally to shape and clean the canal properly; lingual shoulder should be
removed as it prevents direct access to the root canal
BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Clinical remarks [2, 20]

Table 7.4 Morphological aspects of the root and root canal anatomy of maxillary first premolars
Tooth notation (5 and 12), (4| and |4), or (14 and 24)
(right/left)
Overall length 21.5 mm (15.5–28.9 mm)
Root length 13.4 mm (8.3–19.0 mm)
Complete root 11.8–13.5 years (male-female)
formation
Tooth axes angulation 7° (orthoradial) and 11° (proximal)
Number of roots Two (buccal and palatal roots; 21.9% independent; 32.7% bifurcation at the apical third);
one (43%); three (two buccal and one palatal root; 2.4%)a
Two (55.3%) ,one (43.1%), three (1.6%)b
Apical root curvature B, palatal (36.2%), straight (27.8%), distal (14%), buccal (14%), S-shaped (8%); P,
straight (44.4%), buccal (27.8%), distal (14%), palatal (8.3%), S-shaped (5.5%)
Root grooves Prominent mesial developmental depression and groove on the palatal aspect of the
buccal root (reported as between 62% and 100%)

pilararaya@ejercer.cl
7 Root Canal Anatomy of Maxillary and Mandibular Teeth 185

Table 7.4 (continued)

Number of canals 2 (84.2%), 1 (8.3%), 3 (7.5%)c
2 (77.3%), 1 (20.1%), 3 (1.2%), others (1.3%)b
Canal configuration Types IV (62%), II (18%), I (8%), V (7%), VIII (5%)c
Types IV (50.1%), I (20.1%), II (17.4%), VI (4.9%), V (3%), III (1.5%), VIII (1.2%), VII
(0.4%), others (1.3%)b
Canal cross section One-rooted: coronal (oval); middle and apical (round)
Two-rooted: coronal (oval to round connected by a thin isthmus); middle (ovoid); apical
(round)
Three-rooted: coronal (oval); middle and apical (round)
Canal taper B: BL 0.03 mm/mm, MD 0.02 mm/mm
P: BL 0.05 mm/mm, MD 0.04 mm/mm
Transverse anastomosis 34.2% (coronal, 16.4%; middle, 58%; apical, 25.6%)
Furcation canals 11%
Apical foramen position Central, 12%; lateral, 88%
Accessory canals 17.8–49.5% (coronal, 4.7%; middle, 10.3%; apical, 74%)
Apical ramification 20–35.5%
Canal curvature B: clinical view, 0–35°; proximal view, 0–32°
P: clinical view, 0–37°; proximal view, 0–68°
Canal diameter B: BL, 0.30 mm (0.23–0.33 mm); MD, 0.23 mm (0.20–0.27 mm)
P: BL, 0.23 mm (0.17–0.29 mm); MD, 0.17 mm (0.17–0.19 mm)
Anomalies Three canals [38]; furcation groove [39]; gemination/fusion [40]; dens evaginatus [41]
Clinical remarksd In cross section at the CEJ, the palatal orifice is wider buccolingually and kidney-shaped
because of the mesial concavity of the root; this concavity results in the danger of a
lateral perforation during instrumentation; the palatal canal usually is slightly larger than
the buccal canal; high incidence of furcation groove on the palatal aspect of the buccal
root; palatal canal is usually larger than the buccal canal; the roots are considerably
shorter and thinner than in the canines; during access cavity preparation, pulp horns may
be confused with the actual canal orifices
B buccal root, P palatal root, BL buccolingual direction, MD mesiodistal direction
a
Bramante et al. [6]
b
CBCT studies (Chap. 6)
c
Vertucci [9]
d
Clinical remarks [2, 20]

Table 7.5 Morphological aspects of the root and root canal anatomy of maxillary second premolars
Tooth notation (4 and 13), (5| and |5), or (15 and 25)
(right/left)
Overall length 21.2 mm (15.2–28.4 mm)
Root length 14.0 mm (8.0–20.6 mm)
Complete root 12.6–13.8 years (male-female)
formation
Tooth axes angulation 7° (orthoradial) and 7–10° (proximal)
Number of roots 1 (90.3% single-rooted; 7.7% with apical bifurcation), 2 (2%)a
1 (86.2%), 2 (13.5%), 3 (0.3%)b
Apical root curvature Straight (37.4%), distal (29.5%), buccal (15.7%), S-shaped (13%), distal (4.4%)
Root grooves Shallow developmental groove on the mesial side
Number of canals 1 (53.7%), 2 (46.3%)c
2 (56.7%), 1 (42.7%), 3 (0.4%), others (0.3%)b
Canal configuration Types I (48%), II (22%), III (5%), IV (11%), V (6%), VI (5%), VII (2%), VIII (1%)c
Types I (42.7%), II (18.7%), IV (17.6%), V (9.6%), VI (6.3%), III (4%), VII (0.5%), VIII
(0.4%), others (0.3%)b
Canal cross section Coronal and middle, oval; apical, round
Canal taperd BL, 0.19 mm/mm; MD, 0.03 mm/mm
(continued)

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Table 7.5 (continued)

Transverse anastomosis 30.8% (coronal,18.8%; middle, 50%; apical, 31.2%)
Furcation canals 1.6%
Apical foramen position Central, 22.2%; lateral, 77.8%
Accessory canals 12.9–59.5% (coronal, 4%; middle, 16.2%; apical, 78.2%)
Apical ramification 22.2–32.2%
Canal curvature Clinical view, 0–53°; proximal view, 0–40°
Canal diameter BL: 0.37 mm (0.16–1.35 mm)
MD: 0.26 mm (0.14–0.37 mm)
Anomalies Three canals [38]; dens invaginatus [42]
Clinical remarkse It typically has a single root with a single canal. Less frequently, second premolars have
two roots, each with a separate root canal; the root canal system is wider buccolingually
than mesiodistally; apical curvature is common; the proximity of this tooth to the sinus
can lead to drainage of a periradicular abscess into the sinus; with age, the height of the
coronal pulp decreases in the area of the pulpal horns and the pulpal roof (secondary
dentin). The floor of the pulp chamber, however, remains at the level of the tooth cervix;
the roots of maxillary premolars may be curved in all possible directions and often exhibit
two bends
a
Bramante et al. [6]
b
CBCT studies (Chap. 6)
c
Vertucci [9]
d
Single-rooted teeth
e
Clinical remarks [2, 20]

Table 7.6 Morphological aspects of the root and root canal anatomy of maxillary first molars
Tooth notation (3 and 14), (6| and |6), or (16 and 26)
(right/left)
Overall length 20.1 mm (17.0–27.4 mm)
Root length MB, 12.9 mm (8.5–18.8 mm); DB, 12.2 mm (8.9–15.5 mm); P, 13.7 mm (10.6–17.5 mm)
Complete root 9.2–10.1 years (male-female)
formation
Tooth axes angulation 0° (orthoradial) and 15° (proximal)
Number of roots 3 (2 buccal and 1 palatal; 100%)a
3 (97.7%), 2 (1.8%), 4 (0.3%), 1 (0.2%)b
Apical root curvature MB, distal (78%), straight (21%), S-shaped (1%); DB, straight (54%), mesial (19%), distal
(17%), S-shaped (10%); P, buccal (55%), straight (40.7%), mesial (3.2%), distal (1.1%)
Root grooves MB, mesial and distal depressions; P, slight longitudinal depression on the palatal side
Number of canals 3 (30–40%), 4 (60–70%)a
MB, 2 (60.4%), 1 (29.3%), 3 (0.1%), others (0.4%); DB, 1 (98.6%), 2 (1.4%); P, 1
(99.26%), 2 (0.7%), others (0.04%)b
Canal configuration MB, types I (45%), II (37%), IV (18%)a; types I (39.1%), II (29.3%), IV (26%), V (2%),
III (1.6%), VI (1.4%), VII (0.1%), VIII (0.1%), others (0.4%)b; DB, type I (100%)a; types I
(98.6%), II (0.4%), V (0.4%), III (0.3%), IV (0.2%), VI (0.1%)b; P, type I (100%)a; types I
(99.26%), II (0.3%), III (0.2%), IV (0.1%), V (0.1%), others (0.04%)b
Canal cross section MB: coronal and middle (oval of flat-oval); apical (round)
DB and P: oval or round
Canal taper MB1, BL 0.07 mm/mm, MD 0.05 mm/mm; MB2, 0.05 BL mm/mm, MD 0.0 mm/mm;
DB, BL 0.07 mm/mm, MD 0.04 mm/mm; P, BL 0.07 mm/mm, MD 0.10 mm/mm
Transverse anastomosis 52% (MB root only) (coronal, 10%; middle, 75%; apical, 15%)
Furcation canals 18%
Apical foramen position MB, central 24%, lateral 76%; DB, central, 19%, lateral 81%; P, central 18%, lateral 82%

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 187

Table 7.6 (continued)

Accessory canals MB, 51% (coronal, 10.7%; middle, 13.1%; apical, 58.2%); DB, 36% (coronal, 10.1%;
middle, 12.3%; apical, 59.6%); P, 48% (coronal, 9.4%; middle, 11.3%; apical, 61.3%)
Apical ramification 32.3–86.3%
Canal curvature Clinical view MB1, 0–42°; MB2, 23–49°; DB, 0–48°; P, 0–47°
Proximal view MB1, 0–54°; MB2, 0–36°; DB, 0–41°; P, 0–38°
Canal diameter BL, MB1 0.19 mm (0.12–0.26 mm); MB2, 0.19 mm (0.14–0.23 mm); DB, 0.22 mm
(0.07–0.73 mm); P, 0.29 mm (0.09–0.45 mm)
MD, MB1, 0.13 mm (0.08–0.18 mm); MB2, 0.16 mm (0.15–0.16 mm); DB, 0.17 mm
(0.07–0.39 mm); P, 0.33 mm (0.11–0.72 mm)
C-shaped canalsb 0.83% (0.3–1.1%)
Root fusionb Types I (1.13%), III (7.1%), II (0.23%), IV (0.2%), V (0.2%), VI (0.1%)
Anomalies One canal [43]; five canals [44]; six canals [45]; seven canals [46]; eight canals [47];
C-shaped canals [48]; four-rooted [49]; hypertaurodontism [50]
Clinical remarksc There are two MB canals in majority of cases; location of the MB2 canal varies greatly,
but is mostly located palatal and mesial to the MB1; 16% of MB2 canals cannot be
effectively instrumented and sealed because it is often sharply curved, or highly calcified
compared with the MB1 canal, and is difficult to access, particularly in older patients; the
palatal root often curves buccally at the apical third; palatal and MB roots contain one,
two, or three root canals, while DB have one or two canals; a concavity exists on the distal
aspect of the MB root, which makes this wall thin; in older individuals, or in patients with
considerable tertiary dentin, the pulp chamber is reduced in size, which makes access
cavity preparation and detection of the individual canal orifices more difficult;
developmental depressions and discoloration of the pulpal floor should be used as clinical
guides
MB mesiobuccal root/canal, DB distobuccal root/canal, P palatal root/canal, BL buccolingual direction, MD mesiodistal
direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Clinical remarks [2, 20]

Table 7.7 Morphological aspects of the root and root canal anatomy of maxillary second molars
Tooth notation (2 and 15), (7| and |7), or (17 and 27)
(right/left)
Overall length 20.0 mm (16.0–26.2 mm)
Root length MB, 12.9 mm (9.0–18.2 mm); DB, 12.1 mm (9.0–16.3 mm); P, 13.5 mm (9.8–18.8 mm)
Complete root 13.6–14.6 years (male-female)
formation
Tooth axes angulation 0–5° (orthoradial) and 11° (proximal)
Number of roots 3 (2 buccal and 1 palatal; 53.7% independent; 19.5% fusion buccal roots; 8.5% fusion MB
and palatal roots; 5.8% fusion DB and palatal roots; 12.5% all roots fusion)a
3 (73.7%), 2 (14.9%), 1 (10.7%), 4 (0.7%)b
Apical root curvature MB, distal (54%), straight (22%), others (24%); DB, straight (54%), mesial (17%), others
(29%); P, straight (63%), buccal (37%)
Root grooves MB, mesial and distal depressions; P, slight longitudinal depression on the palatal side
Number of canals 3 (50–70%), 4 (30–50%)c
MB, 1 (66.1%), 2 (33.7%), 3 (0.05%), others (0.2%); DB, 1 (99.6%), 2 (0.4%); P, 1
(99.67%), 2 (0.35%), 3 (0.01%), others (0.01%)
Canal configuration MB, types I (71%), II (17%), IV (12%)c; types I (39.1%), II (29.3%), IV (26%), V (2%),
III (1.6%), VI (1.4%), VII (0.1%), VIII (0.1%), others (0.4%)b; DB, type I (100%); types I
(98.6%), II (0.4%), V (0.4%), III (0.3%), IV (0.2%), VI (0.1%)b; P, type I (100%)c; types I
(99.26%), II (0.3%), III (0.2%), IV (0.1%), V (0.1%), others (0.04%)b
Canal cross section MB, coronal and middle (oval of flat-oval); apical (round); DB and P, oval or round
(continued)

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188 M. A. Versiani et al.

Table 7.7 (continued)

Canal taper MB1, BL 0.07 mm/mm, MD 0.05 mm/mm; MB2, BL 0.05 mm/mm, MD 0.0 mm/mm; DB,
BL 0.07 mm/mm, MD 0.04 mm/mm; P, BL 0.07 mm/mm, MD 0.10 mm/mm
Transverse anastomosis 21% (MB root only) (coronal, 8%; middle, 72%; apical, 20%)
Furcation canals 10%
Apical foramen position MB, central 12%, lateral 88%; DB, central 17%, lateral 83%; P, central 19%, lateral 81%
Accessory canals MB, 50% (coronal, 10.1%; middle, 14.1%; apical, 65.8%); DB, 29% (coronal, 9.1%;
middle, 13.3%; apical, 67.6%); P, 42% (coronal, 8.7%; middle, 11.2%; apical, 70.1%)
Apical ramification 20–38.8%
Canal curvature Clinical view MB, 0–49°; DB, 0–64°; P, 0–41°
Proximal view MB, 0–33°; DB, 0–40°; P, 0–42°
Canal diameter BL, MB1 0.19 mm (0.12–0.26 mm); MB2, 0.19 mm (0.14–0.23 mm); DB, 0.22 mm
(0.07–0.73 mm); P, 0.29 mm (0.09–0.45 mm);
MD, MB1, 0.13 mm (0.08–0.18 mm); MB2, 0.16 mm (0.15–0.16 mm); DB, 0.17 mm
(0.07–0.39 mm); P, 0.33 mm (0.11–0.72 mm)
C-shaped canalsb 2.88% (0.5–3.8%)
Root fusionb Types I (6.3%), II (7.4%), VI (4.7%), V (4.3%), IV (3.2%), III (0.7%), others (3.5%)
Anomalies One or two canals [51]; five canals [52]; gemination/fusion [53]; four-­rooted [54];
hypertaurodontism [55]
Clinical remarksd This tooth is similar to the first molar, but is smaller and exhibits less divergence of the
roots; generally, the three roots are grouped closer together and are sometimes fused; the
second molar usually has one canal in each root; however, it may have two or three MB
canals, one or two DB canals, or three palatal canals; teeth with fused roots occasionally
have only two canals (buccal and palatal) of equal length and diameter; DB canal is
usually detected more mesially, compared with the first molar
MB mesiobuccal root/canal, DB distobuccal root/canal, P palatal root/canal, BL buccolingual direction, MD mesiodistal
direction
a
Bramante et al. [6]
b
CBCT studies (Chap. 6)
c
Vertucci [9]
d
Clinical remarks [2, 20]

Table 7.8 Morphological aspects of the root and root canal anatomy of mandibular incisors
Tooth notation
C: (24 and 25), ( | 1 and 1| ), or (31 and 41)
(left/right)
L: (23 and 26), ( | 2 and 2|), or (32 and 42)
Overall length C, 20.8 mm (16.9–26.7 mm); L, 22.1 mm (18.5–26.6 mm)
Root length C, 12.6 mm (7.7–17.9 mm); L, 13.5 mm (9.4–18.1 mm)
Complete root C, 8.1–9.2 years (male-female); L, 8.8–9.9 years (male-female)
formation
Tooth axes angulation C: 0° (orthoradial) and 15° (proximal)
L: 0° (orthoradial) and 10° (proximal)
Number of roots C: 1 (100%)a,b
L: 1 (100%)a; 1 (99.92%); 2 (0.08%)b
Apical root curvature C: straight (66.7%), buccal (18.8%), distal (12.5%), S-shaped (2%)
L: straight (54%), distal (33.3%), buccal (10.7%), S-shaped (2%)
Root grooves Longitudinal root depressions on both proximal sides
Number of canals C: 1 (73.4%), 2 (26.6%)a; 1 (86.5%), 2 (14.4%), others (0.1%)b
L: 1 (84.6%), 2 (15.4%)a; 1 (79.7%), 2 (20.2%), others (0.1%)b
Canal configuration C: types I (70%), II (5%), III (22%), IV (3%)a; types I (86.5%), III (8.1%), V (2.8%),
II (2%), IV (1.4%), VII (0.1%), others (0.1%)b
L: types I (75%), II (5%), III (18%), IV (2%)a; types I (79.7%), III (11.9%), V (3.8%),
II (2.6%), IV (1.8%), VII (0.1%), others (0.1%)b
Canal cross section Ovoid and considerable broader buccolingually than mesiodistally
Canal taper BL, 0.11 mm/mm; MD, 0.01 mm/mm

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 189

Table 7.8 (continued)

Transverse anastomosis –
Furcation canals –
Apical foramen position C, central 25%, lateral 75%; L, central 20%, lateral 80%
Accessory canals C: 0–20% (coronal, 3%; middle, 12%; apical, 85%)
L: 0.9–18% (coronal, 2%; middle, 15%; apical, 83%)
Apical ramification 3.2–7.8%
Canal curvature C, clinical view, 0–17°; proximal view, 0–35°
L, clinical view, 0–31°; proximal view, 0–33°
Canal diameter BL, 0.37 mm (0.13–0.80 mm); MD, 0.25 mm (0.12–0.33 mm)
Anomalies Three canals [56]; gemination/fusion [57]; dens invaginatus [58]; two roots [59]
Clinical remarksc Most incisors have a single root; often a dentinal bridge is present in the pulp chamber
that divides the root into two canals; the two canals usually join and exit through a single
apical foramen; but, they may persist as two separate canals; if a second root canal exists,
it is positioned further lingually and is generally curved; therefore, removal of the lingual
shoulder is critical; canal cross section is oval-shaped, wider buccolingually than
mesiodistally
C central incisor, L lateral incisor, BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Clinical remarks [2, 20]

Table 7.9 Morphological aspects of the root and root canal anatomy of mandibular canines
Tooth notation
(22 and 27), ( | 3 and 3 |), or (33 and 43)
(left/right)
Overall length 25.9 mm (16.1–34.5 mm)
Root length 15.9 mm (9.5–22.2 mm)
Complete root 11.4–13.5 years (male-female)
formation
Tooth axes angulation 3° (orthoradial) and 2° (proximal)
Number of roots 1 (94%), 2 (6%)a; 1 (98.57%), 2 (1.43%)b
Apical root curvature Straight (68.2%), distal (19.6%), buccal (6.8%), mesial (0.8%), S-shaped (1.5%), others
(3.1%)
Root grooves Longitudinal root depressions are present on both sides
Number of canals 1 (88.2%), 2 (11.8%)a; 1 (92.4%), 2 (7.3%), others (0.3%)b
Canal configuration Types I (78%), II (14%), III (2%), IV (6%)a; Types I (92.4%), III (2.7%), II (1.9%), IV
(1.5%), V (1.2%), others (0.3%)b
Canal cross section Wide buccolingually in the coronal and middle thirds; round at the apical third
Canal taper BL, 0.07 mm/mm; MD, 0.05 mm/mm
Transverse anastomosis –
Furcation canals –
Apical foramen position Central, 30%; lateral, 70%
Accessory canals 4.5–30% (coronal, 4%; middle, 16%; apical, 80%)
Apical ramification 2.2–46.9%
Canal curvature Clinical view, 0–23°; proximal view, 0–37°
Canal diameter BL, 0.47 mm (0.18–0.75 mm); MD, 0.36 mm (0.18–0.72 mm)
Anomalies Two canals [60]; three canals [61]; two roots [60]
Clinical remarksc The root canal is narrow mesiodistally but usually very broad buccolingually; in
two-rooted canines, a lingual shoulder must be removed to gain access to the entrance of a
second canal; the lingual wall is almost slit-like compared with the larger buccal wall
BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Clinical remarks [2, 20]

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190 M. A. Versiani et al.

Table 7.10 Morphological aspects of the root and root canal anatomy of mandibular first premolars
Tooth notation
(21 and 28), ( | 4 and 4 |), or (34 and 44)
(left/right)
Overall length 22.4 mm (17.0–28.5 mm)
Root length 14.4 mm (9.7–20.2 mm)
Complete root 11.9–13.3 years (male-female)
formation
Tooth axes angulation 5° (orthoradial) and 3° (proximal)
Number of roots 1 (86.6%; apical bifurcation 2.8%; middle or apical trifurcation 10.6%)a; 1 (97.5%), 2
(2.5%)b
Apical root curvature Straight (47.5%), distal (34.8%), lingual (7.1%), buccal (2.1%), S-shaped (6.4%), others
(2.1%)
Root grooves Longitudinal depressions are often present on both sides, deeper on the distal. Sometimes
depressions may be quite deep and end in a buccolingual apical bifurcation
Number of canals 1 (66.6%), 2 (1 buccal and 1 lingual; 31.3%), 3 (2 buccal and 1 lingual; 2.1%)a; 1
(71.3%), 2 (27.9%), 3 (0.1%), others (0.7%)b
Canal configuration Types I (70%), V (24%), III (4%), IV (1.5%), VIII (0.5%)a; Types I (71.3%), V (18.7%),
IV (3.5%), III (2.8%), II (2.3%), VI (0.5%), VII (0.1%), VIII (0.1%), others (0.7%)b
Canal cross sectionc
Ovoid and is widest buccolingually in the coronal and middle thirds; round at the apical
third
Canal taperc BL, 0.10 mm/mm; MD, 0.05 mm/mm
Transverse anastomosis 32.1% (coronal, 20.6%; middle, 52.9%; apical, 26.5%)
Furcation canals 0.7%
Apical foramen position Central, 15%; lateral, 85%
Accessory canals 8.8–44.3% (coronal, 4.3%; middle, 16.1%; apical, 78.9%)
Apical ramification 21.7–44.7%
Canal curvature Clinical view, 0–30°; proximal view, 0–57°
Canal diameter BL, 0.35 mm (0.20–0.80 mm); MD, 0.28 mm (0.16–0.54 mm)
C-shaped canalsb 1.56% (0.7–4.1%)
Anomalies Three canals [62]; four canals [63]; radicular groove [64]; C-shaped [65]; dens evaginatus
[66]; dens invaginatus [67]; gemination/fusion [68]
Clinical remarksc The root canal system may present different configurations; when a single canal is
present, it is wider buccolingually than mesiodistally; at the cervical third is oval-shaped
and tends to become round at the middle and apical thirds; the lingual canal, when
present, tends to diverge from the main canal at a sharp angle; because of the lingual
inclination of mandibular teeth and the small lingual cusp of the premolars, access cavity
preparation should be carried out from the buccal aspect toward the central fissure
BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Single-rooted with one root canal
d
Clinical remarks [2, 20]

Table 7.11 Morphological aspects of the root and root canal anatomy of mandibular second premolars
Tooth notation
(20 and 29), ( | 5 and 5 |), or (35 and 45)
(left/right)
Overall length 22.1 mm (16.8–28.1 mm)
Root length 14.7 mm (9.2–21.2 mm)
Complete root 12.8–14.0 years (male-female)
formation
Tooth axes angulation 5° (orthoradial) and 9° (proximal)
Number of roots 1 (92%), 2 (8%)a; 1 (98.5%), 2 (1.5%)b
Apical root curvature Distal (39.8%), straight (38.5%), buccal (10.1%), lingual (3.4%), S-shaped (6.8%), others
(1.4%)

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 191

Table 7.11 (continued)

Root grooves Frequent at the middle third on the distal surface
Number of canals 1 (89.3%), 2 (10.7%)a; 1 (84.7%), 2 (15.05%), 3 (0.05%), others (0.2%)b
Canal configuration Types I (97.5%), V (2.5%)a; I (84.7%), V (13.44%), II (0.7%), III (0.5%), IV (0.3%), VI
(0.07%), VIII (0.05), VII (0.04%), others (0.2%)b
Canal cross sectionc
Ovoid buccolingually in the coronal and middle thirds; round at the apical third
Canal taperc BL: 0.10 mm/mm; MD: 0.05 mm/mm
Transverse anastomosis 30% (coronal, 0%; middle, 66.7%; apical, 33.3%)
Furcation canals 0.3%
Apical foramen position Central, 16.1%; lateral, 83.9%
Accessory canals 4–48.3% (coronal, 3.2%; middle, 16.4%; apical, 80.1%)
Apical ramification 14.8–80.4%
Canal curvature Clinical view, 0–29°; proximal view, 0–42°
Canal diameter BL, 0.35 mm (0.20–0.80 mm); MD, 0.28 mm (0.16–0.54 mm)
C-shaped canalsb 0.72% (0.6–1.5%)
Anomalies Three canals [69]; four canals [70]; five canals [71]; two roots [72]; C-shaped [73]; dens
evaginatus [74]; taurodontism [71]; gemination/fusion [75]
Clinical remarksd The root canal is more often oval than round; the lingual canal, when present, tends to
diverge from the main canal at a sharp angle; the canal morphology may present many
variations, but less often than first premolars; care must be taken to avoid the danger of
artificially straightening the canal or excessive widening of the delicate apical third of the
canal
BL buccolingual direction, MD mesiodistal direction
a
Vertucci [9]
b
CBCT studies (Chap. 6)
c
Single-rooted with one root canal
d
Clinical remarks [2, 20]

Table 7.12 Morphological aspects of the root and root canal anatomy of mandibular first molars
Tooth notation
(19 and 30), ( | 6 and 6 |), or (36 and 46)
(left/right)
Overall lengtha 20.9 mm (17.0–27.7 mm)
Root length M, 14.0 mm (10.6–20.0 mm); D, 13.0 mm (8.1–17.7 mm)
Complete root 9.2–10.0 years (male-female)
formation
Tooth axes angulation 10° (orthoradial) and 13° (proximal)
Number of roots 2 (92.2% independent; 5.3% fusion), 3 (2.5%)b; 2 (86.9%), 3 (12.5%), 1 (0.55%), 4
(0.05%)c
Apical root curvature M: distal (84%), straight (16%); D: straight (73.5%), distal (18%), mesial (8.5%)
Root grooves Mesial root commonly has prominent root depressions on the mesial and distal surfaces
Number of canals 2 (8%), 3 (56%), 4 (36%)b
M, 1 (single canal 12.8%; apical bifurcation 6.6%), 2 (independent 40.3%; confluent at
the apical third 30.2%)d; 1 (2.37%), 2 (96.59%), 3 (0.03%), others (1.01%)c; D, 1 (single
canal 73%; middle bifurcation 2%), 2 (independent 3.7%; confluent at the apical third
12.7%)d; 1 (70.3%), 2 (29.56%), others (0.14%)c
Canal configuration M: types I (12%), IV (43%), II (28%), VI (10%), V (8%) VIII (1%)b; types IV (71.3%), II
(19.9%), III (2.9%), I (2.37%), V (2.1%), VI (0.3%), VII (0.09%), VIII (0.03%), others
(1.01%)c
D: types I (70%), II (15%), IV (5%), V (8%), VI (2%)b; types I (70.3%), II (13%), IV
(10.1%), III (3.6%), V (2.7%), VI (0.08%), VII (0.08%), others (0.14%)c
Canal cross sectione M, oval or flat-oval at the coronal and middle thirds and round at the apical third; D, oval
buccolingually at the coronal and middle thirds and round at the apical third
Canal taper MB, BL 0.06 mm/mm, MD 0.03 mm/mm; ML, BL 0.06 mm/mm, MD 0.02 mm/mm; D,
BL 0.15 mm/mm, MD 0.06 mm/mm
(continued)

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192 M. A. Versiani et al.

Table 7.12 (continued)

Transverse anastomosis M: 63% (coronal, 12%; middle, 75%; apical, 13%)
D: 55% (coronal, 10%; middle, 72%; apical, 18%)
Furcation canals 23%
Apical foramen position M, central 22%; lateral 78%; D, central 20%; lateral 80%
Accessory canals M: 45% (coronal, 10.4%; middle, 12.2%; apical, 54.4%)
D: 30% (coronal, 8.7%; middle, 10.4%; apical, 57.9%)
Apical ramification 19.4–30.9%
Canal curvature Clinical view MB, 9–48°; ML, 0–44°; D, 0–75°
Proximal view MB, 0–59°; ML, 0–59°; D, 0–44°
Canal diameter BL, MB, 0.40 mm (0.20–0.52 mm); ML, 0.38 mm (0.32–0.67 mm); D, 0.46 mm (0.28–
1.69 mm); MD, MB, 0.21 mm (0.19–0.39 mm); ML, 0.28 mm (0.23–0.37 mm); D,
0.35 mm (0.18–0.69 mm)
C-shaped canalsc 0.53% (0.1–1.7%)
Radixc Paramolaris, 0.37% (0.11–1.21); entomolaris, 12.19% (0.5–29.7%)
Anomalies Five canals [76]; six canals [77]; seven canals [78]; radix [79]; taurodontism [80]; apical
curvature [12]; gemination/fusion [81]; isthmuses [82]; three roots [83]; C-shaped [84];
middle mesial canal [85]; middle distal canal [86]
Clinical remarksf It usually has two roots, but occasionally it has three, with two or three canals in the
mesial root and one, two, or three canals in the distal root; the distal surface of the mesial
root and the mesial surface of the distal root have a concavity, which makes the dentin
wall very thin; the presence of root canal isthmuses averages 55% in the mesial root and
20% in the distal root; multiple accessory foramina may be present in the furcation area;
the dentin overhang at the mesial orifice must be removed to lessen the danger of
penetration
BL buccolingual direction, MD mesiodistal direction, M mesial root, D distal root
a
Overall length from mesial root apex to tip of MB cusp; root length: from cervical line to root apex
b
Vertucci [9]
c
CBCT studies (Chap. 6)
d
Bramante et al. [6]
e
Two-rooted teeth with three independent root canals
f
Clinical remarks [2, 20]

Table 7.13 Morphological aspects of the root and root canal anatomy of mandibular second molars
Tooth notation
(18 and 31), ( | 7 and 7 |), or (37 and 47)
(left/right)
Overall lengtha 20.6 mm (15.5–25.5 mm)
Root length M, 13.9 mm (9.3–18.3 mm); D, 13.0 mm (8.5–18.3 mm)
Complete root 13.8–14.8 years (male-female)
formation
Tooth axes angulation 15° (orthoradial) and 12° (proximal)
Number of roots 2 (independent 39.2%; bifurcation at the middle third 31.8%; fused roots 26.7%), 3
(2.3%)b; 2 (78.6%), 1 (19%), 3 (2.2%), 4 (0.2%)c
Apical root curvaturea M: distal (60.8%), straight (27.2%), buccal (4%), S-shaped (8%)
D: straight (57.6%), distal (18.4%), mesial (13.6%), buccal (4%), S-shaped (6.4%)
Root grooves Mesial root commonly has prominent root depressions on the mesial and distal surfaces
Number of canals 2 (16.2%), 3 (72.5%), 4 (11.3%)d; M, 2 (87.1%), 1 (12.5%); D, 1 (92.56%), 2 (7.44%)c
Canal configuration M, types II (38%), I (27%), IV (26%), V (9%)d; types IV (47.8%), II (32.8%), I (12.5%),
III (3.27%), V (3%), VI (0.2%), VII (0.1%), others (0.33%)c; D, types I (92%), II (3%), IV
(4%), V (1%)d; types I (92.56%), II (4.4%), IV (2%), III (0.5%), V (0.5%), VI (0.04%)c
Canal cross sectione M, oval or flat-oval at the coronal and middle thirds and round at the apical third; D, oval
buccolingually at the coronal and middle thirds and round at the apical third
Canal taper MB, BL 0.06 mm/mm, MD 0.03 mm/mm; ML, BL 0.06 mm/mm, MD 0.02 mm/mm; D,
BL 0.15 mm/mm, MD 0.06 mm/mm

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 193

Table 7.13 (continued)

Transverse anastomosis M: 31% (coronal, 10%; middle, 77%; apical, 13%)
D: 16% (coronal, 11%; middle, 74%; apical, 15%)
Furcation canals 11%
Apical foramen position M: central 19%; lateral 81%; D: central 21%; lateral 79%
Accessory canals M: 49% (coronal, 10.1%; middle, 13.1%; apical, 65.8%)
D: 34% (coronal, 9.1%; middle, 11.6%; apical, 68.3%)
Apical ramification 17.5–35.7%
Canal curvature Clinical view MB, 0–50°; ML, 0–51°, D, 0–67°
Proximal view MB, 0–69°; ML, 0–50°; D, 0–35°
Canal diameter BL, MB 0.40 mm (0.20–0.52 mm), ML 0.38 mm (0.32–0.67 mm), D 0.46 mm (0.28–
1.69 mm); MD, MB 0.21 mm (0.19–0.39 mm), ML 0.28 mm (0.23–0.37 mm), D 0.35 mm
(0.18–0.69 mm)
C-shaped canalsc 16.33% (1.9–44%)
Radixc Paramolaris, 0.93% (0.11–1.61); entomolaris, 1.25% (0.4–3.5%)
Anomalies One canal [87]; two canals [88]; five canals [89]; apical curvature [12]; gemination/fusion
[90]; isthmuses [82]; C-shaped [91, 92]; middle mesial canal [93]
Clinical remarksf This tooth is very similar to the first molar; however, the roots are shorter, the canals are
more curved, and the range of variation is higher. It may have one to five canals, although
the most prevalent configurations are three and four canals; the two mesial orifices are
located closer together; a relatively common variation in root morphology is the presence
of C-shaped canal; clinical signs of the presence of C-shaped canals include continuous
pain and persistent bleeding from the root canal and confluent canals; mesial and distal
roots appear tapered or fused on the radiograph; the apices of this tooth often are closed to
the mandibular canal
BL buccolingual direction, MD mesiodistal direction, M mesial root, D distal root
a
Overall length from mesial root apex to tip of MB cusp; root length: from cervical line to root apex
b
Bramante et al. [6]
c
CBCT studies (Chap. 6)
d
Vertucci [9]
e
Two-rooted teeth with three independent root canals
f
Clinical remarks [2, 20]

Table 7.14 Combined data from CBCT studies on root and root canal morphology of maxillary permanent teeth
Number of roots (%) Vertucci’s classification (%)
Tooth group Number of teeth 1 2 3 4 I II III IV V VI VII VIII Other
Central incisor 3125 99.94 0.06 0 0 99.20 0.1 0.1 0.5 0.1 0 0 0 0
Lateral incisor 3068 99.94 0.06 0 0 98.50 0.8 0.2 0.1 0.4 0 0 0 0
Canine 3148 100 0 0 0 97.0 0.8 1.2 0.2 0.7 0 0 0 0.1
First premolar 2575 43.1 55.3 1.6 0 20.10 17.4 1.5 50.1 3.0 4.9 0.4 1.2 1.3
Second premolar 2345 86.2 13.5 0.3 0 42.70 18.7 4.0 17.6 9.6 6.3 0.5 0.4 0.3
First molar 8934 0.2 1.8 97.7 0.3
MB root 8934 39.10 29.3 1.6 26.0 2.0 1.4 0.1 0.1 0.4
DB root 7473 98.60 0.4 0.3 0.2 0.4 0.01 0 0 0
P root 8445 99.26 0.3 0.2 0.1 0.1 0 0 0 0.04
Second molar 9570 10.7 14.9 73.7 0.7
MB root 9353 66.10 15.3 2.8 13.0 1.9 0.6 0.1 0.05 0.2
DB root 9570 99.60 0.2 0.07 0.1 0.03 0 0 0 0
P root 9570 99.67 0.1 0.1 0.1 0.05 0 0 0.01 0.01
In bold letters, the highest percentage frequency regarding the number of roots and canal configuration in each group of
teeth is highlighted. References: central and lateral incisors [94–99]; canine [94, 95, 97, 99–101]; first premolar [97,
102–105]; second premolar [97, 102–104, 106]; first molar (MB root) [97, 107–124]; first molar (DB root) [97, 107, 108,
111, 112, 114, 116–124]; first molar (palatal root) [97, 107–112, 114, 116–124]; second molar (DB and palatal roots) [97,
108–110, 112, 114, 117–123, 125, 126]; second molar (MB root) [97, 108, 110, 112–114, 117–123, 125, 126]

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194 M. A. Versiani et al.

Table 7.15 Combined data from CBCT studies on root and root canal morphology of mandibular permanent teeth
Number of roots (%) Vertucci’s classification (%)
Tooth group Number of teeth 1 2 3 4 I II III IV V VI VII VIII Other
Central incisor 11,860 100 0 0 0 86.5 2.0 8.1 1.4 2.8 0 0.1 0 0.1
Lateral incisor 11,805 99.92 0.08 0 0 79.7 2.6 11.9 1.8 3.8 0 0.1 0 0.1
Canine 10,009 98.57 1.43 0 0 92.4 1.9 2.7 1.5 1.2 0 0 0 0.3
1st premolar 6043 97.5 2.5 0 0 71.3 2.3 2.8 3.5 18.7 0.5 0.1 0.1 0.7
2nd premolar 6350 98.5 1.5 0 0 84.7 0.7 0.5 0.3 13.4 0.07 0.04 0.05 0.2
1st molar 7388 0.55 86.9 12.5 0.05
Mesial root 7388 2.37 19.9 2.9 71.3 2.1 0.3 0.09 0.03 1.01
Distal root 6712 70.3 13.0 3.6 10.1 2.7 0.08 0.08 0 0.14
2nd molar 7439 19.0 78.6 2.2 0.2
Mesial root 6734 12.5 32.8 3.27 47.8 3.0 0.2 0.1 0 0.33
Distal root 7439 92.56 4.4 0.5 2.0 0.5 0.04 0 0 0
In bold letters, the highest percentage frequency regarding the number of roots and canal configuration in each group of
teeth is highlighted. References: central and lateral incisors [94, 97, 99, 127–134]; canine [94, 97, 99, 100, 127, 129,
133–135]; first premolar [97, 98, 103, 104, 136–142]; second premolar [96–98, 103, 104, 109, 137–140, 142–144]; first
molar (mesial root) [97, 118, 119, 145–154]; first molar (distal root) [97, 118, 119, 145–153, 155]; second molar (mesial
root) [97, 118, 119, 146, 147, 149, 151, 152, 156, 157]; second molar (distal root) [97, 109, 118, 119, 146, 147, 149,
151, 152, 155–158]

7.2 Maxillary Teeth Frontal View Lateral View

The term maxillary refers to the upper jaw, or

maxilla.

7.2.1 Maxillary Central Incisors

The maxillary central incisors are centered in the

maxilla, one on either side of the median line, with
the mesial surface of each in contact with the mesial
surface of the other. The pulp cavity follows the
general outline of the crown and root. In this way,
pulp chamber is very narrow in the incisal region
and wider in the mesiodistal dimension than in the
Transversal Cross-Sections
labiolingual dimension [3]. Morphological aspects
of the root and root canal anatomy of this tooth Coronal Third Middle Third Apical Third
group are detailed in Table 7.1, while Figs. 7.1, 7.2,
and 7.3 illustrate this tooth in various aspects.

7.2.2 Maxillary Lateral Incisors

The maxillary lateral incisor supplements the

central incisor in function, and the crowns bear a Fig. 7.1 Different views of the internal anatomy of a rep-
close resemblance; however, lateral incisor is resentative maxillary central incisor

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 195

Fig. 7.2 3D models depicting the internal anatomy of maxillary central incisors

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196 M. A. Versiani et al.

Fig. 7.3 3D models depicting the internal anatomy of maxillary central incisors

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth
Frontal View Lateral View
Transversal Cross-Sections
Coronal Third Middle Third Apical Third
Fig. 7.4 Different views of the internal anatomy of a rep-
resentative maxillary lateral incisor
smaller in all dimensions except root length. The
pulp chamber is narrow in the incisal region and
may become very wide at the cervical level of the
tooth, while pulp horns are usually prominent
[3]. Morphological aspects of the root and root
canal anatomy of this tooth group are detailed in
Table 7.2, while Figs. 7.4, 7.5, and 7.6 illustrate
this tooth in various aspects.
7.2.3 Maxillary Canines
Maxillary canines are the longest teeth in the
mouth; the crowns are usually as long as those
of the maxillary central incisors, and the single
roots are longer than those of any of the other
teeth. Therefore, maxillary canine has the larg-
est buccolingual root dimension of any tooth in
the mouth, and because the pulp cavity corre-
sponds closely to the outline of the tooth, the
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197
size of the pulp chamber of this tooth may also
be the largest in the mouth [3]. Morphological
aspects of the root and root canal anatomy of
this tooth group are detailed in Table 7.3, while
Figs. 7.7, 7.8, and 7.9 illustrate this tooth in
various aspects.
7.2.4 Maxillary First Premolars
The premolars are so named because they are
anterior to the molars in the permanent dentition.
The maxillary first premolar has two cusps, a
buccal and a lingual, each being sharply defined.
The buccal cusp is usually about 1 mm longer
than the lingual cusp, and, because of that, the
pulp horn usually extends further incisally under
the buccal cusp than the lingual cusp. The
maxillary first premolar may have two well-
­
developed roots, two root projections that are not
fully separated, or one broad root. The majority
of maxillary first premolars have two root canals,
but a small percentage of teeth may have three
roots that sometimes are undetectable radio-
graphically. The pulp chamber floor is below the
cervical level of all the variations found in this
tooth group [3]. Morphological aspects of the
root and root canal anatomy of this tooth group
are detailed in Table 7.4 and Fig. 7.10, while
Figs. 7.11, 7.12, 7.13, and 7.14 illustrate maxil-
lary premolars in various aspects.
7.2.5 Maxillary Second Premolars
The maxillary second premolar supplements the
maxillary first premolar in function and closely
resembles maxillary first premolar. The maxil-
lary second premolar may have a crown that is
noticeably smaller cervico-occlusally and also
mesiodistally; however, it may also be larger in
those dimensions. Usually the root of the sec-
ond premolar is as long as, if not a millimeter or
so longer than, that of the first premolar. Most
maxillary second premolars have only one root
and canal. Two roots are possible, although two
canals within a single root may also be found.
The pulp cavity may demonstrate well-devel-
198 M. A. Versiani et al.

Fig. 7.5 3D models depicting the internal anatomy of maxillary lateral incisors

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 199

Fig. 7.6 3D models depicting the internal anatomy of maxillary lateral incisors

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200
Frontal View Lateral View
Transversal Cross-Sections
Coronal Third Middle Third Apical Third
Fig. 7.7 Different views of the internal anatomy of a rep-
resentative maxillary canine
oped pulp horns; others may have blunted or
nonexistent pulp horns. The pulp chamber and
root canal are very broad in the buccolingual
aspect of teeth with single canals [3].
Morphological aspects of the root and root canal
anatomy of this tooth group are detailed in
Table 7.5 and Fig. 7.15, while Figs. 7.11, 7.12,
7.13, and 7.14 illustrate maxillary premolars in
various aspects.
7.2.6 Maxillary First Molars
The maxillary molars are the largest and strongest
maxillary teeth, by virtue both of their bulk and of
their anchorage in the jaws. The crown of this
tooth is wider buccolingually than mesiodistally.
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M. A. Versiani et al.
The maxillary first molar is normally the largest
tooth in the maxillary arch. It has four well-
developed functioning cusps and one supple-
mental cusp of little practical use. The maxillary
first molar usually has three roots and four
canals. The palatal root usually has the largest
dimensions, followed by the mesiobuccal and
distobuccal roots, respectively. The mesiobuccal
root is often very wide buccolingually and usu-
ally possesses an accessory canal commonly
called MB2, which usually is the smallest of all
the canals in this tooth [3]. Maxillary molars
present the greatest clinical challenge for end-
odontic treatment. This is because the complex-
ity of the root canal system surpasses that of all
other teeth within the human dentition. More
extensive use of the clinical microscope has con-
tributed to the discovery that not only a fourth
canal but other additional canals also exist.
Morphological aspects of the root and root canal
anatomy of this tooth group are detailed in
Table 7.6 and Fig. 7.16, while Figs. 7.17, 7.18,
7.19, and 7.20 illustrate maxillary molar teeth in
various aspects.
7.2.7 Maxillary Second Molars
The maxillary second molar supplements the first
molar in function. The roots of this tooth are as
long as, if not somewhat longer than, those of the
first molar. The tendency for root fusion is greater
in the second maxillary molar than in the first
maxillary molar, but the palatal root is usually
separate. Most often maxillary second molars
possess three roots and three canals. The mesio-
buccal root of the maxillary second molar is not
as complex as that formed in the maxillary first
molar. The tendency for a very wide mesiobuccal
canal is not present in the maxillary second molar
[3]. Morphological aspects of the root and root
canal anatomy of this tooth group are detailed in
Table 7.7 and Figs. 7.21 and 7.22, while
Figs. 7.17, 7.18, 7.19, and 7.20 illustrate maxil-
lary molar teeth in various aspects.
7 Root Canal Anatomy of Maxillary and Mandibular Teeth 201

Fig. 7.8 3D models depicting the internal anatomy of maxillary canines

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202 M. A. Versiani et al.

