[2009 ]

THE ROOT CANAL MORPHOLOGY

Endodontics
Dr.Shawfekar Bte Hj Abdul Hamid TOSHIBA 1/03/09]
THE ROOT CANAL MORPHOLOGY
MAXILLARY CENTRAL INCISOR
#11. The root canal morphology of the upper central incisor is optimal from an e
ndodontic point of view. There is practically always only one root canal that is
straight or almost straight. The cross-section of the canal is fairly round. Fr
om a proximal view, the long axis of the canal meets the incisal area at the inc
isal edge or slightly palatally. This means that, while access to the pulp chamb
er is made from the palatal surface for aesthetic reasons, this does not lead to
an unsymmetrical preparation, which is a more likely risk when preparing root c
anals in lower incisors.
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MANDIBULAR CENTRAL INCISOR
#41. The mandibular central incisor always has one root, but often (20 %) has tw
o root canals. Usually (75 %), the two canals join before the apical foramen. Th
e canal(s) is very flattened: wide in the bucco-lingual dimension and narrow in
the mesio-distal dimension. Only the most apical part of the canal is more round
. The long axis of the canal traverses the incisal edge or the labial surface of
the crown. Because the access opening is made, for aesthetic reasons, in the li
ngual surface, there is always a risk that the lingual canal is missed unless it
is specifically looked for with a pre-curved file. For the same reason there is
a risk of unsymmetrical preparation of the labial side of the root canal. The c
anal(s) of the lower central incisor is almost always straight unlike in the low
er lateral incisor, where the root tip and canal often curve sharply distally.
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MAXILLARY LATERAL INCISOR
#12. The upper lateral incisor has both similarities and differences to the uppe
r central incisor. It has, practically always, one canal with an oval or round c
ross-section. However, the apical canal often curves distally, which makes the p
reparation much more difficult than in the upper central incisor. Sometimes the
root tip curves labially, which is difficult to see in the radiograph, a similar
situation to the palatal roots of upper molars, which appear straight radiograp
hically but typically have a buccal apical curvature.
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MANDIBULAR LATERAL INCISOR
#42. The lower lateral incisor is quite similar to the lower central incisor. Ho
wever, the lateral incisor is approximately 2 mm longer and the apical root and
canal often curve distally, which must be taken into consideration during instru
mentation.
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MAXILLARY CANINE
#13. The upper canine is the longest tooth, and occasionally longer files of 28
or 31 mm lengths are needed for the root canal treatment. It always has only one
root canal, which usually has an oval cross-section. The root canal is typicall
y quite large, but often the few most apical millimeters before the foramen are
much narrower. This may lead to incorrect working length if the position of the
apical constriction is determined only with tactile sensation with the file and
fingertips. Like the upper lateral incisor, the apical canal in the upper canine
may have a pronounced curve, usually either distally or labially, although not
quite so frequently. Awareness of the possibility of apical curvatures and caref
ul assessment of root canal anatomy are essential in order to avoid complication
s in therapy.
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MANDIBULAR CANINE
#43. The mandibular canine is the second longest tooth in the dentition, it is o
nly 1 - 2 mm shorter than the upper canine. As in the lower incisors, there are
often two canals, which usually (but not always) join before the apex. Sometimes
there are two roots in the lower canine: a buccal root and a lingual root. The
canal is much more flattened than in the upper canine. The canal is, however, qu
ite large and usually does not cause any technical problems during instrumentati
on. However, teeth with two roots are often quite difficult to instrument. As in
the lower incisors, the long axis of the canal meets the crown surface at the i
ncisal edge or on the labial surface. If not taken into consideration, this may
lead to a deviated preparation, the emphasis again being on the labial side of t
he canal. The lingual canal must be looked for using a small file with a curved
tip. The lower canine is often quite straight, but sometimes the root tip and th
e canal curve distally and/or labially.
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MAXILLARY FIRST PREMOLAR
#14. The upper first premolar normally has two roots and two root canals. Occasi
onally only one root is present, but even then two canals are still often found.
The root tips are very fine which may result in perforation even in a straight
canal if a large apical open size is attempted. The roots are often equally long
but 1 - 2 mm differences may occur. The root tips and apical canals may curve i
n the mesio-distal or bucco-palatal dimensions. Rarely, the upper first premolar
has three roots and three root canals (= molarization) as with upper molars, al
though the roots are much finer and smaller.
