C-Shaped canal

Jafarzadeh 2007 - Review

Fernandes et al., 2014 - Review
History
First reported: in endodontic literature- Cooke and Cox 1979

Prevalence
Especially prevalent in mandibular second molars of Chinese and Lebanese
populations

Found in mandibular first molars (Bolger 1988), maxillary molars (Yilmaz Z 2006,
Dankner 1990), mandibular first premolars(Lu TY 2006), maxillary lateral incisors
(Boveda C 1999).

Most common - mandibular second molars.(Bolger WL 1998, Dankner 1990)

When present on one side, - found in contralateral - 70-81% (Sabala CL 1994))

Prevalence (refer to Fernandes 2014 review for
literature details)
● Mandibular second molars → 2.7%-45.5%.
● Mandibular premolars → 29.7% in chinese highest - Indian and Iranian
● Maxillary first molars → 0.12%
● Maxillary third molars → 4.7%
● Mandibular third molars → 3.5-4%
● Mandibular second premolars → 1%
● Palatal canal of maxillary second molars (Singla & Aggarwal, 2010)
Definition
◦Named for cross sectional morphology of the root and root canal.
◦Pulp chamber – single ribbon –shaped orifice with a 180 degree arc or
more
◦Pulp chamber - Starts at mesiolingual line angle and sweeps around the buccal to
the end at the distal aspect of pulp chamber.
◦Below orifice level – variation
Single ribbon-like, C shaped canal from orifice to apex (rare)
2-3 distinct canals below the C-shaped orifice.
Main anatomic features - presence of in or web connecting individual root canals
Challenge

Debridement and obturation

Root morphology

Roots are commonly fused on its buccal or lingual aspect

Etiology
1. Failure of Hewrtwig’s epithelial root sheath to fuse on lingual or buccal root
surface
2. Root coalescence because of deposition of cementum with time (Manning
1990)
 Classification (Fan Cheung, Fan Gutmann, Bian
2004)
1. Melton’s classification (Melton 1991)
Category I: continuous C-shaped canal running from the pulp chamber to the apex defines a C-shaped outline without
any separation (i.e., C1 in Fig. 1).

Category II: the semicolon-shaped (;) orifice in which dentine separates a main C-shaped canal from one mesial distinct
canal (i.e., C2 in Fig. 1).

Category III: refers to those with two or more discrete and separate canals:
subdivision I, C-shaped orifice in the coronal third that divides into two or more discrete and separate canals that join
apically;
subdivision II, C-shaped orifice in the coronal third that divides into two or more discrete and separate canals in the
midroot to the apex;
subdivision III, C-shaped orifice that divides into two or more discrete and separate canals in the coronal third to the
apex (i.e., C3 in Fig. 1).

No Clear description of difference between categories II and III and clinical

significance
2. Fan’s classification (Fan et al 2004) modified from
3. Fan’s Classification (Radiographic classification)
Fan et al 2004 - different paper from 2.
Type I
Type II
Type III
Morphology of pulp chamber floor (DETAILS)
Type I: a peninsula-like floor with a continuous C-shaped orifice.
Type II: a buccal, strip-like dentin connection exists between the
peninsula-like floor and the buccal wall of the pulp chamber that separates the C-
shaped groove into mesial (M) and distal (D) orifices. Sometimes the mesial orifice
was separated into (MB) and (ML) orifice by another strip-like dentin between the
peninsula-like floor and the mesial wall of the pulp chamber.
Type III: only one mesial, strip-like dentin connection exists between the
peninsula-like floor and the M wall, which separates the C-shaped groove into a
small ML orifice and a large MB-D orifice.
Type IV: Non-C-shaped floors. One distal canal orifice and one oval or two round
mesial canal orifices are present.
Morphology of pulp
chamber floor
(To the point)
(Min et al., 2006)

Type I: continuous C-shaped orifice.

Type II: a buccal, strip-like dentin that separates the C-shaped groove into
mesial (M) and distal (D) orifices. Sometimes the mesial orifice was separated
into (MB) and (ML) orifice
Type III: small ML orifice and a large MB-D orifice.
Type IV: Non-C-shaped floors. One distal canal orifice and one oval or two round
mesial canal orifices are present.
 Clinical application (of the
pulp chamber floor
classification)

● continuous C-shape or arc like

Mesiobuccal-Distal (MB-D): 1- 3 canals
● If the orifice is oval or flat: 1-2 canals
● If the orifice is round: 1 canal below the
orifice.
(Min et al., 2006) - (same research gropu:
guttman, Cheung,...)
Diagnosis
Criterias :

1. General outline of a C shaped root , regardless of whether a separate canal

or orifice was observed
2. Others
a. Fused roots
b. Longitudinal groove on lingual or buccal surfaces of the root
c. At least one cross section of the canal belongs to C1, C2, or C3 configuration.