Fig. 7.9 3D models depicting the internal anatomy of maxillary canines

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 203

Fig. 7.10 Different Frontal View Lateral View

views of the internal
anatomy of a
representative maxillary
first premolar

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

Palatal

Buccal

7.3 Mandibular Teeth
The term mandibular refers to the lower jaw, or
mandible.
7.3.1 Mandibular Incisors
The mandibular central incisors are centered in
the mandible, one on either side of the median
line, with the mesial surface of each one in con-
tact with the mesial surface of the other. The
right and left mandibular lateral incisors are dis-
tal to the central incisors. The mandibular inci-
sors have smaller mesiodistal dimensions than
any of the other teeth. The central incisor is
somewhat smaller than the lateral incisor, which
is the reverse of the situation in the maxilla.
These teeth are similar in form and have smooth
crown surfaces that show few traces of develop-
mental lines. The mandibular central incisor is
the smallest tooth in the mouth, but the bucco-
lingual dimension of its root is very large. This
tooth usually has one canal; two canals may be
found, but not very frequently. The pulp horn is
well developed in this tooth. The mandibular

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Fig. 7.11 3D models depicting the internal anatomy of maxillary premolars

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 205

Fig. 7.12 3D models depicting the internal anatomy of maxillary premolars

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206 M. A. Versiani et al.

Fig. 7.13 3D models depicting the internal anatomy of three-rooted maxillary premolars

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 207

Fig. 7.14 3D models depicting the internal anatomy of three-rooted maxillary premolars

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208 M. A. Versiani et al.

Fig. 7.15 Different Frontal View Lateral View

views of the internal
anatomy of a
representative maxillary
second premolar

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

Palatal

Buccal

lateral incisor tends to be a little larger than the
mandibular central incisor in all dimensions,
and the pulp chamber is also larger. The pulp
canal may taper gently from the apex or narrow
abruptly in the last 3–4 mm of the canal [3].
Morphological aspects of the root and root canal
anatomy of this tooth group are detailed in
Table 7.8, while Figs. 7.23, 7.24, and 7.25 illus-
trate this tooth in various aspects.
7.3.2 Mandibular Canines
The mandibular canine crown is narrower mesio-
distally than that of the maxillary canine, although
it is just as long in most instances and, in many
instances, is longer by 0.5–1 mm. The root may
be as long as that of the maxillary canine, but
usually it is somewhat shorter. The pulp cavity of
the mandibular canine tends to be a little shorter

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 209

Frontal View Lateral View

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

P P
P

MB 2
DB
DB MB DB
MB

MB 1

Fig. 7.16 Different views of the internal anatomy of a representative maxillary first molar

to that of the maxillary canine. A not rare varia-
tion in the form of the mandibular canine is bifur-
cated roots, and it is also not uncommon to find
two roots or at least two canals. Because the pres-
ence of two canals cannot be easily detected
radiographically, their presence must be ruled out
clinically as well. Some mandibular canines
demonstrate an abrupt narrowing of the pulp cav-
ity when passing from the region of the pulp
chamber to the region of the pulp canal. Other
mandibular canines demonstrate an abrupt nar-
rowing of the pulp canal in the apical region [3].
Morphological aspects of the root and root canal
anatomy of this tooth group are detailed in
Table 7.9, while Figs. 7.26, 7.27, and 7.28 illus-
trate this tooth in various aspects.
7.3.3 Mandibular First Premolars
The first premolar is always the smaller of the
two mandibular premolars, whereas the opposite
is true, in many cases, of the maxillary premo-
lars. Most of these teeth have one canal, but two
or three canals are possible. The pulp chamber is
usually very large, and the pulp cavity may taper
gently toward the apex or abruptly as the root
canal starts. The root of the first premolar usually

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210 M. A. Versiani et al.

Fig. 7.17 3D models depicting the internal anatomy of maxillary molars

shows a deep developmental groove which has
been associated with complex anatomical fea-
tures including C-shaped and extra root canals
[3]. Morphological aspects of the root and root
canal anatomy of this tooth group are detailed in
Table 7.10 and Fig. 7.29, while Figs. 7.30, 7.31,
and 7.32 illustrate mandibular premolar teeth in
various aspects.
7.3.4 Mandibular Second Premolars
The second premolar has three well-formed cusps
in most cases, one large buccal cusp and two
smaller lingual cusps. It usually has one root and
canal that may be curved, but usually in the distal
direction. The pulp horns are prominent, and the
pulp chamber and root canal gently taper toward

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 211

Fig. 7.18 3D models depicting the internal anatomy of maxillary molars

the apex. The single root of the second premolar is
larger and longer than that of the first premolar.
The root is seldom, if ever, bifurcated, although
some specimens show a deep developmental
groove buccally [3]. Morphological aspects of the
root and root canal anatomy of this tooth group
are detailed in Table 7.11 and Fig. 7.33, while
Figs. 7.30, 7.31, and 7.32 illustrate mandibular
premolar teeth in various aspects.
7.3.5 Mandibular First Molars
The mandibular first molar is usually the largest
tooth in the mandibular arch. It has five well-­
developed cusps and two well-developed roots,
one mesial and one distal, which are very broad
buccolingually. These roots are widely separated
at the apices. The buccolingual cross section of
the mandibular first molar demonstrates a large

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212 M. A. Versiani et al.

Fig. 7.19 3D models depicting the internal anatomy of maxillary molars

pulp chamber that may extend well down into the
root formation. The mesial root usually has a
more complicated root canal system because of
the presence of two canals. The distal root usu-
ally has one large canal, but two canals are often
present. Occasionally, a fourth canal is present
that has its own separate root [3]. Morphological
aspects of the root and root canal anatomy of this
tooth group are detailed in Table 7.12 and
Fig. 7.34, while Figs. 7.35, 7.36, 7.37, 7.38, 7.39,
and 7.40 illustrate mandibular molar teeth in vari-
ous aspects.
7.3.6 Mandibular Second Molars
Normally, the second molar has four well-­
developed cusps, two buccal and two lingual, of
nearly equal development. The tooth has two well-
developed roots, one mesial and one distal. These

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 213

Fig. 7.20 3D models depicting the internal anatomy of maxillary molars with fusion or gemination

roots are broad buccolingually, but they are not as
broad as those of the first molar, nor are they as
widely separated. The buccolingual section of the
mandibular second molar demonstrates a pulp
chamber and pulp canals that tend to be more vari-
able and complex than those found in the mandib-
ular first molar [3]. Morphological aspects of the
root and root canal anatomy of this tooth group are
detailed in Table 7.13 and Fig. 7.41, while
Figs. 7.35, 7.36, 7.37, 7.38, 7.39, and 7.40 illus-
trate mandibular molar teeth in various aspects.
7.4  oot Canal Configuration
R nondestructive imaging technologies, such as
in Epidemiological Studies
Dental diaphanization has been widely used in
the study of anatomical features of the root and
root canal system. This technique has been
shown to be very useful in revealing the com-
plexity of the root canal system and for classify-
ing anatomically several root canal configuration
types. Consequently, some results from studies
using this method were previously detailed in
this chapter. However, diaphanization is a time-­
consuming procedure, and, because of its
destructive nature, irreversible changes and arti-
facts are produced in the specimens.
Consequently, past studies using this technique
were restricted in terms of sample size and,
moreover, prone to methodological shortcom-
ings. To overcome some of these drawbacks,
micro-CT and CBCT, have been proposed for
the study of root and canal anatomy. The most
important advantage of using CBCT in this type
of study is the possibility of performing in vivo
analysis of large populations, addressing the

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214 M. A. Versiani et al.

Frontal View Lateral View

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

P P

MB 2
MB 2
DB DB
MB
DB
MB 1

MB 1

Fig. 7.21 Different views of the internal anatomy of a representative maxillary second molar

influence of several variables such as ethnicity,
aging, gender, etc. In Chap. 6, the main results
obtained in the in vivo and ex vivo morphologi-
cal research studies of distinct groups of teeth
using CBCT and micro-CT methods were
described. In this chapter, outcomes from epide-
miological studies using CBCT in large popula-
tions, in which both root and root canal anatomy
were evaluated, were selected and combined,
aiming to offer an overview of the percentage
frequency of different number of roots and root
canal configuration types in all groups of teeth
(Tables 7.14 and 7.15). Despite most of the
highest percentage frequencies observed in
these studies were in accordance with results
obtained by conventional methods, newest
information regarding root canal configuration
are now available.

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 215

Fig. 7.22 3D models depicting the internal anatomy of maxillary second molars with fused roots (Courtesy of Dr.
Ordinola-Zapata)

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216 M. A. Versiani et al.

Fig. 7.23 Different Frontal View Lateral View

views of the internal
anatomy of a
representative
mandibular incisor

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 217

Fig. 7.24 3D models depicting the internal anatomy of mandibular incisors

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218 M. A. Versiani et al.

Fig. 7.25 3D models depicting the internal anatomy of mandibular incisors

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 219

Fig. 7.26 Different Frontal View Lateral View

views of the internal
anatomy of a
representative
mandibular canine

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

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220 M. A. Versiani et al.

Fig. 7.27 3D models depicting the internal anatomy of mandibular canines

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 221

Fig. 7.28 3D models depicting the internal anatomy of double-rooted mandibular canines

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222 M. A. Versiani et al.

Fig. 7.29 Different Frontal View Lateral View

views of the internal
anatomy of a
representative
mandibular first
premolar

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 223

Fig. 7.30 3D models depicting the internal anatomy of mandibular premolars

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224 M. A. Versiani et al.

Fig. 7.31 3D models depicting the internal anatomy of mandibular premolars

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 225

Fig. 7.32 3D models depicting the internal anatomy of mandibular premolars

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226 M. A. Versiani et al.

Fig. 7.33 Different Frontal View Lateral View

views of the internal
anatomy of a
representative
mandibular second
premolar

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 227

Frontal View Lateral View

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

Mesial Distal MV
MV

D
D ML
ML

Fig. 7.34 Different views of the internal anatomy of a representative mandibular first molar

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228 M. A. Versiani et al.

Fig. 7.35 3D models depicting the internal anatomy of mandibular molars

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 229

Fig. 7.36 3D models depicting the internal anatomy of mandibular molars

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230 M. A. Versiani et al.

Fig. 7.37 3D models depicting the internal anatomy of mandibular molars

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 231

Fig. 7.38 3D models depicting the internal anatomy of the mesial root of mandibular molars with middle mesial canals

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232 M. A. Versiani et al.

Fig. 7.39 3D models depicting the internal anatomy of mandibular molars with C-shaped canal configuration

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7 Root Canal Anatomy of Maxillary and Mandibular Teeth 233

Fig. 7.40 3D models depicting the internal anatomy of mandibular molars with radix

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234 M. A. Versiani et al.

Fig. 7.41 Different Frontal View Lateral View

views of the internal
anatomy of a
representative
mandibular second
molar

Transversal Cross-Sections

Coronal Third Middle Third Apical Third

Mesial Distal

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 The Complexity of the Apical
Anatomy
Domenico Ricucci, Elizeu A. Pascon,
and José F. Siqueira Jr.
Abstract
The apical portion of the root canal system is
characterized by a very complex and variable
anatomy. The main canal displays a constric-
tion located slightly short of the main apical
foramen, but ramifications are common. After
pulp exposure by caries, necrosis and infec-
tion progress slowly in an apical direction and
give rise to apical periodontitis, even before
the pulp is completely necrotic and infected.
Bacteria infecting the apical portion of the
root canal system are the main cause of post-
treatment apical periodontitis. The ideal api-
cal limit of endodontic procedures is the
apical constriction, but this structure is not
always present. Pathologic changes, such as
resorption of the apical root structure and
canal calcification, may make it difficult to
establish an adequate working length for end-
odontic procedures. In the light of the histo-
logical and microbiological conditions of the
apical pulp tissue, the apical patency concept
seems justified in cases with pulp necrosis/
infection.
D. Ricucci, M.D., D.D.S. (*)
Private Practice, Cetraro, Italy
e-mail: dricucci@libero.it
E. A. Pascon, D.D.S., M.Sc., Ph.D.
Private Practice, São Paulo, SP, Brazil
J. F. Siqueira Jr., D.D.S., M.Sc., Ph.D.
Department of Endodontics, Faculty of Dentistry,
Estácio de Sá University, Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_8
pilararaya@ejercer.cl
8
8.1 Introduction
There is general agreement that the root canal sys-
tem anatomy in the apical region, with its physio-
logical and pathological variations, can rarely be
fully anticipated on the basis of conventional peri-
apical radiographs or cone beam computed tomog-
raphy (CBCT). This includes ramifications and
lateral canals, frequently present in the apical third,
the fine variations in the topography of their foram-
ina, and also the sequelae of infection/inflamma-
tion, such as resorption and calcification.
The complexity of the root canal anatomy in
the apical third and the preoperative histologic
and microbiologic conditions of the pulp tissue
can be regarded as the two major factors affecting
the success rate of the endodontic treatment [1,
2]. Inflammation—up to necrosis—of the pulp
tissue consequent to caries, trauma, or periodon-
tal disease may considerably alter the apical den-
tin and cementum, resulting in morphological
changes that may have an impact on root canal
instrumentation and obturation procedures.
8.2 Anatomical Features
of the Apical Root Canal
System (in the Absence
of Pathology)
The root canal usually narrows toward the apex
and then expands to form the apical foramen.
241
242 D. Ricucci et al.

The narrowest part of the canal forms the apical
constriction, which is located just short of the
apical foramen. Its distance to the apical fora-
men varies from 0.5 to 1 mm in teeth from indi-
viduals with different ages [3–5]. The
configuration of exclusively a single canal, with
no ramifications, terminating at the geometrical
top of the root (Fig. 8.1) is relatively uncommon.
In more than 60% of the teeth, the apical fora-
men is not located at the root apex, and the dis-
tance between the apical foramen and the
radiographic apex ranges from 0 to 3 mm [3, 6].
Kuttler [3] observed that the mean apex-to-fora-
men distance was 0.48 mm for young individu-
als and 0.6 mm for older ones, while Dummer
et al. [4] reported a mean apex-to-­foramen dis-
tance in anterior teeth of 0.36 mm. The fact that
the main foramen frequently ends at a location
short of the root apex (Fig. 8.2) represents a
problem for the endodontist, because this condi-
tion can only be recognized in the radiographs
when the foramen exits on the mesial or distal
aspect of the root [7].
The analysis of the mineralized tissue topog-
raphy (dentin and cementum) forming the apical
structure and their interrelationship deserves par-
ticular attention. The cementum layering the
external apical surface folds into the foraminal
opening extending to varying distances in coro-
nal direction. The area where the cementum ends
in the apical canal is called cementum-dentin
junction (CDJ). In the past, it was believed that
the CDJ coincided with the smaller diameter or
“apical constriction” [8, 9]. Thus, it was recom-
mended that this point be the apical limit of root
canal instrumentation and obturation procedures
[10]. However, histologic observations show that
the CDJ rarely coincides with the apical constric-
tion. In longitudinal sections cut through the api-
cal canal, the CDJ is frequently observed to be
several millimeters higher on one wall than on
the opposite wall [1, 11, 12] (Fig. 8.3).
It is also salient to address the characteristics
of the soft tissue present in the apical canal.
Odontoblasts are absent in the funnel-shaped
foraminal area. Therefore, in the very end of the

a b

Fig. 8.1 Examples of single root canals ending approximately at the geometrical top of the root. (a) Single-rooted
maxillary third molar. (b) Distal root of a mandibular first molar (hematoxylin-eosin, original magnification ×16)

pilararaya@ejercer.cl
8 The Complexity of the Apical Anatomy 243

a b

Fig. 8.2 (a, b) Mesial roots of mandibular first molars. Sections show foramens ending at a location short of the radio-
graphic apices (hematoxylin-eosin, original magnification ×16)

It has to be kept in mind, however, that the

Fig. 8.3 Maxillary premolar with apical periodontitis.
The CDJ is located at different levels on opposite walls,
and it does not coincide with the apical constriction
(hematoxylin-eosin, original magnification ×16)
canal, the tissue should not be called pulp tissue,
as it is indistinguishable from the adjacent peri-
odontal ligament. In fact, it is constituted mainly
by fibroblasts and collagen bundles, and it is
crossed by numerous vessels and nerves entering
the pulp space.
discussion on the combination of tissues present
in the apical end of the canal may be purely aca-
demic, with little or no practical impact on the
clinic. In fact, it is a common occurrence that the
main canal in the apical third divides into two or
more branches, each ending on the external root
surface with a distinct foramen.
The anatomical complexity of the root canal
system, and particularly of the apical third, has
been discussed in the dental literature since the
beginning of the last century. Several studies
have been published describing the varying anas-
tomosing canal system [13, 14]. Kuttler [3]
­provided a deep morphological analysis of the
apical root region.
In the past, the most commonly used methods
for studying the root canal anatomy and to ascer-
tain the presence of ramifications of the main
canal, as well as localization and number of
foramina, were based on tooth clearing [15, 16].
Images were obtained showing that in some
instances the apical anatomy of all teeth were

pilararaya@ejercer.cl
244 D. Ricucci et al.

a b

Fig. 8.4 Cleared roots of teeth whose canals were Mesial root of a mandibular first molar showing a very
injected with a dye. (a) Maxillary canine. An apical delta complex apical anatomy (Courtesy of Dr. G. Riitano.
with several branches is present in the apical root end. (b) From collection of Dr. F. Riitano)

very complex, with the main canal dividing into

two or more branches that give rise to an intricate
system (Fig. 8.4). These observations raised the
concern that, from a clinical point of view, there
could not be correspondence between the shape
of endodontic files and the apical canal morphol-
ogy [16] (Fig. 8.4).
Scanning electron microscopy (SEM) has also
been widely used in the study of morphology,
location, and number of foraminal openings [17]
(Fig. 8.5). The limitation of this methodology is
that it allows exclusively for the observation of
the external surface of the structure under investi-
Fig. 8.5 Apex of the distal root of a mandibular first
gation. Therefore, only the external apical sur-
molar examined with SEM. Four foraminal openings are
face can be analyzed, together with the outer present (Courtesy of Dr. Pablo Ensinas)
morphology of foramina.
The advent of three-dimensional (3D) imag- of lateral canals and/or apical ramifications was
ing, specifically the micro-computed tomography approximately 75%. Ramifications were reported
(micro-CT), has overcome most limitations of to occur more commonly in the apical portion
previous investigation techniques. This technol- and in posterior teeth [15]. Vertucci [22] reported
ogy is nondestructive and has the great advantage that ramifications are found in the apical third of
that the internal anatomy of teeth can be recon- the root in 73.5% of the cases, while in the mid-
structed and observed from various angles dle third and in the coronal third, they are
[18–20]. observed in 11% and in 15%, respectively.
The frequency of ramifications deserves par- Using a micro-CT approach that involved
ticular attention. Ricucci and Siqueira [21] in a centerline-­fitting algorithm, Xu et al. [23]
sample of 493 human teeth investigated with assessed the morphologic features of lateral
light microscopy found that the overall ­prevalence canals in the apical 3 mm of 204 permanent

pilararaya@ejercer.cl
8 The Complexity of the Apical Anatomy
teeth. They found lateral canals (total number
178) in 93 apical root segments. The number of
lateral canals varied from 1 to 7 per root.
Interestingly the median diameter of the ramifi-
cations was 67.0 μm (data ranging from 16.7 to
238.4 μm).
A distinction is made between lateral canals
and apical deltas. Lateral canals are those
­branching from the main canal, which is still dis-
tinguishable up to its exit. On the other hand, the
morphological pattern observed when a root
canal divides into three or more ramifications
near the root apex, with the main canal becoming
indistinguishable, is referred to as “apical delta”
[24]. The apical delta can be defined as an intri-
cate system of spaces within the root canal that
allows free passage of blood vessels and nerves
from the periapical compartment to the pulp tis-
sue [24].
Using a large sample from a native Chinese
population (1400 permanent teeth; 100 teeth for
each tooth type except for the third molar), Gao
et al. [24] investigated the frequency and the mor-
phologic features of apical deltas in human teeth
with micro-CT and a centerline-fitting algorithm.
A total of 136 apical deltas were detected, and the
prevalence of the apical delta was 9.7% (6.3%,
8.8%, and 15.8% in anterior, premolars, and
molars, respectively). Of the 136 apical deltas,
634 apical delta branches, ranging from 3 to 18,
were detected. Data concerning vertical exten-
sion of the apical deltas is especially relevant
from a clinical perspective. The median vertical
distance from the beginning of the first apical
delta branch to the apex was 1.87 mm (ranging
from 0.62 to 5.08 mm), and 13% (18/136) were
more than 3 mm long. According to this numbers,
if 3 mm of the apical structure are resected during
surgical procedures, in 87% of the cases, the api-
cal deltas with infecting bacterial biofilms will be
fully removed. However, the other 13% of the
apical deltas with longer vertical extensions
would harbor exposed biofilm-infected ramifica-
tions. Therefore, a valid practical recommenda-
tion is to meticulously observe the resected
surface under surgical microscope with dyes for
remaining ramifications and eventually extend
the resection length accordingly [24].
pilararaya@ejercer.cl
245
The reported prevalence of apical deltas in
human permanent teeth may vary considerably
and is likely dependent on the geographical areas
where the studies were conducted, the tooth type,
and the analytical methods. In a Turkish popula-
tion, the prevalence of apical deltas was found to
be as high as 23.5% in mandibular lateral inci-
sors, while it was 9.8% in mandibular central
incisors and 7.8% in mandibular canines [25].
8.3 Histopathologic Facts
Affecting the Apical Dentin-­
Pulp Complex
Establishment of pulp necrosis and bacterial col-
onization in the root canal has a profound impact
on the condition of the apical canal system, which
may adversely affect the outcome of endodontic
treatment procedures. The successive events tak-
ing place in the progress of pulp degeneration are
discussed next.
When the pulp is exposed by caries, acute
inflammation usually takes place and conse-
quently leads to the establishment of necrotic
areas in the coronal pulp. Bacteria from the caries
biofilm usually invade and colonize the necrotic
compartments of tissue. The advance of inflam-
mation, necrosis, and infection through the pulp
tissue in an apical direction is usually a slow pro-
cess. In early stages, tissue areas involved by
necrosis are minimal. Bacteria are observed in
the necrotic tissue, surrounded by a concentration
of polymorphonuclear leukocytes (PMNs). An
accumulation of chronic inflammatory cells sur-
rounds the area with acute inflammation, while
the rest of the pulp can be vital and free from sig-
nificant pathological changes. With passage of
time, successively larger areas of the coronal
pulp become involved by necrosis and infection,
and the process trespasses the root canal orifices
to reach the radicular pulp tissue, gradually
advancing toward the apical part of the root canal.
Contrary to a widely held opinion, it is not
necessary that the entire pulp becomes necrotic
and the frontline of infection reaches the apical
foramen for apical periodontitis to develop. Early
inflammatory changes can be observed in the
246
a­ pical periodontal tissues even when necrosis is
still confined to the pulp chamber. In many teeth,
widening of the periodontal ligament space can
be radiographically discernible at this stage.
From a clinical perspective, it is important to
point out that most of the tissue present in lat-
eral canals and apical ramifications is vital and
free from bacterial colonization [2, 12, 26–28]
(Figs. 8.6 and 8.7). These ramifications are
unlikely to be debrided with contemporary
instrumentation devices and protocols. On the
contrary, maintaining the vitality of the tissue in
these spaces is advantageous (Fig. 8.8). Thus, in
all cases where vital tissue is observed in the
root canals, after working length is established
at or near the apical constriction with an elec-
tronic apex locator and confirmed with radio-
graphs, it is advised that instrumentation be
performed without the use of high concentra-
tions of sodium hypochlorite, and no attempts
should be taken to force obturation materials
a b
Fig. 8.6 (a, b) Apex of the mesial root of a mandibular
first molar with the clinical diagnosis of irreversible pulpi-
tis. Vital tissue is present in the main canal and in the
pilararaya@ejercer.cl
D. Ricucci et al.
into ramifications with the intention “of filling
them.” In fact, this might create an unnecessary
larger wound.
In later stages, as necrosis and bacterial
infection are progressing in an apical direction,
a distinct area of transition between necrotic
and viable pulp tissue is often observed. This is
characterized by the following gradient of tis-
sue r­eactions: necrosis/infection–acute inflam-
mation–chronic inflammation–uninflamed
tissue.
Vital, although inflamed, tissue can be
observed in the apical canal also in a certain
­number of cases where a frank periapical radio-
lucency is observed (Fig. 8.9). In a histological
study based on serial sections of 50 apices with
apical periodontitis lesions, Ricucci et al. [28]
observed the presence of vital tissue with vary-
ing degrees of inflammation in the apical por-
tion of the canal in 18 cases, which is in about
one-third of the specimens. Explanation for this
a­ pical ramification (hematoxylin-eosin, original magnifi-
cation ×25 and ×50)
8 The Complexity of the Apical Anatomy
a b
Fig. 8.7 (a) Maxillary second premolar with caries pen-
etrating the pulp chamber and the clinical diagnosis of
irreversible pulpitis. The radiograph shows widening of
the PDL space around the apex. (b) Section cut at the cen-
is simple in terms of inflammation and immu-
nology. As the frontline of infection advances in
an apical direction, the inflamed tissue also
retreats. The extent of the inflamed tissue will
vary from case to case, but it is not restricted to
a small area adjacent to the frontline of infec-
tion. Bacterial virulence factors may diffuse
through the tissues and cause inflammation in a
large area, not only restricted to the narrow area
immediately in contact with the most advanced
bacteria.
From a clinical viewpoint, the important fact
is that the most advanced front of bacterial
infection is in many cases confined to a more
coronal position in the main canal lumen
(Fig. 8.9b). Therefore, the inflamed connective
tissue remaining in the most apical portion may
not be colonized by bacteria, which is similar to
the periradicular inflammatory tissue. This con-
dition is referred to as “partial necrosis” and
pilararaya@ejercer.cl
247
ter of the main canal, displaying a large apical ramifica-
tion. Vital pulp tissue can be observed. Note the thickened
periodontal tissue remaining attached to the root at extrac-
tion (hematoxylin-eosin, original magnification ×16)
helps explain the high rate of success in treat-
ment of teeth with apical periodontitis with
instrumentation limited to 1 mm short of the
apex [29].
The explanation for the resistance of this
apical pulp tissue to necrosis likely resides in
the circulatory system present in the apical
region of the root canal system. The apical third
is the area where ramifications of the main
canal are abundant, and neurovascular bundles
enter from the rich circulatory network of the
periodontal ligament. This allows for the con-
tinuous arrival of nutrients and oxygen, as well
as defense cells and molecules in that most api-
cal area that guarantee survival and oppose bac-
terial advance.
However, if no treatment is provided, it is
highly likely that, with passage of time, the last
portion of apical tissue, including the tissue in
ramifications, will be inevitably affected by
248
Fig. 8.8 Buccal root of a maxillary first premolar that was
extracted because the tooth was non-restorable. The pulp was
vital and the canals were instrumented with NiTi files before
extraction. Working length was established 1.5 mm short of
the radiographic apex. The section shows that short instrumen-
tation respected the tissue present in the apical delta, which
appears vital and continuous with a widened periodontal liga-
ment (hematoxylin-eosin, original magnification ×25)
a b
Fig. 8.9 Mandibular premolar with the diagnosis of
necrotic pulp, extracted with an apical periodontitis lesion
attached. (a) Section showing that the canal ends on the left
side and a ramification is present on the opposite site. Vital
tissue is present in the apical canal (hematoxylin-­eosin, origi-
nal magnification ×25). (b) Section proximal to that in (a).
pilararaya@ejercer.cl
D. Ricucci et al.
necrosis and infection (Fig. 8.10). When infec-
tion reaches the entire extent of the root canal
system up to the apical foramen (and some-
times slightly beyond), possibly affecting api-
cal r­ amifications, complete disinfection
becomes a significant challenge for clinicians.
This is confirmed by histopathologic and histo-
bacteriologic analyses of tissue biopsies con-
sisting of apex and periapical pathologic
tissues, which were obtained by surgical proce-
dures. They displayed that biofilms residing in
apical intricacies of the canal system were not
affected by chemomechanical preparation fol-
lowed by long-term calcium hydroxide medica-
tion [30]. Persistent infection was also observed
even when different irrigants were used in the
same canals and each of them activated by
ultrasonics [31]. Histologic research also did
not lend credit to the common belief that “fill-
ing” the ramifications with obturation materials
would kill bacteria [21]. An in vivo study con-
ducted in human teeth demonstrated that obtu-
ration materials squeezed into lateral canals
and ramifications do not exert significant anti-
bacterial effects, and bacterial biofilms were
observed to remain undisturbed into those
spaces [32].
c
The vital tissue in the apical canal is free from bacteria.
Bacterial biofilms can be observed in the necrotic portion of
the canal, located more coronally (arrow) (Taylor’s modified
Brown & Brenn, original magnification ×16). (c) Section
taken approximately 50 sections away from those in (a, b),
displaying a third foramen (original magnification ×16)
8 The Complexity of the Apical Anatomy 249

a b c

Fig. 8.10 Mandibular premolar with necrotic pulp. (a)
Section cut at the center of the canal showing a delta.
Necrotic tissue and bacterial aggregation can be observed
in ramifications (Taylor’s modified Brown & Brenn, origi-
nal magnification ×16). (b) Magnification of the area of
ramification indicated by the lower arrow in (a). Biofilms
are present in the irregularities of the canal walls.
Concentrations of PMNs in the lumen, intermixed with
scattered bacterial cells (original magnification ×400). (c)
Magnification of the area indicated by the upper arrow in
(a). Large biofilm surrounded by PMNs (original magnifi-
cation ×400)

8.4 Changes in the Apical In teeth with apical periodontitis, both cemen-
Structure as a Result tum and dentin may be resorbed to varying
of Pathologic Conditions extents, up to the point that resorption can be
appreciated on the radiograph. Histologic sec-
Two opposite phenomena may take place conse- tions show loss of hard tissue, enlargement of the
quent to inflammation/infection of the pulp tis- foraminal region (Fig. 8.11a), and shortening of
sue, namely, resorption and apposition of the apical structure with loss of the apical con-
mineralized tissue, i.e., calcification. striction (Fig. 8.11b).
Odontoclasts are the cells responsible for Dystrophic calcifications can also be observed in
tooth resorption. They are motile, multinucleated the apical canal third as pulp stones embedded in the
giant cells and are formed by the fusion of mono- apical canal walls or free in the canal lumen. In addi-
nuclear precursor cells of the monocyte-­ tion, cementum may sometimes show considerable
macrophage lineage. Their morphology is similar thickness, in a condition known as hypercementosis.
to that of osteoclasts. These cells are attracted to Both resorption and calcifications may interfere with
the site of injury by bacterial products or by the proper apical instrumentation, including difficulties
release of pro-inflammatory cytokines produced to establish an adequate working length and to
by host cells. Odontoclasts adhere to the root sur- debride/disinfect the apical canal segment.
face, dissolve the mineralized tissue, degrade the
organic matrix, and create resorption depressions
underneath them on the tooth surface, called 8.5 Apical Limit of Root Canal
Howship’s lacunae. Histologically, resorption Instrumentation
lacunae may be observed on the apical root canal and Obturation: Still
walls of teeth with partial pulp necrosis, when the a Controversial Issue
apical tissue is still vital. When necrosis reaches
the most apical canal, areas of previous resorp- Precise working length determination is an essen-
tion can be seen as irregularities of the walls, tial step in root canal treatment. The length of
often colonized by bacterial biofilms [2]. canal preparation and obturation is a significant

pilararaya@ejercer.cl
250
a b
Fig. 8.11 (a) Maxillary second premolar with necrotic
pulp and a large apical periodontitis lesion. Section cut
through the canal shows resorption of the foraminal walls.
Note the biofilms in the canal lumen (Taylor’s modified
Brown & Brenn, original magnification ×16). (b)
predictor of successful outcome in endodontics
[29, 33, 34]. However, in the light of the dis-
cussed variations in the normal anatomy in
“healthy” teeth and the morphological changes
occurring as a consequence of pulp inflamma-
tion/necrosis, the problem of the apical limit of
endodontic procedures is far from reaching con-
sensus. Gluskin [35] stated that the only thing we
can say “…is that the anatomy is unpredictable…
and the positions we choose to fill out root canals
are inconsistent.”
There seems to be general agreement that the
original Schilder’s recommendation of using the
radiographic apex as the practical apical limit of
endodontic instrumentation and obturation [36,
37] is in contrast to any biological concepts and
evidence. In fact, Schilder’s recommendation
invariably results in instrumentation beyond the
root canal limit, inside the adjacent periodontal
ligament [11, 12]. The vast majority of endodon-
tic schools teach to restrict the operative proce-
dures within the root canal limits, which is short
of the radiographic apex [38].
Although inconsistent [11, 12] (Fig. 8.3), the
CDJ is still indicated by many as the ideal point
for termination of the endodontic procedures
[10]. Although it is admitted that the position and
anatomy of the CDJ may vary considerably from
tooth to tooth, from root to root, and from wall to
wall in each canal, it continues to be erroneously
believed that this point coincides with the apical
constriction [39].
pilararaya@ejercer.cl
D. Ricucci et al.
Mandibular second premolar with necrotic pulp and a
large apical periodontitis lesion. Section cut through the
foramen. Resorption has removed mineralized tissue, to
the point that the root end appears blunt (hematoxylin-
eosin, original magnification ×25)
The apical constriction is the narrowest part of
the root canal with the smallest diameter of blood
supply, and preparation to this point results in a
small wound site and optimal healing conditions
[11]. The apical constriction is advocated by many
authors as the ideal and practical point where the
endodontic procedures should end [4, 6, 39]
regardless of the type of tissue present on opposite
walls [2, 11, 12] (Fig. 8.3). However, it has to be
taken into consideration that the apical constric-
tion may be absent in cases with pulp necrosis and
apical periodontitis lesions, because root apical
resorption of varying severity may have taken
place [27, 28, 40] (Fig. 8.11). Still, in such circum-
stances an effort must be made to confine end-
odontic procedures within the root canal limits.
Locating the apical constriction or, in its
absence, the endpoint of the root canal space is
not always an easy task using common clinical
means. To determine the length of each root
canal, a careful study of properly exposed radio-
graphs, tactile sensation, and knowledge of api-
cal anatomy, supplemented with the use of an
electronic apex locator, will assist the clinician in
establishing the correct working length. After the
first electronic apex locator (EAL) was intro-
duced in 1962 [41], the first two generations of
EALs were found to be unreliable when com-
pared with radiographs, with many of the read-
ings being significantly longer or shorter than the
accepted working length [10], and this was par-
ticularly frequent in the presence of conductive
8 The Complexity of the Apical Anatomy
fluids in the canal. The main shortcoming of early
apex locators was overcome by the adoption of
multiple frequencies to determine the distance
from the end of the canal and with the introduc-
tion of the “ratio method” [42].
Most modern EALs are capable of recording
the point where the tissues of the periodontal
ligament begin outside the root canal [43].
However, it must be kept in mind that, although
modern EALs are reported to have more than
90% accuracy, they still have some limitations.
a b c d
e f
Fig. 8.12 Mandibular second premolar with vital pulp
at the moment it was endodontically treated, 13 years
earlier. (a) The radiograph shows caries destruction of
the crown and the coronal portion of the root. Periapical
conditions are normal. The tooth was extracted and pro-
cessed for histologic evaluation. (b) Photograph of the
apical third at the end of the demineralization process,
while the specimen is immersed in the clearing agent.
The obturated apical canal can be seen, but apical rami-
fications, apparently not injected with obturation materi-
als, can also be distinguished. (c) Section cut
approximately at the center of the canal, encompassing
the apical end of the filling (almost entirely removed by
histological processing). Soft tissue is present apically.
pilararaya@ejercer.cl
251
On the other hand, no individual technique is
truly satisfactory in determining endodontic
working length [10].
From a wound-healing perspective, very
good results are observed when root canal treat-
ment procedures are restricted to the confines of
the root canal system, i.e., at or near the apical
constriction (Fig. 8.12a, b), and infection is
effectively controlled. In most cases, the tissue
in the very apical segment of the canal and in
contact with the filling material can remain vital
The foramen appears completely closed by mineralized
tissue in this section, but the presence of vital tissue in
the foramen indicates that there must be an opening for
vessels in the neighboring section (hematoxylin-eosin,
original magnification ×100). (d) Magnification of the
area indicated by the arrow in (c). Uninflamed connec-
tive tissue in contact with the obturation material (origi-
nal magnification ×400). (e) Section cut through the exit
of the ramification running horizontally in (b) (original
magnification ×100). (f) High power view of the area
indicated by the arrow in (e). Uninflamed connective tis-
sue with fibroblasts and collagen fibers, adjacent to
small masses of obturation materials (original magnifi-
cation ×400)
252
and uninflamed (Fig. 8.12c, d). This tissue
strand is continuous with the periodontal tissue,
and its origin can be either a tissue remaining in
the apical end after instrumentation or a peri-
odontal tissue ingrowing into the apical canal.
The apical foramen may be narrowed by the
deposition of concentric layers of cementum
(Fig. 8.12c, d), but total closure is seldom if ever
observed [44].
The fate of the tissue present in apical ramifi-
cations or deltas is relevant to the clinical out-
come. In cases with vital noninfected tissue in
ramifications at the time of treatment (Figs. 8.6,
8.7, and 8.9), if the pulp tissue is severed to a
level that mechanical instrumentation does not
interfere with the tissue present in ramifications
(Fig. 8.8), and no filling materials are pushed
into these spaces, the vitality of the tissue will
be maintained by the vessels entering from the
rich circulatory network present in the peri-
odontal ligament, the result being a healthy con-
nective tissue with fibroblasts and collagen
bundles (Fig. 8.12e, f) [21]. This picture is
totally different from cases with long-standing
pulp necrosis, in which necrosis and bacterial
colonization are established in the apical ramifi-
cations (Fig. 8.10). Instruments and irrigants
cannot effectively reach and disinfect these
areas. Intracanal medication can sometimes fail
to significantly improve disinfection in these
regions. Therefore, infection spread to lateral or
apical ramifications can result in apical peri-
odontitis lesions that are recalcitrant to treat-
ment in the short term, with occurrence of
persistent symptoms [30], or in the long term,
with lesions that become larger at follow-ups
[31]. In such cases, histobacteriologic analysis
of biopsies consisting of the apex with sur-
rounding pathologic tissue obtained during sur-
gical endodontic procedures demonstrated the
presence of bacteria/bacterial biofilms, which
were not affected by the root canal treatment
procedures [30, 31]. On the other hand, the long
heralded idea that filling lateral canals and api-
cal ramifications with thermally softened gutta-
percha and sealer would kill infecting bacteria
has been proven untrue [32].
pilararaya@ejercer.cl
D. Ricucci et al.
8.6  he Complexity of the Apical
T
Anatomy and the Concept
of Apical Patency
The apical patency concept is another reason of
controversy in endodontics. In its original defini-
tion, “patency” means the use of “a small flexible
K-file, which will passively move through the
apical constricture without widening it” [45]. The
intention is to keep the very apical portion of the
canal free from debris accumulation and to allow
antibacterial irrigants to penetrate the full length
of the canal. The concept gained popularity
among clinicians and dental schools [38], to the
point that it was included in the Glossary of
Endodontic Terms by the American Association
of Endodontists [46].
In general, the discussion on advantages and
disadvantages of “apical patency” does not seem
to consider the different histological and micro-
biological conditions of the apical pulp tissue. In
fact, in teeth with pulp necrosis, where the possi-
bility that the frontline of infection has reached
the apical foraminal area, the use of a patency file
may theoretically favor mechanical disruption of
the biofilms and help diffusion of irrigants in the
most apical canal [47]. However, histobacterio-
logic analysis of failed cases showed that, despite
the use of a patency file, all apical ramifications,
including those with a straight course, harbored a
biofilm [31]. On the other hand, a patency file
might potentially cause extrusion of debris and
irrigants into the periapical area leading to post-
operative pain. From the analysis of the literature,
it is not clear whether the use of a patency file has
an influence on debris extrusion through the fora-
men. Clinical studies showed that maintaining
apical patency did not increase the occurrence of
postoperative pain and flare-up [48, 49]. In all
cases with apical ramifications or deltas, the
important aspect to be considered is that a patency
file will follow just one of the branches (the one
with the straightest route), with no effects on the
remaining branches (Figs. 8.4, 8.5, 8.6, 8.7, and
8.10a). Needless to say, the clinician is not aware
of this occurrence, as ramifications and deltas are
seldom visible in the periapical radiographs.
8 The Complexity of the Apical Anatomy
A study reported that the achievement of patency
of the canal terminus resulted in better outcomes
for both treatment and retreatment cases [50].
In all cases with vital pulp preoperatively, the
use of a patency file is biologically contraindi-
cated [12]. After having obtained a clean apical
pulp wound like that illustrated in Fig. 8.8, mov-
ing a file through randomly one of the two
­ramifications invariably means cutting into undis-
turbed tissue, causing a larger wound.
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 C-Shaped Root Canal System
9
James L. Gutmann

Abstract
While the prevalence of C-shaped canals is low
in many parts of the world, the incidence may
be high in specific countries and ethnic popula-
tions. One of the contributing factors that masks
more detailed information on this anatomical
variation is the difficulty in using periapical
radiographs alone to determine its presence.
While the literature is replete with studies that
indicate that mandibular second molar and first
premolar may exhibit this variation most often,
other teeth such as the maxillary molars may
also demonstrate this anatomical complexity.
1778 [3], and Thomas Bell in 1831 [4]. Keith and
Knowles provided a description of the C-shaped
canal anatomy in 1911 [5], with Keith providing
greater clarity in 1913 in what was being character-
ized as a molar of the Brelade dentition [6] (Fig. 9.1).
Further evidence for this anatomical occurrence can
be seen in the publications of Hess in 1917 [7],
Keller in 1928 [8], and Nespoulos in 1929 [9], with

9.1 Introduction

Historically, and as of this date, the C-shaped root/

canal configuration was identified in 12.5% from the
remains of a group of 17 individuals from the El
Mirador cave in the Sierra de Atapuerca (Spain) near
the city of Burgos [1]. The remains were dated to
4400 years ago (the Bronze Age) and represent one
of the first, if not the first, record of this anatomical
configuration in Europe. In recent centuries, there
were suggestions of C-shaped root/canal anatomies
in 1743 according to Malpighii [2], John Hunter in

J. L. Gutmann, D.D.S., Cert. Endo., Ph.D.

Texas A&M University College of Dentistry,
Dallas, TX, USA Fig. 9.1 (a) The labial aspect of a second lower molar of
e-mail: jlg@histden.org Brelade dentition; (a′) chewing surface; (a″) distal aspect;
(a‴) cross section of root. Reproduced from Keith [6]
© Springer International Publishing AG, part of Springer Nature 2019 255
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_9

pilararaya@ejercer.cl
256 J. L. Gutmann

morphological reconstructions by Mayer in 1960 in their analysis of the C-shaped variant in 1941 [12]
[10] (Fig. 9.2a–c). Initially, Keith [6] described this referred to this anatomy as a “gutter-shaped root
anatomical variation as a form of taurodontism. canal,” while Tratman [13] in 1950 referred to the
According to Kato et al. [11], Nakayama and Toda morphology as “horseshoe reduction form.”

a b c

d e

f g h

Fig. 9.2 (a–c) Morphological reconstructions by Mayer of Endodonzia, 2010). (d, e) Current example of a reconstructed
two C-shaped molars and one premolar, respectively [10]. C-shape found in a mandibular second molar (Courtesy of
Reproduced by permission of Nicola Perrini (Storia anatom- Dr. Bing Fan, Wuhan China); (f–h) Examples of C-shaped
ica del sistema dei canali radicolari. Società Italiana di canals (Courtesy of Dr. Bing Fan, Wuhan China)

pilararaya@ejercer.cl
9 C-Shaped Root Canal System
Contemporarily, the clinical perspective on the
C-shaped canal was highlighted and amplified by
Cooke and Cox in 1979 [14], although descrip-
tions were provided a few years earlier by Piñeda
and Kuttler [15] and Waikai [16]. Cumulatively,
these papers set in motion a renewed interest
in all phases of the clinical management of the
C-shaped canal system (Fig. 9.2d–h).
9.2 Present Literature
Documentation
Today’s literature is replete with studies that have
attempted to determine the incidence of C-shaped
canals in specific populations, many of which
were highlighted in recent systematic reviews
[11, 17–19]. Most have identified this finding in
Asian populations that may vary by country.
a b
e f
Fig. 9.3 (a) Mandibular second molar with a C-shaped
root and canal. Unique with this molar is that the “C”
opens to the lingual. Most commonly this anatomy is seen
to open to the buccal or vestibular; (b–d) Three mandibu-
lar second molars that give the appearance of having
C-shaped roots/canals when viewed on two-dimensional
radiographs; (e) CBCT of a maxillary molar that exhibits
pilararaya@ejercer.cl
257
While the majority of published studies address
the presence of this anatomical anomaly in man-
dibular second molars [20–55] (Fig. 9.3a–d),
other teeth, such as maxillary molars (Fig. 9.3e,
f), including third molars [56–70] and mandibu-
lar premolars (Table 9.1) [71–82], have been the
focus of numerous recent studies [83, 84] and
systematic reviews [85].
9.3 Classification of C-Shaped
Canal Morphologies
Due to the high incidence of C-shaped canal mor-
phologies found in the mandibular second molars,
the features that they present are primarily used
for the classification purposes. The resultant ana-
tomical characteristics are due to incomplete root
separation that is speculated to be caused by the
c d
g
a C-shaped canal configuration (Reproduced from
Siqueira Lopes et al. 2016); (f) Proximal view of maxil-
lary molars that exhibit root fusion, primarily in the sec-
ond molar. These teeth often will display a C-shaped root
canal system; (g) Endodontic access opening exposing an
eccentric ribbon-shaped canal space that characterizes the
C-shaped canal
258 J. L. Gutmann