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MANDIBULAR FIRST PREMOLAR
#44. All teeth in the lower jaw can have more than one root canal. Double canals
are particularly frequent in the mandibular first premolars, with approximately
30% of these teeth having two root canals. First premolars with one canal are q
uite easy to instrument, the canal is oval in cross-section and seldom curves se
verely. When there are two canals, the files usually easily find the buccal cana
l, while the lingual canal often requires bending of the instrument tip. Molariz
ation in the lower first premolar is very rare.
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MAXILLARY SECOND PREMOLAR
#15. The upper second premolar has a single root more often than the first premo
lar. In the cervical area there are often two root canals but in many cases they
unite before the apical foramen. The root is normally straight but may curve in
the apical area, particularly distally. Upper second premolars with three roots
(molarization) are very rare.
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MANDIBULAR SECOND PREMOLAR
#45. The mandibular second premolar resembles the first premolar, but the lingua
l canal is present only occasionally. Instead, molarization is more frequent tha
n in the first premolar, yet still quite rare. The root canal is oval in cross-s
ection and rather straight with only a slight distal curvature in some canals.
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MAXILLARY FIRST MOLAR
#16. Maxillary molars have from one to three roots and from two to four root can
als. From an occlusal view the pulp chamber is situated rather mesially, which h
as to be taken into account when cutting the access cavity. The upper first mola
r is perhaps the most variable tooth when it comes to root canal morphology, and
provides quite a challenge in endodontics. There are usually three roots with t
hree or four root canals. Dentists are quite familiar with the mesiobuccal, dist
obuccal and palatal canals, but not with the fourth canal, which is known as the
mesiocentric or mesiopalatal, mb2 or accessory mesiobuccal canal. This fourth c
anal is usually difficult to find just by clinical inspection and is not apparen
t in the radiograph. However, finding all canals is necessary for successful the
rapy. The distobuccal canal is often easy to locate and instrument. It is typica
lly rather straight or curves only slightly mesially, or sometimes distally. The
palatal canal always looks straight radiographically but often has a buccal cur
vature. If this curvature is not identified by careful exploration with files it
can lead to perforation 2 - 4 mm before the apex. Moreover, in radiographs a fi
le will still appear to be in the canal but in reality it is only superimposed o
nto the canal. The palatal canal is often 1 - 2 mm longer than the buccal canals
. Two palatal roots in the upper first molar have been reported in the literatur
e. The mesiobuccal root is the most challenging to treat. The root is usually cu
rved all the way to the apex, which increases the risk of tip perforation and st
rip perforation. The distal surface of the root is concave which increases the r
isk of strip perforation.
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The mesiopalatal canal is present in well over half of cases, with some authors
reporting over 90% incidence. The canal orifice is difficult to find because it
is typically situated near the mesial wall of the pulp chamber. While the other
three canals can readily be found, the fourth canal must always be actively look
ed for with suitable instruments. The orifice is usually located 1 - 3 mm palata
lly from the mesiobuccal canal. In most cases the mesiopalatal canal joins the m
esiobuccal canal before the apex.
MANDIBULAR FIRST MOLAR
#46. The mandibular first molar is perhaps the most frequently endodontically tr
eated molar. It is, however, often quite difficult to treat because of its root
canal anatomy. It usually has 3 - 4 canals, two in the mesial root and one or tw
o in the distal root. The Distal canal(s) is normally straight all the way to th
e apex, oval or flattened in crosssection, but quite large, which makes instrume
ntation easy. Often the most apical 1 - 2 mm of this canal curves up to 90 degre
es distally, but this is seldom a clinical problem. The distal canal may also cu
rve mesially, but the curvature is not sharp and usually remains easy to instrum
ent. The mesial canals in the first molar are often a challenge for the dentist.
Both the mesiobuccal and mesiolingual canals are usually curved along their who
le length, and the curvature is typically greatest in the apical region. The can
als curve distally, but they also curve buccally or lingually at the same
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time. Bucco-lingual curvatures are not readily seen in the radiograph, which emp
hasizes the importance of the dentist's knowledge of possible variations in cana
l morphology. One must routinely search for four canals in the lower first molar
. The distal canals often start together and separate a few millimeters below th
e pulp chamber floor. Both distal and mesial canals can join before the apex. Th
is is important to detect before obturation, to gain optimal results. Mandibular
first molars with two canals are rare. Usually, finding only two canals indicat
es that the mesiobuccal canal has not yet been located.
