JOURNAL OF DENTAL SCIENCES

Volume 2 Issue 2

C-SHAPED ROOT CANAL SYSTEM IN MANDIBULAR SECOND MOLAR: A CASE REPORT AND DISCUSSION
Dr. Pruthvi Patel M.D.S. Dr. Shashin Shah M.D.S. Dr. Nirav Parmar M.D.S. Abstract Recognition of unusual variations in the canal configuration is critical as it has been established that the root with a single tapering canal and apical foramen is an exception rather than the rule. C-shaped root canal is an important anatomic variation which presents a thin fin or web connecting the root canals and its early recognition facilitates the management of such teeth. Key Words : C-shape, Canal Configuration, Anatomy Introduction The C-shaped canal, which was first documented in endodontic literature by Cooke and Cox in 1979 , is so named for the cross-sectional morphology of the root and root canal. Once recognized, it provides a challenge with respect to debridement and obturation, especially because it is unclear whether the C-shaped orifice found on the floor of the pulp chamber actually continues to the apical third of the root. Because of the great challenges encountered in the management of C configuration; etiology, classification, diagnosis and treatment of this variation is discussed along with a case showing C- shaped canal in a mandibular second molar. Case Report A 19 year old female reported to the Department of Conservative Dentistry and Endodontics, Faculty of Dental Science, Dharamsinh Desai University, Nadiad with the chief complaint of severe pain in lower left posterior region. Clinical examination revealed deeply carious occlusal lesion in 37. Pain on percussion was present. No significant findings were recorded in the medical history. Intra-oral periapical radiograph showed coronal radiolucency involving the pulp chamber and a single conical root outline (Illustration 1).
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After the access cavity was prepared, the pulpal floor revealed one semicolon type of canal orifice extending from distal canal to mesiobuccal canal and the other orifice of mesiolingual canal separately, suggestive of C-shape canal anatomy. Canal system identification was confirmed by taking working length intra-oral periapical radiograph (Illustration 2).

Illustration 2 Working Length radiograph Distal, mesiobuccal and mesiolingual canal spaces were prepared normally and the isthmus area was cleaned using smaller k-files not more than ISO no. 25. This was followed by cleaning with ultrasonic files. 1.25% Sodium hypochlorite and 17% EDTA were used as irrigants alternatively. After relieving the occlusion, canals were dried with sterile paper points and temporized with ZOE cement. During the second visit, patient was totally asymptomatic. Master cone intraoral periapical radiograph was taken (Illustration 3)

Illustration 1 - Pre-Operative radiograph On electrical and thermal pulp testing, the tooth was nonresponsive to stimuli, suggestive of loss of tooth vitality. All the tests performed confirms the diagnosis of pulp necrosis. Lecturer Reader Dept. of Conservative Dentistry & Endodontics Faculty of Dental Science, Dharmsinh Desai University, Nadiad - 387 001. Gujarat, India

Illustration 3 Master Cone radiograph Address of correspondence : Dr Pruthvi Patel M.D.S. Dept. of Conservative Dentistry and Endodontics, Faculty of Dental Science, Dharmsinh Desai University, Nadiad - 387 001. Gujarat, India Mobile : 9825738912 E-mail : phpatel162@rediffmail.com 34

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Obturation was carried out using lateral/vertical condensation of warm gutta-percha (Illustration 4&5).

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Illustration 4 Post-operative radiograph

