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IntematiMMl EiuMmtk ^eanul (1990) 23,40-45

Root canal anatomy of mandibular second molars. Partn C-shaped canals

S. A. MANNING

Melbourne, Melbmme, Victoria, Australia

Department ofRestorative Dentistry, Faculty of Dental Science, Universityof

Summary. The root canal anatomy af 19 dibular second molars with C-^aped canals was investigated by rendering the roots transparent and allowing the canal system to be observed by black ink infiltration. The presence of three root canals was most frequent, and lateral canals were found in all roots. Transverse anastomoses were found in 15 of the 19 roots. The apical foramen was most commonly situated awayfrom the apex, and apical deltas were found in 16 of the 19 roots. The C- shaped canals were found more frequently in Asians than in other racial groups (P < 0.02). The formation of C-shaped roots and their racial predilection is discussed. A case report of the root canal treatment of a C-shaped canal is included and suggestions are made concerning suitable pro- cedures for use in root canal treatment of these complex canal systems.

Introduction

C-shaped

roots

and

root

canals

were first

docutnented in 1908 (Keith 1913) and 1911 (Keith & Knowles 1911), after examination of the skeletal remains of members of the Neanderthal race. The mandibular second molar showed a C-shaped root and, on sec- tioning, a C-shaped root canal (Fig. 1). The roots and canal anatomy of these teeth was

quite different to that found amongst so-called 'modem man'. These findings were cited

in support of the argument that Neanderthal

man was not a predecessor of modem man but

a collateral species that had become extinct

(Keith 1913). During investigations of the dentition of East Greenland Eskimos, C- shaped roots and root canals in mandibular second molars were observed (Pederson 1949). These findings disproved the theory that Neanderthal man was a species collateral to modem man, and it is now thought that the

Correspondence: Mr S. A. Manning, 1 Lister House, 11-^12 Wimpole Street, London W1M7AB, UK.

40

Neanderthal race were predecessors of the Mongoloid race (Tratman 1950), which includes Asian populations. Indo-European teeth were compared with teeth from Asians of Malaysia, and a number of differences were noted, including the find- ing of G-shaped roots and root canals in many mandibular second molars (Tratman 1950); also noted was a third root in mandibular first and third molars. Teeth with C-shaped roots were originally classified as taurodents. The term taurodontism was invented in 1913 (Keith 1913) to liken teeth with C-shaped roots to those seen in cud-chewing animals (taurus is the Latin word for 'bull'). The definition of teeth that fit this description has since been changed. The shape and number of roots is deter- mined by Hertwig's epithelial sheath, which bends in a horizontal plane below the ameio- cemental junction and fuses in the centre leaving openings for roots (Orban & Mueller 1929). Fused roots may form either by coalesc- ence due to cementum deposition with time, or as a result of failure of Hertwig's epithelial sheath to develop or fuse in the furcation area (Pederson 1949). Failure to fuse on the buccal aspect would result in formation ofa groove on the lingual aspect, and failure to fuse on the lingual would give a buccal grove. Fusion fail- ure on both the buccal and lingual aspects would result in formation of a conical or prism-shaped root. Investigations ofroot development in mouse molars showed that roots were formed by the meeting of dentine leaflets (Flschlschweiger & Clausnitzer 1988). The fusing of these leaflets was sometimes irregular, forming accessory catuls and occasionally, especially in the third molars, the leaflets failed to form. In the case of mandibular molars such failure of dentine leaflet formation resulted in a C-shaped root

A'

A'"

Root canals ofmandibular second molars

B

41

Fig. I. Description of Neanderthal and modem English mandibuiar second molars (Keith & Knowles 1919):

A, labial aspect of second lower molar of Brelade dentition (Jersey); A', its chewing surface; A", distal aspect; JK'", section of root; B, labial aspect ofthe same tooth of a modem English dentition; B', the distal aspect of the same. (This text is not covered by copyright and the authors are deceased.)

and canal. It was p<Ktulated that trauma, such as radiation or chemical interference, could cause this irregular fusion of leaflets (Fischlschweiger & Ciausnitzer 1988). The failure of leaflet formation, resulting in the development of C-shaped roots in the lower molars, is likely to be of genetic origin rather than being related to trauma, because of its previously documented racial predilection. C-shaped canals were first documented in the endodontic literature by Cooke & Cox (1979) in three case reports. Similar reports have since been published (Wells & Bemier 1984, Rabie 1985, Barnett 1986). Studies of the root canal anatomy of mandibular second molars from Japanese (Kotoku 1985), Chinese (Yang et at. 1988) and Hong Kong Chinese (Walker 1988) populations have found a high incidence of C-shaped roots and their canals. Investigation of the root canal anatomy of mandibular second molars likely to have orig- inated from Caucasians found that most were two-rooted, with an absence (Ainamo & Loe 1968, Tamse & KaflFe 1981, Vertucci 1984) or near absence (Weine et al. 1988) of C-shaped roots. The aim of this investigation of C-shaped canals was to provide further knowledge of their root canal anatomy to aid root canal treatment.

Materials and methods

One hundred and forty-nine mandibular second molars were collected and stored in

Table I. Number of teeth with different canal configurations in C-shaped roots

Canal tj'pe'

Cana! type

1

2-1

1-2-1

2

1-2

3

Number

3

4

1

1

3

7

•Canal type: 1, single canal; 2-1, two canals that join apically; 1—2—1, one canal that divides but rejoins apically; 2, two separate canals; 1-2, one cana! that divides apically; 3, three separate canals.

water immediately after extraction. Infor- mation concerning the patient's age, sex, race (Caucasian, Asian, Indian or other), and the side of the mouth from which the tooth originated, was recorded at the same time. Teeth were prepared and rendered trans- parent using the techniques described pre- viously by Manning (1990). The roots were examined with a stereo dissecting microscope (magnification x 20) and data were collected according to the following categories: canal type; apical foramen position; presence and position of transverse anastomoses; presence of a delta of canals at the apex.