MAXILLARY SECOND MOLAR
#17. The maxillary second molar closely resembles the first molar. However, the
number of canals is usually three, sometimes two, but also four canals can be fo
und (two canals in the mb root). A typical upper second molar resembles the firs
t molar, the difference being that the orifices of the mb and db canals are clos
er together; sometimes almost forming a line (mb - db - pal). Sometimes the two
buccal canals are side by side in the mesio-distal dimension. The apical part of
the palatal and the mesiobuccal canals is not as curved as in the first molar.
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MANDIBULAR SECOND MOLAR
#47. The lower second molar is much like the first molar but generally easier to
instrument because the curvatures are milder. The occurrence of four canals in
the second molar is more rare than in the first molar, and only two canals is a
more frequent possibility than in the first molar. A small percentage of lower s
econd molars have a special root canal anatomy; two or more of the canal opening
s in the pulp chamber floor join to form a C-shaped groove. This has occasioned
the name "Cshaped canals". Usually the mb or ml canal joins the distal canal, so
metimes both mesial canals join the distal canal. Deeper in the root there somet
imes are further ramifications.
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MAXILLARY THIRD MOLAR
#18. The upper third molar is often a "reduced version" of the second molar. The
re are usually two or three root canals, and the orifices of the buccal canals m
ay be very close to each other. Some upper third molars have a root canal anatom
y similar to first molars. Sometimes the buccal canals share the same orifice in
the pulp chamber but then separate 1 - 4 mm below the chamber floor (this may a
lso occur in the second molar). Some upper third molars have additional roots an
d/or root canals.
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MANDIBULAR THIRD MOLAR
#48. The lower third molar resembles the first and second molars, but the probab
ility of teeth with four canals is again less and of teeth with two canals great
er. Third molars are shorter than the other molars, which makes instrumentation
easier. However, many third molars have very curved canals and may be difficult
to instrument.
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SPECIAL MORPHOLOGY FOR ROOT CANALS
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Dentine structure
Evaginations
Evaginations are morphological anomalies where the pulp has made an extension to
wards the tooth surface. Dentine and enamel follow the pulpal extension which ma
y be seen as an extra cusp or enamel pearl on the tooth surface. Evaginations ar
e rare, and are usually seen in lower premolars. They typically cause occlusal i
nterference. If eliminated by grinding in one appointment, pulpal exposure and d
amage will follow. Gradual grinding of 0.1 mm per month before occlusal contact
is established may help to avoid pulpal inflammation.
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Invaginations
Invaginations are shallow or deep developmental cavities in tooth crowns, covere
d partly or totally by enamel walls. Their frequency has been reported to be bet
ween 0.1 and 10%. They are most frequent in upper lateral incisors, but can be f
ound in any tooth. Invaginations are divided into four main types (see drawing).
Invaginations often increase the risk of pulp infection, and they should be wel
l sealed with a permanent filling whenever found, in order to reduce the risk of
infection in the pulp or in the periodontal tissues. Deeper invaginations (type
2) should be cleaned mechanically and by irrigation, and they should be filled
to their whole depth if possible. Type 3 and 4 invaginations are problematic to
treat if the infection penetrates to the tissues.
Pulp stones
Pulp stones are calcified structures that may form within vital pulpal tissue Th
ey are often oval or round, but they may also have an irregular shape. Sometimes
pulp stone(s) may diffusely fill a major part of the pulpal chamber.
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Size and morphological features have been used for classification of intrapulpal
calcifications, but classifications have little significance in endodontics. Pr
eviously, pulp stones were thought to be a sign of pulpal pathosis, but evidence
for this is lacking. Nowadays pulp stones are not regarded as an indication for
endodontic therapy. If endodontic treatment is, however, started for other reas
ons, pulp stones may complicate gaining access to the root canals or obtaining c
orrect working length. Use of ultrasound often helps to remove pulp stones durin
g root canal preparation.