(NB: C-shaped canal is a finding - not a diagnosis)

Radiographic diagnosis ( may be difficult to interpret
due to thickness of bone trabeculae.

Preoperative + 20 degree mesial or distal projection

Cooke and cox 1979 - said impossible to diagnose from radiograph

Haddad et al 1999- said C-shaped canals showed common charateristics

a. Radicular fusion / proximity

b. Large distal canal
c. Narrow mesial canal
d. Blurred image of third canal in between (Gulabivala 2001)
Clinical Diagnosis
1. Anatomy of floor of pulp chamber
2. Persistence of hemorrhage or pain when separate canal orifices were found
(Lambrianidis 2001)
3. Deep groove on buccal or lingual surface

File can be passed from mesial to distal

Configuration of entire C-shaped canal system should be examined

Management
Problem:

● High percentage of irregularities (accessory & lateral canals and apical

delta) → difficulty in C&S and in sealing the entire canal
● Chances of missing out on canals because of bifurcation, dentin fusion, and
curvatures.

Access cavity: modifications might be needed - to facilitate location and

negotiation of the complete canal system
Management
Negotiation of the canals: morphology of pulp chamber floor indicates the
possible number of canals
● continuous C-shape or arc like Mesiobuccal-Distal (MB-D): 1- 3 canals
● If the orifice is oval or flat: 1-2 canals
● If the orifice is round: 1 canal below the orifice.
(Min et al., 2006)
Management
C&S:

● Careful probing with small files to characterize the C- shaped canal

● Orifice portion:
○ Of the canal: Widen with GG
○ Of the slit: must be widened
● Isthmus:
○ C1 and C2: narrow ismuth - Careful not to perforate
○ Do not use GG in ismuths
○ Should not be prepared larger than 25 - risk of perforation.
● Canals instrumentation:
○ Ni-Ti - safe to use
○ After debridement - use k-file or h-files: filling of the isthmus areas
○ Risk of lingula wall strip perforation: it is very thin - ML walls → use anti-curvature technique (Abou Rass
et al., )
○ Apical preparation - not larger than #30 (0.06 taper) -
● Ultrasonic irrigation - to reach isthmus - Very important step.
● Careful ultrasonic instrumentation to prevent perforation.
Management
Obturation:

Problem:
1. Divergent areas that are frequently unshaped
2. Communications between main canals of C- shape

● Buccal isthmus is difficult to seal- may not be prepared enough

Management
Obturation:

Cold lateral condensation

● Place large diameter file in the most distal portion of the canal, before seating the master cone in
the mesial canal.
● The file is then withdrawn and the master cone of the distal canal is seated, followed by placement
of accessory cones in the middle portion of the C-shaped canal.
Management
Obturation:

Thermoplasticized gutta-percha technique

● Communications exist between the main canals of the C-shape → GP may pass from one canal
to another
● Place master points simultaneously in the C-shaped canal.
● A large plugger is placed on one of the seared master points while the other master point is down
packed with a smaller plugger. This increases the resistance towards the passage of obturating
material from one canal to another.
● The smaller plugger is then held in place while the other point is down packed.
● This offers backpressure on entrapped filling materials and enhances the seal.

● Ordinola- Zapata et al.: analyzed gutta-percha filled area of C-shaped canals filled with Maggiore's
modified MicroSeal technique with reference to the radiographic features. They found that the
apical third was less accurately filled and concluded that C2 canals with a 60° angle could be
less difficult to fill than a 120° or 150° C2 canal.
Management
Obturation:

EndoTec II (developed by Howard Martin)

Zap and Tap maneuver - (Liewehr et al., 1993):
● method which considerably decreases the incidence of dislodgement of GP(in case of
warm vertical compaction)
● Combines both cold lateral condensation and warm vertical compaction

1. Sealer in canals - do cold lateral compaction obturation: 1 master cone, 1-2 accessory GPs
2. Preheat EndoTec plugger for 4-5 seconds before insertion ( zap)
3. Move the hot instruments in and out in short continuous strokes (taps)- 10-15 times - very little
apical pressure
4. Plugger removed while still hot → add accessory canals in the created spaces and use followed by
cold spreader to complete with cold lateral compaction
5. 2 plugger at the same time - to increase resistance to passage of obturation material from one
canal to another
Restoration and Prognosis
Post placement-

distal canal should be considered

Mesial - possible perforation

Review :

Furcal breakdown should be looked for

Important Literature - MRD Purposes
Gulabivala (Eastman dental hospital - NHS)

Cooke and Cox 1979