Table 9.1 Incidence of C-shaped canals in mandibular first premolars

Investigators Country Sample size No. C-shaped rootsR/canalsC Total (%) Method of evaluation
Baisden et al. [71] USA 106 15R 14 Sectioning
Sikri and Sikri [72] India 112 11C 10 Angled X-rays
Lu et al. [73] China 82 15C 18 Sectioning
Rahimi et al. [74] Iran 163 4C 2.4 Ink/clearing
Fan et al. [75] China 358 86R 24 Micro-CT
Velmurugan et al. [76] India 100 1C 1 Clearing
Sandhya et al. [77] India 100 2C 2 Spiral CT
Fan et al. [78] China 534 97C 18 Micro-CT
Yu et al. [79] China 178 2C 1.1 CBCT
Yang et al. [80] China 440 5C 1.14 CBCT
Gu et al. [81] China 148 29C 20 Micro-CT
Arsian et al. [82] Turkey 110 4C 2.5 CBCT

failure of Hertwig’s epithelial root sheath to fuse a m m m

on the lingual or buccal surface [17, 86]. This
results in a ribbon-shaped canal space that is often
eccentric to the lingual side of the C-shaped radic-
ular dentin [28, 32] (Fig. 9.3g). The concept of a
C-shaped morphology is based on the cross sec- d d d
tion of the root and the canal. The floor of the pulp b C1 C2
chamber in C-shaped root often displays a single,
ribbon-shaped orifice with an arc of 180° or more, b
a
which may begin at the mesial-lingual line angle
C3 C4
and move around the buccal to the end at the distal
aspect of the chamber (Fig. 9.3g). Similar to an
c d e
iceberg where 7/8 its anatomy and shape lies
below the surface of the water, the anatomy of the C5
C-shaped root canal can display a wide range of
variations over the length of the root that have f
been seen historically through sections and con- c a b c
temporarily through the use of the micro-CT.
In the last 10 years, there have been few trea-
tises that have provided a thorough assessment of
the C-shaped root canal configurations [11, 17–
19]. However, the initial attempt to classify this
d e f
unusual anatomical finding and its particular
irregularities was addressed by Melton in 1991
and was characterized as follows [87] (Fig. 9.4a):

• Category I: A continuous C-shaped canal

that flows from the pulp chamber to the apex
delineates a C-shaped outline without any
separation.
• Category II: A semicolon-shaped orifice in
which dentin separates the main C-shaped
canal from one distinct mesial canal.
Fig. 9.4 (a) Diagrammatic representation of Melton’s
classification of C-shaped canal orifices; (b) Classification
of C-shaped canals according to Dr. Bing Fan (Reproduced
by permission from Fan et al. [28]); (c) Examples of some
micro-CT images of a tooth with C-shaped canal system.
a, canal orifice; b, coronal, third point; c, mid-­root; d, api-
cal, third point; e, 2 mm above apex; f, 1 mm above apex
(Reproduced by permission from Fan et al. [28])

pilararaya@ejercer.cl
9 C-Shaped Root Canal System
• Category III: Those anatomies with two or
more discrete and separate canals with a: (1)
subdivision I, C-shaped orifice in the coro-
nal third that divides into two or more dis-
crete and separate canals joining apically; (2)
­subdivision II, C-shaped orifice in the coronal
third that divides into two or more discrete and
separate canals in the mid-root to the apex;
and (3) subdivision III, C-shaped orifice that
divides into two or more discrete and separate
canals in the coronal third.
In Melton’s classification, only three arbitrary
section levels were chosen, therein abandoning
all the information on how the anatomy of the
canals may change over their length from orifice
to apex. Needless to say, the micro-CT was not
available at this time to provide better clarifica-
tion of the anatomical variances.
The next major classification system pre-
sented took advantage of the newer technology
with the application of extensive micro-CT sec-
tions. Accordingly, and bolstered with new ana-
tomical information, Fan et al. [28] modified
Melton’s classification as follows (Fig. 9.4b):
• Category I: The shape of the canal was an
interrupted “C” with no separation or division.
• Category II: The canal shape resembled a
semicolon resulting from a discontinuation of
a b
Fig. 9.5 Radiographic types: (a) type I; (b) type II; (c) type III (Reproduced by permission from Fan et al. [29])
pilararaya@ejercer.cl
259
the “C” outline; however, either angle created
should be no less than 60°.
• Category III: Two or three separate canals
were present and both angles created were less
than 60°.
• Category IV: Only one round or oval canal
was present in that cross section.
• Category V: No canal lumen could be observed
(usually seen near the apex only) in this
variant.
Fan and co-investigators felt that although
the C-type orifice may have looked like two or
three separate orifices, an isthmus linking them
was often discernible. The single, round, or oval
canal that may be found near the apex should
be considered as a variation because other parts
of the canal have shown the “C” configuration.
Furthermore, they noted that “C” shape often
varies along the root length so the clinical crown
morphology or the appearance of the orifice may
not be good predictors of the actual canal anat-
omy (Fig. 9.4c). In this classification, one of the
canals in the C2 category would appear as an arc
(i.e., the C2 canal would be more likely to extend
into the fused area of the root where the dentin
wall may be quite thin) [17].
To establish more clinical relevancy, Fan et al.
[29] classified the C-shaped root canals radio-
graphically into three types as follows (Fig. 9.5):
c
260 J. L. Gutmann

• Type I: conical or square root with a vague, before exiting at the apical foramen (foram-
radiolucent longitudinal line separating the ina) (Fig. 9.6a).
root into distal and mesial parts. There was a • Type II: conical or square root with a vague,
mesial and a distal canal that merged into one radiolucent longitudinal line separating the

a a b c

d e f

b a b c

d e f

c a b c

d e f

Fig. 9.6 (A) Radiograph and the corresponding micro-
­CT cross sections of a type I tooth. (a) Canal orifice; (b)
1.5 mm below the orifice; (c) coronal-third point of canal;
(d) middle of canal; (e) apical-third point; (f) 0.5 mm from
the apex; (B) Radiograph and the corresponding micro-
­CT cross sections of a type II tooth. (a) Canal orifice; (b)
1.5 mm below the orifice; (c) coronal-third point; (d) mid-
dle of canal; (e) apical-third point; (f) 0.5 mm from the
apex; (C) Radiograph and the corresponding micro-CT
cross sections of a type III tooth. (a) Canal orifice; (b)
1.5 mm below the orifice; (c) coronal-third point; (d) mid-
dle of canal; (e) apical-third point; (f) 0.5 mm from the
apex (Reproduced by permission from Fan et al. [29])

pilararaya@ejercer.cl
9 C-Shaped Root Canal System
root into distal and mesial parts. There was a
mesial and a distal canal, and the two canals
appeared to continue on their own pathway to
the apex (Fig. 9.6b).
• Type III: conical or square root with a vague,
radiolucent longitudinal line separating the
root into distal and mesial parts. There was a
mesial and a distal canal, one canal curved to
and superimposed on this radiolucent line
when running toward the apex, and the other
canal appeared to continue on its own path-
way to the apex (Fig. 9.6c).
While two-dimensional radiograph imaging
has given us a reasonable assessment of the pres-
ence of a C-shaped canal system (Figs. 9.3b–d),
bone image superimposition could significantly
decrease the accuracy of canal recognition [38].
Therefore, to enhance this recognition with
in-­
depth anatomical details, Fan et al. [34],
using an intraradicular contrast medium and
micro-CT assessment (Figs. 9.7 and 9.8), pro-
vided a better delineation of this classification.
Additionally, and more recently, Amoroso-Silva
and colleagues [47] provided a greater analysis
of the C1–C4 configurations (Figs. 9.9 and 9.10)
with the C1 configuration and the distal aspect
of the C2 configuration exhibiting the highest
area values, low roundness values, and large
a b
Fig. 9.7 Classification of radiographic images after contrast medium introduction. (a) Type I; (b) Type II; (c) Type III
(Reproduced by permission from Fan et al. [34])
pilararaya@ejercer.cl
261
apical diameters. Furthermore, the analysis of
the prevalence of the different cross-section
configurations showed that these were predomi-
nantly of the C4 and C3 varieties (1 mm from
the apex) and the C1 and C2 varieties in the cer-
vical third.
In an attempt to assess the three-dimensional
(3-D) morphology of the C-shaped root canal,
Gao and associates [32] used micro-CT and 3-D
reconstruction to classify the canals into three
types (Figs. 9.11 and 9.12).
• Type I (Merging): canals merged into one
major canal before exiting at the apical fora-
men; partial dentin fusion area may appear in
the coronal and/or middle portion of the canal
system.
• Type II (Symmetrical): separated mesial canal
and distal can be located at the mesial part and
distal part of the root, respectively. From the
buccal-lingual view, symmetry of the mesial
canal and distal canal was evident along the
longitudinal axis of the root.
• Type III (Asymmetrical): separate mesial and
distal canals were evident. From a buccal-­
lingual view, the distal canal may have a large
isthmus across the furcation area, which com-
monly made the mesial and distal canal
asymmetrical.
c
262 J. L. Gutmann

a b c d e

f g h i j

k l m n o

Fig. 9.8 Canal variation and 3-D reconstructed canal
configuration of three radiographic types. (a–e) Type I (a,
radiograph; b, reconstructed canal image; c, coronal third
point; d, middle point; e, apical third point); (f–j) Type II
(f, radiograph; g, reconstructed canal image; h, coronal
third point; i, middle point; j, apical third point); (k–o)
Type III (k, radiograph; l, reconstructed canal image; m,
coronal third point; n, middle point; o, apical third point)
(Reproduced by permission from Fan et al. [34])

a b
3 mm
>D: 2.97 (1.89 - 3.88)
<D: 0.99 (0.31 - 1.53)
2 mm
2 mm
>D: 2.42 (1.78 - 5.48) >D: 1.35 (0.78 - 1.79)
<D: 0.88 (0.29 - 1.86) <D: 0.57 (0.47 - 0.75)

1 mm 1 mm
>D: 2.41 (0.95 - 2.86) >D: 0.59 (0.26 - 1.58)
<D: 0.63 (0.47 - 0.77) <D: 0.39 (0.21 - 0.82)

c Distal Mesial

3 mm 3 mm
>D: 1.57 (0.46 - 2.86) >D: 1.12 (0.25 - 4.19)
<D: 0.49 (0.16 - 0.86) <D: 0.43 (0.13 - 0.70)
2 mm 2 mm
>D: 1.69 (0.17 - 2.38)
>D: 0.94 (0.29 - 2.38)
<D: 0.49 (0.20 - 0.90)
<D: 0.31 (0.11 - 0.53)
1 mm 1 mm
>D: 1.78 (0.82 - 2.46) >D: 0.63 (0.20 - 1.79)
<D: 0.39 (0.31 - 0.74) <D: 0.20 (0.09 - 0.43)

Fig. 9.9 Medians and ranges of the major (>) and minor (<) diameters found at the apical third in the (a) C1, (b) C4,
and (c) C2 configurations (Reproduced by permission from Amoroso-Silva et al. [47])

pilararaya@ejercer.cl
9 C-Shaped Root Canal System 263

a Distal MB ML

3 mm 3 mm

>D: 1.10 (0.48 - 1.94) >D: 0.58 (0.24 - 1.50) 0.49 (0.22 - 0.87)
<D: 0.39 (0.25 - 0.78) <D: 0.22 (0.11 - 0.49) 0.16 (0.11 - 0.51)

2 mm 2 mm
>D: 0.78 (0.46 - 1.11) >D: 0.46 (0.29 - 0.62) 0.30 (0.08 - 0.61)
<D: 0.35 (0.21 - 0.78) <D: 0.19 (0.13 - 0.53) 0.11 (0.09 - 0.51)

1 mm 1 mm

>D: 0.52 (0.31 - 0.95) >D: 0.53 (0.22 - 0.81) 0.26 (0.15 - 0.54)
<D: 0.34 (0.10 - 0.72) <D: 0.21 (0.13 - 0.45) 0.17 (0.09 - 0.29)

Distal Mesial
b
3 mm 3 mm

>D: 1.27 (0.26 - 2.62)

>D: 0.99 (0.45 - 2.33)
<D: 0.31 (0.13 - 0.47)
<D: 0.41 (0.29 - 0.63)

2 mm 2 mm
>D: 0.75 (0.45 - 2.08)
>D: 0.85 (0.26 - 2.10) <D: 0.27 (0.09 - 0.41)
<D: 0.35 (0.27 - 0.57)

1 mm 1 mm
>D: 0.65 (0.28 - 1.45) >D: 0.47 (0.25 - 1.48)
<D: 0.40 (0.23 - 0.61) <D: 0.27 (0.09 - 0.35)

Fig. 9.10 Medians and ranges of the major (>) and minor and (b) one mesial root canal system (Reproduced by per-
(<) diameters of the different cross sections evaluated at mission from Amoroso-Silva et al. [47])
the apical third in the C3 configuration with (a) two mesial

a b c

Fig. 9.11 3-D classification of C-shaped canal configuration. (a) Merging type; (b) symmetrical type; (c) asymmetrical
type (Reproduced by permission from Gao et al. [32])

pilararaya@ejercer.cl
264 J. L. Gutmann

a1 a2 a3

b1 b2 b3

c1 c2 c3

Fig. 9.12 3-D reconstructed C-shaped canal configura-
tion. (a1–a3) Type I. Canals merged into one major canal
before exiting at the apical foramen; (b1–b3) Type II. The
mesial canal and distal canal were nearly equal in size and
had openings at the apex, respectively; (c1–c3) Type III.
The distal canal had a big isthmus or fin area crossing the
fused area. The mesial canal and distal canal had openings
at the apex, respectively (Reproduced by permission from
Gao et al. [32])

pilararaya@ejercer.cl
9 C-Shaped Root Canal System
9.4 Anatomical Characterization
of C-Shaped Canals in Molars
9.4.1 Floor of the Chamber
Min et al. [31] provided a detailed description of
the morphology of the pulp chamber floor
approximately 3 mm above the orifices
(Fig. 9.13a). Scanned cross sections were recon-
structed, and the images generated were assessed
and assigned to one of the following four types
(Fig. 9.14):
• Type I: a peninsula-like floor with a continu-
ous C-shaped orifice.
• Type II: a buccal, strip-like dentin connection
that exists between the peninsula-like floor
and the buccal wall of the pulp chamber that
separates the C-shaped groove into mesial and
distal orifices. Sometimes the mesial orifice
was separated into a mesiobuccal (MB) and a
mesiolingual (ML) orifice by another strip-­
like dentin between the peninsula-like floor
and the M wall of the pulp chamber.
• Type III: only one mesial strip-like dentin
connection between the peninsula-like floor
and the mesial wall that separates the C-shaped
groove in a small ML orifice and a large MB
a b
C1
CEJ C3a
C4
Fig. 9.13 (a) Location of measurements for mandibular second molars with a C-shaped canal system; (b) Classification
of canal configurations according to Min et al. 2006 (Reproduced by permission from Min et al. [31])
pilararaya@ejercer.cl
265
distal orifice. The MB distal orifice was
formed by the merging of the MB orifice and
the distal orifice.
• Type IV: Non-C-shaped floors. One distal
canal orifice and one oval or two round M
canal orifices are present.
9.4.2 Descending Canal
Morphology
To determine the canal morphology from orifice
to a point 3.0 mm from the root apex, Min et al.
[31] made sections, 2 mm below the orifice (C1),
one-third the distance between the orifice and the
anatomical apex (C2), the midpoint from the ori-
fice to the apex (C3a and C3b), and a point 3 mm
from the apex. Configurations were analyzed and
classified as follows (Figs. 9.13b and 9.15):
• C1: continuous C-shaped canal
• C2: MB distal and an ML canal
• C3a: mesial and distal canals
• C3b: MB, ML, and distal canals
• C4: single round or oval canal
Amoroso-Silva and colleagues [47] provided
a further detailed delineation of the coursing of
C2
C3b
266 J. L. Gutmann

M D M D M D M D

Type I Type II Type III Type IV

Fig. 9.14 Types of the pulpal floor: M, mesial side; D, distal side (Reproduced by permission from Min et al. [31])

D M M D M D

a1 a2 a3

M D M D D M

b1 b2 b3

M D M D D M

c1 c2 c3

D M M D M D

d1 d2 d3

Fig. 9.15 3-D reconstructed pulpal floor (M, mesial side; all the teeth is placed up and down (Reproduced by per-
D, distal side). (a1–a3) Type I; (b1–b3) Type II; (c1–c3) mission from Min et al. [31])
Type III; (d1–d3) Type IV. The buccal-lingual direction of

pilararaya@ejercer.cl
9 C-Shaped Root Canal System 267

the C-shaped canal systems in mandibular sec-
ond molars as seen in Figs. 9.9 and 9.10. Detailed
measurements, along with specific shapes, help
to clarify the exact nature of this anatomy from
orifice to apex in the different classifications.
exit points well coronal to the apical termination
of the root and have cementodentinal junctions
that are placed deeply inside the root structure
(Fig. 9.16).

9.5 Anatomical Characterization

9.4.3 Apical Termination of C-Shaped Canals
in Premolars
The apical termination of C-shaped canals has
been characterized by many authors to a level 9.5.1 Radicular Groove
approximately 1.0 mm from the apex [28, 29, 32,
34, 47]. However, a view from the apex may The presence of C-shaped root canals in premo-
afford a different interpretation, as many canals lars has also received attention in multiple studies
break into deltas, multiple accessory canals, and (Table 9.1), with percentages ranging from 10.7%

a b

c d

Fig. 9.16 (a) View of root apex of C-shaped root. Note
the variety of apical terminations, their size, and locations.
The actual cementodentinal junction is located deep
inside the apical foramina; (b, c) Apical terminations of
C-shaped canal systems demonstrating significant ana-
tomic complexities (Courtesy of Dr. Bing Fan, Wuhan
China); (d) Apex of a C-shaped root with three canal
foramina visible. Root canal instruments in each canal
that extend to the root surface; however, each is approxi-
mately one to three beyond the cementodentinal junction.
This creates major problems in the clinical management
of the root canal procedures

pilararaya@ejercer.cl
268 J. L. Gutmann

to 24%, the highest percentages being reported in
Mongoloid populations [75, 78, 81, 85, 88].
Along with the internal canal anatomical varia-
tions, which vary significantly from the orifice to
apical terminus (Fig. 9.17), unique external anat-
omy has also been identified in the form of mesi-
ally placed radicular grooves [73, 75] (Fig. 9.18)
that extended from 3 mm below the cementoe-
namel junction to the root apex (Fig. 9.19). While
not always present, these grooves may pose sig-

C1 C1 C1

C2 C2 C2

C3 C3 C3

C4a C4b C4c

C5 C6 C6

Fig. 9.17 Examples of some

micro-CT images of premolars indi-
cate the classification of canal con-
figuration (Reproduced by
permission from Fan et al. [75])

pilararaya@ejercer.cl
9 C-Shaped Root Canal System
CEJ
CTP
MP
ABP
AP
Fig. 9.18 Planes for observation and measurement. CEJ
cementoenamel junction, CTP coronal top plane of the
groove, MP middle plane of the groove, ABP apical bot-
tom plane of the groove, AP apical plane (Reproduced by
permission from Fan et al. [75])
Fig. 9.19 Two bilaterally matched mandibular premolars
that exhibit the mesial groove as described by Fan et al.
[75]
pilararaya@ejercer.cl
269
nificant clinical concerns [81]: (1) during root
canal enlarging and shaping procedures, due to
the thinness of the root wall adjacent to the
groove, (2) during tooth restoration if the place-
ment of a post is anticipated, and (3) as the groove
may predispose to the accumulation of dental
plaque and calculus, creating a periodontal prob-
lem. However, when the groove was not identi-
fied, there was no C-shaped canal system in the
tooth [78]. (Note: only the anatomy of the man-
dibular premolar is being addressed, as this tooth
presents with the most irregularities in its appear-
ance and is the specific focus of most studies.)
9.5.2  anal Anatomy and Apical
C
Termination
As seen in Fig. 9.20, there is a highly variable
course of the canal anatomy longitudinally in
mandibular first premolars [75, 78], with the for-
mation of the actual C-shape occurring at multi-
ple levels and not in all canals that may be
present. Fan et al. [78] classified these shapes as
(1) a continuous C-shape only, (2) semilunar
shape in the buccal canal only, (3) a combination
of continuous C-shape and buccal semilunar, and
(4) a C-shaped canal interrupted by a non-C-­
shaped canal.
Accessory canals that originated in furcation
areas of the semilunar buccal canal were also
noted in 57 of the 327 reconstructed canal system
models’ close furcation, which exited into mesial
groove (Fig. 9.21). This finding may further com-
plicate treatment procedures both endodontically
and periodontally.
Finally, Yang et al. [80] addressed the canal
termination apically in these complex premolars
and found that most had a termination of 0–2 mm
from the root apex. However, within the popula-
tion studied (335 teeth), 72 teeth had a distance of
0–1 mm; 192 teeth, 2 mm; 61 teeth, 3 mm; 5
teeth, 4 mm; and 5 teeth, 5 mm. Furthermore,
these findings are supported by Fan et al. [78]
when reviewing the apical anatomical variables
as seen in Fig. 9.20.
270 J. L. Gutmann

Fig. 9.20 Root canal configurations

of mandibular first premolars. Green,
a b c d
non-C-shaped canal; red, continuous
C-shaped canal; yellow, semilunar buc-
cal canal. (a) Type Ia (1-1); (b) Type Ib
(1-1); (c, d) Type IIIb (1-2-1); (e, f)
Type Vb (1-2); (g) Type VIIb (1-2-1-
2); (h) unclassified canal (Reproduced
by permission from Fan et al. [78])

e f g h

a b c

d e f

Fig. 9.21 A complicated canal system in mandibular first cross section at 3.30, 6.29, 8.55, 10.58, 11.01, and
premolars. Green, non-C-shaped canal; red: continuous 12.42 mm from CEJ, respectively (Reproduced by per-
C-shaped canal; yellow, semilunar buccal canal. (a–f) The mission from Fan et al. [78])

pilararaya@ejercer.cl
9 C-Shaped Root Canal System
9.6 Clinical Management
Problems
Key problems encountered during cleaning and
shaping C-shaped canals include difficulty in
removing pulp tissue and necrotic debris, exces-
sive hemorrhage, working length determination,
and persistent discomfort during instrumentation.
Because of the large volumetric capacity of the
C-shaped canal system, housing transverse anas-
tomoses, and irregularities [32], many techniques
have been advocated for the enlarging, shaping,
cleaning, disinfecting, and filling of these canal
systems [89–95].
Acknowledgment The author would like to thank Dr.
Bing Fan, Wuhan University School of Stomatology,
Wuhan, China, for his generous support in the use of
materials on C-shaped canals.
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 Part III
Influence of Root Canal Anatomy
in Clinical Practice

pilararaya@ejercer.cl
 Internal Tooth Anatomy and Root
Canal Instrumentation
10
José F. Siqueira Jr, Isabela N. Rôças,
and Domenico Ricucci

Abstract 10.1  bjectives of Root Canal

Root canal preparation can be regarded as the
most important phase of the endodontic treat-
ment. Its main purposes are to clean, disinfect,
and shape root canals. These objectives, how-
ever, may be difficult to be attained in curved
root canals or in teeth with complex internal
anatomy. Residual bacteria and debris may
remain unaffected in unprepared canal walls,
isthmuses, lateral canals, apical ramifications,
dentinal tubules, and recesses from oval/flat-
tened canals and compromise the treatment
outcome. Some strategies have been devised
to improve the effects of chemomechanical
procedures in teeth with root curvatures and
complex anatomy.
J. F. Siqueira Jr., D.D.S., M.Sc., Ph.D. (*)
Department of Endodontics, Faculty of Dentistry,
Estácio de Sá University, Rio de Janeiro, RJ, Brazil
e-mail: jf_siqueira@yahoo.com
I. N. Rôças, D.D.S., M.Sc., Ph.D.
Molecular Microbiology Laboratory,
Faculty of Dentistry, Estácio de Sá University,
Rio de Janeiro, RJ, Brazil
D. Ricucci, M.D., D.S.
Private Practice, Cetraro, Italy
O
Preparation
Root canal preparation is intended to clean, disin-
fect, and shape the root canal. These objectives
are distinct but are achieved simultaneously by
means of the mechanical effects of instrumenta-
tion and the mechanical and chemical effects of
irrigation. Consequently, the instrumentation/
irrigation phase is also commonly referred to as
chemomechanical procedures.
There are basically three conditions that the
clinician faces routinely for root canal treatment:
teeth with vital and irreversibly inflamed pulps,
teeth with necrotic pulps with or without primary
apical periodontitis, and retreatment cases
because of posttreatment apical periodontitis. In
teeth with irreversible pulpitis, infection is usu-
ally restricted to the coronal parts of the canal
and is easily controlled by abundant irrigation of
the pulp chamber with sodium hypochlorite
(NaOCl) after conclusion of the access cavity
preparation. Then, under strict aseptic condi-
tions, the clinician needs to clean the canal by
removing the inflamed vital pulp tissue as much
as possible. This is because pulp remnants may
interfere with the quality of obturation, may serve
as substrate for a secondary infection and/or, may
remain inflamed and cause postoperative pain.
In necrotic untreated teeth and treated teeth
with indication for retreatment because of post-
treatment apical periodontitis, an infection is

© Springer International Publishing AG, part of Springer Nature 2019 277

M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_10

pilararaya@ejercer.cl
278
established in the root canal system: primary
infection in the necrotic teeth and persistent or
secondary infection in the retreatment cases. In
these cases, in addition to cleaning the canal from
the necrotic pulp tissue or the previous filling
material, the clinician also needs to combat infec-
tion (disinfection). The successful treatment out-
come will depend on how effective the clinician
is in achieving these goals [1].
Therefore, the chemomechanical preparation
can be regarded as the most important phase of
the root canal treatment. This is because cleaning
and infection control promote an environment
conducive to periradicular tissue healing. In addi-
tion, a continuously conical shape is sculpted to
be receptive for placement of an adequate
obturation.
Numerous studies have shown that the main
factor associated with a poor endodontic treat-
ment outcome (characterized by persistence or
appearance of apical periodontitis) is the inade-
quate quality of the previous root canal treatment
[2–5]. This means that the clinician failed to pro-
mote sufficient cleaning, shaping, and disinfec-
tion to promote or restore the periradicular health.
In addition to the technical difficulties to perform
endodontic treatment, which requires extensive
specific training, the very complex anatomy of
the root canal system of many teeth poses signifi-
cant challenges for proper achievement of clean-
ing, disinfection, and shaping. This chapter deals
with this issue.
10.2  hallenges in Root Canal
C localizing all canals during preparation and
Preparation
Many challenges are faced by clinicians when treat-
ing root canals. For instance, while infection control
is paramount for optimal treatment outcome, no
available technique, instrument, or substance can
predictably eradicate all bacteria from the root canal
system. It remains unknown how much cleaning
and disinfection is sufficient to promote total heal-
ing. Inadequate cleaning and disinfection may leave
residual bacteria in levels sufficient to cause persist-
ing symptoms and periradicular inflammation. On
the other hand, overzealous canal enlargement may
pilararaya@ejercer.cl
J. F. Siqueira et al.
lead to excessive removal of dentin and predispose
the tooth to fracture.
Anatomic variations, including lateral canals
and apical ramifications, isthmuses, curvatures,
and oval-shaped or flattened canals, present a sig-
nificant challenge for adequate cleaning and dis-
infection of the root canal system. To maximize
tissue removal and bacterial elimination in these
areas, the clinician relies on the chemical effects
of irrigants and interappointment medications as
well as in strategies to take these chemicals to
those difficult-to-reach areas. This issue will be
discussed in detail in the next sections.
Another challenge relates to establishing and
maintaining the working length throughout the
canal procedures. This is crucial to ensure opti-
mal cleaning and disinfection as well as to pre-
vent blockage of the apical canal or
over-instrumentation. As discussed below in the
section on apical limit of instrumentation, the
association of electronic apex locators and peri-
apical radiographs are required for a more accu-
rate working length determination.
Difficulties in locating extra canals in multi-­
rooted teeth may predispose to persistent symp-
toms and/or decreased treatment outcome. This is
more complicated in teeth with apical periodonti-
tis, because the missed canal can be infected.
Knowledge of tooth and root canal anatomy is of
utmost importance to avoid missing canals, and it
is recommended that, at least in difficult cases,
magnification and illumination be optimized by
using an operating microscope or a surgical loupe
with light source, increasing the chances for
inspection of the access cavity.
10.3  he Complex Anatomy
T
of the Root Canal System
Endodontic instruments are essentially designed
to prepare the main root canal, which is the prin-
cipal and most voluminous area of the root canal
system. The main canal harbors the largest
amounts of pulp tissue and, in infected cases,
bacteria and their products. However, the canal
system also comprises other structures that repre-
10 Internal Tooth Anatomy and Root Canal Instrumentation
sent potential areas for spreading of bacterial
infection. They include isthmuses (Fig. 10.1), lat-
eral and apical ramifications, recesses, and den-
tinal tubules (Fig. 10.2).
Bacteria colonizing the infected root canal
system associated with either primary or post-
treatment apical periodontitis are usually orga-
nized in biofilm structures attached to the canal
walls [6–12]. In addition to the main root canal,
bacterial biofilms can occur in anatomical varia-
tions including lateral and apical ramifications
(Fig. 10.3) and isthmuses (Fig. 10.4) [13–16].
Bacteria at the bottom of biofilm structures may
also invade and colonize the subjacent dentinal
tubules [8, 17, 18].
Isthmuses are very common in some groups of
teeth, especially molars. For instance, the occur-
rence of an isthmus in the mesial root of man-
dibular molars can be regarded as a rule rather
than exception. Studies reported an incidence of
isthmuses communicating the two mesial canals
in 70–88% of the mandibular molars [13, 19]. In
the apical 5 mm of the same group of teeth,
Mannocci et al. [20] found isthmuses in 17–50%
of the specimens; the highest prevalence occurred
at the 3-mm level. Other authors have reported an
isthmus in the apical 3–5 mm of molar roots in up
to 80% of the cases [21–23].
Fig. 10.1 Mandibular
first molar from an adult
male patient with
necrotic pulp and apical
periodontitis. Crosscut
section from the middle
third of the mesial root
displays a thin long and
irregular isthmus
connecting the two main
canals (Taylor’s
modified Brown &
Brenn; original
magnification ×16)
pilararaya@ejercer.cl
279
Ramifications include furcation canals, lateral
canals, and apical ramifications (Fig. 10.5). They
can occur in any tooth and anywhere along the
length of the root but are more frequent in the
apical portion and in posterior teeth [15, 24]. In
general, ramifications have been observed in
about 75% of the teeth [15]. Specifically by canal
segments, the occurrence of ramifications has
been found in 73.5% of the apical, 11% of the
middle, and 15% of the coronal thirds [25].
Given the high frequency of ramifications, it is
intriguing why lateral periodontitis lesions are
not so commonly observed. This may be related
to the size and patency of the ramification as well
as its microbiologic conditions. The larger the
ramification, the more room for bacterial coloni-
zation and accumulation of bacterial virulence
factors. The diameters of lateral foramina in
molars range from 10 to 200 μm [26]. The largest
diameter of lateral foramina is nearly two to three
times smaller than the mean diameters reported
for the main apical foramen [27–29]. This helps
explain why lesions of endodontic origin are
much more common in the apical than in the lat-
eral aspect of the root.
Bacterial invasion of dentinal tubules can
occur in about 70–80% of the canals of teeth with
apical periodontitis [17, 30]. Even though a shal-
280 J. F. Siqueira et al.

a b c

d e

Fig. 10.2 (a) Palatal root of a non-restorable maxillary
first molar with necrotic pulp in a 32-year-old man. The
apical periodontitis lesion remained attached to the root
tip at extraction. (b) Section cut approximately at the cen-
ter of the main canal and foramen (Taylor’s modified
Brown and Brenn; original magnification ×16). (c) Portion
of the middle third of the canal, coronal to that shown in
(b). The canal is apparently empty, with few debris (origi-
nal magnification ×50). (d) High-power view of the area
indicated by the upper arrow in (c). Area of previous
resorption in a portion of the canal where atubular tertiary
dentin had been produced. The area is filled by necrotic
debris and bacteria (original magnification ×400). (e)
High-power view of the area indicated by the lower arrow
in (c). An apparently atubular tertiary dentin was “tun-
neled” by the resorptive process. An irregular resorption
area is present more coronally. These areas harbor bacte-
ria. Note that bacteria colonized some dentinal tubules
(original magnification ×400)

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10 Internal Tooth Anatomy and Root Canal Instrumentation 281

Fig. 10.3 Distal root

apex of a mandibular
first molar from a
20-year-old man,
endodontically treated
4 years before. The
apical radiolucency
failed to heal, symptoms
were present, and
root-end resection was
indicated. Histologic
sections demonstrated
numerous apical
ramifications, some of
which were filled by
thick bacterial biofilms
(arrows) (Taylor’s
modified Brown &
Brenn; original
magnification ×16)

a b c

d e

Fig. 10.4 Mandibular first molar in a 42-year-old woman
with necrotic pulp and apical radiolucencies. (a)
Postoperatory radiograph. (b) 10-year follow-up radio-
graph. The apical radiolucencies were unchanged, and
severe periodontal involvement is present. Extraction was
decided. (c) The mesial root was divided into three seg-
ments. The photograph of the middle third shows that an
isthmus was present. (d) Crosscut section parallel to the
plane in (c). The overview confirms the isthmus connect-
ing the two mesial canals (Taylor’s modified Brown &
Brenn; original magnification ×16). (e) Middle magnifica-
tion of the isthmus (original magnification ×100). The
area indicated by the arrow is magnified in the inset. A
biofilm can be observed adhering to the wall of the isth-
mus (original magnification ×630). (f) Middle magnifica-
tion of the area of the left canal indicated by the arrow in
(d) (original magnification ×100). (g) High-power view of
the canal wall indicated by the arrow in (f). Bacterial bio-
films can be observed between the root canal filling mate-
rial and the canal wall (original magnification ×400)

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f g
Fig. 10.4 (Continued)
Fig. 10.5 3D reconstruction of micro-computed tomo-
graphic scans of a mandibular premolar showing apical
ramifications (delta). Courtesy Profs. José C. Provenzano
and Marília Marceliano-Alves, Laboratory of Micro-CT,
Department of Endodontics, Estácio de Sá University
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J. F. Siqueira et al.
low penetration is more common in vivo, bacte-
rial cells can be observed reaching approximately
300 μm in some teeth [8]. Bacterial cells pene-
trating deep into tubules are unlikely to be
eliminated by chemomechanical prepara-
­
tion alone (Fig. 10.6).
Oval and flattened canals are a challenge for
proper instrumentation, especially using rotary
instruments. This is because rotary instrumenta-
tion sculpts a round preparation and leaves behind
recesses in the extremities of the largest canal
diameter that are usually left untouched
(Fig. 10.7). By definition, oval, long oval, and
flattened canals are those presenting a ratio
between the maximum and minimum cross-­
sectional diameter of <2:1, 2–4:1, and >4:1,
respectively [31] (Figs. 10.8 and 10.9). The over-
all prevalence of long oval root canals in the api-
cal third is about 25%, with mandibular incisors
and maxillary second premolars exhibiting an
increased prevalence of this configuration
(>50%) [32]. The distal canal of mandibular
molars is also usually oval or flattened.
Morphological studies have reported the fail-
ure of the endodontic treatment, characterized by
a posttreatment apical periodontitis, in teeth pre-
senting with persistent infections in isthmuses [6,
10, 11], lateral canals and apical ramifications [6,
10, 14, 33–35], recesses [10], and dentinal tubules
[6, 10, 18]. This emphasizes the need for proper
infection control not only in the main canal lumen
but also in the entire root canal system.
10 Internal Tooth Anatomy and Root Canal Instrumentation
a b
d e
Fig. 10.6 Experimental case. Canals of the mesial root of
a non-restorable mandibular molar were instrumented
with NiTi rotary files. Irrigation was performed with 5%
sodium hypochlorite. Care was taken during instrumenta-
tion to irrigate the canals for a period of 45 min. Obturation
was performed in the same visit with a warm gutta-percha
technique and a sealer. The tooth was extracted 7 days
later. (a) Radiograph of the mesial root taken in a mesio-
distal projection. (b) Photograph of the root taken at the
end of the demineralization process, while the root was
10.4  urved Canals: Great
C make the final shape of the preparation irregular,
Challenge for Preparation
The root curvature is another anatomic factor that
may influence the preparation outcome. While
usually uneventful in straight canals, carving a
shape is usually challenging in curved canals.
When passed along the curvature, the instrument
tends to straighten to return to its original shape.
This results in more pressure applied by the
instrument cutting blades against the inner wall
of the curvature as well as on the opposite wall in
the apical segment of the canal (Fig. 10.10).
These effects are more pronounced with greater
curvatures and larger/stiffer instruments and
pilararaya@ejercer.cl
283
c
immersed in the clearing agent. (c) Crosscut section taken
approximately at the level of the line in a and b. The two
mesial canals are connected by a wide isthmus at this level
(Taylor’s modified Brown & Brenn; original magnifica-
tion ×16). (d) Middle magnification of the area of the
canal wall indicated by the arrow in (c). Many tubules
appear colonized by bacteria to a considerable depth
(original magnification ×100). (e) High-power view of the
area demarcated by the rectangle in (d) showing bacterial
cells inside the tubules (original magnification ×400)
predisposing to procedural errors, including
ledge, perforation, deviation (zip), foramen trans-
portation, and blockage with debris. As a matter
of fact, because of the complexity introduced by
curvature, the concepts of instrumentation and
advances in instrument manufacturing have been
based on strategies to deal with curved canals.
In the past, because of the physical limitations
of stainless steel instruments, the common rec-
ommendation was that curved canals be enlarged
to small apical diameters. The reasons to reduce
the apical preparation size in curved canals were
basically that (a) smaller preparations result in
less cutting of the canal walls with consequent
284
Fig. 10.7 Maxillary first molar root canal-treated 7 years
before. Instrumentation was performed with NiTi rotary
files. Irrigation with 5% sodium hypochlorite. Obturation
with warm gutta-percha technique. Despite the use of the
operating microscope, only one canal orifice could be
located in the mesiobuccal root. The tooth was extracted
because of nontreatable periodontal disease. (a) Crosscut
sections from the middle third of the mesiobuccal root.
The rotary file had instrumented only a minimal portion of
less uncontrolled cutting action and (b) small
instruments are more flexible and therefore less
likely to cause procedural errors [36]. However,
the greatest problem with small preparation sizes
is that this may compromise the cleaning and dis-
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J. F. Siqueira et al.
the unique long oval mesiobuccal canal. Note that, despite
abundant irrigation, the untouched portion of the canal
lumen is filled with necrotic tissue (Taylor’s modified
Brown & Brenn; original magnification ×16). (b) Crosscut
sections from the middle third of the distobuccal root.
Unlike the other root, the round original morphology of
this canal allowed instrumentation of the entire canal cir-
cumference (original magnification ×16)
infecting efficacy of chemomechanical proce-
dures as well as the quality of the root canal
filling.
To make root canal shaping more predictable
and safer in curved canals, advances in instru-
10 Internal Tooth Anatomy and Root Canal Instrumentation 285

Fig. 10.8 Example of

long oval canal.
Crosscut section from
the middle third of the
distal root of a
mandibular fist molar
with necrotic pulp. Note
that the canal lumen is
filled with necrotic
debris and bacterial
biofilm (Taylor’s
modified Brown &
Brenn; original
magnification ×16)

Fig. 10.9 Example of

flattened canal. Crosscut
section from the middle
third of the mesial root
of a mandibular first
molar with vital pulp
(hematoxylin and eosin;
original magnification
×16)

ment manufacturing and design as well as in
instrumentation techniques have been introduced.
Manufacturing of endodontic instruments using a
nickel-titanium (NiTi) alloy represents a major
breakthrough in endodontics. NiTi alloy presents
a lower modulus of elasticity than the previously
used stainless steel, providing instruments with
increased elasticity and resistance to plastic
deformation. NiTi instruments allow for prepara-
tions of curved canals that are larger at the apical
part, more centered, and with reduced incidence
of errors when compared to stainless steel instru-
ments [37–40].
The properties of superelasticity and resis-
tance to cyclic fatigue of the NiTi alloy permit
that instruments be continuously rotated along a
curvature. Therefore, the large majority of NiTi
instruments currently available for root canal

pilararaya@ejercer.cl
286
Fig. 10.10 The curvature introduces complexity to root
canal preparation and forces the instrument to exert a
higher cutting action on certain walls (arrows)
preparation are engine-driven and can be used in
either continuous or reciprocating rotation.
Innovative designs of the helical shaft and tip,
different cross-sectional designs, and larger or
variable tapers have also enhanced the instru-
ments’ performance during preparation of curved
root canals. Surface finishing by electropolishing
has also been used to remove surface defects of
the instrument, increasing its fatigue resistance
[41–45].
Over the years, more changes to improve flex-
ibility and resistance to fatigue fracture of end-
odontic instruments have been introduced,
including different thermomechanical treatments
and modified chemical composition of the NiTi
alloy. In this context, two important modifica-
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J. F. Siqueira et al.
tions in the NiTi alloy included the M-wire alloy
[46, 47] and the R-phase (NiTi alloy in a different
phase of crystalline structure) [48]. Some manu-
facturers have subjected instruments with high
martensite content to a heat treatment, generating
instruments that are more flexible (and colored—
gold or blue—due to an oxide layer).
Moreover, instruments with different designs
and concepts have been devised to deal with
canals that are challenging to prepare because of
complex anatomy, including oval and flattened
canals. These specific instruments include the
Self-Adjusting File (SAF) system (ReDentNOVA,
Ra’anana, Israel), TRUShape (Dentsply Sirona,
Tulsa, OK, USA), and XP-endo Shaper (FKG, La
Chaux-de-Fonds, Switzerland).
Despite the numerous brands of instruments
available in the marketplace over the last decade,
studies evaluating the treatment outcome when
using them are scarce. Actually, many instru-
ments have been removed from the market even
before a single study assessing their clinical per-
formance is published.
10.5 Apical Limit of Preparation
The periradicular tissue response to root canal
treatment is influenced by the apical length of the
intracanal procedures. This has important conse-
quences on the development of postoperative
pain and the long-term treatment outcome.
As for postoperative pain, many studies have
shown that absence or occurrence of a mild dis-
comfort is normal after root canal preparation short
of the apex and usually subsides in less than 1 week
[49–51]. However, if the root canal procedures are
intentionally or accidentally taken beyond the api-
cal foramen, such as in the event of over-instru-
mentation, severe discomfort may be expected,
especially in infected teeth. Studies reported that
intentional enlargement of the apical foramen dur-
ing root canal treatment increased the incidence
and intensity of postoperative pain [52, 53].
The apical limit of preparation has been
widely discussed in terms of long-term treatment
outcome. A successful outcome is better charac-
terized when a root canal-treated tooth presents
10 Internal Tooth Anatomy and Root Canal Instrumentation 287

with no radiographically detectable apical films, rendering them more susceptible to the irri-
periodontitis lesion and absence of signs and gants and host defenses; (b) carry antibacterial
­
symptoms of infection, including pain, swelling, irrigants to the most apical part of the canal, pos-
or draining sinus tract [54–56]. sibly enhancing disinfection in this region; and
The treatment outcome of teeth with vital (c) maintain the apical foramen unblocked,
pulps does not appear to be significantly affected reducing the risks of procedural accidents and
by the apical limit of the root canal procedures, postoperative pain [63]. A study has reported bet-
provided aseptic conditions are maintained and ter treatment outcome for treatment and retreat-
bacteria are prevented from gaining entry into the ment when patency files were used [64].
root canal [57]. Obviously, gross over-­ How about the working length for apical prep-
instrumentation should be avoided as it can result aration in infected teeth? A study demonstrated
in postoperative pain. The commonly recom- that the optimum success rate for endodontic
mended working length for teeth with vital pulps treatment of infected teeth is observed when
is 1–2-mm short of the radiographic apex. treatment procedures finish at 0–2 mm from the
Because of infection, root canals containing radiographic apex [54]. In a study of over 1300
necrotic pulp tissue associated or not with apical canals treated by a single operator, Ricucci et al.
periodontitis as well as root canal-treated teeth [65] found the best outcome for teeth with
with posttreatment disease are a quite different necrotic pulps treated at 1–1.5-mm short of the
matter. In most of these cases, bacteria reach the apex.
apical part of the canal and can be located near or Because the root apex is usually visible radio-
at the apical foramen and apical ramifications, in graphically, it has been widely used as a reference
close contact with the periradicular tissues [6, 35, for determination of the working length. However,
58, 59]. establishment of apical limit on the basis of radio-
Because bacteria remaining in the apical por- graphs is just an estimate. Electronic length mea-
tion of the canal may put the treatment outcome surement devices have been used for determination
at risk, the length of the chemomechanical proce- of the root canal terminus with a satisfactory
dures should ideally not be shorter than the apical degree of accuracy and reliability [66–68].
level of infection. The problem is that the apical Commercially available electronic apex locators
level of infection may be anywhere from the mid- have been reported to be accurate to within
dle to the apical canal [60–62] and cannot be ±0.5 mm from the apical foramen in 90–100% of
accurately clinically determined. Thus, it is cases, irrespective of the pulpal diagnosis [68–
advisable to extend the apical limit of instrumen- 74]. A radiograph should always be taken to con-
tation as close as possible to the canal terminus. firm the electronic measurements.
Nevertheless, one must be aware that the risks of
instrumenting the canal to this point include the
possibility of over-instrumentation, which can 10.6 Apical Width of Preparation
force infected debris and previous filling materi-
als into the periradicular tissues and predispose In the clinical setting, sufficient root canal clean-
to postoperative pain and treatment failure. ing and disinfection cannot be reliably ascer-
To effectively clean and disinfect the most tained so as to establish the preparation end point.
apical part of infected root canals, the use of Several criteria have been proposed:
patency files has been proposed. By this concept,
a small file is taken up to 1 mm longer than the (a) Dentinal filings collected on instruments are
canal terminus before instrumentation and after clean after visual inspection.
each change of instrument size. This small file (b) The irrigating solution is clean when col-
should be passively moved through the apical lected in a gauze after rinsing the canal.
constriction without widening it. Patency files are (c) The clinician has a tactile feeling of glassy
expected to (a) disorganize apical bacterial bio- smooth walls.