TABLES
Table 1
The average length of teeth in the upper jaw varies from 19mm to 26 mm. The cani
ne is the longest tooth in the upper jaw followed by the central incisor. The ce
ntral incisor is the only tooth that is regularly straight to the root tip. The
lateral incisor typically has a distal or buccal apical curvature. Upper canines
may be straight but may also curve buccally or distally. Most teeth in the prem
olar and molar regions have curved roots. Double canals are practically never fo
und in upper incisors or canines. Single-rooted premolars and mesiobuccal roots
of upper molars often have double canals. As in the lower jaw, double canals are
located in the bucco-lingual dimension.
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Table 2
The average length of teeth in the lower jaw varies from 19mm to 25 mm. The cani
ne is the longest tooth in the lower jaw and only slightly shorter than the uppe
r canine. The central incisor is usually straight, down to the root tip. Most lo
wer premolars and canines are also quite straight, while lateral incisors and mo
lars typically have curved roots. All teeth in the lower jaw can have double can
als. Double canals are located in the bucco-lingual direction. In the molars, do
uble canals are typically found in mesial canals, but may be also found in dista
l canals, particularly in the first molar.
Terminology
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24
Apical canal
Apical preparation assumes a key role in successful therapy of apical periodonti
tis, because it is the bacteria, particularly in this area of the root canal, th
at are responsible for the development of the periapical lesion. The technical g
oal of treatment of apical periodontitis is to reach the apical constriction and
all regions of the root canal system with preparation instruments, intracanal m
edicaments and the root filling. If this can be done successfully, prognosis of
the therapy is good. Variations in apical root canal morphology, however, may co
mplicate treatment, as in the case of an apical delta, which may offer areas of
concealment for micro-organisms. Details of apical root canal morphology often c
annot be seen in radiographs.
Changes in morphology
Ageing and various irritants, such as deep caries lesions, cause several changes
in teeth. Pulp chambers and root canals become narrow and more obliterated beca
use of secondary dentine produced by odontoblast cells in the pulp. Also the cro
wn becomes shorter because of occlusal wear. It is important to understand the e
ffects of these changes on endodontic treatment.
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Canal cross-sections
Thorough knowledge and understanding of the cross-sectional shape of root canals
in different teeth and tooth groups is essential for successful endodontic trea
tment. Optimally, the canal should be round or only slightly oval to allow easy
access for preparation instruments to all parts of the root canal system. In pra
ctice, however, many root canals are flattened and asymmetric in shape. The cros
s-sectional shape of the root canal also changes during its course from the pulp
chamber towards the apex. In the apical 1 - 4mm, most canals become oval or rou
nd. This again facilitates cleaning of the apical canal, which is essential for
control of the infection and helps to give the canal a shape that can be tightly
filled with a root filling.
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Curved canals
Up to 90% of all root canals are curved to some degree. Canal curvatures are a c
hallenge to preparation and can cause different kinds of technical complications
(preparation of curved canals). Canals that curve in the mesio-distal dimension
are usually easily detected in radiographs. However, many canals also curve in
the buccolingual dimension, which can only occasionally be detected in radiograp
hs. For optimal clinical results it is important to detect all curvatures in ord
er to select the correct instruments and avoid complications. The type of curvat
ure dictates the ease or difficulty of instrumentation. Even curvatures with a l
ong radius are easy to prepare with the right choice of instruments and techniqu
es. Sharp curves with a short radius and S-shaped curvatures are always very dem
anding and easily result in transportation, ledges and even perforations. Even u
p to 90% of all root canals are more or less curved. Canal curvatures are a chal
lenge to preparation and can cause different kinds of technical complications (s
ee preparation of curved canals). Canals that curve in the mesio-distal directio
n are usually easily detected in radiographic pictures. However, many canals cur
ve also in the bucco-lingual direction, which can only occasionally be detected
in radiographs. For optimal clinical results it is important to detect all curva
tures in order to select the correct instruments and avoid complications. The ty
pe of curvature dictates the ease or difficulty of instrumentation: even curvatu
res with a long radius are easy to prepare with the right choice of instruments
and techniques, sharp curves with a short radius and S-shaped curvatures are alw
ays very demanding and easily result in transportation, steps and even perforati
ons.