Category I: continuous C-shaped canal running from the pulp chamber to the apex defines a C-shaped outline without any separation. (C1) Category II: the semicolon-shaped (;) orifice in which dentine separates a main C-shaped canal from one mesial distinct canal (C2) Category III: simply have two or more distinct canals. (C3) Fans classification (anatomic classification) As in Meltons classification, there has been no clear description of the difference between category II and III, Fan et al in 2004 modified Meltons method into following categories. (Illustration. 6) Category I: the shape is an uninterrupted C with no separation. (C1) Category II: the canal shape resembles a semicolon resulting from a discontinuation of the C outline, but either angle or should be no less than 60. (C2) (Illustration. 7)
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Illustration 5 Post-obturation photograph Discussion C configuration is mostly seen in mandibular second molar followed by other mandibular molars and maxillary molars respectively. It appears to be genetically determined and may be used in tracing the ethnic origin of the subject. Prevalence of C-shaped canal in mandibular second molar has been reported to be 2.7% in the American population, 10% in the Thai population and 31.5% in the Chinese population. When present, over 70% of individuals have this canal configuration bilaterally in mandibular second molar. Etiology: Failure of Hertwigs epithelial root sheath to fuse on buccal or lingual root surface is the main cause for occurrence of Cshaped roots, which always contain a C-shaped canal. However, C-shaped root may form by coalescence because of deposition of cementum with time. Meltons classification: Melton et al in 1991 proposed the following classification of C-shaped canals based on their cross-sectional shape (Illustration 6)
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Illustration 7 Measurement of angles for the C2 canal. Angle is more than 60. (A and B) Ends of one canal cross-section, (C and D) ends of the other canal cross-section; M, middle point of line AD; , angle between line AM and line BM; , angle between line CM and line DM Category III: two or three separate canals are present and both angles, and , are less than 60. (C3) (Illustration 8)

Illustration 8 Measurement of angles for the C3 canal. Both angle and angle are less than 60. (A and B) Ends of one canal cross-section; (C and D) ends of another canal crosssection; M, middle point of line AD; , angle between line AM and line BM; , angle between line CM and line DM Category IV: only one round or oval canal is found. (C4) Category V: no canal lumen can be observed, usually seen near the apex. (C5) Shape of canal varies along the length of the root. i. e., a canal may emerge as C1 shape at orifice, become C2 or C3 at mid root, and again C1 at apex. Illustration 6 Classification of C-shaped canal configuration 35