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(d) Preparation size is predetermined based on
mean apical diameters for the different
groups of teeth.
(e) The canal is enlarged two to four file sizes
beyond the first file to bind.
However, these indicators are far from being
accurate. Canals that fulfill virtually all these cri-
teria may still contain tissue remnants and resid-
ual bacteria. Therefore, in the lack of an accurate
method, chemomechanical procedures should be
considered complete when the canal is enlarged
to instrument sizes that are compatible with the
root anatomy and volume and sufficiently large
to be safe and effective in terms of bacterial
reduction.
Several ready-to-go instrument kits are avail-
able in the marketplace. This means that the api-
cal diameter of preparation is not decided on the
basis of the individual root canal the clinician is
treating but on the instrument sizes available in
the kit he or she is using. The anatomy of each
individual root canal system is unique, with a
high subject-to-subject variability that makes any
standardization prone to error. One-size-fits-all
approach will certainly not serve to properly
clean, shape, and disinfect all canals.
Perhaps, the method for determining the final
apical size of instrumentation that is closer to
considering each canal as an individual entity is
the determination of the first file to bind (criterion
“e”). Discounting the errors that are expected in
canals that are noncircular (oval, flattened) or
with coronal calcifications, this is at least an
attempt to gauge the initial canal diameter and
then use this measure as a parameter to determine
the final apical size. This could be three or four
instruments larger than the first one to bind but
also taking into account the mean initial diame-
ters 1-mm short of the foramen as revealed in the
literature [32, 75–77] (criterion “d”).
The apical width of preparation is conceivably
as important as the apical limit with regard to the
treatment of infected teeth. Studies have revealed
that the larger the apical preparation size of
infected canals, the greater the intracanal bacte-
rial reduction [78–86]. Also, the disinfecting ben-
efit of sodium hypochlorite over saline irrigation
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J. F. Siqueira et al.
has been shown to be more significant at large
apical preparation sizes [83, 86]. The larger the
apical preparation size, the cleaner the apical
canal [87, 88].
A randomized prospective study of treatment
outcome evaluated the effects of apical prepara-
tion size in relation to the first apical binding file
[89]. The authors found that the healing rate of
apical periodontitis gradually increased with
increasing instrument size: 48% (two sizes larger),
71% (three sizes), 80% (four sizes), 85% (five
sizes), and 92% (six sizes). Statistical analysis
however revealed that only two sizes larger showed
significantly less improvement than the others. A
systematic review concluded that the best current
available clinical evidence suggests that large api-
cal preparations improve the treatment outcome of
teeth with apical periodontitis [90].
The width of preparation must be large enough
in the apical segment to increase cleaning and
disinfection and at the same time must be com-
patible with the root anatomy so as not to result in
overpreparation with consequent ledge formation
or perforation. Care must also be taken to avoid
overenlargement of the coronal segment of the
canal, which would promote unnecessary weak-
ening of the root with consequent predisposition
to fracture [91].
Instruments with large constant tapers have
the disadvantage that the deeper they are
­introduced in the canal, the more unnecessary
coronal dentin is cut. Then, it is recommended
that instruments of large tapers but decreased tip
sizes be used in the coronal aspects of the canal,
while instruments with large tips but small tapers
are used in the apical segment [92]. To circum-
vent this problem, instruments with variable
tapers have been introduced and are commonly
available (Reciproc, WaveOne, ProTaper, etc.).
Recently, the concept of minimally invasive
endodontics has been introduced. It claims for
retaining as much dentin structure as feasible, to
protect the tooth from future fracture. This con-
cept involves conservative access preparations
and apical preparation sizes smaller than usual.
The effects of minimally invasive approaches on
root canal cleaning, shaping, and disinfection as
well as the on healing of apical periodontitis and
10 Internal Tooth Anatomy and Root Canal Instrumentation
tooth survival have not been consistently evalu-
ated. Even so, as discussed above, it is advisable
to avoid excessive dentin removal during prepa-
ration, as, for instance, by using rotary instru-
ments that have small coronal dimensions while
maintaining large apical sizes to support infec-
tion control.
10.7 Irrigation: Improving
Cleaning and Disinfection
Irrigation is an essential step during root canal prep-
aration. Its main objectives are as follows [63]:
(a) Mechanical removal of bacteria and their
products as well as pulp and dentinal debris
by flushing
(b) Chemical disinfection
(c) Dissolution of soft tissue
(d) Smear layer removal
(e) Lubrication of instruments during negotia-
tion and cutting
The mechanical and chemical effects of irriga-
tion play a crucial role in root canal cleaning and
disinfection. Mechanical effects of irrigation are
related to the flow of the irrigants in the root
canal, either under a positive or negative apical
pressure. Any liquid irrigant (e.g., saline, sodium
hypochlorite, NaOCl, chlorhexidine, CHX, etc.)
exerts mechanical effects. Indeed, bacterial
reduction is significantly achieved by the
mechanical effects of saline irrigation [78, 85,
86]. However, the chemical effects of irrigants
that have antibacterial activity (NaOCl, CHX)
significantly improve bacterial elimination from
infected canals [83, 86, 93–97].
Several substances have been proposed as the
main irrigants during root canal preparation.
Sodium hypochlorite (NaOCl) is the most widely
used irrigant solution and has stood the test of
time. Solutions have been used in concentrations
ranging from 0.5% to 6%. NaOCl has a strong
broad-spectrum antimicrobial activity and kills
most oral bacteria in short-time contact [98, 99].
NaOCl has also tissue-dissolving ability, which
may improve root canal cleaning [100–102].
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Chlorhexidine (CHX) has been proposed as an
alternative to NaOCl, mostly because of the
strong odor and tissue toxicity of the latter. CHX
is a cationic bis-biguanide that has good antibac-
terial efficacy against several oral species [98, 99,
103, 104]. It has substantivity in dentin [105,
106] and displays acceptable tissue compatibility
[107, 108].
Several clinical studies have compared the
intracanal antibacterial effectiveness of NaOCl
and CHX when used as the main irrigant and
reported no significant difference between them
[109–112]. Other properties should also be taken
into account when the clinician is selecting a sub-
stance for root canal irrigation. CHX has lower
toxicity than NaOCl [108, 113] and exhibits sub-
stantivity in dentin, which may prolong its anti-
microbial effects [105, 106]. On the other hand,
CHX lacks the tissue-dissolving ability, which is
one of the greatest benefits of NaOCl [101, 114].
In order to exploit the advantages of both irrig-
ants, some clinicians have used NaOCl as the
main irrigant during instrumentation and then
perform a final rinse with CHX as a supplemen-
tary step [115, 116]. This approach has shown
promising results in terms of enhancing root
canal disinfection [115, 117, 118]. It is important
to point out that an irrigant like saline or distilled
water must be used between the use of NaOCl
and CHX in order to prevent the chemical reac-
tion between them with the resulting formation
of an orange-brown pigmentation that contains
para-chloroaniline [119, 120].
The cutting action of instruments on dentinal
walls during canal preparation leads to smear
layer formation, which is approximately 1–2 μm
thick; smear plugs can also be packed into the
dentinal tubules to a depth of up to 40 μm [121].
Smear layer removal has been recommended for
enhanced disinfection and adaptation of the fill-
ing material [122–124]. The inorganic compo-
nent of the smear layer can be removed by
demineralizing substances or products, including
ethylenediaminetetraacetic acid (EDTA) [125],
citric acid [126], and doxycycline-containing
products (BioPure MTAD, Dentsply, Tulsa, OK,
USA and Tetraclean, Ogna Laboratori
Farmaceutici, Milano, Italy) [127, 128].
290
10.8 Effects of Anatomy
on Shaping
As previously discussed, anatomic factors may
pose a significantly challenge to root canal shap-
ing. Curvatures, oval/flattened canals, and other
pathologic or iatrogenic conditions may influ-
ence attainment of a proper continuous conical
shape during instrumentation.
The curvature introduces a great complexity to
instrumentation as the instrument’s cutting action
is more directed to some walls than others. Studies
using micro-computed tomography (micro-CT)
[129–132] and histobacteriological [16] methods
have shown that surface areas of the main root
canal may remain unaffected by instruments, even
when using contemporary rotary NiTi instru-
ments. This occurs mostly because:
(a) The size of preparation is smaller than the
original canal diameter. Preparations that are
a b
Fig. 10.11 Representative 3D reconstructions of micro-­
computed tomographic scans taken before (green) and
after (red) root canal preparation with different techniques
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J. F. Siqueira et al.
larger than the initial canal diameter have
more chances to incorporate irregularities
and touch all the canal walls.
(b) The canal is curved, and/or its morphology is
irregular, oval/flattened, or C-shaped in cross
section. In curved canals, the instruments are
directed to certain walls and may fail to touch
others. In canals with irregular cross section,
the instrument may not reach all recesses.
Different preparation techniques leave from
10% to 50% of the root canal surface area
untouched [132–135] (Fig. 10.11). The amount
of unprepared walls is even higher in oval or flat-
tened canals. A histological study showed that
only 40% of the apical wall area of oval canals
were contacted by rotary instruments [136].
Micro-CT studies have reported a range from 5%
to 80% of unprepared areas in oval canals after
using different instrumentation techniques [132,
135, 137–142]. In oval canals, less unprepared
c
in mesial canals from mandibular molars. Unprepared
areas are in green. (a) Self-adjusting File; (b) Reciproc;
(c) Twisted File (TF)
10 Internal Tooth Anatomy and Root Canal Instrumentation
walls have been observed after using the SAF
system, because this instrument was designed
mostly for better adaptation in canals that are
irregular in cross section [132, 139–141, 143].
10.9 Effects of Anatomy
on Cleaning and Disinfection
The main steps of root canal treatment involved
with infection control are chemomechanical
preparation and intracanal medication. The for-
mer is of utmost importance for cleaning and dis-
infection, since instruments and irrigants act
primarily in the main canal, which is the area
with the largest bulk of pulp tissue and bacterial
density.
Numerous studies have shown that instrumen-
tation and irrigation are highly effective in sub-
stantially reducing the intracanal bacterial
populations [83, 84, 144–148]. Clinical [83, 86]
and in vitro studies [95, 96, 119] have clearly
demonstrated that preparation using an antibacte-
rial irrigating solution such as NaOCl signifi-
cantly enhances disinfection when compared to
irrigation with saline. Most canals instrumented
and irrigated with 2.5% NaOCl have the number
of bacteria reduced 102- to 105-fold and an overall
reduction of bacterial counts of 95–99% [95, 97,
149, 150]. Regular exchange and the use of large
volumes should maintain the optimum antibacte-
rial effectiveness of the NaOCl solution,
compensating for the effects of concentration
­ Canals that are flattened or oval-shaped are
[95]. It has been reported that the beneficial
effects of using NaOCl when compared to saline
are only observed after significant apical enlarge-
ment [83, 86].
Despite the excellent antibacterial effects
obtained by chemomechanical preparation using
either NaOCl or CHX as the irrigant, clinical
bacteriological studies have demonstrated that
30–60% of the previously infected root canals
still have detectable levels of bacteria after instru-
mentation [83, 84, 111, 112, 145, 150–157].
The main reasons for bacteria to persist after
chemomechanical procedures are that they are
resistant to treatment or they are unaffected by
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instruments/irrigants. While some microorgan-
isms have been shown to be resistant to some
endodontic antimicrobial agents [158, 159],
resistance to debridement and to NaOCl is highly
unlikely to occur. Bacteria usually survive to
treatment procedures not because they are more
resistant but because they were not affected by
instruments and irrigants.
Bacteria remain unaffected because treatment
was inadequately carried out (small instrumenta-
tion, preparation too short of the apex, poor irri-
gation, etc.) or because bacteria were located in
difficult-to-reach areas. Actually, the latter is the
main reason for bacterial persistence even after
diligent endodontic treatment.
Anatomic complexities represent physical
constraints that pose a serious challenge to ade-
quate disinfection. The main root canal lumen
and minor anatomical irregularities are usually
incorporated into preparation and affected by
NaOCl, but bacteria and organic tissue may
remain in areas not reached by instruments and
irrigants [10, 13, 16, 160, 161]. Unaffected areas
include root canal walls untouched by instru-
ments, recesses, dentinal tubules, isthmuses, lat-
eral canals, and apical ramifications [13–16, 18,
129, 132, 137]. These areas are usually not
affected because of the inherent physical limita-
tions of instruments and the short retention time
of irrigants within the root canal. If bacterial bio-
films remain in untouched and unaffected canal
areas, the treatment outcome is put at risk [1].
often suboptimally cleaned and disinfected by
currently hand or rotary NiTi instrumentation
using reaming motions [136, 137, 162–166].
Recesses are commonly left untouched at the
extremities of the canal largest diameter (usually
the buccolingual diameter) (Fig. 10.12). In addi-
tion to harboring remnants of pulp tissue or bac-
terial biofilms, such recesses may also be packed
with dentin chips generated and pushed therein
by rotating instruments [167–169]. Packed
debris can interfere with the quality of obtura-
tion [170] and, in infected root canals, can har-
bor bacteria to serve as a potential source of
persistent infection [10].
292
Fig. 10.12 Oval canal
after rotary
instrumentation.
Recesses may be left
untouched at the
extremities of the canal
largest diameter (arrows)
10.10 T
 he Need to Enhance
Disinfection
Bacterial populations in infected canals are sig-
nificantly eliminated by instrumentation and irri-
gation, but residual bacteria may still be found in
many cases. This means that some canals are
filled in the presence of detectable bacteria. The
problem is that studies have demonstrated that
residual infection projects a poor outcome [171–
174]. Therefore, in 30–60% of the cases, there is
a need to supplement disinfection in order to cre-
ate a biologically favorable environment condu-
cive to periradicular tissue healing.
Because bacteria surviving the effects of
instruments and irrigants are usually located in
areas difficult or impossible to reach during
instrumentation, approaches have been proposed
to improve disinfection after the instrumentation/
irrigation phase [175]. Predictably enhanced
results have been obtained mostly after place-
ment of an interappointment antimicrobial medi-
cation, such as a calcium hydroxide paste [16, 83,
84, 118, 157].
Some strategies have been developed to
improve single-visit disinfection and then obvi-
ate the need for interappointment medication and
consequently another visit to complete treatment.
Approaches for optimized single-visit disinfec-
tion (OSD) include new systems and substances
that either replace conventional chemomechani-
cal procedures or supplement their effects [175].
pilararaya@ejercer.cl
J. F. Siqueira et al.
OSD strategies include instruments especially
designed to adjust to the root canal anatomy, the
EndoVac system for negative pressure irrigation,
final canal rinse with CHX or MTAD (Dentsply
Sirona), sonic or ultrasonic activation of NaOCl,
photodynamic therapy (PDT), photon-induced
photoacoustic streaming (PIPS) using Er:YAG
laser energy at sub-ablative power levels (Fotona,
Ljubljana, Slovenia), and the GentleWave multi-
sonic wave system (Sonendo, Laguna Hills, CA,
USA).
The new instruments devised to deal with
canals exhibiting irregular shapes include SAF,
TRUShape, and XP-endo Shaper systems. While
the latter two were recently launched and still
need studies reporting on their cleaning and dis-
infecting ability in oval or flattened canals, the
SAF system has been already extensively stud-
ied. This is a hollow and flexible instrument
designed to adapt itself to the root canal cross-­
sectional shape [176]. The surface of the instru-
ment is lightly abrasive and acts like sandpaper to
scrape dentin and enlarge the canal. A great
advantage of the SAF system is that the irrigant is
continuously delivered throughout instrument
operation. Studies have shown that SAF instru-
mentation presents superior cleaning, shaping,
and disinfection in oval canals when compared to
conventional instruments [139, 177–179].
However, in round or narrow canals, SAF shows
no significant benefits over conventional rotary
NiTi instruments [132, 180].
10 Internal Tooth Anatomy and Root Canal Instrumentation
In addition to the use of special instruments,
strategies to deal with oval/flattened canals
include (a) using hand files in circumferential fil-
ing motion for the entire preparation or comple-
menting rotary instrumentation; (b) when using
rotary instruments, preparing the flattened canal
as if it were two or three separate entities [137];
and/or (c) supplementing cleaning and disinfec-
tion by using ultrasonic activation of NaOCl and
final rinse with CHX [117].
Ultrasonic activation of irrigants, especially
NaOCl, has been widely recommended for root
canal disinfection and has been referred to as
“passive ultrasonic irrigation” (PUI) [181, 182].
Ultrasonic antibacterial and cleaning effects are
usually related to the phenomena of acoustic
streaming and cavitation [183–185]. Moreover,
ultrasonics also warms and may move the irrigant
into areas of complex anatomy. In vitro studies
evaluating the intracanal antibacterial effective-
ness of PUI with NaOCl as the irrigant applied
after chemomechanical procedures have shown
inconclusive results [94, 117, 186, 187]. As for
clinical trials, molecular microbiology studies
revealed no significant antibacterial benefits of
the PUI approach [180, 188]. A study using peri-
apical radiography and cone-beam computed
tomography to compare the outcome of endodon-
tic treatment with and without additional ultra-
sonic activation of the irrigant found no significant
difference between the two groups [189].
As for the other OSD approaches, clinical
studies have showed no significant improvement
in disinfection when using the EndoVac irriga-
tion system [190], sonic activation of irrigants
with EndoActivator [157], and final rinse with
MTAD [191]. Final rinse with CHX has shown
inconclusive results [115, 118, 156]. So far, there
is no information from clinical studies about the
antibacterial effectiveness of PDT, PIPS, and
GentleWave systems.
Therefore, while some OSD approaches
may have shown a potential to improve cleaning
and disinfection in a single visit, most of the
results come from in vitro studies and as such
represent low-level evidence. There is no consis-
tent clinical evidence showing that these OSD
approaches can predictably reduce the bacterial
pilararaya@ejercer.cl
293
bioburden to levels significantly below that
achieved by conventional instrumentation/irriga-
tion. Thus, even though research has been direct
toward expediting disinfection, current evidence
indicates the need for an interappointment anti-
microbial medication to enhance disinfection of
the root canal system in teeth with primary or
posttreatment apical periodontitis.
10.11 Correlative Evaluation
of Instrumentation Using
Micro-CT and Other
Analytical Methods
Numerous methods have been used to investigate
the cleaning, shaping, and disinfecting effects of
chemomechanical procedures. One of the most
recently used methodologies to assess root canal
shaping is micro-CT. The greatest advantage of
micro-CT is its nondestructive nature, permitting
to compare the root canal morphology before and
after preparation in extracted teeth.
A parameter commonly evaluated in micro-­CT
studies is the amount of unprepared root canal sur-
faces. Several studies have revealed that a relatively
large amount of surface area of the main canal
remains uninstrumented, especially in curved or
oval/flattened canals, regardless of the instruments
and techniques used [132–135]. Inferences have
been made about the clinical implications of these
findings, with the possible retention of bacterial
biofilm and pulp tissue remnants on walls that were
not touched [132, 192]. On the other hand, one
might expect that NaOCl used for irrigation could
reach, clean, and disinfect these walls, given its
antimicrobial and tissue-­dissolving effects.
Therefore, it is important to evaluate the mor-
phological conditions of the uninstrumented
canal surfaces. This is only possible by combin-
ing findings from micro-CT with other analytical
methods. A study combined micro-CT and
microbiological methods in a correlative evalua-
tion of the effects of chemomechanical prepara-
tion using different instrument systems and found
no correlation between the amount of unprepared
surface areas and residual bacterial levels [132].
However, the specific conditions of the uninstru-
294
mented areas could not be assessed by the meth-
ods used.
In another micro-CT/microbiology correlative
study, Alves et al. [193] evaluated the disinfect-
ing ability of two OSD approaches—PUI and
XP-endo Finisher—in the mesial canals of man-
dibular molars. Teeth were anatomically matched
between groups based on micro-CT, the canals
were contaminated and instrumented using
NaOCl irrigation, and the OSD approach was
applied. The amount of unprepared areas was
revealed by micro-CT. Samples were taken from
the canal and from the isthmus area identified by
micro-CT and processed by cryopulverization. A
quantitative molecular microbiology method
showed that the OSD approaches resulted in a
small additional bacterial reduction, which was
significant only for XP-endo Finisher. Correlative
analysis once again revealed no statistically sig-
a b
Fig. 10.13 (a) Representative 3D reconstruction of
micro-computed tomographic scans taken before (green)
pilararaya@ejercer.cl
J. F. Siqueira et al.
nificant relationship between bacterial reduction
and the percentage of unprepared areas. None of
the tested approaches could predictably disinfect
the isthmus area as shown by the correlative
approach using micro-CT, cryopulverization, and
molecular microbiology methods [193].
A correlative study used micro-CT and micros-
copy (optical and scanning electron microscopy
(SEM)) to describe the morphological conditions
of the uninstrumented canal walls of teeth with
vital or necrotic pulps [194]. Preparation was car-
ried out with a reciprocating NiTi system and
NaOCl irrigation. The surfaces identified as
unprepared by micro-CT analysis were micro-
scopically examined for the presence of pulp rem-
nants, residual bacteria, and dentinal chips. Except
for the coronal portion of canals with vital pulps,
most uninstrumented areas contained tissue rem-
nants and/or bacteria (Fig. 10.13).
and after (red) root canal preparation in a mandibular pre-
molar. (b) Scanning electron micrograph of the area
marked in (a), showing debris on the unprepared wall
10 Internal Tooth Anatomy and Root Canal Instrumentation
10.12 Why Do We Succeed?
There are several studies in the literature evaluat-
ing the causes of root canal treatment failure.
However, the complex anatomy of the canal sys-
tem from most teeth and the inability of instru-
ments, irrigants, and techniques to completely
clean and disinfect the whole system raise an
interesting question: why does nonsurgical root
canal treatment succeed?
There is no definite answer for this, but the
high success rate for root canal treatment follow-
ing acceptable standards in teeth with apical peri-
odontitis may be explained as follows:
1. The initial bacterial infection was restricted
to the main canal. Instruments and irrigants
act primarily in the main root canal. Treatment
of many infected teeth may succeed when
infection has not spread to other difficult-­to-
reach areas of the system and was properly
controlled by chemomechanical procedures.
2. Bacterial infection was effectively eradicated
from the whole root canal system. If treatment
followed acceptable standards and included
strategies to reach infection in isthmuses,
recesses, ramifications, and dentinal tubules,
then there are more chances for the root canal
system to be successfully disinfected and api-
cal periodontitis to heal.
3. Residual bacteria are in subcritical load. It is
well known that for apical periodontitis to
heal, the root canal does not need to be steril-
ized (all bacteria killed). Actually, bacterial
counts should be reduced to levels compatible
with tissue healing [1]. Therefore, the possi-
bility exists that in many cases bacteria located
in difficult-to-reach areas are in low numbers
or were reduced by treatment procedures.
4. Residual bacteria do not have frank access to
the periradicular tissues. For bacteria to cause
apical periodontitis, they need to have unre-
stricted access to the periradicular tissues via
apical or lateral foramina or perforations.
Many anatomic complexities occur in the
middle/coronal parts of the canal. Located in
these areas, bacteria may not be significantly
affected by treatment and can persist.
pilararaya@ejercer.cl
295
However, if they cannot contact the periradic-
ular tissues, they have few chances to compro-
mise the treatment outcome.
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pilararaya@ejercer.cl
 Internal Tooth Anatomy and Root
Canal Irrigation
Christos Boutsioukis
Abstract
Complex anatomy is undoubtedly one of the
main obstacles to cleaning and disinfection of
the root canal system by irrigants. The diame-
ter of the areas that need to be reached in com-
bination with the viscosity of the irrigants
seems to limit irrigant flow mostly within the
wider areas irrespective of the method used;
so, transport of molecules/ions to narrow areas
relies primarily on diffusion, a much slower
and inefficient process. Syringe irrigation per-
forms similarly to other irrigation methods in
the main root canal, provided that the needle is
inserted close to working length and the canal
is adequately enlarged. However, additional
delivery and activation methods are needed to
clean fins, uninstrumented oval extensions,
isthmuses, and accessory canals. Adding more
impediments to this challenging procedure by
reducing the size of the access cavity or that of
the main root canal should be avoided.
C. Boutsioukis, D.D.S., M.Sc., Ph.D.
Department of Endodontology, Academic Centre for
Dentistry Amsterdam (ACTA), University of
Amsterdam and Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
e-mail: c.boutsioukis@acta.nl
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_11
pilararaya@ejercer.cl
11
11.1 Introduction
The complex anatomy of the root canal system is
undoubtedly one of the main limitations during
treatment [1, 2]. Microorganisms residing in
areas difficult to reach by instruments and irrig-
ants are considered the primary cause of failure
following both primary treatment and nonsurgi-
cal retreatment [2, 3], so efforts to improve clean-
ing and disinfection of the complete root canal
system are highly justified. In order to achieve
these goals, mild modifications of the internal
anatomy are necessary; an access cavity must be
prepared and, in the majority of cases, the main
root canal needs to be enlarged so that irrigants
can reach the apical anatomy [4]; omitting this
critical step seems to hinder the action of the irri-
gants considerably [5]. Nevertheless, even after
adequate root canal enlargement, a number of
further obstacles must be overcome by irrigants
before cleaning, and disinfection of the complete
root canal system is possible.
This chapter discusses the performance of
currently available irrigation methods in the vari-
ous parts of the root canal system along with the
limitations imposed by the anatomy and attempts
to highlight critical parameters affecting irrigant
penetration in these areas based on the available
evidence.
303
304
11.2  ransport of Irrigants Inside
T air bubble but not between the irrigant and tissue
the Root Canal System
Irrigants, and particularly their chemically active
particles (molecules/ions), must ideally reach all
areas of the root canal system in sufficient
amounts in order to disrupt the biofilm, kill
microorganisms, dissolve pulp tissue remnants,
and remove dentin debris [1, 4, 6]. The quickest
and most efficient mechanism for such transport
is the bulk fluid motion (irrigant flow) occurring
during irrigant delivery or activation; this process
is termed convection [7]. Besides facilitating the
transport of particles, irrigant flow also contrib-
utes to the mechanical cleaning of the root canal
system in areas where the moving irrigant comes
in direct contact with the aforementioned targets.
Nevertheless, bulk irrigant flow is mostly limited
to the wider parts of the root canal system.
In areas that cannot be reached by the flow,
particles may still be transported by diffusion, the
random particle movement in a fluid, but this
mechanism is markedly slower than convection,
and its rate is further affected by the size of the
particles, temperature, and concentration gradi-
ents [7]. Moreover, diffusion does not contribute
to the mechanical cleaning. Given the anatomical
complexity of the root canal system and the time
constraints of a typical treatment session, it is
strongly advisable to employ convection as a pri-
mary means of transport to deliver abundant irri-
gant at least to the full extent of the main root
canal and only rely on diffusion in order to reach
more remote areas where bulk flow is inherently
limited.
11.3 Surface Tension
and Viscosity of Irrigants
It is frequently assumed that irrigant penetration
inside the root canal system, especially in narrow
spaces like accessory canals and dentinal tubules,
may be improved by decreasing the surface ten-
sion of the irrigants [8–11]. However, surface
tension is important only at the interface between
two immiscible fluids [12, 13]; such an interface
exists, for instance, between the irrigant and an
pilararaya@ejercer.cl
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fluid or dentinal fluid because these fluids are
miscible. Root canal walls are hydrophilic and
easily wetted by irrigants [14–16], so there is cur-
rently no evidence to suggest that such an inter-
face exists regularly inside the root canal system
and limits irrigant penetration in vivo.
Recent studies have confirmed that adding
wetting agents (surfactants) to common irrigants,
in order to reduce their surface tension, does not
improve sodium hypochlorite penetration into
dentinal tubules [17, 18]. Moreover, a lower sur-
face tension doesn’t seem to enhance sodium
hypochlorite’s antimicrobial effect against either
planktonic bacteria [19] or bacteria inside den-
tinal tubules [17] or its tissue-dissolution capac-
ity [20–22]. On the contrary, the addition of
surfactants appears to accelerate the loss of free
available chlorine [23]. Removal of calcium from
dentin and removal of the smear layer by com-
monly used chelators also seem to be unaffected
by their surface tension [16, 24].
It is noteworthy that irrigant surface tension
may indeed become an important factor during ex
vivo or in vitro experiments if very dry specimens
or artificial canals made of hydrophobic materi-
als are used or if root canals are irrigated by non-­
aqueous liquids, for instance, certain oil-based
contrast agents. Nevertheless, such findings
should be disregarded as artifacts created due to
unrealistic experimental conditions. Furthermore,
surfactants may exert some antibacterial effect
themselves independent of the surface tension
reduction [25], so proper control experiments are
required to exclude this possibility.
Although irrigant flow inside the root canal
system is not affected by surface tension, it is
always affected by the viscosity of the irrigants, a
property that describes their internal friction and
resistance to flow [12, 26, 27]; a lower-viscosity
liquid will flow more easily. The viscosity of
sodium hypochlorite is similar to that of distilled
water [28, 29] and seems to increase slightly with
concentration and decrease with increasing tem-
perature [19]. Its effect on irrigant penetration
has been largely overlooked in the endodontic
literature but there are some indications that a
lower irrigant viscosity can indeed provide an
11 Internal Tooth Anatomy and Root Canal Irrigation 305

advantage [30]. Moreover, it has been reported
that adding surfactants to sodium hypochlorite
can actually increase the viscosity of the solution
to some extent [19], thus hindering instead of
improving irrigant penetration inside the root
canal system.
11.4 Pulp Chamber
The pulp chamber is the first part of the root canal
system that is accessed during treatment.
Cleaning and disinfection of the pulp chamber
has been generally considered a straightforward
procedure due to the easy access by both instru-
ments and irrigants and the optimum visibility
provided by the dental operating microscope.
However, preparation of conservative and espe-
cially ultraconservative “ninja” access cavities
according to the principles of minimally invasive
endodontics [31–35] could compromise cleaning
while providing only doubtful advantages in
terms of tooth resistance to fracture.
11.5 Main Root Canal
Along with the pulp chamber, the main root
canal is perhaps the most accessible part of the
root canal system that can be enlarged and, at
least, partially cleaned by instruments [36, 37].
Optimum cleaning of the main canal and effec-
tive irrigant penetration and exchange are pre-
requisites for the cleaning and disinfection of
other areas that are more difficult to reach. Just
as the access cavity and pulp chamber act as a
reservoir of irrigant during instrumentation, the
main root canal also acts as a reservoir of irrigant
enabling diffusion of particles toward more
remote areas. Furthermore, the flow created in
the main canal during irrigant delivery or activa-
tion drives the flow in other areas when such a
flow is possible.
One important obstacle in the main root canal
is that the irrigant cannot flow unobstructed
through the apical foramen, so, from a fluid
dynamics point of view, the canal behaves as an
apically closed system [38–42]. Effective irrigant
exchange and cleaning in such a system is far
more challenging compared to a system open at
both ends [12, 43, 44], and clear guidelines have
been published for ex vivo and in vitro irrigation
experiments to recreate these clinically realistic
conditions [41, 42]. An interesting deviation
occurs when irrigant is extruded through the api-
cal foramen [45], but, in most cases, this repre-
sents only a very small amount compared to the
large amounts used to flush the main root canal
[46–48], so the concept of an apically closed sys-
tem remains valid.
Delivering irrigants only in the pulp chamber
or in the coronal third of the root canal using
syringes and large needles (21–23 G) (Table 11.1),
a technique that was advocated in the past [30,
49], means that irrigants are only transported
toward the apical third by the files or by diffu-

Table 11.1 Medical ISO 9626:1991/Amendment.1:2001 (medical needles)

needle specifications Int. diameter
according to ISO Gauge Metric Ext. diameter (mm) (mm) Corresponding
9626:1991/Amd.1:2001 size size (mm) Min Max Min instrument size*
[66] and corresponding
21 0.80 0.800 0.830 0.490 90
size of endodontic
instruments 23 0.60 0.600 0.673 0.317 70
25 0.50 0.500 0.530 0.232 55
26 0.45 0.440 0.470 0.232 50
27 0.40 0.400 0.420 0.184 45
28 0.36 0.349 0.370 0.133 40
29 0.33 0.324 0.351 0.133 35
30 0.30 0.298 0.320 0.133 35
31 0.25 0.254 0.267 0.114 30
32 0.23 0.229 0.241 0.089 25
*Non-existing instrument sizes were rounded up to the next available size.

pilararaya@ejercer.cl
306 C. Boutsioukis

sion. Nowadays, syringe irrigation by fine nee-
dles is widely used [1, 50–55], but its effectiveness
depends on root canal enlargement and insertion
of the needles close to working length (WL) [52,
53, 56–61].
Under the same conditions, closed-ended nee-
dles are always less effective than open-ended
needles regarding apical irrigant exchange [39,
44, 53, 60–64]. Due to the very-low-intensity jet
created and its partially lateral direction, irrigant
penetration is limited to 1 mm or less apically to
the tip of a closed-ended needle even under ideal
conditions [62], and only a slight improvement
can be achieved by increasing the apical size, the
taper, or the irrigant flow rate (Figs. 11.1 and
11.2) [39, 44, 60, 61, 63, 65]. Therefore, root

25/.06 30/.06 35/.06 45/.06 55/.06

18

15

12

9
25/.06 30/.06 35/.06 45/.06 55/.06
6

0
Velocity
Magnitude
(m/s)

Fig. 11.1 Triads of time-averaged irrigant velocity con-
tours (left) and vectors (middle) and streamlines (right)
depicting irrigant flow when a closed-ended (top) or an
open-ended needle (bottom) are placed at 3 mm short of
WL in 0.06-tapered root canals having various apical
sizes according to computer simulations. Needles are col-
ored in red. Irrigant penetration apically to the needle tip
is improved as the apical size increases, and this effect is
more pronounced for the open-ended needles. Reprinted
and modified with permission [60, 61]

pilararaya@ejercer.cl
11 Internal Tooth Anatomy and Root Canal Irrigation 307

30/.02 30/.04 30/.06 F3 (30/.09)

18

15

12

9
30/.02 30/.04 30/.06 F3 (30/.09)

0
Velocity
Magnitude
(m/s)

Fig. 11.2 Triads of time-averaged irrigant velocity
contours (left) and vectors (middle) and streamlines
(right) depicting irrigant flow when a closed-ended
(top) or an open-ended needle (bottom) are placed at
3 mm short of WL in size 30 root canals having different
tapers according to computer simulations. The fourth
case refers to the shape of the ProTaper Universal F3 file
(Dentsply Tulsa Dental, Tulsa, OK, USA). Needles are
colored in red. An increase in the taper improves irrig-
ant penetration, and this effect is more pronounced for
the open-ended needles. Reprinted and modified with
permission [61]

pilararaya@ejercer.cl
308
canals need to be prepared to an apical size that
allows insertion of this needle within 1 mm from
WL while also providing enough space around
the needle for the reverse irrigant flow toward the
root canal orifice; a minimum apical size 30–35
(depending on the taper) seems necessary to sat-
isfy these requirements for the widely used 30 G
needles (Table 11.1) [66, 67].
Open-ended needles create a more intense jet
of irrigant apically, which is a clear advantage in
terms of irrigant penetration in the main root
canal [62, 63, 65]. Nevertheless, jet penetration
also depends on the apical size and taper of the
root canal and on the irrigant flow rate [44, 53,
62, 63, 65]. The irrigant cannot reach farther than
1 mm apically to the needle tip in root canals hav-
ing an apical size less than 30 (Fig. 11.1) [59, 60],
and insertion of a 30 G open-ended needle at
1 mm from WL in such root canals without bind-
ing is not feasible; binding of an open-ended
needle very close to WL could lead to irrigant
extrusion through the apical foramen [47].
Penetration is greatly improved in larger root
canals, which allows for the placement of these
needles at 2–3 mm short of WL without compro-
mising irrigant exchange (Figs. 11.1, 11.2, and
11.3) [44, 53, 60, 61, 63, 65] while reducing the
risk of irrigant extrusion [47]. Therefore, simi-
larly to the closed-ended needles, a minimum
apical size 30–35 is also required for irrigation
with open-ended needles to reach the full extent
of the main root canal [53, 60–62].
Several ex vivo studies could not detect sig-
nificant differences between syringe irrigation
and several other delivery or activation methods,
including negative pressure irrigation, sonic, and
ultrasonic activation, regarding the removal of
soft-tissue remnants, hard-tissue debris, bacteria,
or biofilm from the main root canal [68–75] when
it was adequately enlarged and the needle was
placed within the recommended distance from
WL. The results of a randomized controlled clini-
cal trial that evaluated healing of apical periodon-
titis in teeth with a single root canal and relatively
simple anatomy also showed no difference
between syringe irrigation and ultrasonic activa-
tion [76], which seems to be in line with the
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aforementioned studies. Interestingly, there are
also several studies that could not detect signifi-
cant differences between syringe irrigation and
other methods even though it was not clear
whether the requirements for apical enlargement
and insertion close to WL were actually met [54,
77–83]. On the contrary, studies showing that
syringe irrigation resulted in inferior cleaning
and disinfection of the main root canal compared
to other methods generally did not enlarge the
canals to an adequate size and/or inserted the
needles too far from WL [38, 52, 84–86], but
there are a few exceptions [87, 88].
These apical size requirements are at variance
with the emerging trend of minimal root canal
instrumentation aiming to preserve as much hard
dental tissue as possible [31]. Even though there
are no specific guidelines available, minimal
shaping frequently combines a smaller apical
size (≤25) with increased taper (≥6%). However,
there is no evidence that increased taper can com-
pensate for the reduction in the apical size regard-
ing irrigant penetration; to the contrary, the effect
of apical size seems to be more pronounced than
the effect of taper [60, 61].
Root canal curvature per se doesn’t appear to
limit irrigant penetration during syringe irriga-
tion as long as the canal can be adequately
enlarged and the needle can be inserted close to
WL [51, 64]. However, extreme curvature can
limit apical enlargement. Finer and more flexible
irrigation needles (31–32 G) may reach closer to
WL in such root canals, but there is very limited
information about their ability to deliver the irrig-
ant, the resulting flow, and cleaning of root
canals. Moreover, these needles require three to
six times stronger force to be applied to the
syringe compared to a 30 G needle, to reach the
same flow rate [89]. Other irrigation methods
such as apical negative pressure irrigation and
laser-activated irrigation that also require inser-
tion of cannulas or tips very close to WL are also
limited by the smaller apical size [90–92].
It is rather unlikely that any method based on
transverse oscillation of files/tips inside the root
canal (e.g. sonic or ultrasonic activation) can pro-
vide significant advantages in minimally shaped
11 Internal Tooth Anatomy and Root Canal Irrigation 309

1 mm 2 mm 3 mm 4 mm 5 mm

18

15

12

1 mm 2 mm 3 mm 4 mm 5 mm 9

0
Velocity
Magnitude
(m/s)

Fig. 11.3 Triads of time-averaged irrigant velocity ended needle (bottom) are placed at 1–5 mm short of
contours (left) and vectors (middle) and streamlines WL according to computer simulations. Needles are
(right) depicting irrigant flow in a size 45/0.06 taper colored in red. Reprinted and modified with permis-
root canal when a closed-ended (top) or an open- sion [53]

or extremely curved root canals; such oscillating
files/tips make frequent wall contact even in ade-
quately enlarged straight root canals, which
seems to dampen the oscillation [93, 94]; multi-­
point wall contact inside narrow and curved
canals will probably dampen the oscillation even
more [95]. A small ex vivo study observed differ-
ences in the performance of ultrasonic activation
in straight and curved canals [87] that could be
attributed to wall contact and dampening.
However, another in vitro study could not detect
any influence of curvature on the irrigant penetra-
tion apically to an ultrasonic file [96], but the arti-
ficial root canal was made of a very soft material
which, unlike dentin, may have been unable to
provide strong dampening.