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Double canals
Double canals means two canals in one root. Double canals can be separate from t
he pulp chamber down to the apex, both having their own apical foramen. However,
the canal may also begin as one canal, divide into two canals, and join again b
efore the apex. Double canals are almost always situated as buccal and lingual c
anals in the root, which makes their detection in radiographs difficult. However
, knowing the possibility of their existence together with careful analysis of r
adiographs and clinical examination helps to find double canals. From the clinic
al point of view it is important to be aware of the possibility of double canals
. Double canals can be present in most roots. Maxillary incisors and canines are
the only teeth where double canals are practically never found. Also the palata
l and distobuccal roots of upper molars usually have only one root canal. Double
canals are most frequent in mesial roots of mandibular molars, followed by the
mesiobuccal root of the maxillary first molar, upper second premolar and lower f
irst premolar. Roughly one fifth of lower incisors and canines also have double
canals, but most of these join shortly before the apex.
Analysis of radiographs
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Double canals are almost always located bucco-lingually, so that they may be dif
ficult to detect in radiographs. However, a reliable way to identify double cana
ls is to follow the radiographic shadow of the canal; if the shadow suddenly alm
ost disappears, it is a strong indication of canal ramification. Taking the radi
ograph at a different horizontal angle also helps to find double canals in many
teeth. In looking for double canals it is important to identify the periodontal
ligament space that often projects on the tooth and may resemble a canal.
Molarization
Sometimes premolars have a root morphology similar to that of molars, a phenomen
on known as molarization. Thus lower premolars will have a mesial and a distal r
oot just like lower molars, and upper premolars have two buccal roots and one pa
latal root just like upper molars. The crowns in these premolars with molarizati
on usually look quite normal, particularly in the upper premolars. Sometimes the
re may be an extra cusp present and the crown may be slightly longer mesio-dista
lly. The frequency of molarization in premolars is approximately 1%. In the maxi
lla it is more frequent in the first premolar whereas in the mandible it is more
frequent in the second premolar. These teeth usually have three root canals, bu
t mandibular premolars can sometimes have only two.
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C-shaped canals
The C-shaped canal is a special feature of some lower second molars. Approximate
ly 1% of lower second molars have C-shaped canals. The name comes from the appea
rance of the pulp chamber floor when viewed from above. Some or all of the canal
orifices are joined in the form of a groove or isthmus with a shape of the lett
er C. In teeth with three canals the mesiobuccal canal usually joins the distal
canal. In some teeth both mesial canals join the distal canal at the cervical ar
ea near the pulp chamber floor. The canals may later, closer to apex, separate a
gain to leave the tooth via separate foramina.
Taurodontism
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Taurodontism is a special anatomic variation occasionally seen in molars. The pu
lp chamber continues apically far beyond the normal height: often the root canal
s start only a few millimeters before the apex. Taurodontism makes root canal tr
eatment more difficult because localization of canal orifices is more complicate
d. In cases of pulpitis, control of bleeding can also take a lot of time and eff
ort compared to teeth with normal anatomy.
SELF ASSESSMENT
Morphology Self Assessment
Maxillary teeth
True The only teeth with always one root canal are maxillary central incisors Fa
lse
The only teeth with always one root canal are maxillary incisors
The only teeth with always one root canal are maxillary incisors and canine
The root tip of maxillary lateral incisor often bends mesially
The root tip of maxillary lateral incisor often bends distally
The average length of an intact maxillary lateral incisor is ca 23 mm
The average length of an intact maxillary canine is ca 24 mm
The root tip of maxillary canine may bend distally and labially
Mandibular canine is the longest tooth
First maxillary premolar is the shortest tooth
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Molarization may occur in all front teeth and premolars
Maxillary "molarization" premolars have two buccal roots and one palatal root
The roots in three-rooted maxillary premolars are easy to detect in the radiogra
phs
Maxillary second premolar with two root canals has one mesial and one distal can
al
Two root canals in maxillary second premolar usually join 1 - 5 mm before apex
Maxillary first molar has usually three (3) root canals
Maxillary second molar has usually three (3) root canals
MB1 and MB2 canals of upper molars often join before apex
Sometimes maxillary second molar has only one root canal
MB2 canal is located in the distobuccal root The openings of MB1 and MB2 canals
in the same root are of same size and equally easy/difficult to find MB2 canal i