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Fan et al. classified C-shaped roots according to their radiographic appearance into three types: (Illustration 9)
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Illustration 9 Radiographic types. (A) Type I, (B) type II, and (C) type III Type I: Conical or square root with a vague, radiolucent longitudinal line separating the root into mesial and distal parts. There is a mesial and a distal canal, that merges into one before exiting at the apical foramen. Type II: Conical or square root with a vague, radiolucent longitudinal line separating the root into mesial and distal parts. There is a mesial and distal canal, and the two canals appear to continue on their own pathway to the apex. Type III: Conical or square root with a vague, radiolucent longitudinal line separating the root into mesial and distal parts. There is a mesial and distal canal: one canal curves to and superimposes on this radiolucent line when running towards the apex, and the other canal appears to continue on its own pathway to the apex. Diagnosis Practically it is very difficult but not impossible to diagnose a C-shaped canal from pre-operative radiograph which usually shows single fused roots or images of two distinct roots. So, clinical recognition of C-shaped canal is unlikely until access to the pulp chamber has been achieved. Micro-computed tomography also helps in diagnosing it in a non-destructive manner. Intra-oral periapical radiograph taken while negotiating the canals may reveal any of the following characteristics. - instruments tending to converge at the apex - instruments appearing both clinically and radiographically to be centered and appearing to be exiting at the furcation. The pulp chamber has large occluso-apical dimensions with low bifurcation. Root displays a deep buccal and/or lingual longitudinal groove at the line of fusion between mesial and distal roots, predisposing to localized periodontal disease which may be the first diagnostic indication to this anatomical variant. Canal system preparation and obturation As irregular areas in C-shaped root canal system may house soft tissue remnant or infected debris which may escape thorough cleaning and filling procedures, many modified techniques have been provoked to manage such cases endodontically. The mesiobuccal, mesiolingual and distal canal spaces can be prepared normally. However, the isthmus should not be
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prepared with larger than ISO no. 25 files; otherwise, strip perforation is likely. Extravagant use of small files and copious irrigation is a key to thorough debridement of narrow canal isthmuses. Alternative canal cleaning techniques, such as those that use ultrasonics, would be more effective. The ribbon canal space is frequently eccentric to the lingual side of the C-shaped radicular dentin. An anticurvature filing method in the coronal third of the canal is needed to prevent perforation. If dentin filing is directed buccaly, perforation will likely be avoided. The mesiobuccal, mesiolingual and distal canal spaces can be obturated as standard canals. However, sealing the isthmus is difficult if lateral condensation is the only method used. Because this isthmus may not be prepared with a sufficient flare to permit deep placement of the spreader, application of thermoplasticized gutta-percha is more appropriate. Gutta-percha can be thermoplasticized with spreaders heated in an open flame or electric spreaders or delivered by injectable systems. Martin developed a device Called EndoTec II (Medidenta, Inc.,Woodside, NY) that appears to achieve the best qualities of both techniques, lateral compaction as well as vertical compaction of warm gutta-percha,. In 1993, an Army group found they could measurably improve compaction while obturating a mandibular molar with a C-shaped canal by using the EndoTec in what they termed a zap and tap maneuver: preheating the EndoTec plugger for 4 to 5 seconds before insertion (zap) and then moving the hot instrument in and out in short continuous strokes (taps) 10 to 15 times. The plugger was removed while still hot, followed by a cold spreader with insertion of additional accessory points. The compaction of softened gutta-percha should move guttapercha and sealer into the root canal aberration. But in Cshaped canals, conditions are different for two reasons: (1) divergent areas that are frequently unshaped and may offer resistance to obturating material flow and (2) communications between the main canals of the C-shape, through which the entrapped filling materials that should be captured between the apical tug-back area and the level of condensation may pass from one canal to another. In 2000, Walid described the use of two pluggers simultaneously to down pack the main canals in a C-shaped canal. After placing two master cones in main canals( distal and mesiobuccal canals in this case), a large plugger is placed at orifice of distal canal, blocking the canal entrance, while down packing the mesiobuccal canal with smaller plugger. Then smaller plugger is held in place while down packing the distal canal. Blocking canal entrance with a plugger increases the resistance toward the passage of obturating material from one canal to another. Conclusion Although the prevalence is less, when sound principals of biomechanical preparation and obturation are followed, the long term prognosis for the C-shaped root retention equals that of other molars.
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References 1. Cooke HG 3rd, Cox FL. C-shaped canal configurations in mandibular molars. J Am Dent Assoc 1979;99:836 839. 2. Fan B. The anatomy of C-shaped canal system in mandibular second molars. Contemporary Endodontics 2005;1-3. 3. Melton DC, Krell KV, Fuller MW. Anatomical and histological features of C shaped canals in mandibular second molars. J Endod 1991;17:384388. 4. Fan B, Cheung GS, Fan M, Gutmann JL, Bian Z. Cshaped canal system in mandibular second molars: Part IAnatomical features. J Endod 2004;30:899 903. 5. Fan B, Cheung GS, Fan M, Gutmann JL, Fan W. Cshaped canal system in mandibular second molars: Part IIRadiographic features. J Endod 2004;30:904908. 6.

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Fan B, Yi. Min, Jun Yang. Negotiation of c-shaped canal systems in mandibular second molars. J Endod 2009;35:1003-1008. 7. Lisa HM, Gary SP. Evaluation of a rotary instrumentation method for c-shaped canals with micro-computed tomography. J Endod 2008;34: 1233-1238. 8. Ingle JI, Newton CW, West JD, et al. Obturation of the radicular space. In Ingle JI, Bakland LK.Endodontics, 5t ed.London: BC Decker Inc., 2002;6256 64. 9. Liewehr FR, Kulild JC, Primack PD. Obturation of a Cshaped canal using an improved method of warm lateral condensation. J Endod 1993;19:474 477. 10. Walid N. The use of two pluggers for the obturation of an uncommon C-shaped canal. J Endod 2000;26:422 424.

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