pilararaya@ejercer.cl
310
Despite the absence of obvious limitations to
its performance, Photon-Initiated Photo-acoustic
Streaming (PIPS) also doesn’t seem to provide a
significant advantage against microbes in root
canals prepared to an apical size smaller than 30
[97]. Thus, based on the currently available evi-
dence, the main alternatives in narrow and curved
canals are manual dynamic activation with a
well-fitting gutta-percha point [52] or a multi-
sonic activation system [83].
Just as a very small root canal is difficult to
irrigate, limitations arise also in very large root
canals. In such cases, the irrigant can easily pen-
etrate to the full extent of the main canal [60, 61],
but its velocity decreases because more space is
available for the flow, causing a reduction in the
mechanical cleaning effect as indicated by the
25 35 45 55 25
Fig. 11.4 Time-averaged distribution of shear stress on
the root canal wall during irrigation by a closed-ended
(left) or an open-ended needle (right) positioned at 3 mm
short of WL in 0.06-tapered root canals having various
pilararaya@ejercer.cl
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wall shear stress (Fig. 11.4) [60, 61]. Since high
wall shear stress only affects a limited area of the
main root canal near the needle tip during syringe
irrigation [52, 53, 60–62], a possible way to
improve mechanical cleaning in such cases would
be to move the needle along the root canal during
delivery in order for the high shear stress to affect
as much of the root canal wall as possible; this
longitudinal needle movement may also provide
an advantage even in smaller root canals.
Air bubbles may be entrapped in the apical
part of the main root canal during irrigation and
could block irrigant penetration, a phenomenon
termed “apical vapor lock” [42, 98–101]. Bubble
entrapment seems to be more frequent in narrow
root canals, but early studies probably overesti-
mated its frequency by inserting the needles too
35 45 55
1000
800
600
400
200
0
Wall
Shear Stress
(N/m2)
apical sizes according to computer simulations. Only half
of the root canal wall is shown to allow simultaneous
evaluation of the needle position. Needles are colored in
red. Reprinted and modified with permission [60]
11 Internal Tooth Anatomy and Root Canal Irrigation
0.083 mL/s 0.260 mL/s
1 mm
3 mm
Fig. 11.5 Bubble entrapment (vapor lock) in the apical
part of size 50/0.04 taper root canals according to com-
puter simulations and in vitro experiments. The irrigant
was delivered at a flow rate of 0.083 or 0.260 mL/s
through a 30 G closed-ended needle inserted at 1 or 3 mm
short of WL. The blue surface depicts the air-irrigant
far away from WL, irrigating at a very low flow
rate (Fig. 11.5), or using artificial root canals
made of hydrophobic materials [101]. Contrary
to widely held views [42, 98, 102], apical vapor
lock doesn’t seem to be a major problem during
irrigation. The bubbles can be easily removed or
their entrapment can be prevented by adequate
enlargement of the root canal to a minimum api-
cal size 35 and insertion of irrigation needles
very close to WL, even briefly, without the need
for any supplementary irrigation methods [101].
The same applies to the removal of the smear
layer which is formed on the wall of the main
root canal where metal instruments cut dentin
[103, 104]. Remote areas and a considerable part
of the main root canal remain untouched by
instruments [36], thus, also free of smear layer.
pilararaya@ejercer.cl
311
0.083 mL/s 0.260 mL/s
interface in the computer simulations. Only large bubbles
occupying completely a part of the apical root canal create
a vapor lock (stars). Smaller bubbles floating in the irrig-
ant (arrows) are of minor importance because they cannot
block irrigant penetration to any part of the root canal.
Reprinted and modified with permission [101]
Therefore, its removal concerns only a part of the
main root canal and should be possible using
syringe irrigation, albeit a combination of irrig-
ants is most likely needed [1]. Interestingly, the
use of ultrasonic files to activate chelators and
improve smear layer removal seems to be even
counterproductive because the resulting increase
in the temperature can actually decrease their
calcium-binding capacity [2].
Finally, it is noteworthy that ultrasonic irrigant
activation may be able to modify, to some extent,
the anatomy of the main root canal by removing
small amounts of dentin and causing transporta-
tion, especially when ultrasonic K-files are used
(Fig. 11.6); this has been demonstrated ex vivo or
in vitro in both straight [105] and curved root
canals [106, 107].
312
Fig. 11.6 Three-­
dimensional
K-file
reconstructions of
micro-computed
tomography scans
depicting the root canal
wall after preparation
(yellow) and the amount
of dentin removed by
different ultrasonic files
(red) after 30 and 60 s of
activation. Reprinted
and modified with
permission [107]
30 s 60 s
11.6 Uninstrumented Oval
Extensions and Fins
Most of the available instruments and techniques
are unable to completely prepare oval root canals
and fins extending laterally from the main root
canal [108–112]. Therefore, cleaning and disin-
fection of these uninstrumented areas needs to
be accomplished by irrigants entering through
the main root canal. In addition to biofilm and
pulp tissue remnants, dentin debris may be
packed in these areas during instrumentation,
which may hinder the access of irrigants [113].
Current evidence is mostly limited to ex vivo or
in vitro studies on the removal of dentin debris
from artificial grooves and depressions on the
root canal wall, a process that is likely to depend
primarily on the mechanical cleaning effect,
while there is very limited information about the
removal of pulp tissue remnants and, more
importantly, of biofilm. Increasing the apical
size from 30 to 40 or 50 doesn’t seem to affect
irrigation of these areas by various methods
[114], but size 30 may already provide an ade-
quate pathway for the irrigants. The taper of the
pilararaya@ejercer.cl
C. Boutsioukis
Endo Soft
Instrument
Irrisafe Control
30 s 60 s 30 s 60 s 30 s 60 s
main root canal seems to have a significant effect
on the cleaning process of artificial grooves and
depressions when combined with a smaller api-
cal size (#20) [115]. Furthermore, the length,
width, and depth of these spaces are likely to
affect their cleaning.
Several studies agree that supplementary irri-
gation methods perform better than syringe irri-
gation in the removal of dentin debris [29, 87, 90,
93, 114, 116–118] or soft-tissue remnants [119]
from fins and uninstrumented oval extensions,
but the relative effectiveness of each method is
unclear. Laser-activated irrigation appears to be
the most effective method followed by ultrasonic
activation [90], at least in straight root canals, but
the performance of both methods is likely to
depend on several operating parameters. For
instance, cleaning by ultrasonic activation is sig-
nificantly improved when high power is used
[120] and when the files/tips oscillate toward the
area of interest [121], conditions that may not be
met during clinical use. Intermittent ultrasonic
activation for short periods of time (≤20 s) com-
bined with irrigant refreshment between activa-
tion periods seems to be a more effective method
11 Internal Tooth Anatomy and Root Canal Irrigation
than continuous activation for longer periods
(≤3 min) [122, 123] and repetitions of this pro-
cess seem to have a cumulative effect [29]. In
fact, the number of repetitions appears to be more
important than the duration of the activation peri-
ods [29, 116], which may be related to the
unsteady oscillation and the resulting intense
streaming created at the startup of each activation
period [123]. The cleaning effect of ultrasonic
files seems to extend up to 3 mm apically to their
tip, at least in straight canals and when using high
power [96].
Continuous irrigant delivery and ultrasonic
activation through oscillating needles also appear
to be more effective than syringe irrigation and
several other methods [118], but a direct com-
parison to the more widely used intermittent
ultrasonic activation is lacking. An automated
positive-pressure pulsed-delivery system seems
to be less effective than ultrasonic activation, at
least in straight root canals [87, 114], but there
are some indications that it may surpass ultra-
sonic activation in curved canals [87]. Sonic acti-
vation applied by plastic tips or metal needles
appears less effective than ultrasonic activation
but still better than syringe irrigation under cer-
tain conditions [93, 117], and the same seems to
apply to manual dynamic activation with gutta-­
percha points and apical negative pressure irriga-
tion [118]. Nevertheless, these rankings are based
on a limited number of studies.
11.7 Isthmus
An isthmus is a narrow ribbon-shaped connec-
tion between two adjacent root canals in the same
root that may contain biofilm, pulp tissue rem-
nants, and dentin debris [124]. The cleaning of
the isthmus is far more challenging than cleaning
of the main root canal [72–74, 125], and the limi-
tations resemble those of oval extensions and
fins. However, the isthmus may be accessed by
irrigants from two sides, namely, from each of
the main root canals that is connected to, and this
could be an advantage. An additional access for
pilararaya@ejercer.cl
313
irrigants may also exist if the isthmus extends
coronally till the pulp chamber.
Two studies could not detect significant differ-
ences in the removal of dentin debris from the
isthmus between syringe irrigation and several
other supplementary methods, including inter-
mittent ultrasonic activation, continuous irrigant
delivery, and ultrasonic activation by an oscillat-
ing needle, sonic activation, and apical negative
pressure irrigation [70, 71], but their findings
may have been affected by the low sensitivity of
the two-dimensional evaluation method that was
used. Recent studies using micro-computed
tomography have shown that ultrasonic activa-
tion, apical negative pressure irrigation, and an
additional finishing rotary NiTi instrument can
remove more dentin debris from the isthmus
compared to syringe irrigation [75, 113, 126].
Similar results were obtained regarding the
removal of pulp tissue remnants by intermittent
ultrasonic activation or continuous irrigant deliv-
ery and ultrasonic activation by an oscillating
needle; both methods performed better than
syringe irrigation [72, 77, 127, 128], even though
the use of large needles may have hindered inser-
tion close to WL, a parameter that remains impor-
tant also for the cleaning of the isthmus [55]. A
multisonic activation system was also found to be
more effective than syringe irrigation in the
removal of pulp tissue remnants from the middle
and apical third of the isthmus [83], but there was
a large imbalance in the volume of irrigant used
by the two methods.
No significant difference was found between
ultrasonic activation and an additional finishing
rotary NiTi instrument concerning the removal of
bacteria from the main canal, isthmus, any acces-
sory canals, and dentinal tubules evaluated in
combination [129]. Nevertheless, other methods
seem to be somehow less effective; manual
dynamic activation with a gutta-percha point left
more pulp tissue remnants than apical negative
pressure irrigation [125], and sonic activation
only showed an advantage over syringe irrigation
in some areas coronally to the tip of the needle
regarding the removal of artificially placed col-
314
lagen [73]. Furthermore, a combined syringe
delivery and evacuation device was equally or
less effective in the removal of pulp tissue rem-
nants compared to syringe irrigation [74].
From a fluid dynamics point of view, a patent
isthmus can provide a significant advantage for
irrigant penetration by eliminating the crucial
problem of the apically closed system [130]; irri-
gants can follow a continuous path from one root
canal to the other through the isthmus without the
need to create a reverse flow within the same
canal. The closer the connection is to the apex,
the more effective the flushing of the main root
canals should be. A recent study combined
syringe delivery in one of the connected root
canals and apical negative pressure evacuation in
the second canal in order to force the irrigant
through the isthmus and demonstrated more
effective removal of dentin debris compared to
either syringe irrigation or apical negative pres-
sure irrigation alone, and also compared to ultra-
sonic activation [131]. A similar advantage is
likely to exist when two patent root canals merge
near the apex, even without a patent isthmus con-
necting them.
11.8 Accessory Canals
and Dentinal Tubules
Accessory canals and dentinal tubules present
similar challenges for root canal irrigation but at
different length scales. Accessory canals are per-
ceived to be smaller than the main canal but
larger than dentinal tubules; morphological
investigations of accessory foramina have
reported diameters of 10–200 μm [132]. Dentinal
tubules, on the other hand, have an approximate
diameter of 0.5–3.2 μm [133]. During irrigation,
both accessory canals and dentinal tubules behave
as closed-ended cavities, similarly to the main
canal, so the same limitations apply. However, it
is usually impossible to enter the accessory
canals, let alone dentinal tubules, with instru-
ments or irrigation systems. Chemo-mechanical
preparation can only partially remove tissue rem-
pilararaya@ejercer.cl
C. Boutsioukis
nants from the entrance of accessory canals
[134], which is also likely for dentinal tubules.
Irrigant flow in accessory canals and dentinal
tubules is driven by the flow in the main canal
and appears to be limited to a depth approxi-
mately twice their diameter (Fig. 11.7), while dif-
fusion dominates irrigant transport beyond that
point [135]. Therefore, optimum irrigant refresh-
ment in the main canal in order to maintain a
favorable concentration gradient, any increase in
the temperature of the irrigants, and a longer
application period could enhance particle trans-
port [135]. The importance of these three param-
eters for sodium hypochlorite penetration and its
antimicrobial effect inside dentinal tubules have
been verified in ex vivo studies [136–138], but
similar studies on accessory canals are lacking.
Nevertheless, it is difficult to maintain the irrig-
ant temperature above 35–37 °C inside the root
canal in vivo unless preheated irrigant is con-
stantly delivered [139] or the irrigant is heated in
situ [140, 141], so temperature-driven accelera-
tion of diffusion is usually short term. Evidently,
the smear layer seems to reduce the antimicrobial
effect of irrigants inside the dentinal tubules, but
it doesn’t create an impermeable barrier [142].
Regarding accessory canals, there seems to be
a consensus that intermittent ultrasonic activation
and continuous irrigant delivery and ultrasonic
activation by an oscillating needle are the most
effective methods for irrigant penetration and
cleaning of accessory canals, while syringe irri-
gation, apical negative pressure irrigation, and
sonic activation seem less effective [141, 143–
145]. These findings can be explained by the
intense streaming created in the main root canal
during ultrasonic activation [146], which can also
ensure an optimum concentration gradient, and
by the temperature increase [140, 141]. The level
and angulation of the accessory canals doesn’t
seem to influence irrigant penetration and clean-
ing, as long as the accessory canal entrance can
be reached by the flow in the main canal [106,
141, 143–145].
Ultrasonic activation also seems to achieve
deeper penetration inside dentinal tubules com-
11 Internal Tooth Anatomy and Root Canal Irrigation
a Main
root canal
Dentinal tubule
2.5 mm
b 10-12
Fig. 11.7 Flow pattern (left) and velocity magnitude (right,
logarithmic scale) of the convection inside dentinal tubules as
obtained from computer simulations. The direction of the
flow in the main root canal (a, parallel to the wall; b, at 45° to
pared to sonic activation, manual dynamic activa-
tion with a gutta-percha point, and syringe
irrigation, with sonic activation being slightly
more effective than the latter two methods [147].
An automated positive-pressure pulsed-delivery
system appears to be more effective than syringe
irrigation as well [148]. However, it should be
noted that, in addition to sub-optimum enlarge-
ment of the main root canals and inadequate
insertion depth of the needles, a dye was used as
a marker to quantify penetration in both studies,
and it may behave differently than common irrig-
ants [142]. Interestingly, the dye penetrated up to
2.3 mm following syringe irrigation for 1 min
[148], which was considerably deeper than the
reported 300 μm maximum penetration of sodium
hypochlorite after application for 2–20 min [136,
138]. Another study could not detect any differ-
ence in the antimicrobial effect of syringe irriga-
pilararaya@ejercer.cl
315
Main
root canal
10
Dentinal tubules
10-3
10-6
2.5 mm
10-9
10-15
Velocity
Magnitude
(m/s)
the wall) is indicated by the large blue arrows. Close to the
tubule orifices, the flow is always parallel to the wall. Irrigant
velocity decreases rapidly inside the dentinal tubules.
Reprinted and modified with permission [135]
tion and laser-activated irrigation when the main
root canal and dentinal tubules were examined in
combination [149].
Nevertheless, the importance of accessory
canal and dentinal tubule cleaning for the success
of root canal treatment is debated [134, 150].
Despite the limitations in the cleaning of acces-
sory canals and the fact that their contents remain
largely undisturbed by treatment procedures, api-
cal periodontitis doesn’t seem to persist around
them in many cases [134]. Furthermore, dentinal
sclerosis, a physiological process that begins
around the third decade of life in the apical part
of the root canal and progresses coronally, gradu-
ally blocks many dentinal tubules [151], thus pre-
venting the penetration of both bacteria and
irrigants. This is an important confounder very
frequently overlooked in studies on dentinal
tubule infection and disinfection [152].
316
11.9 Concluding Remarks
Despite the constant development of new irriga-
tion methods, it is likely that complex anatomy
will remain the ultimate challenge for root canal
irrigation. The viscosity of the irrigant together
with the diameter of the areas that need to be
reached appear to be the main parameters limit-
ing the flow irrespective of the method used. On
the other hand, treatment time is likely to be the
main limitation for diffusion of particles to
remote sites. Our current understanding of irrig-
ant transport and action inside the root canal sys-
tem is evidently incomplete, and further research
is needed to identify potential solutions to these
problems. However, it must be remembered that
cleaning and disinfection of the root canal system
is an inherently demanding task and adding more
obstacles by the preparation of ultraconservative
access cavities or by minimal root canal shaping
should be avoided, especially in the absence of
evidence that these practices provide an
advantage.
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 Internal Tooth Anatomy and Root
Canal Obturation
Arnaldo Castellucci
Abstract
The ultimate objective of the root canal ther-
apy is the three-dimensional obturation of the
endodontic space after it has been completely
cleaned, shaped, and disinfected. The purpose
of obturation is to seal all “portals of exit” to
impede any sort of communication or exchange
between the endodontium and periodontium. It
must therefore completely and durably fill the
root canal space, in which no empty spaces
should remain at all. It has been repeatedly
demonstrated that most of endodontic failures
are related to incomplete obturation of the
endodontium. On the other hand, it is well
known that the root canal system can be disin-
fected and not sterilized. For this reason, the
canal obturation should be considered like the
very last step of cleaning, because it represents
the only way to neutralize the bacteria left in
the root canal walls and in the dentinal tubules.
Understanding the biological reasons why a
cleaned, shaped root canal requires to be obtu-
A. Castellucci, M.D., D.D.S.
Private Practice Limited to Endodontics,
Florence, Italy
Endodontics, University of Cagliari Dental School,
Cagliari, Italy
Micro-Surgical Endodontics, Specialty of Oral
Surgery, University Federico II of Naples,
Naples, Italy
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_12
pilararaya@ejercer.cl
12
rated will guide in selecting the best filling
materials and techniques.
12.1 Biological Considerations
for Root Canal Obturation
In 1931, Rickert and Dixon [1] formulated the
“hollow tube” theory, according to which an empty
space within a living organism tends to fill with
tissue fluids in a short period of time. This theory
was based on the observation of an inflammatory
reaction around the ends of hollow steel and plati-
num anesthetic needle fragments implanted in
experimental animals. This reaction did not occur
if the implant was made of a solid, nonporous
material [1]. Two years later, Coolidge [2] arrived
at the conclusion that, just as within unfilled or
underfilled root canals, fluids that accumulate
within empty spaces are rapidly colonized by bac-
teria that reach these spaces by means of a phe-
nomenon of “anachoresis.” In other words, bacteria
transported by the blood circulation (bacteremia)
colonized these areas, where they remained shel-
tered from phagocytosis by the organism’s
defenses. In the tissue fluids that had been col-
lected, bacteria found a nutritional source that
could sustain them. The irritating substances
derived from the breakdown of the organic mate-
rial contained in the tissue fluid and from the prod-
ucts of bacterial metabolism were supposedly the
cause of the surrounding inflammatory reaction.
323
324
For years, this theory has influenced the con-
cept that root canals must be filled to the apex and
therefore that any empty spaces must be
­completely obliterated: unfilled portions of the
root canal must serve as a reservoir for the accu-
mulation of tissue fluids and inflammatory exu-
date, as this would quickly be colonized by
bacteria through anachoresis, which would pre-
vent or delay the healing of the periapical lesion.
More recent studies showed evidence refuting
the “hollow tube” theory [3–7]. It has been demon-
strated, in experimental animals, that it is possible
to implant in fresh sockets sterile empty glass [3] or
polyethylene [4, 8] tubes or even empty root canals
[6], causing only mild inflammation or none around
the open ends of the tubes. Other authors [7] dem-
onstrated in experimental animals that empty
spaces made inside plastic teeth implanted in fresh
sockets did not produce any inflammation around
the open ends, while in many cases these spaces
were subsequently filled up with fibrous tissue or
bone. The latter occurred more frequently with
larger size apical openings [6]. More recent studies,
therefore, strongly invalidate the previous “hollow
tube” theory and make it possible to conclude that
empty spaces within a living tissue are not neces-
sarily accompanied by inflammation or tissue
destruction; on the contrary, they can be associated
with physiological repair (Fig. 12.1a, b).
In 1981, Delivanis et al. [9] have denied the
possibility of the existence of the anachoresis
within an empty tube filled only with tissue fluids
or within a root canal following pulpectomy, in
experimental animals. The selective localization
in areas of chronic inflammation of blood-borne
bacteria (anachoresis) is a well-known phenom-
enon, experimentally demonstrated [10–15]. For
example, it explains the presence of bacteria in a
pulp that has not been exposed to the oral envi-
ronment but has been compromised by a trauma.
In order for the anachoresis to occur, the presence
of blood vessels is, however, necessary: bacteria
can easily localize in a space where tissue is pres-
ent, even inflamed or on the way to necrosis, but
still with blood circulation and not simply in a
space filled only with tissue fluids where blood
circulation doesn’t exist. Based on the aforemen-
tioned arguments, it can be concluded that
cleaned and shaped root canals must also be com-
pilararaya@ejercer.cl
A. Castellucci
pletely obliterated, not to prevent the bacterial
colonization of the tissue fluids but rather to pre-
vent the survival and multiplication, inside the
fluids which inevitably accumulate there, of bac-
teria remaining from even the most thorough
sterilization procedures of the root canal.
It is universally recognized that complete ster-
ilization and removal of all pulpal debris from an
infected root canal is very difficult, if not impos-
sible, to achieve [16–21] (Fig. 12.1c, d). What is
achieved, in most cases, is the disinfection of the
root canal system. The microorganisms remain
isolated inside the root canal system, possibly
within dentinal tubules that have remained
infected deeper than the level of the shaped den-
tinal wall [22]. They, therefore, are beyond the
reach of the organism’s phagocytic defenses, and
the presence of necrotic pulp remnants in associ-
ation with the accumulating exudate can serve as
a source of nutrients and contribute to the main-
tenance of their viabilities. If, however, the root
canal system is completely obturated in its three
dimensions, any remaining microorganism will
be entrapped within the dentinal tubules between
the cementum on one side and the canal filling
material on the other, with no possibility for pro-
liferation or survival [23–27] (Fig. 12.1e, f).
Confirming Morse’s findings [28], Moawad [29]
has demonstrated that such bacteria entrapped
within a completely filled root canal are nonvia-
ble within 5 days after root canal filling.
Peters et al. [27] demonstrated that there is no
evidence that special measures (calcium hydrox-
ide or iodoformic paste) should be taken to kill
the bacteria in the dentinal tubules. Those bacte-
ria either do not survive the treatment, are inacti-
vated subsequently, or remain in insufficient
numbers to sustain or cause pathology. This is, of
course, supported by the notion that a high per-
centage of “properly treated” cases are successful
[30–32]. This is clearly not because of the almost
unobtainable sterility of the treated dentin-pulp
complex but rather the reduced amount of
remaining bacteria just before obturation. Other
in vitro studies demonstrated that most bacteria
in the dentinal tubules died within 24 h after
removal of the nutrient medium [33].
Sjøgren et al. [34] studied the influence of the
presence of infection at the time of root canal
12 Internal Tooth Anatomy and Root Canal Obturation 325

a b

c d

e f

g h

Fig. 12.1 (a) Preoperative radiograph of a lower left first
molar; (b) radiograph 2 months later. This period of time
elapsed because of neglect on the part of the young
patient. The four canals had been cleaned, shaped, and
medicated with cresatin. Note the progression of the heal-
ing process, which has proceeded although canals had not
yet been obturated and thus were completely empty; (c)
scanning electron microscopic (SEM) view of the apical
third of a cleaned and shaped lower incisor. Note the pres-
ence of a large calcification adhering to the wall a few
millimeters from the foramen (×60); (d) detail of c. Note
the presence of organic material in the area immediately
apical to the calcification, where the instruments obvi-
ously could not be worked (×4000); (e) postoperative
radiograph of the case of a; (f) 2-year recall radiograph; (g)
a radiolucency is present at the apex of both the first and
the second lower premolars, which appear to be under-
filled. The first premolar also shows a wider periodontal
ligament space on the distal aspect, a screw post, an empty
space between the dentin and the obturating material api-
cal to the screw post. Clinically, there is a deep and narrow
probing defect: the tooth had a vertical root fracture and
therefore had to be extracted; (h) the 3-year recall radio-
graph shows the complete healing of the two lesions, both
where a nonsurgical retreatment has been performed and
where the tooth has been extracted. In both cases the same
result was accomplished: the complete elimination of the
infection from the root canal system

pilararaya@ejercer.cl
326
­ lling on the outcome of endodontic treatment in
fi
teeth with apical periodontitis. They theorized that
the success was obtained despite positive bacte-
rial cultures because the remaining bacteria were
“entombed” in the canal. Interestingly, among
the bacteria present at the time of root filling in
cases that healed successfully, the authors found
Peptostreptococcus anaerobius, Actinomyces
naeslundii, Fusobacterium nucleatum, and
Enterococcus faecalis, and all the cases worked
when the canals were filled to or beyond the ter-
minus. In other words, it means that the only cases
that failed were those obturated short, confirming
that bacteria remaining in the disinfected root canal
had space to survive, proliferate, and be responsible
for the endodontic failure. Obturation, with gutta-
percha and sealer after chemomechanical clean-
ing and disinfection with sodium hypochlorite,
also deprives the remaining microorganisms from
their nutrition supply thereby reducing their ability
to cause or maintain disease. It has also been sug-
gested that gutta-­percha has a certain bacteriostatic
activity, perhaps due of its zinc oxide content [35].
However, gutta-percha and sealer alone should not
be used without prior disinfection and shaping of
the root canal system.
Klevant and Eggink [36] have hypothesized
that, because of the deficient blood circulation in
even a perfectly cleaned, shaped, but unobturated
root canal, the accumulated tissue fluids could
disintegrate and become themselves irritants of
the periapical tissues, even in the absence of bac-
teria. In conclusion, the reason for a complete root
canal obturation in its three dimensions is not only
to prevent apical leakage but also to prevent coro-
nal leakage. Figure 12.1b shows healing in prog-
ress without any filling material in the root canals.
However, if the coronal seal was compromised,
the entire root canal system would be reinfected,
and a periapical lesion could develop again.
12.2 Properties of the Filling
Materials
In view of these biological motivations for canal
obturation, the qualities required to ensure a suc-
cessful outcome in endodontic therapy will now
be examined.
pilararaya@ejercer.cl
A. Castellucci
The practice of endodontics based on chemo-
therapy, antimicrobial agents, and mummifiers is
without a doubt outdated. It was based on the
concept that the pharmacological properties of
the ideal obturation material should assist nature
to seal the canals with calcific or connective tis-
sues [22]. In deference to the ancestral fear of
focal infection, the emphasis was placed on bac-
teriologic control to ensure that all microorgan-
isms had been completely eliminated from the
root canal before proceeding to obturation. It was
also motivated by the complexity and unpredict-
ability of the anatomy of the root canal system.
On account of these anatomical difficulties,
Sargenti [37] felt that dentists would never be
able to clean and obturate this anatomy, so that it
was even pointless to try. At the root of chemico-­
pharmacological endodontics, there is also an
important historical reason which explains why
endodontics has developed as a stepchild of phar-
macology. As Schilder has noted [38], many of
the world’s leading endodontists had previously
been professors of pharmacology or other mate-
ria medica.
Underlying the practice of chemical endodon-
tics is the desire to save time, with all the related
practical consequences, for both the patient and,
even more, for the dentist. Endodontic therapy
with unpredictable chemical therapeutic agents
has been replaced by biologically predictable
techniques. Enormous contributions to modern
endodontics have been made by academics and
researchers such as Prinz [39], Buckley [40],
Cook [41], Rhein [42], and Callahan [43] since
the end of the nineteenth century. These early
authors developed the fundamental principles that
the success of endodontic therapy and the elimi-
nation of periapical inflammation depend essen-
tially upon adequate root canal enlargement,
cleaning, and filling. These three principles were
understood more than a century ago and represent
the basis of modern endodontic therapy.
In 1918, Price [44] wrote that “the human
body can be considered a hermetically sealed
container, the alimentary tract being an infolded
tube and continuous with the exterior. Pulpless
teeth are openings thru nature’s protective armor
and, as such, will be the port of entrance of infec-
tion into the body, unless they are hermetically
12 Internal Tooth Anatomy and Root Canal Obturation
sealed.” It has therefore been accepted for some
time now in endodontics, as in the other branches
of dentistry, the secret of success, apart from
cleaning of the endodontium, which is compara-
ble to the extirpation of all carious tissue in
restorative dentistry, lies in the sealing properties
of the obturation, just as amalgam in restorative
dentistry, the inlay and the crown in prosthetic
dentistry, and the marginal periodontium in peri-
odontics which must all have the property of
sealing. The use of medicated pastes to sterilize
and seal the root canals must therefore now be
considered anachronistic. Such pastes should
represent a panacea for endodontics, but in actu-
ality they conceal a lack of operative availability
and an inexplicable fear, if not ignorance, of end-
odontic anatomy.
Schilder [45] emphasizes that in endodontics,
the elimination of irritants from the root canal sys-
tem by means of cleaning and shaping, mechani-
cal disinfection, and total obturation of the
endodontium are important. “In the final analysis,”
he states that “it is the sealing off of the complex
root canal system from the periodontal ligament
and bone that ensures the health of the attachment
apparatus against breakdown of endodontic ori-
gin” […] “The rationale of Endodontics should be
designed to eliminate the root canal system as if
the tooth were extracted” [46] (Fig. 12.1g, h).
Similarly, back in 1918, Price [44] already asserted
that “root fillings are castings made within the
pulp chambers of teeth. They must conform so
exactly to the size and shape of that chamber that
neither microorganisms nor fluids, which may be
external to the tooth, can enter or find lodgment.
The form of this chamber is complex, uncertain,
and indeterminate and may vary through a very
wide range, which fact makes it necessary that the
root filling material, or a sufficient part of it, be
inserted in a moldable and plastic state.”
12.3 Apical Extent of Obturation
12.3.1 Cemento-Dentinal Junction
Many authors, in agreement with Grove [47],
maintain that the canal obturation must stop at
the cemento-dentinal junction, which corre-
pilararaya@ejercer.cl
327
sponds to the maximal apical constriction. The
pulp tissue terminates at this point, and the tis-
sue of the periodontal ligament begins. The
walls are no longer made of dentin but cemen-
tum. In theory, this view is correct in that the
apical constriction should ensure a good barrier
to the filling material, which must maximally
respect the periodontium. By obturating to this
point, the root canal is obturated without invad-
ing the periapical tissues. In practice, however,
things go differently.
As early as 1929, Coolidge [48] wrote that the
site of the cemento-dentinal junction is so vari-
able that trying to use it as a landmark is of little
help to the endodontist. This junction often has
unclear limits and can be found at different levels
within the root canal (Fig. 12.2a). The cemento-­
dentinal junction can even be found on the exter-
nal surface of the root [49]. Skillen [50] also
emphasized that it is histologically impossible to
define a clear line of demarcation between the
pulp on one side and the “periodontal membrane”
on the other, so that it is also histologically
impossible to find a point within the root canal
where the pulpal tissue ends and the periodontal
tissue begins (Fig. 12.2b). In agreement with
Coolidge [48], Orban [51] states that from a prac-
tical point of view, it is not possible to use the
cemento-dentinal junction as a boundary of the
endodontic obturation and that when it is identi-
fied, more often than not it is by chance. One
must also keep in mind that, also from a practical
point of view, relying on tactile sensation to
localize the cemento-dentinal junction as the site
of maximal apical constriction can often be mis-
leading. The maximal constriction of the canal
lumen may be due to the presence of a narrowing
of the canal (Fig. 12.2c) or to a calcification that
may vary in distance from the true end of the
endodontium (Fig. 12.2d). In summary, for both
histological and clinical-practical reasons, it is
unfortunately not possible, however desirable, to
exactly terminate the obturation each time at the
cemento-dentinal junction.
According to Ricucci and Langeland [52], the
apical limit of canal instrumentation and obtura-
tion should not be the radiographic terminus of
the canal nor should it be the cemento-dentinal
junction or the distance of 1 mm from the radio-
328
a b c d
Fig. 12.2 (a) The cemento-dentinal junction is difficult to
locate, even histologically; (b) the neurovascular bundle of
the pulp has the same characteristics both before and after
having crossed the apical foramen; (c) the apical constric-
tion in this case is due to a narrowing of the canal lumen,
not to the cemento-dentinal junction; (d) in this case, the
apical constriction is due to the presence of a calcification
graphic apex, but rather the “apical constriction,”
the anatomical location of which cannot be clini-
cally determined with accuracy (since the dis-
tance between the apical constriction and the
radiographic apex is “non-measurable” and
“ever-changing”) but it has been demonstrated as
far as 3.8 mm from the anatomic apex [53].
According to these authors, “the only way to
localize the apical constriction is to have ade-
quate radiographs, knowledge of anatomy and
tactile sense, while apex locators are of no help.”
In other words, according to these authors, “the
instrumentation and the obturation should termi-
nate where the instruments stop” (Fig. 12.2e).
And all this in respect of the apical pulp stump,
“which is always vital, even in presence of an
apical lesion, and if it becomes necrotic, it will be
removed by the periodontal circulation and by a
foreign body reaction.” On the other hand, many
authors like Blašković-Šubat et al. [54] and Olson
et al. [55] say that the arbitrary rule that canal
preparation should terminate 1 mm short of the
radiographic apex is becoming increasingly
unacceptable in modern endodontic therapy. This
technique could result in instrumentation short of
the true canal terminus, possibly leaving necrotic
and infected debris behind and leading to treat-
ment failure.
According to Schilder [56], having three-­
dimensionally obturated a root canal as far as
0.5–1 mm from the radiographic terminus of the
pilararaya@ejercer.cl
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e
distant from the cemento-dentinal junction, which is also
difficult to identify; (e) in such a case, to terminate the
instrumentation and obturation at the “constriction” means
to remain 7 or may be even more millimeters short, since
the calcification (which is a “constriction”) is located coro-
nally and will impede a more apical position of the instru-
ments, to reach the “correct” working length
canal is in practice equivalent to having filled it
completely. It is this that has led to the success of
the therapy.
In defining the apical region, it is now neces-
sary to examine the terminology in order to clar-
ify the confusion existing in the literature.
• The anatomical apex is the geometric vertex
of the root.
• The radiographic apex is the anatomic apex as
seen on the radiograph.
• The radiographic terminus of the canal refers
to the point where the endodontic instrument
within the root canal radiographically encoun-
ters the external profile of the root.
• The endodontic or physiologic apex indi-
cates the cemento-dentinal junction, which
usually (but not necessarily) corresponds to
the maximal point of narrowing of the canal
lumen.
• The apical constriction is the narrowest point
of the root canal, not necessarily the cemento-­
dentinal junction.
• The apical foramen is the opening of the root
canal on the external surface of the root
(Fig. 12.3a).
It is now obvious that radiographically, in a
straight canal, the foramen is at the radiographic
apex, while in a curved canal, the foramen has
nothing to do with the radiographic apex
12 Internal Tooth Anatomy and Root Canal Obturation
(Fig. 12.2b); therefore, to use this as a reference
point of the working length, and then for the
obturation, is nonsense. The electronic apex is
the reading of the electronic apex locator when
the endodontic instrument introduced in the root
canal is touching the periodontal ligament and is
exactly at the foramen.
12.3.2 Radiographic Terminus
of the Canal
Some authors claim that it is preferable to extend
the obturation to the radiographic terminus of the
canal, since this gives the greatest assurance of
having obturated the entire root canal system,
even if this sometimes leads to overfilling of few
fractions of a millimeter beyond the apex.
Obviously, we all agree with Schilder that some
very curved canals emerge in the roots at points
that are not radiographically visible, several mil-
limeters away from the anatomic apex. In these
cases, obturation to the radiographic terminus of
the canal is to be avoided, because this would
entail considerable excess. In such exceptional
cases, filling the root canal 0.5–1 mm short is
also to be avoided, because the filling material
would be equally in the periapical tissues
(Fig. 12.3c, d). Nonetheless, these cases are the
exception and not the rule, and they must be
treated, like any other case, to the “electronic
apex.” In other words, in these cases the operator
a b
Fig. 12.3 Morphological aspects of the anatomic apex.
(a) Illustration of the canal apex showing the anatomic
apex (A), apical foramen (F), cemento-dentinal junction
(D), and endodontic apex (E); (b) postoperative radiogra-
phy of a mandibular molar showing the anatomic apex
pilararaya@ejercer.cl
329
should rely on the reading of the electronic apex
locator and not on the radiograph.
Nowadays, reliable electronic apex locators
are available, and we know that they indicate the
end of the canal (which is the foramen), and for
sure they don’t indicate the location of the
cemento-dentinal junction or the apical constric-
tion; we can assert that all of our endodontic
treatments are performed at the “electronic
apex,” which about 50% of the times coincides
with the radiographic apex because the root
canal is straight. The other 50% of the times, the
root canal is not straight but is curved, and when
it makes a curvature, about 40% of the times the
curvature is to the mesial or to the distal (so that
we can still see the “radiographic terminus of the
canal”), and only about 10% of the times the
­curvature is to the buccal or to the lingual. These
are the cases where we must rely on the elec-
tronic apex locators, and these are the cases that
appear to be “radiographically short” [57]. The
successful outcome of cases obturated to the
radiographic terminus of the canal (Fig. 12.4a–
c) is therefore due to the completeness and three-­
dimensionality of the obturation. The minimal
overfilling is irrelevant, just as minimal under-
filling is.
As mentioned, Sjøgren et al. [34] looked at root
canals filled short and long, with positive and neg-
ative culturing results in each group. They showed
that high success rates were achieved regardless of
long or short filling when the culture came back
c d
(AA), the radiographic apex (AR), and the radiographic
terminus of the canal (RT); (c, d) the apical foramen of
this mandibular premolar is not radiographically visible.
Note the distance of the foramen from the vertex of the
root in the buccal (c) and mesial (d) aspects
330
a b
d e
Fig. 12.4 (a) Postoperative radiograph of a right lower
central incisor requiring endodontic treatment for peri-
odontal and prosthetic reasons: the obturation has been
performed to the radiographic terminus of the canal; (b)
the tooth was extracted for periodontal reasons 8 years
later and was photographed under stereomicroscope. Note
the gutta-percha which seals the apical foramen without
the least extrusion; (c) the same apex photographed from
another angle; (d) preoperative radiograph of a mandibu-
lar molar showing excess of obturation material which is
an indication for surgical treatment if it does not seal the
negative, but when the culture came back positive,
only the fully filled cases worked predictably. The
authors theorized that success was achieved
because the remaining bacteria were entombed in
the canal. Infected or not, all cases worked when
the canals were filled to or beyond the terminus.
From this interesting study, we can conclude the
following: because no one can insure sterility in
any given root canal space, the surest chance of
clinical success is gained when root canal systems,
in all of their complexities, are filled to their full
apical and lateral extents, even though that means
that there may be surplus material beyond the con-
fines of the root canal space. This is in agreement
with the findings of Peters et al. [27] who demon-
strated that the presence of a positive bacterial cul-
ture at the time of filling did not influence the
outcome of treatment.
In conclusion, the difference between the
“radiographic apex” and the “radiographic termi-
nus of the canal” must be well understood. If the
root canal is not straight and the foramen is on the
distal, or on the mesial aspect of the root, it is obvi-
pilararaya@ejercer.cl
A. Castellucci
c
f
root canal system or if it has been pushed against anatomi-
cal structures, and the patient is symptomatic. In this case,
the gutta-percha cone was pushed against the mental
nerve, and the patient developed paresthesia; (e) radio-
graph taken immediately after the apical surgery.
Ultrasonic tips (piezoelectric surgery) were used since
high-speed burs could have further damaged the nerve
bundle. Two weeks after the surgery, the paresthesia dis-
appeared completely; (f) 8-year follow-up radiograph.
The patient was asymptomatic, and paresthesia did not
recur
ous that it has nothing to do with the “radiographic
apex”; therefore it makes no sense to advocate an
instrumentation and then an obturation 0.05 mm
or more from the radiographic apex. On the other
hand, the mesial or distal opening of the foramen
can be radiographically appreciated as the “radio-
graphic terminus of the canal.” The only situation
when it is impossible to radiographically see the
terminus of the canal is when the foramen in on the
buccal or on the lingual aspect of the root. In such
cases, the instrumentation and obturation are per-
formed at the “electronic apex,” and the final result
will appear to be “radiographically short,” but we
know that actually it is exactly at the foramen.
12.3.3 Overfilling and Overextension
At this point, it is necessary to make a distinction
between over- and underfilling and between over-
and underextension. Over- and underextension
refer only to the vertical component of the obtura-
tion beyond or short of the apical foramen.
12 Internal Tooth Anatomy and Root Canal Obturation
Underfilling refers to an obturation that has been
performed inadequately in all dimensions (e.g., a
short and narrow silver cone in a longer and wider
root canal or a short obturation full of voids).
Overfilling refers to an obturation that has been
performed in three dimensions in which a small
portion of material extrudes beyond the foramen.
Therefore, the situation of a canal with a slight
overfilling is quite different from that of a canal
with a vertical overextension and an underfilling.
In the former, the obturation fills the entire
endodontium in its three dimensions and an excess
of material issues from the apical foramen. In the
latter case, the obturation material protrudes
beyond the apex without sealing the apical fora-
men and thus without three-dimensionally obtu-
rating the root canal system. The cause of failure in
these cases is not the tip of the silver cone or of the
gutta-percha that “pricks” the periodontium, but
the fact that it does not seal the apical foramen.
Surgery may be indicated, just to improve the api-
cal seal of the root canal system (Fig. 12.4d–f).
Ingle [58] affirmed that, in endodontics, one
achieves a high success rate despite overfillings.
Weine [59] stated that fortunately, since gutta-­
percha is so well tolerated by periapical tissue,
only rarely is a posttreatment failure noted in con-
junction with an overfilling. Most instances show
no abnormal radiographic evidence (Fig. 12.5a),
and in some cases, there is an actual amputation
a b c d
Fig. 12.5 (a) Radiograph of the maxillary left central
incisor, reimplanted after traumatic avulsion 3 years
before. The root has had a replacement resorption. The
gutta-percha radiographically appears to be in direct con-
tact with the bone, and there is no radiographic evidence
of inflammation; (b) preoperative radiograph of an upper
right lateral incisor; (c) postoperative radiograph: the tip
of the cone has slid 2–3 mm beyond the apex, probably
pilararaya@ejercer.cl
331
of the overfilling with phagocytosis of the extra
mass (Fig. 12.5b–f). Schilder [45] claimed that he
has never found a case of failure secondary to
overfilling. Cases that are labeled failures because
of the presence of material beyond the apex are
actually cases of underfilling with vertical overex-
tension of the obturation, and the failure depends
on the presence of bacteria left inside the root
canal system which has not been three-dimen-
sionally obturated [60] most of the times because
the foramen has been transported (teardrop fora-
men). In the literature, it has been widely demon-
strated that the major factors associated with
endodontic failures are inadequate root canal
debridement or incomplete root canal seal [61–
63], while the apical extent of root canal fillings is
not a determining factor [64–66].
The excess material beyond the cemento-­
dentinal junction plays no role in healing [34, 66]
and can be considered irrelevant. It should be
avoided, because it is unnecessary and because it
may bother the patient at the time of obturation
[49]. Exclusive clinical research on the influence
of the excess material on the treatment failure can-
not be taken into consideration, since they exclude
too many variables regarding the cleaning and
shaping of these root canals and the true three-
dimensionality of the obturation. Histologic stud-
ies on experimental animals by Deemer and
Tsaknis [66], Gutierrez et al. [67], and by Tavares
e f
because the “tug-back” of the cone was halfway along its
length rather than at the tip; (d) 12 months later: the
excess material appears to be sectioned at the apical fora-
men; (e) 24 months postoperative, the tip of the cone lies
horizontally over the root apex; (f) the 34-year recall con-
firms that an overfilling in a three-dimensionally obtu-
rated root canal is not an indication for surgery neither is
a cause of endodontic failure
332
et al. [68] have demonstrated that gutta-percha is
perfectly tolerated by the surrounding tissues.
Their results agree with those of Schilder [46] on
human specimens. Gutierrez et al. [67] have also
demonstrated in experimental animals that gutta-­
percha in contact with the tissues and tissue fluids
disintegrates and is subsequently removed by
macrophages. This corresponds to the clinical phe-
nomenon noted in the periapical region of human
teeth. Similarly, Bergenholtz et al. [69] stated that,
in the case of overfilling, the filling material per se
is not necessarily the immediate cause of failure.
Gutta-percha, both in vitro in cell cultures [70] and
in in vivo implants in experimental animals [71,
72], has been shown to be compatible with living
tissues. Recent radiographic studies have demon-
strated that given the time, the extruded canal fill-
ing materials would be removed from the
periradicular tissues [64, 73]. Consequently, the
factors that impede healing in cases of overfilling
are to be investigated elsewhere.
Regarding the greatly feared foreign body
reaction around the excess material, Yusuf [74]
has demonstrated inflammation around the small
a b
e f
Fig. 12.6 (a) Preoperative radiograph of a mandibular
right first molar improperly endodontically treated: the
distal canal is underfilled, and each of the mesial canals
have a gutta-percha cone overextending into the periapical
tissues; (b) intraoperative radiograph: the attempt to
remove the gutta-percha from beyond the foramen failed;
(c) postoperative radiograph: the two cones are still pres-
ent in the lesion; (d) 7-month recall; (e) 3-year recall: the
lesion is completely healed and the two gutta-percha
cones completely disappeared. The radiolucency was
obviously a lesion of endodontic origin maintained by
bacteria left in the root canal system and not a foreign
body reaction, maintained by two pieces of gutta-percha!
pilararaya@ejercer.cl
A. Castellucci
pieces of dentin and cement found beyond the
apex in the granulation tissue, where they act like
a foreign body. In contrast, small pieces of amal-
gam or other canal obturation materials were usu-
ally associated with a fibrous reaction and
encapsulation, without active inflammation. This
is further confirmation of the tissue tolerance of
canal filling material. Thus, accidental overfilling
of a properly cleaned, shaped, and three-­
dimensionally filled canal is not an indication for
surgical removal of the excess (Fig. 12.6a–e,
f–h). If this is true for the excess of gutta-percha,
it is even more when the excess is made with
sealer which, for Pulp Canal Sealer, it has been
demonstrated to have good biocompatibility.
Pertot et al. [75] have demonstrated that 12 weeks
after the root canal sealer was implanted into the
mandibular bone of experimental animals, mac-
rophages, lymphocytes, and plasma cells were no
longer present (Fig. 12.7a, b). In most cases, new
bone was observed in direct contact with the
sealer. The absence of an even moderate inflam-
matory reaction at 12 weeks seemed to indicate
that the reported in vitro toxicity of the freshly
c d
g h
(f) Preoperative radiograph of another mandibular right
first molar improperly endodontically treated: a radiolu-
cency is evident at the apex of the mesial root, and some
filling material (sealer and/or gutta-percha) is present in
the lesion; (g) during retreatment two missed root canals
were found: the distolingual and the middle mesial canals,
both with an independent foramen. Postoperative radio-
graph; (h) 7-year recall: the lesion is completely healed,
and the excess material disappeared. This confirms that it
was just a lesion of endodontic origin maintained by bac-
teria left in two missed root canals and NOT a foreign
body reaction maintained by the material extruded during
the first treatment!
12 Internal Tooth Anatomy and Root Canal Obturation 333

a b

c d

Fig. 12.7 (a, b) Osseous reaction to implanted Pulp
Canal Sealer at 4 weeks; (a) normal bone marrow spaces
(original magnification ×5; Masson’s trichrome); (b) layer
of fibrous connective tissue between Pulp Canal Sealer
and the bone, without evidence of inflammatory cells.
Normal appearance of the bone with living osteocytes and
surrounded by a layer of osteoblasts (original magnifica-
tion ×25; Masson’s trichrome); (c, d) osseous reaction to
implanted Pulp Canal Sealer at 12 weeks; (c) normal bone
marrow spaces with new bone ingrowths into the implant
(original magnification ×5; Masson’s trichrome); (d)
newly formed bone is in direct contact with Pulp Canal
Sealer without fibrous interposition or inflammatory cells
(original magnification ×10; Masson’s trichrome); (e)
normal appearance of newly formed bone with living
osteocytes and normal bone marrow (original magnifica-
tion ×50; Hematoxylin-eosin) (Courtesy of Dr. Wilhelm-­
Joseph Pertot)

pilararaya@ejercer.cl
334
mixed sealers [70–72] decreases and disappears
with time (Fig. 12.7c–e) [76–78].
If we can accept the material that protrudes
beyond the apical foramen by many millime-
ters in cases of endodontic implants, even more
so can the fraction of a millimeter of obturating
material that may accidentally protrude beyond
the apex in a three-dimensionally filled canal
be accepted (Fig. 12.8a, b, e, f). In conclusion,
the presence of protruded gutta-percha in a
failing case must be interpreted not as respon-
sible of the failure but as the consequence of a
transportation of the apical foramen and there-
fore as a consequence of a lack of apical seal
(Fig. 12.8c, d).
a b
d e
Fig. 12.8 (a) Postoperative radiograph of an upper left
lateral incisor; (b) 7 months later: the excess sealer has dis-
appeared; (c) SEM micrograph of a transported root apex
causing extrusion of the gutta-percha cone. The cone,
although surrounded by sealer, is not sealing the foramen;
(d) the root of this maxillary lateral incisor has been cleared.
pilararaya@ejercer.cl
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12.4 Walter Hess Work
and Postoperative
Radiographs
In 1925, Walter Hess and Ernst Zürcher [79] pub-
lished a famous textbook on root canal anatomy
after injecting vulcanized rubber in the root
canals of 2.790 teeth and making these teeth
transparent. The images showed how complex
and bizarre is the root canal anatomy, so that
today we speak in terms of “root canal system.”
Of course, these images were very discouraging,
since it was obvious the enormous difficulty to
take care of all the complexities. And looking at
those images, two endodontists arrived through
the years to opposite conclusions.
c
f
Transportation of the apical foramen and extrusion of mate-
rial through the teardrop foramen had occurred. Following
such a mishap, properly sealing the apical foramen is very
challenging; (e) postoperative radiograph of an upper left
second molar showing extrusion of obturation material; (f)
8 months later: the excess material is no longer present
12 Internal Tooth Anatomy and Root Canal Obturation 335

Angelo Sargenti [37] developed a “magic”
sealer containing paraformaldehyde which was
supposed to “mummify” all the contents of the
“crazy” anatomy: pulp tissue and bacteria, so that
the clinicians didn’t have to worry about cleaning,
shaping, and obturating lateral canals, isthmuses,
bifurcations, etc. Herbert Schilder [22], on the
other hand, has taught that with instruments, we
can work and shape the canal that can be negoti-
ated, while with irrigating solutions like sodium
hypochlorite, we can digest and remove all the
organic materials present in the remaining complex
root canal anatomy. Once the space is completely
empty, we can fill the same space with a thermo-
plasticized material vertically compacted. The soft-
ened gutta-percha mass, which is being compacted
vertically into the conically shaped canal prepara-
tion, automatically assumes a lateral component of
force. This follows routine laws of physics (law of
Pascal of hydrodynamics) and requires no lateral
direction of the instrument on the part of the opera-
tor [80]. If this is true, in our postoperative radio-
graphs, we should be able to see the same “bizarre”
anatomy like the ones showed many years ago by
Hess [79]. And this is exactly what happens, if we
follow a precise protocol (Fig. 12.9).