n first maxillary molar is located on the straight line between MB1 and palatal
canal MB2 canal in first maxillary molar is located mesially to the straight lin
e between MB1 and palatal canal There is always only one palatal canal in maxill
ary molars
Palatal canal in maxillary molars is the narrowest canal
Mesiobuccal root of maxillary molars in flattened mesio-distally
Palatal canal of maxillary molars often curves palatally at the apical end
Palatal canal of maxillary molars often curves buccally at the apical end The ap
ical curvature of maxillary molar palatal canal is readily visible in the radiog
raphs
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Mandibular teeth
True Mandibular incisors and canines have always one root canal False
20 % of mandibular incisors have two canals in the same root (= double canals)
Double canals in mandibular incisors usually join 1 - 5 mm before apex
The root tip of lower lateral incisor often curves distally
Lower incisors of the same patient are always equally long
Lower central incisor is usually longer than the lateral incisor
Mandibular canine has always only one root
Mandibular canine may have two root canals that often join before apex
First mandibular premolar can have one canal
First mandibular premolar can have two canals
First mandibular premolar can have three canals
Two canals are more usual in lower second than in lower first premolar When two
canals are present in lower premolars, the files typically have easier access to
the lingual canal Molarization is more frequent in second than in first lower p
remolar
First mandibular molar has usually three or four root canals
First mandibular molar can have five root canals
Double canals in molar roots (except upper palatal roots) are always buccal and
lingual
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Curved root canals in lower molars curve only in mesio-distal direction
When an extra root is present in lower molars, it is usually mesial
Double canals in molar roots typically have anastomoses
Lower third molar can have up to four root canals
Evagination
True Evaginations are more frequent than invaginations False
Evagination can increase the risk for pulpal infection
Invagination
True Invagination can increase the risk for pulpal infection False
Invaginations occur only in maxillary lateral incisors
Invagination has always a connection to the root canal
A tooth with an invagination cannot be saved from pulpal necrosis
Invaginations cannot occur in mandibular teeth
Type III (three) invagination opens into periodontal tissue in mid-root
Type I invagination is the deepest of the four invaginations
Pulp stone
True A pulp stone is not an indication for endodontic treatment False
Pulp stones are found only in the pulp chamber Pulp stones are found only in the
root canal
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Pulp stones are not always round
Once diagnosed, pulp stones are always easy to remove
Pulp stones are much softer than dentine
Apex
True Apical foramen can be located at the radiographical apex False
Apical foramen can be located at the lateral root surface
One root canal has always only one apical foramen
Lateral canals end at the dentine-cement border
Root surface cement can be found a few micrometers inside the apical canal
Changes in morphology
True Reduction of pulpal space is always a consequence of a pathological phenome
non False
Calcification/obliteration of the pulp is an indication for endodontic treatment
Pulp chamber space reduction occurs mainly by the floor "growing up"
Pulp chamber space reduction occurs mainly by the roof "growing down"
In the apical 1 - 4 mm most canals are oval or round in cross section
Curved canals
True Ca. 10% of the canals are curved False
Canals curve only in mesio-distal direction
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Normal radiographs can detect mesio-distal and bucco-lingual curvatures equally
easily Sharp curves with a short radius are more difficult to instrument than ev
en curves with long radius S-shaped canal curves two times to the same direction
Palatal canal of upper molars often curves buccally
Double canals
True Double canals can join and separate again before apex False
Double canals always join before apex
Difficulty to see double canals in radiographs is because they are located bucco
-lingual Sudden disappearance of canal shadow in mid-root in the radiograph in a
strong indication of a double canal Depending on the angulation, periodontal li
gament space can cause canal-resembling vertical shadows on the root in the radi
ograph
Molarization
True Is equally common/rare in all premolars False
The frequency of molarization is ca 1%
Maxillary "molarization" premolars have two buccal and one palatal root
C-shaped canals
True C-shaped canal is a special feature of lower second molar In C-shaped canal
s the mesial canals join forming a C-shaped orifice in the pulp chamber Ca. 5 %
of lower second molars have a C-shaped canal system False
Taurodontism
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True In taurodontism, the pulp chamber is exceptionally deep
False
Taurodontic teeth are generally difficult to instrument
Taurodontic teeth are easier to root fill than normal teeth
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