Results

Of the 149 mandibular second molars collected, 33 had one root, and of these 19 had C-shaped canals. A variety ofcanal types were found within the G^haped canals, die most frequent havii^ three canals (Table I). Lateral canals were found in all 19 roots with C-

42 5'. A. Manning

Fig.

2.

.\n apicai delta.

shaped canals, while transverse anastomoses were found in 15 of these roots. The apicai foramen was positioned away from the apex in 17 roots, and apical deltas occurred in 16 roots. Figures 2, 3 and 4 illustrate some ofthe com- plex shapes of G-shaped root canals that were observed. C-shaped canals were found more frequently (P<0.02) in Asians.

Discussion The root canal anatomy of teeth with C- shaped canais has only been reported once previously (Yang et al. 1988), when first and second mandibular molars from a Chinese population were examined using a transparent technique (Robertson et al. 1980). C-shaped roots occurred in 2.3 per cent of first molars and 31.5 per cent of second molars. It was found that roots with separate canal orifices formed separate canals, and C-shaped orifices formed separate canals as well as true C- shaped canals. The latter, which were described as roots having a C-shaped canal from the orifice to the apex, occurred in 7.4 per cent of the sample of mandibular second molars. The observed variation in C-shaped roots described by Yang et al. (1988) is probably a

Fig. 3.

.\ type 1 canal .system with an apicai delta.

Fig. 4. Transverse anastomoses in the middle and apical third ofthe root.

result of age changes due to deposition of den- tine on the walls of C-shaped canals, forming separate canals.

Root canals ofmandikular

second molars

4 3

Fig. 5. Preoperative radiograph molar.

of lower left second

Fig. 6. x system.

t

r

it».u«iiw jji^pttFation ofthe canal

Fig. 7. Radiograph following rootfillingofthe type 1 C-shap^J

^i.».

.-ilii i-l.J ^tercha and AH26 cement.

In the present study, all root canals that conformed to the general structure of a ' C and occurred in a G-shaped root were described as C-shaped root canals, whether or not a separ- ate canal or orifice was observed. The classifi- cation system of canal types described in Part I (Manning 1990) was also used to describe the canal system in C-shaped roots. In a type 1 canal, a single canal is present from orifice to apex. A type 1 canal in a C-shaped root is a single C-shaped canal from orifice to apex. This has been described as a true C-shaped canal (Yang el al. 1988). Other more complex canal types were found in C-shaped roots; the type with three canals, which did not necess- arily combine, occurred most frequently.

The high frequency of transverse anasto- moses may be explained by the deposition of

dentine with time in a single canal, forming several canals with channels between them.

Additional precautions are necessary to clean the entire canal system effectively, especially if it contains necrotic debris and bacteria in the canal irregularities. The effec- tiveness of cleaning procedures in relation to C-shaped root canals has not been investigated to date. However, in single rooted teeth the use of sodium hypochlorite and EDTA irrigants, ultrasonic acti%'ation of the irrigants and calcium hydroxide-containing intracanal medicaments provide a cleaner and more fre- quently sterile canal sj'stem (Cameron 1983,

Bystrom & Sundqvist 1985, Bystrom

et al.

1985, Sjogren & Sondqvist 1987). The finding of lateral canals is more diffi- cult to explain. Lateral canals are probably

44

formed by the irregular fusing of dentine leaf- lets at the root formation stage. If one leaflet is missing altogether then the formation of dentine may be more irregular. Teeth with G-shaped canals requiring root canal treatment present a challenge to the clinician. Not only are normal procedures for canal preparation sometimes unsuitable, but the presence ofa high incidence of transverse anastomoses, lateral canals and apical deltas makes it difficult to clean and seal the canal system adequately.

Gase report A 30-year-old Vietnamese lady was referred to the Endodontic Unit of the Department of Restorative Dentistry, University of Melbourne, for a number of root canal treat- ments. The lower left second molar did not respond to vitality tests, but was without symptoms. The tooth was not tender to per- cussion or palpation and there were no perio- dontal pockets associated with it. Radiographic examination showed the presence of radio- paque material in the pulp chamber and extending some distance into the canals (Fig. 5). There was a slight widening of the perio- dontal ligament space in the apicai area, and the tooth appeared to have two roots, with one canal in each. A pulpless tooth with an infected root canal system was diagnosed and the treatment plan was to clean, shape, medicate and seal the root canal system. Because ofthe patient's race and the radiographic appearance ofthe tooth, a C- shaped canal was suspected. Radiographically, teeth with G^haped canals may appear to have two separate root canals and possibly two separate roots. An access cavity was prepared, a C-shaped canal was observed and a single canal form was

diag^nosed, as the canal could be probed all the

way round the circumference of the

working length was established, and the canal was cleaned and prepared using Hedstrom files, with 0.9 per cent sodium hypochlorite and EDTAC irrigating solutions. Ultra- sound' was used to activate the irrigants in the canal after hand preparation was complete.

'C . Th e

^ Cavitron

broach. Dentsply, York, PA, USA.

with

PR30

handpiece

and smooth

The canal was prepared over two appoint- ments, and an intracanal dressing of Pulpdent paste^, a non-setting calcium hydroxide paste, was used. The canal was filled using laterally condensed gutta-percha and AH26 cemenr (Figs 6 and 7).

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