Fig. 12.9 Original images from Hess’s work showing the internal morphology of different teeth followed by postop-
erative radiographs showing similar anatomy

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336
12.5 The Importance
of Obturating Lateral Canals
If we believe in the existence of the “root canal
system” and if we believe in the communications
between the endodontium and the periodontium
and in their role as “portals of exit” of pathology,
then we should agree that all the portals of exit
have the same importance and the same respon-
sibility in determining the beginning and the
growth of lesions of endodontic origin
a b
Fig. 12.10 (a) Each portal of exit from the root canal sys-
tem, that is, each foramen, becomes the sites of entry for
bacterial toxins and tissue breakdown products into the
periodontal ligament (courtesy of Prof. Schilder; modi-
a b c d
Fig. 12.11 (a) Preoperative radiograph of a maxillary
right first molar; (b) intraoperative radiograph. The file is
negotiating a lateral foramen on the mesial aspect of the
palatal root; (c) the file has been pre-curved and introduced
pilararaya@ejercer.cl
A. Castellucci
(Fig. 12.10a). Bacteria don’t make any differ-
ence if they are in the main canal or in a lateral
canal. They need to be eliminated, and the “lat-
eral opening” needs to be sealed exactly like the
main apical foramen (Fig. 12.10b). Now the
question is how can we clean, shape, and obtu-
rate the lateral canals? First of all, the introduc-
tion of an endodontic instrument in a lateral
canal most of the time happens by chance
(Fig. 12.11), and it is not intentional (Fig. 12.12a,
b). Second, we don’t need to “shape” lateral
fied); (b) postoperative radiograph of a maxillary left first
molar showing that the exit of the lateral canal appears to
be larger than the apical foramen
e
in the same canal oriented toward the distal aspect and now
is negotiating the main foramen; (d) postoperative radio-
graph. The presence of the lateral canal obturated with
warm gutta-percha and sealer is evident; (e) 2-year recall
12 Internal Tooth Anatomy and Root Canal Obturation 337

canals, especially considering that in necrotic
cases we may suspect the presence of a lateral
canal because of the presence of a “lateral”
lesion (Fig. 12.12c, d), while in vital cases, it
will be impossible to know in advance the pres-
ence of the lateral ramification. In conclusion, if
on one side lateral canals are impossible to detect
and most of the time impossible to be negotiated,
on the other hand, they don’t require any particu-
lar effort or any particular instrument by the

a b c d

Fig. 12.12 (a) Intraoperative radiograph. One file is
negotiating the main canal, and another one has been
introduced in the lateral foramen; (b) 2-year recall; (c)
preoperative radiograph of a mandibular right first
molar. A gutta-percha cone has been introduced in the
fistulous tract originating from the lateral lesion.
Obviously that lesion is maintained by a lateral canal;
(d) 2-year recall. It is evident the obturation of the lat-
eral canal and the complete healing of both apical and
lateral lesions

Fig. 12.13 SEM images showing few examples of apical ramifications and lateral canals free of pulp tissue and debris

pilararaya@ejercer.cl
338
endodontist: the irrigating solution if properly
used will digest their content (Fig. 12.13), and
the softened obturating material vertically com-
pacted will automatically seal them (Fig. 12.14a–
c). Of course, since these accessory canals are
not shaped, they don’t have any taper, and there-
fore there is no way to control the “apical” extent
of the obturating material. Therefore, quite often
we have a small extrusion of sealer (Fig. 12.14d,
e). However, the use of nontoxic sealer, like the
Grossman sealer and all the sealers based on zinc
a b
d e
Fig. 12.14 (a, b) The clarified tooth shows a lateral canal
about 4 mm from the apical foramen entirely filled with
warm gutta-percha; (c) SEM photograph showing a lateral
canal filled with warm gutta-percha; (d) preoperative
radiograph of a maxillary right second premolar. There is
an apical lesion and a lateral lesion; (e) 2-year recall
showing the obturation of the lateral canal and the com-
pilararaya@ejercer.cl
A. Castellucci
oxide-eugenol, will not cause any problem, and
even though they are not biocompatible, they are
very well tolerated by the organisms and for sure
they are not responsible of any failure. Besides,
new biocompatible bioceramic sealers are
becoming more and more popular so that the
little extrusion will not represent a problem any-
more for anybody. The lack of seal of a lateral
canal can often be responsible of a failure and
require a nonsurgical (Fig. 12.14f, g) or a surgi-
cal retreatment (Fig. 12.15).
c
f g
plete healing of both apical and lateral lesions; (f) preop-
erative radiograph of a maxillary right second premolar.
The large lesion is on the distal aspect of the root, which
means it is maintained by a lateral canal present on the
distal aspect of the root canal; (g) 2-year recall showing
the obturation of the lateral canal and the complete heal-
ing of the large lesion
12 Internal Tooth Anatomy and Root Canal Obturation
a b
c d
Fig. 12.15 (a) Preoperative radiograph of a maxillary
left second premolar. A lateral lesion is present; (b) after
a through a surgical flap, the lateral canal responsible for
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 Managing Complex Root Canal
Anatomies
13
Antonis Chaniotis, Diogo Guerreiro, Jojo Kottoor,
Nuno Pinto, Sergiu Nicola, Oscar von Stetten,
Hugo Sousa, and Carlos Murgel

Abstract of the canal morphology and its variations and

The goal of endodontic therapy is the removal
of all vital or necrotic tissues, microorgan-
isms, and microbial by-products from the root
canal space. Amongst the treatment steps,
chemomechanical procedures play a pivotal
role in eliminating or reducing bacterial popu-
lations from the main root canal, but the disin-
fecting effects of instruments and irrigants
may be somewhat hampered in cases of com-
plex anatomy. Thus, a thorough understanding
the comprehension regarding clinical skills
and armamentarium needed to manage these
complexities are basic requirements for suc-
cessful endodontic therapy. This chapter
details various clinically relevant anatomical
canal complexities and highlights diagnostic
approaches, treatment techniques, and manag-
ing strategies to successfully deal with these
anomalies revealed by clinicians with high
expertise in the field of endodontics.

A. Chaniotis, D.D.S., M.Sc. (*) S. Nicola, D.D.S.

University of Athens, Athens, Greece
University of Warwick, Warwick, UK
Private Practice Limited to Endodontics,
Kalithea, Greece
e-mail: antch8@me.com
D. Guerreiro, D.D.S., M.S.
Resident ASE Endodontics, School of Dentistry,
University of Michigan, Ann Arbor, MI, USA
J. Kottoor, B.D.S., M.D.S.
Department of Conservative Dentistry and
Endodontics, Indira Gandhi Institute of Dental
Sciences, Ernakulam, India
N. Pinto, D.D.S., M.Sc.
Private Practice in the Mayo Clinic,
Lisbon, Portugal
Private Practice, Bucharest, Romania
O. von Stetten
Private Practice, Stuttgart, Germany
H. Sousa, D.D.S., M.Sc.
Clinical Residency, Foramen Dental Education,
Porto, Portugal
Private Practice Limited to Endodontics,
Porto, Portugal
C. Murgel, D.D.S., M.Sc., Ph.D.
Private Practice Limited to Endodontics,
Campinas, Brazil

© Springer International Publishing AG, part of Springer Nature 2019 343

M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_13

pilararaya@ejercer.cl
344
13.1 Introduction
Outcomes of nonsurgical and surgical endodontic
procedures are highly influenced by variations in
canal configuration and cross-sectional shapes as
well as by the presence of canal irregularities and
curvatures. Moreover, the high frequency of fins
and communications between canals within the
same root make it impossible for any mechanical
or chemical technique to completely disinfect the
root canal system. It is noteworthy to point out
that some factors, such as physiologic aging,
pathology and occlusion, as well as the secondary
deposition of dentin, might hamper the anatomi-
cal complexity making shaping and cleaning the
root canals a real challenge. Hence, the purpose of
the treatment must be toward to reduce the level
of contamination as far as possible, entombing the
remaining microorganisms. Clinicians ought,
therefore, to be aware of complex root canal struc-
tures, cross-sectional dimensions, and iatrogenic
alterations of canal anatomy. In this way, it is
advisable careful diagnostic interpretation based
on angled radiographs or tomographic exams,
proper access preparation, and a detailed inspec-
tion of the pulp chamber floor, ideally under mag-
nification with high intensity lighting, aiming to
improve the treatment outcome.
Clinical management of complex canal anato-
mies is a challenging procedure that depends on
individual proficiency to master specific tech-
niques and technological devices. Sometimes,
multiple appointments and special armamentar-
ium are necessary. Therefore, once the anomaly
has been identified preoperatively, another chal-
lenging step must be made toward to properly
negotiate the canal anatomy. Obviously, there are
canal anatomies more challenging than others,
such as of the mandibular premolars, mesiobuccal
roots of maxillary molars, and mesial roots of
mandibular molars. In these cases, dealing with
such complex systems also increases the risk of
iatrogenic events. Therefore, these risks must be
accessed preoperatively and should include root
length and thickness, curvatures, calcification,
number of roots and canals, accessibility of the
tooth, patient cooperation, canal diameter, root
concavities (grooves), isthmuses, periodontal sta-
pilararaya@ejercer.cl
A. Chaniotis et al.
tus, teeth restorability, among others. Once these
anatomical and clinical issues are considered, a
multitude of possible scenarios can be made and a
proper treatment planned. The purpose of this
chapter is to provide readers with several tips
based upon the clinical experience of skillful clini-
cians aiming to diagnose and deal with different
anatomical canal complexities.
13.2 Case Report 1
13.2.1 Patient Information
• Age: 18. Gender: male. Medical history:
noncontributory.
13.2.2 Tooth
• Identification: mandibular left second premo-
lar (tooth 35).
• Dental history: recent root canal therapy
started on the mandibular left side. Patient
referred with a separated instrument inside the
root canal.
• Clinical examination findings: asymptomatic
tooth temporarily restored (Fig. 13.1a, h). No
sinus tract, no swelling, no pain on buccal pal-
pation, soft tissue within normal limits.
Probing depths within 3–4 mm and no sensi-
tivity to percussion.
• Preoperative radiological assessment: previ-
ously initiated therapy with a separated instru-
ment in the root canal system (Fig. 13.1b).
Widening periodontal ligament, interrupted
lamina dura, and apical radiolucency associ-
ated with tooth 35.
• Diagnosis: previously initiated therapy with
asymptomatic apical periodontitis.
13.2.3 Treatment Plan
Nonsurgical Endodontic Treatment
• Preliminary procedures: local anesthesia;
rubber dam isolation; removal of temporary
13 Managing Complex Root Canal Anatomies 345

a b c d e f

g h

i j k l

Fig. 13.1 Nonsurgical endodontic treatment of a mandibular left second premolar with complex apical anatomy by
Diogo Guerreiro

restoration; canal access. Dental operat-
ing microscope was used during all the
procedures.
• Canal preparation: separated instrument and
three canal orifices (two buccal and one lin-
gual) were identified at the middle third, and
an initial negotiation was made with sizes 08
and 10 K-files. Working length was estab-
lished with an apex locator. Preparation was
made with ProTaper Next X3. Lingual canal
merged with the mesiobuccal apically.
• Irrigation: syringe irrigation (30G needle)
with warm 5.25% NaOCl alternated with 17%
EDTA.
• Final irrigation protocol: 5.25% NaOCl with
ultrasonic activation (IrriSafe; Acteon) for
30 s per canal followed by 17% EDTA and
5.25% NaOCl.
• Obturation: gutta-percha and AH Plus sealer
(warm vertical compaction) (Fig. 13.1c–g).
• Additional information: intra-coronal seal
with resin-modified glass ionomer followed
by ceramic onlay restoration (Fig. 13.1i–l).
13.2.4 Technical Aspects
Due to a narrow canal system and abrupt curva-
tures at the orifice level of the trifurcation, clini-
cian should be aware of this anatomical feature
before starting. Preoperative periapical radio-
graphs in different angulations or a tomography

pilararaya@ejercer.cl
346
is important for treatment plan. The use of mag-
nification is imperative to identify canal orifices
at the middle third of the root canal system and
avoid excessive removal of tooth structure. After
enlargement of the main canal to the middle
third with an ultrasonic tip (Start-X #2, Maillefer
Dentsply), direct vibration with an ultrasonic tip
ET40 (Satelec/Acteon) at low power and no irri-
gation was used to remove the separated instru-
ment. Then, canals were negotiated with manual
prebended files initially and enlarged with
rotary files.
13.3 Case Report 2
13.3.1 Patient Information
• Age: 19. Gender: female. Medical history:
noncontributory.
13.3.2 Tooth
• Identification: mandibular left first molar
(tooth 36).
• Dental history: recent composite filling (tooth
36) and decay (tooth 37). Patient complained
a b
e f
Fig. 13.2 Nonsurgical endodontic treatment of a mandibular left first molar with radix entomolaris by Diogo Guerreiro
pilararaya@ejercer.cl
A. Chaniotis et al.
that lower jaw was “very sensitive to cold and
biting” (sic) after restoration of tooth 36.
• Clinical examination findings: slight discom-
fort upon percussion and palpation of the
buccal mucosa. Lingering pain upon sensitiv-
ity test (cold). No sinus tract and soft tissue
within normal limits. Probing depths within
3–4 mm.
• Preoperative radiological assessment: proxim-
ity of the composite resin with the pulp and a
widened periodontal ligament. An additional
distal root was identified (Fig. 13.2a, b).
• Diagnosis: irreversible pulpitis with symp-
tomatic apical periodontitis.
13.3.3 Treatment Plan
Nonsurgical Endodontic Treatment
• Preliminary procedures: local anesthesia; rub-
ber dam isolation; access performed with a
tapered diamond bur and access cavity margins
were refined with an ultrasonic tip (Start-­X #2;
Maillefer Dentsply). Dental operating micro-
scope was used during all the procedures.
• Canal preparation: initial exploration and
patency performed with sizes 08 and 10
c d
g
13 Managing Complex Root Canal Anatomies
K-files. Working length established with apex
locator. Canals were enlarged to ProTaper
Next X2 (Maillefer Dentsply) (Fig. 13.2e).
• Irrigation: syringe irrigation (30G needle)
with warm 5.25% NaOCl alternated with 17%
EDTA (Fig. 13.2f).
• Final irrigation protocol: 5.25% NaOCl with
ultrasonic activation (IrriSafe; Acteon) for
30 s per canal followed by 17% EDTA and
5.25% NaOCl.
• Obturation: gutta-percha and AH Plus sealer
(warm vertical compaction) (Fig. 13.2c, d, g).
13.3.4 Technical Aspects
The particularity of this case is the presence of an
additional root located distolingually referred as
radix entomolaris. An accurate diagnosis of these
supernumerary roots can avoid complications
during root canal treatment, being “missed anat-
omy” the most common. It may be avoided with
several angulated periapical radiographs or a
tomography. Regarding the access cavity and ori-
fice location, note that the orifice of the extra root
is located disto- to mesiolingually from the main
canal of the distal root changing the classic trap-
ezoidal access cavity into a more rectangular out-
line form (Fig. 13.2e, f). Besides, it is noteworthy
the severe root inclination or canal curvature in
the apical third of these roots. Therefore, clini-
cian must be aware of this anatomy to avoid com-
mon mishaps such as canal transportation, loss of
working length, and instrument separation.
13.4 Case Report 3
13.4.1 Patient Information
• Age: 20. Gender: female. Medical history:
noncontributory.
13.4.2 Tooth
• Identification: maxillary left second molar
(tooth 27).
pilararaya@ejercer.cl
347
• Dental history: endodontic treatment started a
week prior and patient complaint of “constant
dull pain” (sic).
• Clinical examination findings: temporary res-
toration. Slight discomfort upon palpation of
the buccal mucosa and pain on percussion. No
sinus tract and soft tissue within normal lim-
its. Probing depths within 3–4 mm.
• Preoperative radiological assessment: previ-
ously initiated canal treatment and widened
periodontal ligament (Fig. 13.3a).
• Diagnosis: previously initiated canal treat-
ment associated with a symptomatic apical
periodontitis.
13.4.3 Treatment Plan
Nonsurgical Endodontic Treatment
• Preliminary procedures: local anesthesia;
rubber dam isolation; removal of temporary
restoration; access preparation. Dental oper-
ating microscope was used during all the
procedures.
• Canal preparation: after preparation of the
palatal canal, a C-shaped mesio- and dis-
tobuccal canal orifices were exposed using
an ultrasonic tip (Start-X #2; Maillefer
Dentsply). Patency was achieved with a size
10 K-file and working length established
with an apex locator (Fig. 13.3b). Glyde path
and preflaring were achieved manually with a
size 20 K-file, and canals were enlarged to a
ProTaper Universal F2 (Maillefer Dentsply)
(Fig. 13.3f, g).
• Irrigation: syringe irrigation (30G needle)
with warm 5.25% NaOCl alternated with 17%
EDTA.
• Final irrigation protocol: 5.25% NaOCl with
ultrasonic activation (IrriSafe; Acteon) for
three times 30 s per canal followed by 17%
EDTA and 5.25% NaOCl.
• Obturation: gutta-percha and AH Plus sealer
(warm vertical compaction) with special
attention to the backfill injection of gutta-­
percha in the C-shaped buccal system
(Fig. 13.3c–e, h).
348 A. Chaniotis et al.

a b c d e

f g h

Fig. 13.3 Nonsurgical endodontic treatment of a maxillary left second molar with C-shaped canal configuration by
Diogo Guerreiro

13.4.4 Technical Aspects 13.5 Case Report 4

This anatomy is classified as a subtype B1 13.5.1 Patient Information

according to the position of the fused root canal
in the maxillary C-shaped molar (Fig. 13.3g). It
is presented as a fusion between the mesiobuccal
and distobuccal canals, forming a semilunar
canal system with its concavity turned to the pal-
atal canal. Although it is not a common occur-
rence in maxillary molars, the clinician should be
aware of this type of challenging anatomy.
Several angulated periapical radiographs may be
necessary to identify this anatomy and to trace
the periodontal ligament in order to identify the
root fusion. Cleaning, shaping, and sealing such
complexity can sometimes be tricky and lead to
failure of the endodontic therapy. C-shaped con-
figurations are also very difficult to clean by
syringe irrigation alone. Therefore, ultrasonic
activation and a large amount of irrigation solu-
tion are important to clean the isthmus area
between buccal canals.
• Age: 30. Gender: male. Medical history:
noncontributory.
13.5.2 Tooth
• Identification: mandibular left second premo-
lar (tooth 35).
• Dental history: tooth’s crown was broken, and
patient felt pain upon biting.
• Clinical examination findings: the tooth was
painful to percussion. Thermal and electrical
vitality tests were negative.
• Preoperative radiological assessment:
unclear image of superimposed roots
(Fig. 13.4a).
• Diagnosis: pulp necrosis and symptomatic
apical periodontitis.

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies 349

a b c d e

f g h i j

Fig. 13.4 Nonsurgical endodontic treatment of a three-rooted mandibular left second premolar by Antonis Chaniotis

13.5.3 Treatment Plan • Obturation: continuous wave of condensa-

• Preliminary procedures: local anesthesia; rubber
dam placement; caries removed under micro-
scope (Fig. 13.4b); access cavity preparation
extended mesiobuccally in order to facilitate the
negotiation of the mesio- and the distobuccal
canals (Fig. 13.4e). Radiographic working
length suggested that mesiobuccal canals joined
in a common portal of exit (Fig. 13.4c, d).
• Canal preparation: Hyflex Controlled Memory
rotary instruments were used in a single length
protocol up to a 35/04 apical enlargement.
• Irrigation: Syringe irrigation (27G slotted end
needle) of 6% NaOCl.
• Final irrigation protocol: a capillary tip was
fitted into the mesiobuccal canal, and large
amounts of fresh 6% NaOCl were delivered
through the interconnecting anatomy. For the
lingual canal, negative pressure irrigation
(EndoVac system) was used. Then, canals
were flooded with EDTA 17% (2 min) fol-
lowed by sterile water (Fig. 13.4f).
tion technique. Three fine medium gutta-
percha cones were adjusted to fit the apical
third of all canals, and the root canal sys-
tem was coated with a resin-based sealer
(Fig. 13.4g–j).
13.5.4 Technical Aspects
In mandibular premolars, unclear radiographic
image of superimposed root is often associated
with the existence of additional roots or canals.
Extended access cavity preparation under magni-
fication can result in the uneventful detection and
management of the additional anatomy. The
darker color of the pulp floor and the transitional
lines from the pulp floor to the axial walls can also
guide operator to the detection of canal orifices.
Modified negative pressure irrigation of intercon-
necting canal systems might be beneficial for a
safer and more effective disinfection of the canal
system.

pilararaya@ejercer.cl
350 A. Chaniotis et al.

13.6 Case Report 5 • Dental history: pain even under amoxicillin

regimen of 2 g per day for over 5 days.
13.6.1 Patient Information • Clinical examination findings: no swelling
or sinus tracts; sensitive to percussion;
• Age: 40. Gender: male. Medical history: cold and electric vitality tests were
noncontributory. negative.
• Preoperative radiological assessment: inade-
quate root canal treatment (silver cones) and
13.6.2 Tooth periapical lesion (Fig. 13.5a). Radiography
suggested fused canals and a possible
• Identification: maxillary left second molar C-shaped configuration.
(tooth 27).

a b c

d e f

g h i

j k l

Fig. 13.5 Nonsurgical endodontic treatment of a maxillary left second molar with fused canals and C-shape configura-
tion by Antonis Chaniotis

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
• Diagnosis: previously treated teeth and symp-
tomatic apical periodontitis with periapical
radiolucency.
13.6.3 Treatment Plan
• Preliminary procedures: local anesthesia;
rubber dam placement; access preparation
through the composite restoration without
water irrigation aiming to melt it until expo-
sition of the silver cones (Fig. 13.5b);
removal of composite remnants with ultra-
sonic tips; retrieval of silver cones with
Stieglitz forceps (Bontempi, International
Inc.) and Hedströem files under microscope
(Fig. 13.5c); pulp chamber floor troughed
using ultrasonic tips (B&L Biotech)
(Fig. 13.5d) and irrigation with 6% NaOCl
and 17% EDTA to reveal a missed distobuc-
cal canal (Fig. 13.5e) and the orifices of the
mesiobuccal, mesiopalatal, and palatal canals
placed in a C-shaped configuration and inter-
connecting anatomy; working length radiog-
raphy revealed a small fragment of silver
cone in the mesial canal system (Fig. 13.5f)
which was bypassed but not removed.
Calcium hydroxide (Ultracal, Ultradent) was
used as intracanal medicament (Fig. 13.5g–
h) and syringe placement verified the inter-
connecting canal anatomy.
• Canal preparation: Hyflex rotary system
(Coltène), G Pathfinder files (Micro-Mega)
and Hyflex X hand files (Coltène) for apical
gauging and enlargement.
• Irrigation: 6% NaOCl activated by passive
ultrasonic activation with a size 15 K ultra-
sonic file (3 × 20 s per canal).
• Final irrigation protocol: After 10 days, patient
was asymptomatic. Calcium hydroxide was
removed (ultrasonic sterile water irrigation),
disinfection procedures were repeated, and
canals flooded with 17% EDTA for 5 min fol-
lowed by sterile water syringe irrigation.
• Obturation: gutta-­percha and AH Plus using
warm vertical compaction technique. Pulp
pilararaya@ejercer.cl
351
chamber floor was then sandblasting with
sodium bicarbonate and mesial C-shaped con-
figuration addressed (Fig. 13.5i). Postoperative
radiograph revealed the interconnecting canal
anatomy (Fig. 13.5j).
13.6.4 Technical Aspects
Maxillary second molars with radiographic
image of a single root might suggest fused roots
and/or C-shape configuration which require mod-
ified access cavities to facilitate its detection.
Although fusion of the mesiobuccal root with the
palatal root is not common, it can exist and com-
plicate the disinfection process. In such cases,
distobuccal root may be hidden in the radiogra-
phy or appear as a stand-alone in an off-angled
projection. Magnification, illumination, and
enhanced disinfection protocols might be
required to address the fused anatomy.
13.7 Case Report 6
13.7.1 Patient Information
• Age: 30. Gender: male. Medical history:
noncontributory.
13.7.2 Tooth
• Identification: mandibular right second pre-
molar (tooth 45).
• Dental history: pain upon biting previously
managed by his referral dentist.
• Clinical examination findings: tooth was
asymptomatic and temporarily restored. Cold
and electric vitality tests were negative.
• Preoperative radiological assessment: tooth
with splitting divergent roots associated with
periapical radiolucency between roots
(Fig. 13.6a).
• Diagnosis: previously initiated treatment with
asymptomatic apical periodontitis.
352 A. Chaniotis et al.

a b c d e

f g h i

Fig. 13.6 Nonsurgical endodontic treatment of a mandibular right second premolar with splitting divergent roots at the
apical third by Antonis Chaniotis

13.7.3 Treatment Plan This single stroke tactile-controlled activa-

• Preliminary procedures: pre-endodontic build-
up with composite resin (Fig. 13.6b); rubber
dam placement followed by coronal access. An
ISO 25 file was inserted until the furcation
level and depth of the pulp floor was recorded.
A Munce bur was inserted to this level
(Fig. 13.6c) and activated to enlarge the access
with a C-shaped trajectory with the concavity
of the C shape toward the mesial plane. Under
the operating microscope, three canal orifices
were discovered (Fig. 13.6d) and pre-curved
size 10 K-files inserted to the canal length
revealing the aberrant anatomy (Fig. 13.6f).
• Canal preparation: for each canal, sizes
15/.04, 20/.04, and 25/.04 pre-curved CM
rotary instruments were sequentially inserted
at the point of maximum frictional resistance
and activated, driven to resistance and
redrawn from the canal (TCA technique).
tion technique allowed to drive CM files to
length safely even in cases where straight-line
access cannot be achieved.
• Irrigation: positive syringe irrigation with 6%
NaOCl.
• Final irrigation protocol: 6% NaOCl with
manual dynamic activation and final rinse
with 17% EDTA and sterile water.
• Obturation: pre-curved gutta-percha cones
and resin-based sealer (Fig. 13.6g). System B
heat source was used to cut the gutta-percha
points at the level of the canal entrances
(Fig. 13.6e). The middle and coronal third of
the canal was filled with injectable thermo-
plasticized gutta-percha.
• Additional information: the tooth was restored
with composite resin, and a postoperative
radiograph was taken (Fig. 13.6h). One-year
follow-up examination revealed uneventful
healing (Fig. 13.6i).

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
13.7.4 Technical Aspects
The internal anatomy of mandibular premolars
might have complicated interconnecting, fused,
or highly curved canals. Occasionally, the root
canal system can also be splitting in two or more
canals/roots deep below the cemento-enamel
junction. In such cases, pre-curving CM rotary
NiTi files activated in maximum engagement
(TCA technique) might be beneficial for the safe
and predictable enlargement of the apical splits to
adequate preparation sizes.
13.8 Case Report 7
13.8.1 Patient Information
• Age: 56. Gender: female. Medical history:
noncontributory.
13.8.2 Tooth
• Identification: maxillary right first (Fig. 13.7a–
g) and second (Fig. 13.7h–o) molars (teeth 16
and 17).
• Dental history: pain upon biting previously
managed by her referral dentist 1 year back.
• Clinical examination findings: teeth were tempo-
rarily restored and tender to vertical percussion.
Palpation, periodontal probing around the tooth,
and mobility were within physiological limits.
• Preoperative radiological assessment: inade-
quate endodontic treatment (Fig. 13.7a, b, h).
The root outline presented as single rooted,
bulbous, and non-confirming, suggestive of
hypertaurodontism.
• Diagnosis: previously endodontic treatment
with symptomatic apical periodontitis.
13.8.3 Treatment Plan
• Preliminary procedures: local anesthesia, rub-
ber dam placement followed by access open-
pilararaya@ejercer.cl
353
ing modified with ultrasonic tip (RS 2;
SybronEndo). Dental operating microscope
was used throughout the procedures.
• Canal preparation: filling materials were
removed using H-files and an ultrasonic tip
(ET 20; Satelec action). Pulp chamber floor
was explored with size 10.04 Micro-Opener
for identification of mesiobuccal (MB), pal-
atal (P), and distobuccal (DB) canal orifices.
Patency was achieved using size 10 K-file
(Fig. 13.7c–f, i–l). Then, working length was
established electronically (Fig. 13.7g, m)
and glide path created until size 15 K-file.
Canal shaping was performed using ProTaper
Universal system up to F3.
• Irrigation: positive syringe irrigation with 3%
NaOCl.
• Final irrigation protocol: 3% NaOCl with
ultrasonic activation (5 × 30 s per canal;
IrriSafe) and final rinse with 17% EDTA, 3%
NaOCl, normal saline followed by 2%
chlorhexidine for 1 min.
• Obturation: preselection of hand plungers
(Buchanan hand pluggers; SybronEndo) and
backfill unit needle B&L Beta (Biotech).
Calcium hydroxide-based sealer (Sealapex)
was used, and gutta-percha was squirted into
the canals (Fig. 13.7o).
13.8.4 Technical Aspects
Careful examination of the preoperative radio-
graphs and knowledge on root canal anatomy is a
prerequisite for identifying developmental anom-
alies. In a hypertaurodontic tooth, because of the
apical positioning of pulpal floor, magnification,
ultrasonic tips, and dynamic irrigation with
increased volume and time are key for successful
removal of gutta-percha and identification of
canals orifices. Tooth 27 had a C-shaped canal
(Fig. 13.7n), which divided into three separated
canals at the apical third. Therefore, squiring
technique was used for a more predictable obtu-
ration procedure (Fig. 13.7o).
354 A. Chaniotis et al.

a b c

d e f

g h i

j k l

m n o

Fig. 13.7 Nonsurgical endodontic treatment of maxillary right first and second molars with hypertaurodontism by Jojo
Kottoor

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
13.9 Case Report 8
13.9.1 Patient Information
• Age: 49. Gender: male. Medical history:
noncontributory.
13.9.2 Tooth
• Identification: maxillary left second molar
(tooth 27).
• Dental history: endodontic treatment initiated
by the general dentist who referred after
observing the unusual canal morphology
(Fig. 13.8a).
• Clinical examination findings: tooth had a
normal shaped crown and mesiodistally frac-
tured temporary filling. It was mild tenderness
to percussion. Periodontal probing and mobil-
ity were within physiological limits, with no
evidence of swelling or a sinus tract.
a b
d e
g h
Fig. 13.8 Nonsurgical endodontic treatment of a maxillary left second molar with hypertaurodontism by Jojo Kottoor
pilararaya@ejercer.cl
355
• Preoperative radiological assessment: a bul-
bous single-rooted tooth with an apically
located pulpal floor suggestive of hypertaur-
odontism (Fig. 13.8a).
• Diagnosis: initiated endodontic treatment with
symptomatic apical periodontitis.
13.9.3 Treatment Plan
• Preliminary procedures: local anesthesia,
disto-occlusal wall buildup with composite
resin, rubber dam placement followed by
modified access opening with ultrasonic tips
(RS 2; SybronEndo) (Fig. 13.8b). Dental
operating microscope was used throughout
the procedures.
• Canal preparation: pulp chamber was explored
with a size 10.04 Micro-Opener (Dentsply
Maillefer) to identify mesiobuccal (MB1,
MB2), distobuccal (DB), and palatal (P) canal
orifices (Fig. 13.8c–e). After working length
c
f
i
356
determination (Fig. 13.8f), a fourth canal ori-
fice was found next to mesiobuccal canal.
ProGlider instrument was used to create the
glide path, while ProTaper Universal was used
up to F3 for shaping the buccal canals and F4
for the palatal canal.
• Irrigation: positive syringe irrigation with 3%
NaOCl.
• Final irrigation protocol: 3% NaOCl with
ultrasonic activation (5 × 30 s per canal;
IrriSafe) and final rinse with 17% EDTA, 3%
NaOCl, normal saline followed by 2%
chlorhexidine for 1 min.
• Obturation: preselection of hand plungers
(Buchanan Hand Pluggers; SybronEndo) and
backfill unit needle B&L Beta (Biotech).
Calcium hydroxide-based sealer (Sealapex)
was used, and gutta-percha was squirted into
the canals (Fig. 13.8g–i).
13.9.4 Technical Aspects
Excessive bleeding was noted upon initial reentry
into the chamber suggesting perforation
(Fig. 13.8b); however, this is a very likely presen-
tation of inflamed pulp tissue in taurodontic teeth. 13.10.3 Treatment Plan
Each taurodontic tooth may have anomalous root
canals in terms of shape and number and needs to • Preliminary procedures: anesthesia; rubber
be approached cautiously. Inadvertent and non-­
specific exploration can lead to unwanted cutting
of chamber wall. As the canals were originating • Canal preparation: removal of the obturation
from the apical third, changing the position/angu-
lation of mirror is allowed for adequate viewing
and exploration within the pulp chamber.
Microscope enhanced the visualization of the
pulpal floor by better illumination of the depths
of the cavity, in combination with use of micro-­
openers and ultrasonics. Because of the complex-
ity of the root canal anatomy and the proximity of
the buccal orifices, the root canal system was
obturated by squirting heated gutta-percha.
pilararaya@ejercer.cl
A. Chaniotis et al.
13.10 Case Report 9
13.10.1 Patient Information
• Age: 60. Gender: male. Medical history:
noncontributory.
13.10.2 Tooth
• Identification: mandibular right second molar
(tooth 47).
• Dental history: patient complains about
esthetic.
• Clinical examination findings: extensive
amalgam restoration in an asymptomatic
tooth.
• Preoperative radiological assessment: incom-
plete endodontic treatment with poor shaping
and insufficient obturation. Fusion roots
suggesting a C-shaped canal configuration
­
(Fig. 13.9a).
• Diagnosis: previously endodontic treatment
with asymptomatic apical periodontitis.
dam isolation; microscope visualization; con-
ventional access to the cavity with a round bur.
material in the pulp chamber with ultrasonic
tips and in the root canal with reciprocating
instrument size 25.08 without hand files
(Fig. 13.9b, c). C-shaped canal configuration
was confirmed (Fig. 13.9d), and the shaping
of the 2/3 of all canals was performed with
Reciproc R25 instrument. After electronic
working length determination, shaping was
completed with a size 25.08 reciprocating
instrument in one session.
13 Managing Complex Root Canal Anatomies
a b
e f
Fig. 13.9 Nonsurgical endodontic treatment of a mandibular right second molar with C-shaped canal configuration by
Nuno Pinto
• Irrigation: 6% NaOCl (manual dynamic acti-
vation); 10% citric acid (MDA); ultrasonic
activation 3 × 20 s.
• Final irrigation protocol: 10% citric acid
(ultrasonic activation for 60 s) followed by
saline solution and alcohol.
• Obturation: epoxy resin-based sealer (AH
Plus) and gutta-percha; warm vertical com-
paction (Fig. 13.9e–h).
13.10.4 Technical Aspects
The anatomy of a C-shaped canal with a type
III Vertucci’s configuration at the middle third
is challenging for shaping, cleaning, and obtu-
ration procedures. In this way, it is important to
combine magnification, ultrasonic activation of
the irrigant, and thermocompaction obturation
techniques.
pilararaya@ejercer.cl
357
c d
g h
13.11 Case Report 10
13.11.1 Patient Information
• Age: 14. Gender: male. Medical history:
noncontributory.
13.11.2 Tooth
• Identification: maxillary right lateral incisor
(tooth 12).
• Dental history: spontaneous pain.
• Clinical examination findings: slight discom-
fort upon percussion and palpation of the buc-
cal mucosa. Presence of a sinus tract.
• Preoperative radiological assessment: image
consistent with type II dens invaginatus mor-
phology with periapical lesion (Fig. 13.10a).
• Diagnosis: pulpal necrosis and chronic apical
abscess.
358
a b
e f
Fig. 13.10 Nonsurgical endodontic treatment of a maxillary right lateral incisor with type II dens invaginatus
­morphology by Nuno Pinto
13.11.3 Treatment Plan
Nonsurgical endodontic treatment
• Preliminary procedures: anesthesia; rubber
dam isolation; microscope visualization; con-
ventional access to the cavity with a round bur.
Cavity margins were refined with ultrasonic
tips (CPR 2 and 3; Obtura Spartan).
• Canal preparation: localization of two canal
orifices which were explored with sizes
10 and 15 K-files. After working length
determination (Fig. 13.10b), canals were
enlarged using K3 rotary system with the
following sequence: 25.10; 25.08; 40.06;
and 35.06.
• Irrigation: syringe irrigation (30G needle)
with 2% chlorhexidine (manual dynamic
irrigation).
• Final irrigation protocol: 2% chlorhexidine.
• Obturation: apical plug (4 mm) of white
ProRoot MTA (Dentsply Maillefer) and back-
fill with warm gutta-percha and AH Plus
sealer (Fig. 13.10c–f).
pilararaya@ejercer.cl
A. Chaniotis et al.
c d
g
13.11.4 Technical Aspects
This tooth had a type II dens invaginatus morphol-
ogy with communication and a totally open apex,
which significantly increase its management dif-
ficulty. In this type of anomaly, preoperative peri-
apical radiographs in different angulations are
­important for treatment planning. Magnification
and u­ ltrasonics are mandatory and ultrasonic tips.
Considering that the main canal was partially
blocked with the invaginated root, an ultrasonic
tip was also used to enlarge the apical foramen of
invagination aiming to completely seal the apex
with MTA. A week later the sinus tract had disap-
peared, and 1 year later the apical lesion was
healed (Fig. 13.10g).
13.12 Case Report 11
13.12.1 Patient Information
• Age: 40. Gender: female. Medical history:
noncontributory.
13 Managing Complex Root Canal Anatomies 359

13.12.2 Tooth • Preoperative radiological assessment: previ-

• Identification: mandibular left first molar
(tooth 36).
• Dental history: canal treatment performed
6 years ago.
• Clinical examination findings: swelling in the
buccal area, pain on biting, probing depths
within 2–3 mm.
ous canal treatment, radiolucency at the apex
of mesial and distal roots, screw post in the
distal root, mesial abutment in a porcelain
fused to metal bridge (Fig. 13.11a).
• Diagnosis: previously endodontic treatment
with symptomatic apical periodontitis.

a b c

d e f

g h i

j k l

m n o

Fig. 13.11 Nonsurgical endodontic retreatment of a mandibular left first molar with independent middle mesial canal
by Sergiu Nicola

pilararaya@ejercer.cl
360
13.12.3 Treatment Plan
Nonsurgical endodontic retreatment through the
bridge and adhesive buildup.
• Preliminary procedures: local anesthesia,
rubber dam isolation, access through the
crown with diamond bur for porcelain and
carbide bur for metal (Fig. 13.11b–d).
Composite core removed with thin ultrasonic
tips (U-file, Mani) then post unscrewed with
Startx #4 (Densply) (Fig. 13.11e–g). Dental
operating microscope used during all the
procedures.
• Canal preparation: S1 in reciprocating move-
ment (90° CW 30° CCW; ATR Technika
motor). Reciproc R25 (VDW) was used alter-
natively until working length was reached
(Fig. 13.11h). Working length was determined
electronically during the treatment with a cus-
tom apex locator connected to handpieces.
• Irrigation: 5.25% NaOCl (syringe irrigation
with 27G open vent needle).
• Final irrigation protocol: 5.25% NaOCl (ultra-
sonic activation; IrriSafe, Acteon) for 60 s fol-
lowed by 17% EDTA and 5.25% NaOCl.
• Obturation: warm vertical compaction of gutta-
percha and AH Plus sealer (Fig. 13.11i–l).
13.12.4 Technical Aspects
Patient choice was to maintain the old bridge, so
retreatment was performed through the crown,
including the removal of the retained screw post,
which was done using sharpened tips with fine
diamond burs up to a thickness less than 0.1 mm.
This procedure was performed several times
since the tip was constantly blunting. During the
retreatment, when cleaning the mesial isthmus,
a middle mesial canal with a separate portal of
exit was revealed (Fig. 13.11h). The postopera-
tive radiography showed a very complex anat-
omy: three separate mesial canals and two distal
canals joining in the apical third (Fig. 13.11l).
pilararaya@ejercer.cl
A. Chaniotis et al.
A 1-year recall showed healing in progress
(Fig. 13.11m–o).
13.13 Case Report 12
13.13.1 Patient Information
• Age: 36. Gender: male. Medical history:
noncontributory.
13.13.2 Tooth
• Identification: mandibular left first molar
(tooth 36) (Fig. 13.12a).
• Dental history: previous root canal treatment
performed 1 year ago.
• Clinical examination findings: asymptomatic;
probing depths within 2–3 mm.
• Preoperative radiological assessment: previ-
ous canal treatment; radiolucency at the apex
of mesial root; fiber posts in both mesial and
distal roots.
• Diagnosis: previously root canal treatment;
asymptomatic apical periodontitis.
13.13.3 Treatment Plan
Nonsurgical retreatment and adhesive buildup
• Preliminary procedures: local anesthesia;
rubber dam isolation; access through the
­composite core with diamond bur (Fig. 13.12b).
Composite core removed with thin ultrasonic
tips (U-file, Mani); fiber posts were carefully
dug with thinned U-files (Fig. 13.12c–g). After
fiber post removal, canal retreatment started
with U-file tips which revealed four mesial
and three distal canal orifices (Fig. 13.12h–k).
Dental operating microscope was used during
the procedures.
• Canal preparation: S1 in reciprocating move-
ment (90° CW 30° CCW; ATR Technika
13 Managing Complex Root Canal Anatomies 361

a b c d e

f g h i

j k l m

n o p q

r s t u

Fig. 13.12 Nonsurgical endodontic retreatment of a mandibular left first molar with seven root canals by Sergiu Nicola

motor) followed by Reciproc R25 (VDW) • Obturation: warm vertical compaction of

used until working length, which was deter-
mined electronically with a custom apex loca-
tor connected to handpieces. A very complex
anatomy was revealed during the retreatment.
• Irrigation: 5.25% NaOCl (syringe irrigation
with 27G open vent needle) at room
temperature.
• Final irrigation protocol: 5.25% NaOCl (ultra-
sonic activation; IrriSafe, Acteon) for 60 s fol-
lowed by 17% EDTA and 5.25% NaOCl
(Fig. 13.12l, m).
gutta-percha and AH Plus sealer (Fig. 13.12n–
u). The core was rebuilt using dual-cure
resin.
13.13.4 Technical Aspects
Fiber posts had to be removed in a conservative
manner trying not to touch the sound dentin. This
goal was achieved using thinned U-files that are
very sharp and precise in digging.

pilararaya@ejercer.cl
362
13.14 Case Report 13
13.14.1 Patient Information
• Age: 48. Gender: male. Medical history:
noncontributory.
13.14.2 Tooth
• Identification: maxillary right second molar
(tooth 17).
• Dental history: tooth 16 was treated in 2012
and had a marginal fistula on the palatal side
(Fig. 13.13a) and a large radiolucent area
between roots (Fig. 13.13b–d), suggesting the
occurrence of vertical fracture. Tooth 17 was
tender to percussion, vitality testing with Endo
Ice was negative, and electrical pulp testing
showed a reaction in the highest setting. After
extraction of the fractured 16, the testing on
17 was repeated with the same results and no
change in clinical symptoms.
• Clinical examination findings: no tenderness
to palpation, pain on biting no longer than
3–4 min, no extended probing depth; old, not
satisfactory ceramic inlay restoration with
susceptible secondary decay under the mesial
ridge (Fig. 13.13e).
• Preoperative radiological assessment: lower
radiopacity was observed under the mesial
ridge near to the mesial pulp horn. Apical area
could not be inspected on the CBCT exam as
all relevant features were covered by the
hypertrophic sinus mucosa radiating from the
periodontal area of tooth 16 (Fig. 13.13f).
• Diagnosis: partial pulp necrosis; asymptom-
atic apical periodontitis.
13.14.3 Treatment Plan
• Preliminary procedures: local anesthesia, rub-
ber dam isolation, and placement of gingival
barrier. After image-guided access cavity
preparation (Fig. 13.13g), canal orifices were
pilararaya@ejercer.cl
A. Chaniotis et al.
identified (Fig. 13.13h), palatal vital pulp tis-
sue was removed (Fig. 13.13i), and orifice
enlargement was performed with ProTaper SX
to a depth of 2 mm (Fig. 13.13j–l).
• Canal preparation: because of the narrow
canal anatomy and small bending in the canal
route, the V-Taper H2 file system (SS White)
was used for preparation. Master apical files
were 30/04 (palatal canal), 25/06 (MB1
and distobuccal canals), and 20/06 (MB2 to
the confluence with MB1) (Fig. 13.13m).
K-file size 15 was used between instru-
ments to ensure patency and to prevent debris
accumulation.
• Irrigation: 5.25% NaOCl (passive ultrasonic
irrigation).
• Final irrigation protocol: 50% citric acid for
60 s; final flush with 5.25% NaOCl (PUI).
• Obturation: epoxy resin-based sealer (AH
Plus) and gutta-percha; warm vertical com-
paction (Fig. 13.13n–p). In the present case,
distobuccal canal was confluent with MB1
(Fig. 13.13q), and the former was obturated
first. After this, gutta-percha point for MB1
was inserted; both points were cut off at ori-
fice level and gently compacted apically to
avoid dislocation. Then, warm gutta-percha
was injected into the MB2 to ensure maxi-
mum hydraulics for the warm vertical com-
paction obturation of the other canal
systems.
13.14.4 Technical Aspects
When there is a confluence of root canals at a
deep level, attention must be given not to block
one of the splitting branches. In this way, it is
preferred to obturate one canal first with the best
fitting gutta-percha point without cutting off the
gutta-percha at orifice level. In this case, CBCT
helped to plan the procedure and to identify the
morphology of the buccal canal systems.
Besides, image-guided access helped to avoid
extending the access cavity too far at the pericer-
vical dentin level.
13 Managing Complex Root Canal Anatomies 363

a b c d

e f g h

j k l m

n o p q

Fig. 13.13 Nonsurgical endodontic treatment of a maxillary right second molar with a confluence of the distobuccal
and mesiobuccal canals by Oscar von Stetten

13.15.2 Tooth
13.15 Case Report 14
• Identification: maxillary right first molar
13.15.1 Patient Information (tooth 16).
• Dental history: tooth 16 was treated in 2012
• Age: 44. Gender: male. Medical history: (Fig. 13.14a) and started to get tender to per-
noncontributory. cussion and biting.

pilararaya@ejercer.cl
364 A. Chaniotis et al.

a b c d

e f

g i j

h k

Fig. 13.14 Nonsurgical endodontic retreatment of a maxillary right first molar with a missed MB2 canal by Oscar von
Stetten

• Clinical examination findings: no tenderness • Preoperative radiological assessment: apical

to palpation, sensitive to percussion, no prob- translucency around the mesial root suggest-
ing depth, pain on biting no longer than ing missed anatomy.
3–4 min; old composite restoration with • Diagnosis: previously initiated therapy with
remaining decay (Fig. 13.14b). symptomatic apical periodontitis.

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
13.15.3 Treatment Plan
• Preliminary procedures: local anesthesia, rub-
ber dam isolation, and placement of gingival
barrier. After access, canal orifices were
located, and coronal gutta-percha was
removed (Fig. 13.14c). After gutta-percha
removal, orifice of MB2 canal was found
(Fig. 13.14d).
• Canal preparation: after orifice enlargement,
rotary Profile 20.04 was used for removal of the
remaining canal filling under constant irriga-
tion. After working length measurement, Profile
25.04 instrument was used to prepare the canals.
Then, Self-adjusting File (SAF) of 2.0 mm was
used for 3 min in each canal. To remove the
gutta-percha remnants, a Micro-­ Opener and
Micro-Debrider (Dentsply) were used under
optical control (Fig. 13.14e). Finally, XP fin-
isher R (FKG) was used under constant irriga-
tion. Final apical preparation was done with a
Mtwo size 30.04 instrument in all canals.
• Irrigation: 5.25% NaOCl; passive ultrasonic
irrigation.
• Final irrigation protocol: 50% citric acid for
60 s, final flush of 5.25% NaOCl with PUI.
• Obturation: epoxy resin-based sealer (AH
Plus) and gutta-percha; warm vertical com-
paction (Fig. 13.14f–k).
13.15.4 Technical Aspects
In retreatment procedures there are important
technical aspects to consider avoiding flare up
and additional iatrogenic problems. It includes
patience and not using solvents (99% of the
cases). Avoid rushing to the apex, working from
floor to floor of the root canal. Vigorous use of
the microscope and suited instruments to remove
the gutta-­percha mechanically is the best way to
handle this kind of cases. Meanwhile, some file
manufacturers introduced a new class of instru-
ments on the market to help us in mechanical
removal of the gutta-percha in hidden areas.
pilararaya@ejercer.cl
365
13.16 Case Report 15
13.16.1 Patient Information
• Age: 52. Gender: female. Medical history:
noncontributory.
13.16.2 Tooth
• Identification: maxillary left third molar
(tooth 28).
• Dental history: recently started non-concluded
root canal therapy.
• Clinical examination findings: temporarily
restored tooth showing no sinus tract, no
swelling, sensitive to percussion, soft tissue
within normal limits, without mobility, and
periodontal probing within physiological
limits.
• Preoperative radiological assessment: sepa-
rated instrument and apical radiolucency in
mesiobuccal root (Fig. 13.15a).
• Diagnosis: previously initiated therapy with
symptomatic apical periodontitis.
13.16.3 Treatment Plan
• Preliminary procedures: local anesthesia, rub-
ber dam isolation, and removal of temporary
restoration (Fig. 13.15b). Modified GG3
(Terauchi File Retrieval Kit) was used for
exposing the coronal part of separated instru-
ment (Fig. 13.15c), and then separated instru-
ment was removed (Fig. 13.15d) according to
the illustration. Dental operating microscope
was used during the procedures.
• Canal preparation: initial negotiation and
scouting of the root canals were carried out
with a pre-curved D-Finder instrument size 8.
After electronic working length determination
(Fig. 13.15e), manual glide path was obtained
using sizes 08, 10, 12, and 15 D-Finder (Mani
Inc.). After achieving the working length,
366 A. Chaniotis et al.

a b c d

e f g h i

j k l

Fig. 13.15 Nonsurgical endodontic treatment of a maxillary left third molar with a separated instrument in the mesio-
buccal canal by Hugo Sousa

each file was coupled to M4 Safety handpiece Elements Motor) up to instrument 25.06
(Kerr Endodontics) and used in an up-and-­ (SM2) in mesiobuccal and distobuccal canals
down movement (1 mm) until it is loosed in and up to 35.06 (ML2) in palatal canal.
the canal. Cleaning and shaping were per- • Irrigation: syringe irrigation (30G needle)
formed using TF Adaptive (Kerr Endodontics; with warm 5.25% NaOCl.

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
• Final irrigation protocol: 17% EDTA (syringe
irrigation) for 1 min followed by 5.25%
NaOCl with manual dynamic activation tech-
nique for 60 s each root canal.
• Obturation: continuous wave of condensation
technique with Elements Obturation Unit with
epoxy resin-based sealer (AH Plus) and gutta-­
percha (Fig. 13.15f–h).
• Additional information: pulp chamber was
sealed (Ionoseal), a temporary restoration was
done, and patient was referred for coronal res-
toration. At 1-month follow-up, tooth was
asymptomatic (Fig. 13.15i). A postoperative
CBCT scan showed a challenging anatomy,
demonstrating the importance of irrigation to
achieve biological objectives (Fig. 13.15j–l)
13.16.4 Technical Aspects
The option to remove the separated instrument is
related to its position in the root canal and the
need to disinfect the complex anatomical system.
In this case, separated instrument was at the ini-
tial canal curvature. To avoid more mishaps, it is
important (1) to use small pre-curved files with-
out apical pressure to scout the root canal. When
an impediment to apical progress is met, the file
needs to be removed and smoothly bent at the last
2 mm, (2) to obtain a straight-line access, (3) to
reduce the area of the file in contact with dentinal
walls, (4) to create a manual glide path up to a
size 15, and (5) to use visual aids such as a dental
microscope.
13.17 Case Report 16
13.17.1 Patient Information
• Age: 28. Gender: female. Medical history:
noncontributory.
13.17.2 Tooth
• Identification: mandibular right second molar
(tooth 47) (Fig. 13.16a)
pilararaya@ejercer.cl
367
• Dental history: tooth was previously treated
and patient complaint of pain from last month
when “biting” [sic].
• Clinical examination findings: leaking resto-
ration with decayed margins; slight discom-
fort upon percussion and palpation of the
buccal mucosa; no sinus tract and soft tissue
within normal limits. Periodontal probing
within physiological limits.
• Preoperative radiological assessment:
S-shaped anatomy and periapical radiolu-
cency (Fig. 13.16b).
• Diagnosis: previously treated tooth; symp-
tomatic apical periodontitis.
13.17.3 Treatment Plan
• Preliminary procedures: local anesthesia; rub-
ber dam isolation; removal of restauration and
decayed tissue followed by access prepara-
tion. After identification of canal orifices,
access cavity was extended toward buccal
with an ultrasonic tip, and a third canal orifice
was found. Dental operating microscope was
used during procedures.
• Canal preparation: obturation material in
mesiolingual and distal canals were removed
with Reciproc R25 instrument (VDW), 1 mm
shorter than the obturation extent. Scouting of
root canals was carried out with hand K-file
sizes 08 and 10 until the first curvature
(Fig. 13.16c) of the mesiobuccal canal. In the
other canals, coronal flaring was performed
using TF Adaptive ML1 in continuous rotary
motion, 1 mm shorter of the first curvature.
Ledges found in the mesiolingual and distal
canals were bypassed with pre-curved
D-Finder file sizes 08 and 10. In the mesio-
buccal canal, a sequence of hand files (from 8
to 15 K-files) was used until reach the second
curvature with M4 handpiece. Then, K-file
size 08 advanced until achieving patency.
After electronic and radiographic working
length determination (Fig. 13.16d, e), manual
glide path was obtained with K-files sizes 08
to15 using M4 handpiece. Cleaning and shap-
ing were accomplished using TF and TF
368 A. Chaniotis et al.

b c d e

f g h i

Fig. 13.16 Nonsurgical endodontic retreatment of a mandibular right second molar with S-shaped curvature by Hugo
Sousa

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
Adaptive up to 25.04 in mesial canals and
25.06 in the distal canal. Canal blocking was
prevented by using multiple recapitulations
with a pre-curved 10 K-file.
• Irrigation: syringe irrigation (30G needle)
with warm 5.25% NaOCl.
• Final irrigation protocol: 17% EDTA (syringe
irrigation) for 1 min followed by 5.25%
NaOCl with manual dynamic activation tech-
nique for 60 s in each root canal.
• Obturation: continuous wave of condensation
technique with Elements Obturation Unit with
epoxy resin-based sealer (AH Plus) and gutta-­
percha (Fig. 13.16f–i).
13.17.4 Technical Aspects
S-shaped anatomy is ideally managed using a
“three-staged shaping technique” with constant
irrigation and recapitulation: (1) Stage 1, shape
the canals to the first point of curvature, i.e.,
1 mm shorter than the maximum engagement
zone of 10 K-file); (2) Stage 2, a pre-curved
hand file is placed to passively negotiate up to
the next resistance point, increase the root canal
size up to this point; and (3) Stage 3, pre-curved
hand files advance to achieve patency after
which the shaping of this area starts. In case of
ledge, curve the tip of the instrument (nearly
45°). After bypassing it, left the file in place and
connect it to the M4 handpiece. Smaller size
files must be super loose in the canal before
using large files to negotiate the canal without
any apical pressure. Then, it is important to
enlarge the canal with i­nstruments 20–25 with
small taper files (4–6%) to avoid additional iat-
rogenic events.
13.18 Case Report 17
13.18.1 Patient Information
• Age: 44. Gender: female. Medical history:
noncontributory.
pilararaya@ejercer.cl
369
13.18.2 Tooth
• Identification: maxillary left first molar (tooth
26).
• Dental history: patient complained about pain
with thermal stimulus.
• Clinical examination findings: no caries
lesion; no sinus tract; probing depth within
physiological limits; no sensitive to percus-
sion; exacerbated response to thermal tests.
• Preoperative radiological assessment: calci-
fied pulp chamber and roots canals
(Fig. 13.17a).
• Diagnosis: irreversible pulpitis; with normal
periradicular tissues.
13.18.3 Treatment Plan
• Preliminary procedures: root canal treatment
was performed with cleaning and shaping of
four canals (Fig. 13.17b). At the 2-year recall
(Fig. 13.17c), patient complained when per-
forming the horizontal and vertical percussion
test (Fig. 13.17d). Additional CBCT examina-
tion demonstrated the presence of an untreated
second buccal canal at the distal root
(Fig. 13.17e, f). After local anesthesia and
rubber dam isolation, a selective access cavity
preparation was done.
• Canal preparation: with the CBCT informa-
tion and magnification, a selective access to
the distal canal was performed using ultra-
sound to remove dentin at the entrance to have
a clear access to the missed canal
(Fig. 13.17g–i).
• Irrigation: 5.25% NaOCl (passive ultrasonic
irrigation).
• Final irrigation protocol: 17% EDTA for
1 min followed by 5.25% NaOCl.
• Obturation: single cone technique (Fig. 13.17j).
After 2 years, patient was asymptomatic.
Radiographic (Fig. 13.17k) and CBCT
(Fig. 13.17l) examinations showed all canals
obturated with a minor widening of the periodon-
tal ligament at the apical region of distal root.
370 A. Chaniotis et al.

a b c

d e f

g h i

j k l

Fig. 13.17 Nonsurgical endodontic retreatment of a maxillary left first molar with five root canals by Carlos Murgel

pilararaya@ejercer.cl
13 Managing Complex Root Canal Anatomies
13.18.4 Technical Aspects
This case illustrates the limitations of conventional
radiography for diagnosing and treatment planning
of a tooth with persistent symptom after root canal
treatment. This is especially important when treat-
ing maxillary molars because the superimposition
of anatomical structures. Information from CBCT
examination allowed a proper diagnosis and treat-
ment plan, while helps in execute minimally inva-
sive treatment to solve patient’s chief complain.
13.19 Case Report 18
13.19.1 Patient Information
• Age: 54. Gender: female. Medical history:
noncontributory.
13.19.2 Tooth
• Identification: mandibular right first molar
(tooth 46).
• Dental history: pain on tooth 46, especially
with thermal stimulus.
• Clinical examination findings: temporary resto-
ration; no tooth discoloration, caries, or enamel
fracture; no periodontal probing; horizontal
and vertical percussion test within ­normal lim-
its; severe response to thermal stimulus.
• Preoperative radiological assessment: reduced
pulp chamber; normal bone structure
(Fig. 13.18a).
• Diagnosis: irreversible pulpits with normal
periradicular tissues.
13.19.3 Treatment Plan
• Preliminary procedures: root canal treatment
was performed (Fig. 13.18b), but after 2 years,
pilararaya@ejercer.cl
371
despite tooth 46 was asymptomatic, radio-
graphic examination showed an apical lesion
at the mesial root suggesting the occurrence of
a chronic periapical process (Fig. 13.18c).
CBCT examination showed an untreated lin-
gual apical canal at the mesial root
(Fig. 13.18d–f). After local anesthesia and
rubber dam isolation, a selective access cavity
preparation was done.
• Canal preparation: with the CBCT infor-
mation and magnification, access to the
apical bifurcation of the mesial canal
was performed using thin ultrasound tips
(Fig. 13.18g).
• Irrigation: 5.25% NaOCl (passive ultrasonic
irrigation).
• Final irrigation protocol: 17% EDTA for
1 min followed by 5.25% NaOCl.
• Obturation: single cone technique (Fig. 13.18h).
After sealed the access with composite resin
(Fig. 13.18i), immediate post-­op radiograph and
CBCT (Fig. 13.18j, k) clearly show both canals
at the mesial root. At 1-year recall, patient was
asymptomatic, and mesial root showed apical
healing (Fig. 13.18l).
13.19.4 Technical Aspects
This case illustrates the limitations of conven-
tional radiography for diagnosing and treatment
planning of a tooth with persistent symptom
after root canal treatment. This is especially
important when treating mandibular first molars
because of the enormous variation of anatomi-
cal structures on their roots. Information from
CBCT examination allowed a proper diagnosis
and treatment plan, while helps in execute mini-
mally invasive treatment to solve patient’s chief
complain.
372 A. Chaniotis et al.

a b c

d e f

g h i

j k l

Fig. 13.18 Nonsurgical endodontic treatment of a mandibular right first molar with a deep bifurcation in the mesial
root by Carlos Murgel

pilararaya@ejercer.cl
 Part IV
Appendix

pilararaya@ejercer.cl
 Contemporary Strategies
for Teaching Internal Anatomy
of Teeth
Bettina Basrani and Marco A. Versiani
Abstract
The importance of preclinical training in end-
odontics has been well established in the lit-
erature for endodontic education. Its primary
purpose is to introduce students to cognitive
and psychomotor skills related to the mor-
phology and spatial and functional relation-
ships of human dentition. The aim of this
chapter is to describe different models to teach
the internal anatomy of the teeth in distinct
levels of the education curriculum in
endodontics.
14.1 Introduction
Sound knowledge of anatomy has been consid-
ered cornerstone of dental education. As a foun-
dational course in the preclinical curriculum in
dentistry, dental anatomy introduces students to
the anatomical and morphological characteristics
of human permanent and primary dentitions [1].
Preclinical disciplines such as dental anatomy
B. Basrani, D.D.S., M.Sc., Ph.D. (*)
Endodontic Program, Faculty of Dentistry, University
of Toronto, Toronto, ON, Canada
e-mail: bettina.basrani@dentistry.utoronto.ca
M. A. Versiani, D.D.S., M.Sc., Ph.D.
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
São Paulo, Brazil
© Springer International Publishing AG, part of Springer Nature 2019
M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_14
pilararaya@ejercer.cl
14
represent an important stage of learning in dental
schools since they enable students to acquire
knowledge for further developing of manual
skills, essential to clinical practice [2, 3].
Therefore, the purpose of education must be
firstly to provide a basic understanding and, sec-
ondly, to develop an ability to acquire further
knowledge [4]. This is especially true in end-
odontics where a clear comprehension of the
complexity of the root canal system and its spa-
tial relationship with surrounding tissues
is extremely important in clinics.
Students of the internal anatomy of teeth must
know that the clinical outcome is largely depen-
dent on their ability to treat root canal systems to
their full apical and lateral extents and how to
choose proper armamentarium to match the canal
dimensions [5]. Thus, a thorough understanding
of the anatomy of the human teeth is an important
constituent of dentistry, particularly regarding
teaching purposes [6, 7]. Concerning the educa-
tional environment, it is generally accepted that
learning progress is strongly oriented toward the
understanding of theoretical backgrounds. If the
students are familiar with the various aspects of
root canal anatomy, they also know much better
how to proceed in clinical practice. Within the
understanding of the basic idea regarding this
subject, students would be able to better internal-
ize all the treatment-related processes [8].
However, the field of endodontics is unique when
compared with other areas of dentistry in that,
375
376 B. Basrani and M. A. Versiani

unlike performing a restoration, the student per- may foster superficial understanding if students
forming endodontic therapy in clinics cannot see are not provided with an opportunity to actively
the object he is working on, the internal anatomy discuss what they are learning [1, 13, 14].
of teeth [9]. To address this problem, numerous Therefore, active preparation for class sessions
techniques have been devised for use in the study (using a variety of digital resources and a review
of the root canal system. sheet with study questions) and small-group dis-
cussions in class has been suggested as a way to
encourage every student to participate and
14.2 Cognitive and Psychomotor assume some accountability to others through
Aspects in Dental Education self- and peer evaluation, improving the quality
of learning [1, 15].
A meaningful foundation in dental anatomy Clinical competence relies on the develop-
includes cognitive and psychomotor aspects. The ment of the widely recognized psychomotor
cognitive aspect is comprised of descriptive and aspect. Inextricably coupled with these psycho-
conceptual knowledge, including a substantial motor skills is the ability to self-evaluate the pro-
body of terminology, while the psychomotor cess of correction and the product itself compared
aspect is divided into visual and motor skills. It is to the desired outcome. Visual perception has
important to point out that the latter is beyond the been suggested as a prerequisite skill for deter-
scope of this chapter. Thus, dental anatomy mod- mining the appropriate goals and strategy for a
ule must improve learning in both aspects by correction [1]. Visual skill is required to observe
making them more relevant to clinical practice normal 3D tooth morphology in detail, to differ-
and incorporating more opportunities for stu- entiate normal tooth morphology from its devia-
dents to actively engage in the learning tions, and to envision correction of the deficient
process [1]. tooth morphology into a product that replicates
The traditional method of learning dental normal tooth morphology; further, motor skill is
anatomy terminology (cognitive aspect) employs also required to execute clinically relevant dental
lectures, textbooks, course manuals, and interac- procedures [1]. In the development of psychomo-
tive tests that allow the students to answer indi- tor skills, the student must teach his hands to do
vidual questions and preserve tooth specimens that which his mind dictates as correct. Models
[10]. In addition, pulpal anatomy has tradition- that simulate teeth in which root canals can be
ally been taught using ground cross sections of visualized would serve as valuable teaching aids
teeth, radiographs, and three-dimensional models in offering direct visual information on the effects
produced by injecting colored resin or dyes into of instrumentation during endodontic proce-
the pulp spaces of decalcified and transparent dures. The visual experiences afforded by these
teeth [1]. In the literature, it is also possible to models would provide mental images which can
find other several teaching aids to develop cogni- be transferred to the performance of endodontic
tive and psychomotor skills such as artificial procedures on the actual teeth [9].
teeth placed in static manikin jaws or phantom The traditional way to learn psychomotor
heads, simulated root canals made in clear resin skills in the root canal anatomy curriculum are
blocks [2, 3, 11], among others [8]. Some of “bench-type” exercises, including creating two-­
these techniques are complicated and time-­ dimensional line drawings by examining extracted
consuming to be developed, and many difficul- teeth and their cross sections. In the case of dental
ties can be encountered during the manufacturing morphology, visual discrimination demands a
process, including the introduction of artifacts, thorough knowledge of normal tooth morphology.
distortion of the original anatomy, and the unfea- To succeed in visual discrimination tasks, stu-
sibility to observe the external and internal anat- dents need to observe and analyze several exam-
omy of teeth in three dimensions simultaneously ples of both ideal tooth morphology and its
[12]. The unavoidable pitfalls of these methods possible deviations. The additional use of magni-

pilararaya@ejercer.cl
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth 377

fication (microscope or loupes) in this laboratory
activity may have a positive effect, enhancing
visual acuity and fine motor skills of the students.
Figure 14.1 shows some examples where students
can learn how to identify distinct colors of the
dentin and its relationship with different condi-
tions of teeth, such as caries, abrasion, restoration,
etc. Besides, the visual skill can be also improved
on recognizing the internal anatomy of the tooth
by comparison with radiographic images. The
students can be asked to take a radiograph from an
extracted tooth in two different angulations (buc-
cal-lingual and mesial-­distal) and then to section
teeth either in their longitudinal or transversal
aspects. After that, students can draw the assorted
colors observed on dentin and its relationship
with the enamel and root canal space (Figs. 14.2
and 14.3). Nowadays, most dental schools con-
tinue to present foundational knowledge in lec-
tures and to develop students’ psychomotor skills
through a combination of two-dimensional draw-
ing projects and exercises to carve teeth from
oversized wax blocks [1]. As a result, neither
knowledge nor psychomotor skills are learned in
the context of clinical practice, thus potentially
hindering the student’s ability to later recall and
apply learning to actual patient care. These short-
comings of the traditional curriculum have been
previously identified [1].
Considering that participatory students’ activ-
ities have been proven to enhance the student
learning environment [10], it is important that
students review content resources related to the
topic prior to class, and then, after laboratory
exercises, in-class presentations based on small-­
group discussions must be performed. In the
small groups, students can ask questions and dis-
cuss the particular laboratory procedures [1]. At
this point, teacher must act as a facilitator, ana-
lyzing the radiographic images and comparing
them to the real anatomy and encouraging par-
ticipation by all students. Finally, the students
can analyze their own interpretation of the images
by showing their own drawings, and this helps to

a b

Fig. 14.1 Examples of forms completed by the students (a-b) with radiographs, cross section, or longitudinal section
of different types of teeth, ad drawings with their own interpretation and remarks

pilararaya@ejercer.cl
378 B. Basrani and M. A. Versiani

a b

c d

Fig. 14.2 Examples of drawings performed by the students on sectioned teeth (a-d) showing the assorted colors
observed on dentin and its relationship with the enamel and root canal space with some remarks

discriminate “ideal” from clinically important
deviations from normal. The interesting aspect of
laboratory activities conducted on a peer teaching
basis is that each student is bringing a complete
different specimen and it promotes discussion
amongst the students, with the teacher as a facili-
tator. In using facilitated learning process, stu-
dents are encouraged to take more control of their
learning process, and the trainer’s role becomes
that of a facilitator and organizer, providing
resources and support to learners. These initial
discussions may be complemented by a forma-
tive assessment activity in a format of interactive
question-and-answer activities. These modifica-
tions allow class time to be used for higher-level
grand-round style discussions rather than for
mere content presentation [1]. Despite the clear
advantage of being easy, fast and not depending
on technology, sometimes the objective to
develop visual skills based on two-dimensional
images, such as line drawing exercises, is ham-
pered because the method fails to provide stu-
dents with a variety of specimens, thus hindering
the development of their ability to discriminate
the normal from unusual tooth morphology. But
the most significant deficiency of this method is
the challenge of portraying 3D relationships of
tooth morphology [1, 16].
For decades, endodontic teaching has relied
almost exclusively on the use of natural human

pilararaya@ejercer.cl
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth 379

a b c

d e

Fig. 14.3 Examples of drawings performed by the students based on longitudinal sections of several types of teeth
(a-d) showing the assorted colors observed on dentin and root canal space

teeth. Practice on extracted teeth has been a uni-
versal method of teaching preclinical endodon-
tics and giving students the opportunity of
gaining expertise before moving to patients [3].
Cross-infection control, originated by the manip-
ulation of extracted teeth, along with ethical fac-
tors is threatening such practice in some teaching
institutions. These drawbacks have stimulated
the development of alternative simulation meth-
ods for endodontic teaching [2].
14.3  pplications of 3D Anatomy
A tion, and can be a valuable aid for self-­
of Teeth in Dental Education
Despite endodontic teaching being based mostly
on the use of natural extracted human teeth [3], it
may have certain limitations for use in preclinical
teaching as they may (1) be difficult to obtain; (2)
become brittle and fracture easily; (3) be third
molars that are not usually treated endodonti-
cally; (4) be extremely varied in internal anat-
omy; (5) break down because of caries or have
large restorations, obliterating external anatomi-
cal landmarks; (6) have smaller pulp chambers
because of the deposition of reparative dentin; or
(7) present variations of internal anatomy which
make the evaluation difficult for students and
teachers [11]. Consequently, several authors have
been proposed the replacement of the natural
teeth by artificial tooth models in resin [3].
Transparent tooth model offers a convenient
and useful method that can be used for studying
and teaching about the morphology of teeth as it
provides a three-dimensional view of root canal
system. Besides, they are standardized, easy to
obtain in quantity, do not pose any risk of infec-
assessments. However, the resin hardness and the
complex internal and external dental anatomy of
most of transparent tooth models do not accu-
rately reproduce natural teeth (Fig. 14.4).
Moreover, sometimes their characteristics of
transparency and lack of radiopacity did not
allow the development of some technical skills
related to radiographic interpretation, making
their use limited in some phases of learning [2].
Actually, a study showed that the perception of
specialists about these types of artificial teeth was
unsatisfactory and did not support the replace-

pilararaya@ejercer.cl
380 B. Basrani and M. A. Versiani

Fig. 14.4 Different conventional transparent tooth models showing that internal and external anatomies do not accu-
rately reproduce natural teeth (images available at https://anatomicalmodels.pt.aliexpress.com)

pilararaya@ejercer.cl
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth
ment of natural teeth [2]. As a result, other
researchers started to seek ways to reproduce the
anatomical and physical characteristics of dental
tissues in artificial teeth.
Recently, CT-based training replicas produced
using three-dimensional printing technology
have improved the use of artificial teeth for teach-
ing purposes. Now, rather than every student hav-
ing a different anatomical challenge hidden in his
or her extracted teeth, all of them can work in the
same clear anatomical form at the same activity
class [5]. Despite some inherent limitations
regarding the development of motor skills using
these resin replicas related to the tactile percep-
tion during access preparation and canal instru-
mentation/obturation, these printing prototypes
can be extremely valuable for anatomical teach-
ing purposes as (1) they allow for complete stan-
dardization of grading, (2) educators can lead a
whole class through each of the classic endodon-
tic challenges instead of teaching a single student
at time, (3) students can practice a given chal-
lenge as many times as they need to achieve com-
petence in that root form, and after which (4) they
can be tested in a nontransparent replica having
the same anatomy [5] (Fig. 14.5). Besides, repli-
cas with different root canal complexities can be
printed as oversized models in a rapid prototyp-
ing 3D printer, allowing the students to held them
in hand to observe details of the internal anatomy
in different views. Additional applications of
printed models in dental education also include
the possibility to (1) scale the teeth for didactic
purposes, (2) build a collection of 3D tooth mod-
els showing atypical or only regionally prevalent
anatomies, (3) produce a large number of teeth
for destructive analysis, (4) present the teeth in
the form of individual substructures that need to
be assembled correctly by the students, and (5)
build an extensive collection of 3D models of
healthy and diseased teeth using raw data made
available online by researchers and dentists from
all over the world [17].
As imaging has been adopted in the modern
dental education, it has benefited from the con-
current development of technologies that have
allowed the material to be presented electroni-
cally. One of the technologies with the greatest
pilararaya@ejercer.cl
381
impact has been the Internet. The Internet has
increasingly been utilized as an educational tool
due to its ability to provide a large volume of edu-
cational material in a single, readily accessible
location as well as permit flexibility in the mate-
rial format. Images, text, interactive quizzes, and
videos can be integrated seamlessly into a com-
prehensive educational resource [18]. This is sup-
ported by studies comparing visual recognition
skills acquired by traditional and computer-based
curricula in dental morphology which have found
that the latter can be a valuable tool to prepare
students for the next learning objective and the
acquisition of motor skills [1, 16]. Visualization
technology has the potential to improve on tradi-
tional techniques for teaching visual discrimina-
tion and should provide students with the
following: (1) an extensive resource to learn den-
tal terms related to tooth morphology, (2) interac-
tive 3D tools to visualize and learn normal
external tooth and pulp cavity morphologies, (3)
an extensive library of 3D images of tooth and
pulp morphologies that deviate from normal, and
(4) progressive evaluation of knowledge in the
form of quizzes that provide immediate feed-
back. However, in a previous experience using
3D interactive software at the University of
Illinois (Chicago), many students have reported
problems with navigation and use of the library
interface because the program was slow and
cumbersome to use on their home computers.
These frustrating delays reduced the students’
motivation to continue using this educational
resource type [1].
The field of endodontic education can also
profit in several ways by the application of tech-
niques and approaches that are already estab-
lished in other scientific disciplines such as (1)
the interactive exploration of tooth anatomy
online, (2) expanded morphometric and volumet-
ric analyses of internal tooth structures, and (3)
large-scale correlations of external and internal
tooth morphology using 3D virtual models [7].
This was only possible due to the recent advances
in noninvasive imaging technologies, named
cone-beam computed tomography (CBCT) and
micro-computed tomography (micro-CT) scans,
which have opened a new world of diagnosis,
382 B. Basrani and M. A. Versiani

Fig. 14.5 (a–d) Replicas of various teeth manufactured True Tooth® images available at https://dentalengineering-
from corresponding real-tooth micro-computed tomogra- lab.com/truetooth/; d shows RepliDens® images available
phy scans using three-dimensional printing technology in at https://www.smartodont.ch/replidens/)
assorted sizes for didactic or teaching purposes (a–c show

pilararaya@ejercer.cl
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth
assessment and evaluation for the endodontists,
and dental profession at large, as well as in end-
odontic research and teaching [17].
The principles of computerized tomographic
imaging are the same for both CBCT and micro-
­CT systems. They use the spatial distribution of
X-ray attenuation to create cross sections of a
physical object that can be used to recreate a vir-
tual model (3D model) with high accuracy, with-
out destroying the original object (see Chap. 6 for
more details). Although CBCT has been in use
for almost two decades, only recently affordable
systems with better spatial resolution have
become commercially available. This technology
provides an imaging modality capable of achiev-
ing a 3D representation of the maxillofacial
region with minimal distortion, being suitable
Fig. 14.6 Dedicated software interface (Kodak Dental
Imaging software; Carestream Health Inc., Rochester, NY,
USA) showing CBCT multiplanar reconstructed images to
be used for educational purposes on root canal anatomy.
pilararaya@ejercer.cl
383
mostly for patient care, while micro-CT scans are
limited to ex vivo applications [12]. However,
within a laboratory setting, CBCT scans can also
be used for educational purposes on root canal
anatomy. In this condition, students can interact
with this 3D diagnostic tool and virtually explore,
with a dedicated software, different views of the
internal anatomy of all groups of teeth using
datasets from real patients (Fig. 14.6). Therefore,
besides the opportunity to learn different aspects
of root canal anatomy, this approach may aid stu-
dents to expand their visual perspective, usually
based on two-dimensional radiography, by using
three-dimensional multiplanar reconstructed
CBCT images.
Different from CBCT, micro-CT technology
is a more sophisticated system of assessment
Within a laboratory setting, students can virtually explore
different views of the internal anatomy of all groups of
teeth and learn various aspects of root canal anatomy,
expanding their visual perspective in three dimensions
384
since it uses high-energy X-rays, which are more
effective at penetrating dense materials, longer
exposure times, smaller X-ray focal spots, and
finer and more densely packed detectors than
conventional tomography. As a result, a signifi-
cant amount of information can be gleaned from
the scans, and slices can be recreated in any
plane; internal and external anatomy can be dem-
onstrated simultaneously or separately, while
data can be presented in 2D or 3D images or
high-resolution videos (Fig. 14.7); i.e., micro-CT
is a powerful tool for research and preclinical
education in fundamental procedures of end-
odontic treatments, as well as for clinicians and
researchers who desire to study dental anatomy
in great detail [12]. Recently, Kato and colleagues
[7] made available freely accessible portable
PDF-embedded 3D models of teeth based on
micro-CT data in which the reader could freely
manipulate the embedded model and activate a
a b
Fig. 14.7 Using micro-CT technology for educational
purposes, a significant amount of information can be
gleaned from the scans, and slices can be recreated in any
pilararaya@ejercer.cl
B. Basrani and M. A. Versiani
series of preset views either by directly accessing
a view in the dropdown menu of the main viewer
window or by opening the “model tree” icon and
switching from one view to the next. According
to the authors, embedded 3D models of teeth in
document format (PDF) files would constitute a
valuable tool for dental students.
14.4 Strategic Improvements
for Web-Based Teaching
of Root Canal Anatomy
Because data from micro-CT devices are digital,
they can be used to generate anatomical tooth
data on a large scale and made publicly accessi-
ble through the Internet, thus circumventing the
problems of individual researchers regarding
access to high-cost scanning devices [7, 19]. This
was the main motto for the creation of a web-­
c
plane; (a) external and (b) internal anatomy can be dem-
onstrated simultaneously or separately, while data can be
presented in (c) 2D or (a, b) 3D images
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth 385

based study guide by Dr. Versiani, Dr. S­ ousa-Neto
and Dr. Pécoraat Ribeirão Preto Dental School in
the University of São Paulo, Brazil, the so-called
Root Canal Anatomy Project (RCAP) (http://
rootcanalanatomy.blogspot.com). This website
has received extensive use since its development.
In its first year (2011–2012), there were 66,500
total hits. In its second year, the total number of
hits increased to 221,000. In the third year, there
were 370,000 hits. In June of 2018, the blog had
been visited by people from 192 different coun-
tries with more than 1,100,000 page views, the
videos were watched more than 150,000 times,
and the available material was downloaded more
than 15,000 times (Fig. 14.8). Considering that
root canal anatomy is a very specific subject in
the endodontic field, the website seems to be
achieving its goals.
The high-resolution images and videos avail-
able for download at the RCAP website can be
freely used for attributed noncommercial educa-
tional purposes by educators, scholars, students,
and clinicians since proper attribution and cita-
tion are included. Considering that nowadays stu-
dents are “digital natives” accustomed to using
web resources, this digital and interactive 3D
resource that can be assessed in any place may
increase motivation of the students to learn the
internal anatomy of teeth. Menu on the left side
allows users to select among several types of per-
manent and primary teeth including rare anatom-
ical variations. Besides, users can assess recent
scientific publications on the topic (including
images) and download editable presentations (in
PowerPoint format) with images and videos of
the most common anatomies in each group of
teeth (Fig. 14.9).
Videos from the RCAP were also developed
based on 3D models obtained from micro-CT
scans, i.e., from real teeth. In the videos, the com-
plexities of the root canal anatomy are high-
lighted through a transparent dentin, while each
tooth rotates around its own axes. Video-assisted
instruction in dentistry has been defined as an

Fig. 14.8 RCAP website statistics: visual representation of the flags from visitors of all 192 countries (available from
Flag Counter at http://s01.flagcounter.com/gmap/e9gS/)

pilararaya@ejercer.cl
386 B. Basrani and M. A. Versiani

Fig. 14.9 RCAP website: menu on the left side in which topic, editable presentations (in PowerPoint format) of the
visitors can download images and videos of several types most common anatomies in each group of teeth, and VXM
of permanent and primary teeth including rare anatomical files, among others
variations, as well as recent scientific publications on the

pilararaya@ejercer.cl
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth
educational tool that uses video images to com-
plement dental education in order to enhance the
technical skills and knowledge acquisition of
dental students [20]. This teaching modality is
student centered and improves students’ critical
self-appraisal. Its superiority over traditional
teaching has been reported in several studies [20,
21] and was attributed to the improved visualiza-
tion and more attention to details because of
­better observation. Some authors have suggested
it as a supplement to conventional demonstration
[20, 22] and mentioned its positive role in
enhancement of the clinical procedures [18, 20].
However, one of the most interesting resources
available to download at the RCAP includes
VXM files of all groups of teeth (Fig. 14.9). A
VXM file contains both the volume data and an
associated transfer function. This format can be
used in the free volume rendering app called
CTVox (Bruker microCT) that runs on either iOS
or Android systems. CTVox displays a set of
reconstructed slices as a realistic interactive 3D
object with intuitive navigation and manipulation
of both object and camera, a flexible clipping tool
to produce cutaway views, background selection
including custom scenery, and an interactive
a b
g h
Fig. 14.10 (a) Icon of CTVox free software for cell
phone and tablet; (b) initial screen; (c) lateral view of the
VXM file of a mandibular incisor; (d, e) changing color,
enlightening, and texture of the volume data by means of
transfer function; (g, h) lateral and upper view of the vol-
ume data (3D model); (i) clipping box was used to cut the
pilararaya@ejercer.cl
387
transfer function control to adjust colors and
transparency. In other words, using a cell phone
or tablet, it is possible to rotate, cut, color, create
movies, enlighten, shadow, and magnify areas of
interest and more, in real time, from real 3D data-
sets of different groups of teeth acquired by
micro-CT technology (Fig. 14.10).
In summary, this user-friendly free digital online
database of 3D tooth models named RCAP is highly
desirable for both research and teaching purposes
around the world and can be used to a better under-
standing of the variation in tooth morphology and
anatomy from different groups of teeth. Additionally,
it may be said that other disciplines in the life sci-
ences, in particular zoology and paleontology, have
begun building repositories primarily for noninva-
sively gathered 3D datasets [19, 23]. Although some
of these repositories are restricted to the presenta-
tion of derived image data such as videos or interac-
tive 3D models, as in the RCAP, several of them
permit deposition of 3D imaging datasets amount-
ing to hundreds of gigabytes or even dozens of
­terabytes of raw data [7]. Given the constant prog-
ress in data storage and archiving technology, it is
just a matter of time until even larger datasets of
human teeth become also available online.
c d e f
i j k l
3D model and expose the root canal system at the coronal
level; (j) lateral view of the volume data without the clip-
ping box; (k) apex view of the mandibular incisor; (l) clip-
ping box was used to cut the 3D model and expose the
root canal system at the apical level
388 B. Basrani and M. A. Versiani

14.5 Concluding Remarks Table 14.1 Summary of curriculum guidelines for root
canal anatomy

The intent of this chapter was to describe differ- Core

curriculum Cognitive
ent models to teach the internal anatomy of the outline skills Psychomotor skills
teeth in the distinct levels of the education cur- Dental Use Reproduce accurate
riculum in endodontics by incorporating clini- terminology appropriate morphological
cally applicable cognitive and psychomotor skills dental characteristics of
terminology permanent dentition
related to human tooth morphology (Tables 14.1
Detailed Describe the Reproduce accurate
and 14.2). Even though increasingly less time is morphology of detailed morphological
devoted to teaching the internal anatomy of teeth permanent morphology of characteristics of
in conventional curricula compared to the devel- dentition permanent inter-arch and
opment of technical skills, nowadays students dentition intra-arch tooth
relationships using
and clinicians may benefit with the sophistication appropriately
of the digital imaging technology. Innovative articulated casts
technologies have enabled significant changes to Detailed Describe the
curriculum delivery. As a result, students can morphology of detailed
primary morphology of
expand their scope of inquiry and have more con-
dentition primary
trol over pacing. Using digital resources to pro- dentition
vide didactic information not only provides Detailed study Describe the
students with unlimited access to instructional of pulp pulp
materials but also changes the role of the instruc- morphology of morphology of
each primary each primary
tor. Instead of lecturing, faculty members fulfill and permanent and permanent
the role of content expert by selecting learning tooth tooth
resources and guiding students during discus- Description of Describe the
sions and laboratory exercises. In addition, as frequent tooth common tooth
anomalies anomalies
facilitators of small-group discussions, instruc-
Adapted from Okeson and Buckman [24]
tors maintain a high level of contact with stu-

Table 14.2 Key components for the study of root canal anatomy
Pre-class preparation
Independent study
• Course manual
• 3D resources
• Assigned reading
• Slide presentation
• Completion of review
sheet with study questions
Resources
• PowerPoint presentations
• Reference literature
• 3D image resources
(transparent teeth; videos
and images from the
RCAP)
• Course manual
• Review sheet with study
questions
Adapted from Obrez et al. [1]
In-class activities
Focused review Small-group discussion
• Brief overview of • Facilitated discussion of
key points of lesson background and clinical
by module director rationale for the laboratory
• Short quiz procedure to follow
• Interactive question-and-­
answer activities
• Individual presentation of the
laboratory practice
Laboratory exercise
• Assessment of completed
review sheet
• Self-assessment and
completion of evaluation
sheet for previous
exercise
• 2D line drawings of
sectioned extracted teeth
and radiographs
• Analysis of 3D prototype
transparent replicas

pilararaya@ejercer.cl
14 Contemporary Strategies for Teaching Internal Anatomy of Teeth
dents, which allows them to monitor student
learning [1]. The rapid increase of noninvasive
and 3D imaging techniques used for the study of
internal tooth structures in recent years can
largely be attributed to the improvement of the
varieties of CT scanners with several applications
of such systems in endodontic research and
teaching. Due to their digital nature, the large
amount of data likely to be made accessible
online to researchers, practitioners, students, as
well as faculty provides a significant stimulus for
the exploration of tooth anatomy. Furthermore,
the data derived from noninvasive imaging tech-
niques freely available on the Internet can be
integrated into dental education and help students
to acquire an improved understanding of the
complex anatomy of the human tooth [7].
References
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 3D Visual Glossary of Terminology
in Root and Root Canal Anatomy
15
Marco A. Versiani, Jorge N. R. Martins,
and Bettina Basrani

Abstract 15.1 Introduction

The study of dental anatomy, physiology, and
occlusion provides one of the basic compo-
nents of the skills needed to practice all phases
of dentistry. The first step in understanding
dental anatomy is to learn the nomenclature
and terminology used to describe or classify
the material included in this subject. While
terminology is an established basis for com-
munication, anatomical terminology serves as
a base for the description of the human body,
not only for educational and forensic purposes
but, above all, for diagnostic and therapeutic
procedures. Therefore, definitions and expla-
nations of terms used in descriptive root and
root canal anatomy are the foundation for
understanding the subject matter presented in
the other chapters of this book. The purpose of
this chapter is to use 3D high-resolution
images to illustrate and define several termi-
nologies associated with root canal anatomy.
M. A. Versiani, D.D.S., M.Sc., Ph.D. (*)
Department of Restorative Dentistry, Dental School
of Ribeirão Preto, University of São Paulo,
São Paulo, Brazil
J. N. R. Martins, D.D.S., M.Sc.
Dental School of Lisbon, University of Lisbon,
Lisbon, Portugal
B. Basrani, D.D.S., M.Sc., Ph.D.
Endodontic Program, Faculty of Dentistry,
University of Toronto, Toronto, ON, Canada
The use of names and terms that identify some-
thing to be mentioned is so ancient as the origin
of human race. The need for communication
made our ancestors to create names to categorize
animals, plants, objects, or parts of them. After
centuries of evolution, several populations were
born, and others disappeared entirely; conse-
quently, different idioms were developed, and
new names adopted. At a certain point, language
was so complex that became mandatory to create
a “collection of words” in one or more specific
languages, often arranged alphabetically, that
provides a core glossary of the simplest meanings
of the simplest concepts.
In any human activity, it is required the adop-
tion of specific vocabularies to address knowl-
edges, techniques, instruments, and materials. In
science, simple, stable, and internationally
accepted systems for naming objects are manda-
tory, and to overcome the variations over time in
languages’ phonology, morphology, semantic,
syntactic, and other features, a system of names
or terms, or the rules for forming these terms,
were adopted in Latin language, a death idiom,
which is usually referred as nomenclatura or
nomenclature codes. Anatomy is a branch of nat-
ural science dealing with the structural organiza-
tion of living things, and considering that some
recommendations that regulate the use of terms
in other science branches may not be applicable,

© Springer International Publishing AG, part of Springer Nature 2019 391

M. A. Versiani et al. (eds.), The Root Canal Anatomy in Permanent Dentition,
https://doi.org/10.1007/978-3-319-73444-6_15

pilararaya@ejercer.cl
392
the word “terminology” has been also used. From
the systematic point of view, anatomy uses a spe-
cial vocabulary, but unlike many others, the ana-
tomical terminology and nomenclature are
distinguished very strictly. Terminology is under-
stood as a system of terms used in a given scien-
tific field, whereas nomenclature, covering the
terms created within the scope of terminology, is
a normalized system of exactly defined terms
arranged according to certain classification prin-
ciples, which is official in the Latin version
only [1].
Endodontics has adopted names for root and
root canal anatomy following the nomenclature
concept, such as radix paramolaris or dens evag-
inatus, but mostly, specific terminologies includ-
ing apex, accessory canal, pulp chamber, and so
on. Some terms might even fit in both concepts.
Consequently, one of the greatest problems on
this field is indeed the multiplicity of names
given to the same anatomy. Dens invaginatus, for
example, has been defined as a developmental
defect resulting from infolding of the crown
before calcification has occurred [2]. In the litera-
ture, however, it has been termed as dens in dente,
dilated composite odontome, dilated odontome,
gestant anomaly, invaginated odontome, dilated
gestant odontome, tooth inclusion, dentoid in
dente, and dens Saltersi [3, 4].
Anatomical terminology serves as a base for
the description of the human body, not only for
educational and forensic purposes but above all
for diagnostic and therapeutic procedures. As
clinical anatomy is the up-to-date field of meet-
ing between anatomists and clinicians, the same
language is strongly required for permitting cur-
rent exchanges, common works, and studies.
Although its recognized importance, the stan-
dardization of endodontic terminology remains a
difficult task because of the high volume of pub-
lications in specialized and general dental jour-
nals in different languages. Trying to organize
many terms used daily by dentists and their staff
in the course of delivering care to patients, the
American Dental Association has developed an
online Glossary of Dental Clinical and
Administrative Terms [5]. More specifically
related to the endodontic field, the American
pilararaya@ejercer.cl
M. A. Versiani et al.
Association of Endodontists has regularly
updated its Glossary of Endodontic Terms [2].
Considering that literature lacks from a specific
glossary of anatomical terms on root and root
canal anatomy, the purpose of this chapter is to
use 3D high-resolution images to illustrate and
define several terminologies associated with this
topic.
15.2 Terminology in Root
and Root Canal Anatomy
1. Accessory Canal—Accessory canals are
any branch of the main pulp canal that com-
municates with the external surface of the
root [2]. Accessory canals include lateral
canals and apical ramifications [6]
(Figs. 15.1, 15.2, and 15.3).
2. Accessory Foramen (Auxiliary
Foramen)—Refers to an orifice on the sur-
face of a root communicating with a lateral
or accessory canal [2] or with an apical delta
[7] (Figs. 15.1, 15.2, 15.3, and 15.4).
3. Alveolar Bone—Bone structure that sup-
ports the teeth. It consists of the buccal and
oral cortical bone, the alveolar wall, and
septa that comprises the tooth socket into
which the roots of the tooth fit and is sup-
ported by the trabecular bone interposed
between alveolar wall and cortical plates [8]
(Figs. 15.5 and 15.6).
4. Anatomic Apex (Apex)—Refers to the tip
or end of the root as determined morphologi-
cally [2] (Figs. 15.2, 15.3, 15.4, and 15.7).
5. Apical Constriction (Physiological
Foramen, Minor Apical Diameter, Minor
Diameter)—The apical portion of the root
canal having the narrowest diameter. It is
generally located 0.5–1.5 mm from the cen-
ter of the apical foramen [2] and has been
recommended as the ideal apical limit for
root canal preparation and filling [9]. Its
shape in longitudinal sections has four pos-
sible configurations: single (48%), tapered,
multi-constricted, or parallel [10] (Fig. 15.2).
6. Apical Foramen (Foramen, Major Apical
Foramen, Main Foramen, pl. Foramina)—
15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 393

Fig. 15.1 Anatomical

landmarks of root and
root canals

1. Apical ramification
2. Root canal
3. Accessory foramen
4. Accessory canal
5. Apical foramen
6. Furcation canal
7. Bifurcation
8. Pulp chamber
9. Pulp chamber roof
10. Pulp chamber floor
11. Pulp horn
12. Crown

Represents the main apical opening of the
root canal, the main exit of the root canal
onto the external root surface [5, 7]. A natu-
ral opening or passage, especially into or
through a bone, also describes openings in
the root structure that communicate with the
dental pulp and generally contain neural,
vascular, and connective elements [2, 11].
Although the major apical foramen and the
anatomic root apex are anatomically close,
they rarely coincide [12], and their distance
can vary according to age or tooth type,
ranging from 0.2 to 3.0 mm [10, 13]. Major
apical foramen mismatched the root apex in
41.6% and 49.4% [14]. It may be round, oval
or elliptical, and semilunar in shape. Location
and shape of the fully formed foramen vary
in each tooth and in the same tooth at differ-
ent periods of life [13] (Figs. 15.1 and 15.3).
7. Apical Ramification (Apical Delta, Delta
System)—Refers to the branching of the
main canal into multiple accessory canals at

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394 M. A. Versiani et al.

Fig. 15.2 Anatomical 1. Anatomic apex

landmarks of root and 2. Apical constriction
3. Major apical foramen
root canals at the apical 4. Dental pulp
region (Courtesy of Dr. 5. Cementum
Francisco Balandrano) 6. Cementodentinal junction
7. Dentin
8. Accessory foramen
9. Accessory canal

Fig. 15.3 Anatomical 1. Anatomic apex

2. Apical ramification
landmarks of root and 3. Root canal system
root canals in a 4. Root canal
5. Pulp chamber floor
maxillary first molar 6. Pulp chamber
(Courtesy of Dr. Holm 7. Pulp chamber roof
Reuver) 8. Pulp horn
9. Root
10. Crown
11. Accessory canal
12. Acessory foramen
13. Apical foramen

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy
Fig. 15.4 Anatomical landmarks of teeth with enamel pearls
or near the apex [2]. Complex root canal sys-
tem in the apical third characterized by an
intricate network of ramifications [15]. A
complex ramification of branches of the pulp
canal located near the anatomical apex with
a main canal not being discernible [7]. Apical
end of root showing one main canal and an
adjacent delta system [16] (Figs. 15.1 and
15.3).
8. Blunderbuss Canal—Old terminology
denoting an incompletely formed root in
which the apical diameter of the pulp canal is
greater than the coronal diameter [2]. A tooth
with blunderbuss canal and open apex can be
an endodontic challenge because of diffi-
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395
1. Enamel pearl (in white)
2. Root canal system (in red)
3. Dentin
4. Enamel projection
5. Root
6. Enamel / crown
7. Accessory foramen
8. Anatomical apex
9. Trifurcation
8
8
7
5 5
9
culty in obtaining an apical seal and existing
thin radicular walls which are susceptible to
fracture [17] (Fig. 15.8).
9. Canal Shape—Refers to the horizontal
dimension (original width, cross-sectional
canal configuration) of the root canal in both
mesiodistal and buccolingual directions, i.e.,
the ratio between the minimal and maximal
horizontal dimensions of the root canal.
Canal shape has been classified as round,
oval, long oval, flattened, or irregular [18].
Traditionally, canal shape has been acquired
from radiographic images or sectioned roots;
using micro-CT, the cross-sectional appear-
ance, round- or more ribbon-shaped, may be
396 M. A. Versiani et al.

Maxillary teeth
(From human cadavers)
1. Enamel
2. Dentin
3. Dentinoenamel junction
4. Pericervical dentin
5. Periodontal ligament (space)
6. Calcification
7. Alveolar bone (cortical)
8. Alveolar bone (trabecular)
9. Lamina dura
10. Cementum
11. Cementoenamel junction

Fig. 15.5 Micro-CT images of bone blocks acquired from human cadavers showing anatomical landmarks of bone,
root, and root canals of maxillary premolars and molars (Courtesy of Dr. Gustavo De-Deus)

expressed as “roundness” and “form factor”
parameters [19], based on the major and
minor diameters of the root canal. The major
diameter is defined as the distance between
the two most distant pixels in that object,
while the minor diameter is the longest chord
through the object that can be drawn in the
direction orthogonal to that of the major
diameter. Roundness of a discreet two-­
dimensional object is defined as 4A/
(π × [dmax]2), where “A” is the area and “dmax”
is the major diameter. The value of round-
ness ranges from 0 to 1, with 1 signifying a
circle. The form factor is calculated by the
equation (4 × π × A)/P2, where “A” and “P”
are object area and perimeter, respectively.
Elongation of individual objects results in
smaller values of form factor [19] (Figs. 15.9
and 15.10).
(a) C-Shaped Canal—The main anatomical
feature of C-shaped canals is the presence
of a fin or web connecting the individual
root canals. The orifice may appear as a
single ribbon-shaped opening with a 180°

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 397

Fig. 15.6 Micro-CT Maxillary molar teeth

images of 2 bone blocks (From a human cadaver)
acquired from a human 1. Mesiobuccal canal 1
cadavers showing 2. Mesiobuccal canal 2 (MB2)
anatomical landmarks of 3. Distobuccal canal
bone, root, and root 4. Palatal canal
canals of maxillary 5. Periodontal ligament (space)
molars (Courtesy of 6. Alveolar bone (cortical)
Dr. Gustavo De-Deus) 7. Alveolar bone (trabecular)
8. Lamina dura
9. Maxillary sinus
10. Maxillary second molar
11. Maxillary first molar

Fig. 15.7 Anatomical 1

landmarks of root and 1
root canal of a two-­
rooted canine (left) and 1
a maxillary first molar 11
(right) 1. Anatomic apex
10 2. Root canal
3. MB2 canal
13 10 4. MB1 canal
5. Lateral canal
6. Furcation canal
7. Pulp chamber floor
8. Pulp chamber
9. Pulp horn
10. Root
2 6 11. Crown
5 2 12. Bifurcation
13. Trifurcation
12
10
10
11

1
1

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398
Fig. 15.8 Morphological
aspects of maxillary lateral
incisors with radicular
grooves
1
arc linking the two main canals [20].
Typically, this canal configuration is
found in teeth with fusion of roots either
on its buccal or lingual aspect [20, 21]. In
such teeth, the floor of the pulp chamber
is usually located deeply and may assume
an unusual anatomical appearance [20].
Melton et al. [21] divided this morphol-
ogy into three categories: I (the continu-
ous C-shaped canal), any C canal outline
without any separation; II (the “semico-
lon” canal shape), canal configuration in
which dentin separated one distinct canal
from a buccal or lingual C-shaped canal
in the same section; and III, two or more
discrete and separate canals. This varia-
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M. A. Versiani et al.
1. Buccal and palatal grooves
2. Blunderbuss canals
1
2 2 2
tion may occur in mandibular first molars,
maxillary molars, mandibular first pre-
molars, and even in maxillary lateral inci-
sors, but it is most commonly found in
mandibular second molars [22]. The
prevalence of C-shaped anatomy varies
according to the population [23]
(Figs. 15.9 and 15.11).
(b) Flattened Canal (Flattened, Flat,
Ribbon, Flat-Oval)—Refers to the hori-
zontal dimensions of the root canal,
when its maximum cross-sectional diam-
eter is four or more times greater than its
minimum diameter [18, 24] (Fig. 15.10).
(c) Irregular-Shaped Canal—Refers to
the horizontal dimensions of the root
15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 399

1
1 1 1

1. Radicular grooves
2. C-shaped canal
3. Root cross-sections
4. Dentin
5. Crown (enamel)
6. Root
7. Root canal system
8. Furcation foramen
1 1 1 1

Fig. 15.9 Anatomical landmarks of root and root canals of mandibular premolars with radicular grooves

canal, when its cross-sectional shape is (f) Round-Shaped Canal—Refers to the

not possible to be classified as round-,
oval-, long oval-, or flat-shaped [18]
(Fig. 15.10).
(d) Long Oval-Shaped Canal—Refers to
the horizontal dimensions of the root
canal, when its maximum cross-­sectional
diameter is two to four times greater
than its minimum diameter [18, 24]
(Fig. 15.10).
(e) Oval-Shaped Canal—Refers to the hor-
izontal dimensions of the root canal,
when its maximum cross-sectional diam-
eter is up to two times greater than its
minimum diameter [18, 24] (Fig. 15.10).
horizontal dimensions of the root canal,
when its maximum cross-sectional
diameter is equal to its minimum diam-
eter [18] (Fig. 15.10).
(g) S-Shaped Canal—Double-curved root
canal [25, 26] (Fig. 15.10).
10. Calcification—Accumulation of calcium
salts in a body tissue. Calcification of pulp
tissue is a very common occurrence, but its
cause is largely unknown. Although esti-
mates of the incidence of this phenomenon
vary widely, it is safe to say that one or more
pulp calcifications are present in at least 50%
of all teeth. There is no unambiguous

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400
Fig. 15.10 Root canal shape of different teeth classified by the conventional and micro-CT methods
evidence whether pulp calcification is a
pathologic process related to various forms
of injury or a natural phenomenon. The clini-
cal significance of pulp calcification is that it
may hinder root canal treatment [27]
(Fig. 15.5).
(a) Metamorphosis (Pulp Canal
Obliteration, Dystrophic Calcification,
Diffuse Calcification, Calcific
Degeneration)—A pulpal response to
trauma characterized by rapid deposition
of hard tissue within the canal space;
entire space may appear obliterated
radiographically due to extensive depo-
sition, even though some portion of the
pulp space remains in histological
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M. A. Versiani et al.
Root canal shape
(Conventional method)
1. Flattened canal
2. Irregular-shaped canal
3. Long oval-shaped canal
4. Oval-shaped canal
5. Round-shaped canal
6. S-shaped canal
Root canal shape
(Micro-ct method)
Roundness parameter values in different
levels of the root canal of a mandibular
incisor calculated throughout
the root and plot in a graphic
sections [2]. Calcific metamorphosis is a
commonly observed phenomenon fol-
lowing traumatic injuries like concus-
sion, subluxation, and luxation.
Depending on the severity of the injury
and the developmental stage of the tooth,
there can be either complete or partial
obliteration of root canals. However, his-
tologically, there is always persistence
of fine residual filaments of pulp tissue
or tracts of organic material without the
presence of any inflammatory compo-
nent [28]. It can induce a yellow discol-
oration of tooth’s crown [29].
(b) Dystrophic Calcification—Diffuse foci
of calcification frequently found in the
15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 401

Fig. 15.11 Mandibular

second molars with
C-shaped canals

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402
aging pulp; usually described as being
perivascular or perineural [2]. Dystrophic
calcification is a response of the dental
pulp to traumatic injury wherein the pulp
produces reparative dentin which can
eventually obliterate the entire pulp
chamber and root canal. Affected teeth
often have an opaque, non-translucent
appearance to the crown [30].
(c) Pulp Stone (Denticle)—A calcified
mass occurring within the pulp or
attached to pulp space walls; classified
as true or false denticles, according to
composition and morphology, and free,
adherent, or interstitial denticles, accord-
ing to their location in relation to the
pulp space walls [2]. Pulp stones might
be present in the dental pulp of healthy,
diseased, or unerupted teeth [31, 32].
Stones may exist freely within the pulp
or attached to the dentin [33]. Pulp
stones range in size from small micro-
scopic particles to large masses that
almost obliterate the pulp chamber space
[31, 32]. They are reported to occur
more often in the coronal region but are
also found in the root canal space [31,
32].
11. Cementodentinal Junction (CDJ,
Dentinocemental Junction)—The region at
which the dentin and cementum are united;
commonly used to denote the point at which
the cemental surface terminates at or near the
apex of a tooth; position can range from 0.5
to 3.0 mm from the anatomic apex [2]. The
terminal apical area of the cementum where
it joins the internal root-canal dentin. From
this point to the anatomic apex, the tissue in
the canal is periodontal. The point of union
between cementum and dentin is variable on
different canal walls in different regions of
the apex [34]. It is a histological landmark,
and its location is generally not the same
area as the apical constriction and estimate
place it approximately 1 mm from the apical
foramen [35] (Fig. 15.2).
12. Cementoenamel Junction (CEJ, Cervical
Line, Amelocemental Junction)—
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M. A. Versiani et al.
Cementoenamel junction represents the ana-
tomic limit between the crown and root
surface [36]. The region at which the enamel
and cementum meet in the cervical region of
the tooth; cementum may overlap the enamel,
cementum and enamel may meet abruptly,
or a gap may exist [2]. During tooth
­development, the enamel deposition does not
cease simultaneously along the entire tooth
circumference, which gives rise to an irregu-
lar contour and varying interrelationships
among the tissues that compose the cemen-
toenamel junction. Consequently, the rela-
tionship between cementum and enamel
varies [36] (Fig. 15.5).
13. Cementum — Cementum covers the ana-
tomic roots of teeth from the cementoenamel
junction continuing to the apex [34]. A min-
eralized tissue covering the roots of teeth
that provides a medium for the attachment of
the periodontal fibers that connect the tooth
to the alveolar bone and gingival tissues; it is
composed of approximately 45–50% inor-
ganic substances and 50–55% organic mate-
rial and water [2]. On the basis of the absence
or presence of cells in the mineralized
cementum matrix, two types of cementum
are recognized: acellular (covering the coro-
nal two-third of the root) and cellular (cover-
ing the apical third) [34] (Figs. 15.2 and
15.5).
14. Cracked Tooth—A thin surface disruption
of enamel and dentin, and possibly cemen-
tum, of unknown depth or extension [2].
Cracks may initiate from coronal tooth struc-
ture or from within the root and affect healthy
or root-treated teeth [37]. Many morphologic,
physical, and iatrogenic factors, such as deep
grooves, pronounced intraoral ­ temperature
fluctuation, poor cavity preparation design,
and wrong selection of restorative materials,
may predispose teeth to fracture [38].
Clinically, cracked teeth have been classified
into five categories: craze line, fractured
cusp, cracked tooth, split tooth, and vertical
root fracture [39] (Fig. 15.12).
15. Crown—Refers to the anatomical portion of
the tooth that is covered by enamel and
15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 403

Fig. 15.12 Cracked mandibular molar

becomes visible in the mouth after the tooth
eruption. The tissues that constitute the
crown are the enamel, dentin, and pulp [11]
(Figs. 15.1, 15.3, 15.7, 15.9).
16. Dens Evaginatus (Evaginated Odontome,
Tuberculated Cusps)—An anomalous out-
growth of tooth structure resulting from the
folding of the inner enamel epithelium into
the stellate reticulum with the projection of
structure exhibiting enamel, dentin, and
pulp tissue [2]. Dens evaginatus is charac-
terized as a pyramidal, conical, or teat-like
enamel tubercle extending from the affected
surface of the involved tooth. In premolars
and molars, it extends from the occlusal sur-
face, in canines and incisors; it usually arises
from the cingulum area of the lingual or
palatal surface. Histologic studies indicate
that the dens evaginatus has a dentinal core
covered by enamel and a slender pulp horn
that may extend into the tubercle [40, 41]
(Fig. 15.13).

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404
Fig. 15.13 Clinical view and radiographic image of a mandibular second premolar with dens evaginatus (arrow)
(Courtesy of Dr. Daniela Bololoi)
17. Dens Invaginatus (Dens In Dente, Dilated
Composite Odontome, Dilated Odontome,
Gestant Anomaly, Invaginated Odontome,
Dilated Gestantodontome, Tooth
Inclusion, Dentoid In Dente, Dens
Saltersi)—A developmental defect resulting
from infolding of the crown before calcifica-
tion has occurred; may appear clinically as
an accentuation of the lingual pit in anterior
teeth; in its more severe form, gives a radio-
graphic appearance of a tooth within a tooth,
hence the term dens in dente [2].
Developmental malformation resulting from
an invagination of enamel organ into the den-
tal papilla, beginning at the crown and some-
times extending into the root before
calcification occurs [42]. Deep folding of the
foramen coecum during tooth development
which in some cases even may result in a
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M. A. Versiani et al.
second apical foramen [43]. Developmental
anomaly resulting in a deepening or invagi-
nation of the enamel organ into the dental
papilla prior to calcification of the dental tis-
sues [4]. The permanent maxillary lateral
incisor appears to be the most frequently
affected tooth [4]. The most commonly used
classification was proposed by Oehlers [42]
into three types: Type I, an enamel-lined
minor form occurring within the confines of
the crown not extending beyond the amelo-
cemental junction; Type II, an enamel-lined
form which invades the root but remains
confined as a blind sac. It may or may not
communicate with the dental pulp; Type III,
a form which penetrates through the root
perforating at the apical area showing a “sec-
ond foramen” in the apical or in the peri-
odontal area. There is no immediate
15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 405

communication with the pulp. The invagina-
tion may be completely lined by enamel, but
frequently cementum can be found lining the
invagination (Figs. 15.14, 15.15, and 15.16).
18. Dental Pulp (Pulp, Pulp Tissue)—A richly
vascularized and innervated specialized con-
nective tissue of ectomesenchymal origin
with specialized cells, the odontoblasts,
arranged peripherally in direct contact with
dentin matrix. The close relationship
between odontoblasts and dentin, sometimes
referred to as the dentin-pulp complex, is one
of several reasons dentin and pulp should be
considered as a functional entity made up of
histologically distinct elements [27]; it is
contained in the central space of a tooth, sur-
rounded by the dentin, with inductive, for-
mative, nutritive, sensory, and protective
functions [2, 44] (Fig. 15.2).
19. Dentin—A mineralized tissue that forms the
bulk of the crown and root of the tooth,
giving the root its characteristic form. It
­ tions. Therefore, in the sectioned surface,
s­ urrounds coronal and radicular pulp, form-
ing the walls of the pulp chamber and root
canals, and it is composed of approximately
67 percent inorganic, 20 percent organic, and
13 percent water. The inorganic material is
formed by hydroxyapatite crystals, while the
organic matrix consists mainly of collagen
[45]. Dentin may be divided in three types:
primary, secondary, and tertiary (reparative
or reactionary) dentin [45] (Figs. 15.2, 15.4,
15.5, 15.9, and 15.17).
20. Dentinoenamel Junction (DEJ)—The
dentinoenamel junction area is represented
by a region 2 μm thick, into which dentin
and enamel fibrils penetrate, forming a
mixed area. When calcification begins, inti-
mate contact of enamel and dentin crystals
occurs in this area resulting in a strong bond
between these two layers [46]. The interface
between the enamel and dentin is composed
of closely arranged dome-shaped excava-

Lingual view Buccal view

1

1
2
3
4
5
6
7

2 3 4
Occlusal view

5 6 7

Fig. 15.14 Morphological aspects of a dens invaginatus mandibular molar

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406 M. A. Versiani et al.

a
b

c d

e f

g i

Fig. 15.15 Clinical view, CBCT (axial, coronal, and sagittal), and radiographic images of dens invaginatus Types III
(a–f) and II (g–i) in maxillary lateral incisors (yellow arrows), depicting the presence of foramen coecum (black arrows)

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 407

Fig. 15.16 Clinical view and CBCT (axial, coronal, and sagittal) images of a dens invaginatus Type III in a maxillary
canine highlighting the presence of the foramen coecum (black arrows) (Courtesy of Dr. Oscar von Stetten)

the dentinoenamel junction complex shows
a scalloped appearance with convexities
directed toward the dentin and concavities
directed toward the enamel. The irregular
interface is c­ onsidered to play an important
role in interlocking the two tissues [47]
(Fig. 15.5).
21. Developmental Root Fusion Lines—Refers
to a pulp chamber darker zone, constituted
by subpulpal grooves or developmental
grooves on the pulpal floor, surrounds the
entrances of the root canals, and once identi-
fied can be used clinically as an indication of
where to locate canal orifices [48, 49]
(Fig. 15.17).
22. Dilaceration—A deformity characterized
by displacement of the root of a tooth from
its normal alignment with the crown; may be
a consequence of injury during tooth devel-
opment. Common usage has extended the
term to include sharply angular or deformed
roots [2]. Dilaceration is the result of a devel-
opmental anomaly in which there is an
abrupt change in the axial inclination
between the crown and the root of the tooth
[50, 51]. According to some authors [50, 52],
a tooth is considered to have a dilaceration
toward the mesial or distal direction if there
is a 90° angle or greater along the axis of the
tooth or root with a small radius, whereas
others [50, 53] define dilaceration as a devia-
tion of 20° or more of the apical part of the
root from the long axis of the tooth
(Fig. 15.18).

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408
1. Developmental root fusion lines
2. Floor-wall junction
3. Orifice
4 Pulp chamber floor
5. Dentin
Fig. 15.17 Anatomical landmarks of the pulp chamber of maxillary and mandibular molars
23. Enamel—A mineralized tissue that forms a
protective covering of variable thickness
over the entire surface of the crown of the
tooth. It develops from the enamel organ
(ectoderm) and is a product of a specialized
type of epithelial cell called ameloblasts
[54]. Enamel is the hardest tissue in the
human body and provides a resistant cover-
ing suitable for mastication. Its composition
is approximately 96% inorganic and 4%
organic substance and water [2] (Figs. 15.4
and 15.5).
24. Enamel Pearl—A focal mass of enamel
located apical to the cementoenamel junc-
tion [2]. The enamel pearl is an ectopic glob-
ule of enamel that is firmly adherent to the
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M. A. Versiani et al.
tooth root. It varies in size and ranges
between 0.3 mm and 4.0 mm in diameter
[55]. Structurally, the enamel pearl is not
always composed of enamel only. Three
types have been described: (1) the true
enamel pearl, which consists entirely of
enamel; (2) the composite enamel pearl
(enamel-dentin pearl), which contains a core
of tubular dentin; and (3) the enamel-dentin-­
pulp pearl, which contains a pulp horn [56]
(Figs. 15.4 and 15.19).
25. Enamel Projection—An apical extension of
enamel usually toward a molar furcation [2]
(Fig. 15.4).
26. Floor-Wall Junction—Refers to the contig-
uous union between the pulp chamber floor
15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 409

Fig. 15.18 Teeth with dilacerated roots

and pulp chamber walls. This union is not a
defined line or edge and is closer to a rounded
angle [49] (Fig. 15.17).
27. Foramen Coecum—Natural coronal open-
ing from the invaginated tissues lumen to the
oral environment in a dens invaginatus tooth.
The foramen coecum is the location where
the dens invaginatus deep folds, during tooth
development, which in some cases even may
result in a second apical foramen [4, 43]
(Figs. 15.15 and 15.16).
28. Furcation (Furca)—The anatomic area of a
multi-rooted tooth where the roots diverge
[2]. The part of the root complex that is
located between separate root structures [57]
(Figs. 15.1, 15.4, and 15.7).
(a) Bifurcation—The anatomic area where
the roots of a two-rooted tooth divide [2]
(Figs. 15.1 and 15.7).
(b) Trifurcation—The area where a tooth
divides into three distinct roots [2]
(Figs. 15.4 and 15.7).
29. Furcation Canal—An accessory canal located
in the furcation [2]. Furcation canals are formed
during tooth development as a result of entrap-
ment of periodontal vessels during the fusion of
the diaphragm which becomes the floor of the
pulp chamber [58] (Figs. 15.1, 15.7, and 15.9).

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410 M. A. Versiani et al.

Fig. 15.19 3D (above) and cross-sectional (below) morphological aspects of four-rooted maxillary molars. MB mesio-
buccal root, DB distobuccal root, RDL radix distolingualis, RML radix mesiolingualis

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 411

Fig. 15.20 Different views of a fusion affecting two maxillary molars

30. Fusion—A “double” tooth resulting from
the union of two adjacent tooth germs [2].
Fusion is commonly identified as the union
of two distinct dental sprouts which occurs
in any stage of the dental organ develop-
ment. They are joined by the dentine; pulp
chambers and canals may be linked or sepa-
rated depending on the developmental stage
when the union occurs. This process involves
epithelial and mesenchymal germ layers
resulting in irregular tooth morphology [59].
Involvement of permanent dentition is very
rare, with the majority of cases seen in ante-
rior teeth [59, 60] (Figs. 15.20 and 15.21).
31. Gemination—A disturbance during odonto-
genesis in which partial cleavage of the tooth
germ occurs and results in a tooth that has a
double or “twin” crown, usually not com-
pletely separated, and sharing a common
root and pulp space [2]. It may be defined as
the formation of two crowns from a single
tooth [61], and results from a developmental
anomaly of the ectoderm and the mesoderm.
The teeth germ divides giving origin to a
“two teeth,” with two crowns or one large
partially separated crown that can share a
pulp chamber and root canal. This condition
affected mostly the permanent maxillary
incisors [59] (Fig. 15.21).
32. Hypercementosis (Cementum
Hyperplasia)—Refers to an excessive depo-
sition of non-neoplastic cementum over nor-
mal root cementum, which alters root
morphology macroscopically appearance [2,
62, 63]. This cementum may be either hypo-
cellular or cellular in nature. The pathogen-
esis of hypercementosis is ambiguous.
Although most of the cases are idiopathic,
several local and ­systemic factors are also
linked to this condition, such as Paget’s dis-
ease, acromegaly, or vitamin A deficiency [2,
63] (Fig. 15.22).
33. Isthmus (Anastomosis, Transverse
Anastomosis)—A thin communication
between two or more canals in the same root
or between vascular elements in tissues [2].
An isthmus is a narrow, ribbon-shaped, com-
munication between two root canals that
contains pulp or pulpal-derived tissue. It is
also known as a corridor, a lateral intercon-
nection, or a transverse anastomosis. Any
root that contains two root canals has the

pilararaya@ejercer.cl
412 M. A. Versiani et al.

a c

d e

f g

Fig. 15.21 (a–e) Gemination of maxillary incisors; (f–g) gemination and fusion in maxillary incisors (Courtesy of Dr.
Antonis Chaniotis)

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy
34. Lamina Dura (Alveolar Bony Socket,
Fig. 15.22 Coronal, sagittal, and transaxial CBCT images
from a distal root of a mandibular first molar presenting
hypercementosis (arrow) (Courtesy of Dr. Oscar von Stetten)
pilararaya@ejercer.cl
413
potential to contain an isthmus [64, 65].
Studies in posterior teeth have shown the
presence of necrotic pulp tissue and biofilms
after shaping and cleaning procedures indi-
cating that conventional disinfection meth-
ods have limited results in these areas [66,
67]. Isthmuses may present different config-
urations, and its prevalence is dependent on
the type of teeth, the root level, and the
patient’s age. Hsu and Kim [68] classified
isthmuses configuration into five types: Type
I, two canals with no notable communica-
tion; Type II, a hair-thin connection between
the two main canals; Type III, differs from
type II because of the presence of three
canals instead of two; Type IV, an isthmus
with extended canals into the connection;
and Type V, there is a true connection or
wide corridor of tissue between two main
canals. On the other hand, Fan et al. [69]
using micro-CT technology, described its
configuration into four categories: Type I
(sheet connection), narrow sheet and com-
plete connection existing between two canals
from the top to bottom of the isthmus.
Sometimes, one or more small dentin fusions
were discerned in the isthmus area; Type II
(separate), narrow but incomplete connec-
tion existing between two canals from the
top to bottom of the isthmus; Type III
(mixed), incomplete isthmus existing above
and/or below a complete isthmus; and Type
IV (cannular connection), narrow cannular
communication between two canals
(Fig. 15.23).
Cribriform Plate of the Alveolar Process,
Alveolar Bone Proper, True Alveolar
Bone)—It is the much thinner, compact bony
layer that lines the wall of each tooth socket
(or alveolus). The only space between the
outer layer of tooth root (which is covered by
cementum), and this alveolar bone is occu-
pied by a periodontal ligament (between 0.12
and 0.33 mm thick) that suspends each tooth
within its alveolus by attaching the circum-
ference of each tooth root to the surrounding
lamina dura [54] (Figs. 15.5 and 15.6).
414 M. A. Versiani et al.

Mandibular
Molar

Mesial

Mesial

Mesial
Distal

Distal

Distal
1 2 3

Mesial

Mesial

Mesial
Distal

Distal

Distal
1 2 3

3
Mesial

Mesial

Mesial
Distal

Distal

Distal

1 2 3
1

Fig. 15.23 Morphological aspects of mandibular molars with isthmus (white arrows) in the mesial root

35. Lateral Canals—Accessory canals located
in the coronal or middle third of the root,
usually extending horizontally from the main
canal [2]. A branch diverging at almost right
angle from a main canal [7] (Fig. 15.7).
36. Major Apical Diameter—The area of the api-
cal foramen where the walls are farthest apart;
usually located in the cementum [2] (Fig. 15.2).
37. MB2—It is a second canal in the mesiobuc-
cal root of maxillary molars. Its occurrence

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy
in maxillary first molars has been reported to
range from 25% to 96%, and a pooled data of
21 studies gave an overall prevalence of 60%
[70]. However, considering only well-­
designed histological and micro-CT studies,
a prevalence of more than 90% MB2 canals
in the first and more than 55% MB2 canals in
the second maxillary molars were found 41.
(Figs. 15.6 and 15.7).
38. Middle Mesial Canal (Intermediate
Canal, Mesio-central Canal, Third Mesial
Canal, Accessory Mesial Canal)—It is an
additional canal positioned between the
mesiobuccal and the mesiolingual canals in
the mesial root of mandibular molars. In the 42.
literature, this anatomical variation has been
found in a percentage frequency ranging
from 0.26% to 46.15%, depending on the
population [71]. It has been classified into
three types: independent, three independent
canals extend from the pulp chamber to the
apex; fin, in the coronal third, orifice of mid-
dle mesial canal is connect to the mesiobuc- 43.
cal and/or mesiolingual canal orifice(s) by a
groove, but the mesial canals leave the root
in three separate foramina; or confluent,
middle mesial canal leaves the pulp cham-
ber, separately or not to the other mesial
canals, and joins the mesiobuccal and/or
mesiolingual by transverse anastomosis,
intercanal connections, or isthmus during its
trajectory to the apical foramen [72]
(Fig. 15.24).
39. Orifice (Root Canal Orifice, Root Canal
Opening)—The opening leading from the
pulp chamber into a root canal, especially in
a tooth with multiple canals [2] (Fig. 15.17).
40. Palatal Groove (Palatogingival Groove,
Palatal Radicular Groove, Radicular
Lingual Groove, Developmental Radicular
Anomaly, Cinguloradicular Distolingual
Groove, Vertical Developmental
Groove)—A developmental groove in a root
that, when present, is usually found on the
palatal aspect of maxillary incisor teeth [2].
It is defined as an anatomic malformation of
developmental origin usually found on the
lingual aspect of the root of maxillary incisor
pilararaya@ejercer.cl
415
teeth. Such grooves usually start near the
cingulum of the incisor and run apically
down the cementoenamel junction, terminat-
ing at various depths along the root [73]. The
incidence of the palatal groove ranges from
2.8% to 18%, depending of the studied popu-
lation [74] (Fig. 15.8).
Pericervical Dentin—The dentin near the
alveolar crest, roughly 4 mm coronal to the
crestal bone and extending 4 mm apical to
the crestal bone. It has been quoted that the
resistance to fracture is closely related to the
amount of residual tooth structure at this
level [75] (Fig. 15.5).
Periodontal Ligament—The periodontal
ligament consists of a dense and unmineral-
ized connective tissue located between the
cementum and the alveolar bone. It is char-
acterized primarily by a large number of col-
lagen fibers that traverse obliquely from the
cementum to the alveolar bone [76]
(Figs. 15.5 and 15.6).
Pulp Chamber—The portion of the pulp
space within the anatomic crown of the tooth
[2]. It is a cavity situated in the center of the
crown and, under no pathological conditions,
resembles the shape of the crown surface. In
anterior teeth, pulp chamber and root canal
are continuous, while in posterior teeth, pulp
chamber floor separates these two compo-
nents. In premolars and molars, pulp chamber
usually presents a square-shape with six sides:
the floor, the roof, and four axial walls identi-
fied as mesial, distal, buccal, or lingual
(palatal). The pulp chamber roof usually pres-
ents projections or prominences associated
with the cusps, mamelons or incisal edges,
denominated pulp horns [54] (Figs. 15.1,
15.3, and 15.7).
(a) Pulp Chamber Floor—Refers to the
most apical internal surface of the pulp
chamber. In anterior teeth, pulp chamber
and root canal are continuous, while in
posterior teeth, pulp chamber floor sepa-
rates these two components and repre-
sents the pulp chamber inter-radicular
dentin. It can vary in size and shape
depending on the tooth and disposition
416 M. A. Versiani et al.

Fig. 15.24 Morphological aspects of middle mesial canals (MMC) in mesial roots of mandibular molars

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy
of the canal orifices [77] (Figs. 15.1,
15.3, 15.7, and 15.17).
(b) Pulp Chamber Roof—Refers to the
most coronal internal surface of the pulp
chamber. In the teeth with occlusal sur-
face, the roof presents a convexity turned
toward the center of the chamber, while
in the anterior teeth, where the occlusal
surface is replaced by an incisal line, the
pulp chamber roof is also converted to a
line equivalent to the incisal line. Pulp
chamber roof usually presents projec-
tions or prominences associated with the
cusps, mamelons or incisal edges,
denominated pulp horns [77] (Figs. 15.1
and 15.3).
(c) Pulp Horn—Extension of pulp tissue
into occlusal or incisal projections fol-
lowing the cusp tips or developmental
lobes [2]. In the cuspid teeth, usually the
number of horns is equal to the number
of cusps [77] (Figs. 15.1, 15.3, and 15.7).
44. Radicular Groove (Developmental
Groove, Root Groove)—A developmental
groove is a shallow groove or line between
the primary parts of the crown or root. The
presence of developmental depressions in
the proximal aspects of the root surface, also
referred as radicular grooves [78], has been
demonstrated in different epidemiological
studies. Overall, radicular groove is wide-
spread in Africans and native Australians and
relatively rare in Western Eurasians [79–81].
The radicular groove is relevant in clinics as
its depth may act as a reservoir for dental
plaque and calculus, increasing the difficulty
for the management of periodontal disease
[82–84]. In mandibular premolar teeth, its
presence has been associated with anatomi-
cal complexities of the root canal system,
such as canal bifurcation and C-shaped canal
configuration [79, 82–87] (Figs. 15.8 and
15.9).
45. Radiographic Apex—Refers to the tip or
end of the root as determined radiographi-
cally; its location can vary from the anatomic
apex due to root morphology and distortion
of the radiographic image [2].
pilararaya@ejercer.cl
417
46. Radix—It is a Latin word for “root”
(Figs. 15.19, 15.25, and 15.26).
(a) Radix Distolingualis—The palatal part
of the root complex of the maxillary
molar is made up of two macrostruc-
tures, which are in principle cone-shaped
and located mesially and distally. The
structures are either separate or non-­
separate in relation to each other. The
distal of the two palatal root structures
has direct affinity to the distopalatal part
of the crown, which is very pronounced.
Under these conditions, the distal root
structure is identified as radix distolin-
gualis, while the mesial structure is
identical with the palatal root compo-
nent [57] (Fig. 15.19).
(b) Radix Entomolaris—A supernumerary
root on a mandibular molar, located dis-
tolingually [2]. The radix entomolaris is
located distolingually and with its coro-
nal third is completely or partially fixed
to the distal root. The dimensions can
vary from a short conical extension to a
“mature” root with normal length and
root canal. In most cases the pulpal
extension is radiographically visible. In
general, the radix entomolaris is smaller
than the distobuccal and mesial roots
and can be separated from, or partially
fused with, the other roots. In the apical
two thirds, a moderate to severe mesially
or distally orientated inclination can be
present [88]. The presence of a separate
radix entomolaris in the first mandibular
molar is associated with certain ethnic
groups. It is rare in Caucasians (3.4–
4.2%), but in populations with
Mongoloid traits (such as the Chinese,
Eskimo, and American Indians), reports
have noted that it occurs with a fre-
quency that ranges from 5% to more
than 30% [88] (Fig. 15.25).
(c) Radix Mesiolingualis—The palatal part
of the root complex of the maxillary
molar is made up of two macrostruc-
tures, which are in principle cone-shaped
and located mesially and distally. The
418 M. A. Versiani et al.

Frontal view

Lateral view

Frontal view

Lateral view

Fig. 15.25 Morphological aspects in different views of mandibular second molars with radix entomolaris (arrows)

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 419

Fig. 15.26 Radiographic and CBCT images of a mandibular second molar with radix paramolaris (yellow arrows)
(Courtesy of Dr. Nuno Pinto)

structures are either separate or non-­ conical extension. This additional root
separate in relation to each other. The can be separated or not from the distal
mesial of the two palatal root structures root [88]. It seems to be rare in European
has direct affinity to the mesiolingual as well as in Mongolian populations [89]
part of the crown, which is very pro- (Fig. 15.26).
nounced. Under these conditions, the 47. Ramification—Refers to a small gap result-
mesial root structure is identified as ing from a localized fragmentation of the
radix mesiolingualis, while the distal epithelial root sheath that includes furcation
structure is identical with the palatal root canals, lateral canals, and apical accessory
component [57] (Fig. 15.19). canals or to an unusual or inconsistent intra-
(d) Radix Paramolaris—A supernumerary canal anatomy [2] (Figs. 15.1, 15.3, 15.4,
root on a mandibular molar, located and 15.7).
mesiobuccally [2, 89].The dimensions 48. Root—Refers to the anatomical portion of
of the radix paramolaris vary from a the tooth that is surrounded by the alveolar
“mature” root with a root canal to a short bone and is covered by cementum and stays

pilararaya@ejercer.cl
420 M. A. Versiani et al.

hidden in the mouth, even after the tooth

eruption, under the gingiva. The tissues that
constitute the root are the cementum, dentin,
and pulp (Figs. 15.3, 15.4, and 15.9).
49. Root Canal System (Pulp Space, Pulp
Canal, Pulp Canal Space, Root Canal)—
The space containing the dental pulp inside
the crown and root of a tooth. The cavity
within the tooth that houses the dental pulp
system. A passage or channel in the root of
the tooth extending from the pulp chamber to
the apical foramen may be narrow, have lat-
eral branches, and/or exhibit irregular mor-
phology [2]. Fischer demonstrated the
challenging nature of the apical root anatomy
for the first time in 1907 by filling approxi-
mately 700 teeth with a collodion solution.
He demonstrated that the root canal space is
often complex, with canals that divide and
rejoin, isthmuses, fins, anastomosis, acces-
sory canals, and apical deltas. The complex-
ity and unpredictability of the root canal
morphology led him to coin the widely used
terminology kanalsystem, which was trans-
lated to English as “root canal system” [90]
(Figs. 15.1, 15.3, 15.4, 15.7, 15.9, and
15.27).
50. Root (Fusion)—Refers to two or more roots
that joined together [91, 92]. The prevalence
of fused roots in maxillary second molars is
four times higher when compared to maxil-
lary first molars [91]. Fused roots may form
by either age-related deposits that can
cement root structures together or as a result
of the failure of Hertwig’s epithelial sheath
to develop or fuse in the furcation area [93].
The presence of fused roots increased the Fig. 15.27 Complexity of the root canal system in man-
possibility that two or more root canals dibular and maxillary molars
merge with the presence of isthmuses or
additional canals, but also assuming a chambers and apically positioned furcations
C-shaped configuration [94]. Fused roots can [2]. Taurodontism can be defined as a change
be a challenge not only from a cleaning and in tooth shape caused by the failure of
shaping perspective but also from a surgical Hertwig’s epithelial sheath diaphragm to
point of view (Fig. 15.28). invaginate at the proper horizontal level. An
51. Taurodontism—A dental morphologic vari- enlarged pulp chamber, apical displacement
ation in which the body of the tooth is of the pulpal floor, and no constriction at the
enlarged, and the roots are reduced in size; level of the cementoenamel junction are the
results in a “taurodont” teeth with large pulp characteristic features. Although permanent

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15 3D Visual Glossary of Terminology in Root and Root Canal Anatomy 421

Fig. 15.28 Morphological aspects of

the root canal system in maxillary
second molars with fused roots
(Courtesy of Dr. Ordinola-Zapata)

pilararaya@ejercer.cl
422
Fig. 15.29 Taurodontism in a mandibular premolar (left) and a maxillary molar (right)
molar teeth are most commonly affected,
this change can also be seen in both the per-
manent and deciduous dentition, unilaterally
or bilaterally, and in any combination of
teeth or quadrants [95] (Fig. 15.29).
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