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Analysis of C-shaped canal systems in mandibular second molars using

surgical operating microscope and cone beam computed tomography: A
clinical approach

Article in Journal of Conservative Dentistry · May 2014

DOI: 10.4103/0972-0707.131785 · Source: PubMed

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J Conserv Dent
v.17(3); May-Jun 2014
PMC4056395

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 Logo of jcdent
J Conserv Dent. 2014 May-Jun; 17(3): 238–243.
doi: 10.4103/0972-0707.131785
PMCID: PMC4056395
PMID: 24944447

Analysis of C-shaped canal systems in mandibular second molars using

surgical operating microscope and cone beam computed tomography: A
clinical approach
Sanjay Chhabra, Seema Yadav,1 and Sangeeta Talwar1
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.
Go to:

Abstract
Aims:
The study was aimed to acquire better understanding of C-shaped canal systems in mandibular second molar teeth through a clinical approach using
sophisticated techniques such as surgical operating microscope and cone beam computed tomography (CBCT).

Materials and Methods:

A total of 42 extracted mandibular second molar teeth with fused roots and longitudinal grooves were collected randomly from native Indian population. Pulp
chamber floors of all specimens were examined under surgical operating microscope and classified into four types (Min's method). Subsequently, samples were
subjected to CBCT scan after insertion of K-files size #10 or 15 into each canal orifice and evaluated using the cross-sectional and 3-dimensional images in
consultation with dental radiologist so as to obtain more accurate results. Minimum distance between the external root surface on the groove and initial file
placed in the canal was also measured at different levels and statistically analyzed.

Results:

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Out ofRoot
42 teeth,
canalmaximum
anatomy of number
the human
of samples
permanent
(15) belonged
teeth. to Type-II category. A total of 100 files were inserted in 86 orifices of various types of specimens.
Evaluation
[Oralof Surg
the Oral
CBCT MedscanOralimages
Pathol.
of 1984]
the teeth revealed that a total of 21 canals were missing completely or partially at different levels. The mean values for
the minimum
Vertuccithickness
FJ were highest at coronal followed by middle and apical third levels in all the categories. Lowest values were obtained for teeth with
Type-III
Oralcategory
Surg Oralat all
Medthree
Oral levels.
Pathol. 1984 Nov;
Reconstructing
58(5):589-99. Indian population history.[Nature.
2009]
Conclusions:
Reich D, Thangaraj K, Patterson N, Price AL,
Singh L
The present
Nature. study
2009revealed
Sep 24;anatomical variations of C-shaped canal system in mandibular second molars. The prognosis of such complex canal anatomies can
461(7263):489-94.
be improved by simultaneous employment
The evaluation of root canal morphology of modern
of the techniques such as surgical operating microscope and CBCT.
C-shaped root canals in mandibular
mandibular first molar in an Indian population second molars
Keywords:
in Cone beam
a Chinese computed tomography,
population.[Endod Dent C-shaped canal systems, Indian population, mandibular second molar, surgical operating microscope
Traumatol.
using spiral computed tomography scan: an in vitro
Go to:1988]
study.[J Endod. 2008]
Yang
Reuben ZP,J,Yang SF, Lin N,
Velmurugan YC,Kandaswamy
Shay JC, ChiDCY
Endod
INTRODUCTION Dent Traumatol.
J Endod. 2008 Feb; 34(2):212-5. 1988 Aug; 4(4):160-3.
Root canal configuration of the mandibular first
premolar.[J Endod. 1992]
The study of root
Baisden MK, canal anatomy
Kulild of teeth
JC, Weller RNin different racial groups is of paramount importance because of endodontic as well as anthropological significance.
Such knowledge
J Endod. 1992 Oct; 18(10):505-8. negotiation and subsequent management of root canal systems.[1]
can aid in localization,
Mandibular premolars: aberrations in pulp space
A lot of studies on root canal
morphology.[Indian systems
J Dent Res.have
1994]been carried out on the teeth from Caucasian populations. The Indian population is considered to be a hybrid of
severalSikri
ethnic groups
VK, Sikri P with characteristics of Caucasian, Mongoloid and Negroid races, which is generally referred to as the Dravidian group.[2] Similar studies
amongIndian
the Indian population are scarce.[3]
J Dent Res. 1994 Jan-Mar; 5(1):9-14.
A mandibular first molarcanal
A high incidence of C-shaped with systems
a C-shaped
amongrootAsian population has been reported.[4] Though this anatomical variant occurs mostly in mandibular second
molars,configuration.[J
it can also be seen Endod. 1988]
in mandibular first premolar,[5,6] the mandibular first molar,[7] the maxillary first molar[8,9] and the maxillary second molar.[10,11]
Bolger WL, Schindler WG
The main anatomical feature of C-shaped canal systems is the presence of a fin or web connecting the individual root canals. They may appear as a single
ribbonJshaped
Endod.opening
1988 Oct; 14(10):515-9.
with a 180° arc linking the two main canals. In general, this canal configuration is found in teeth with fused roots. The floor of the pulp
A C-shaped canal configuration
chamber is usually situated deep and may in aassume
maxillaryan first
unusual anatomical appearance. The prognosis of such cases can be improved by acquiring better
molar.[J Endod. 1984]
understanding of their anatomy with the use of sophisticated techniques such as surgical operating microscope and cone beam computed tomography (CBCT).
Newton CW, McDonald S
In viewJ Endod. 1984 Aug;
of the above, 10(8):397-9.
the present study aimed to evaluate C-shaped canal systems according to Min's method through a clinical approach using surgical
operating microscope in permanent mandibular second molar teeth. In addition, it was aimed to detect the number of canals and missed canals below the orifices
See
aftermore ... of K-files and to analyze the minimum thickness between the initial file and external root surface toward the groove at coronal, middle and apical
insertion
third levels using CBCT technique.

Go to:

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MATERIALS AND METHODS
Forty two freshly extracted mandibular second molar teeth having fused roots and longitudinal grooves were collected randomly from native Indian population
by taking prior detailed history. Specimens with any calcification, cracks, structural defects, extensive caries, restoration, endodontic treatment were excluded.
Teeth were stored in 10% neutral buffered formalin solution. Any attached soft-tissue and calculus was removed with the help of ultrasonic scaler (ARTP-6,
Bonart Med Technologies, USA) before the study.

The access to pulp chamber was made with diamond burs using high speed contra angle airotor hand piece (NSK, Japan) and water spray. Pulp tissue was
extirpated and chamber soaked in 5% sodium hypochlorite solution (Cmident India, Delhi) for 2 h. Pulp floor was examined under surgical operating
microscope (Carl Zeiss Surgical, Oberkochen, Germany) at ×16 magnification and classified according to Min's Method as under [Figure 1]:

An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g001.jpg
Figure 1

Classification of C-shaped canal systems (Min's method). Various types of pulp floors: Type-I (a), Type-II (b), Type-III (c), Type-IV (d)

Type I: Peninsula-like floor presenting a continuous C-shaped orifice [Figure 1a].

Type II: A buccal, strip-like dentin connection between the peninsula-like floor and the buccal wall of the pulp chamber separating the C-shaped groove
into mesial and distal orifices [Figure 1b].

Type III: A mesial, strip-like dentin connection between the peninsula-like floor and the mesial wall, separating the C-shaped groove into a small mesial-
lingual orifice and a large arc-like mesiobuccal distal orifice [Figure 1c].

Type IV: Non-C-shaped floors comprising of one distal canal orifice and one oval or two round mesial canal orifices [Figure 1d].

Subsequently, K-file (Dentsply Maillefer) with ISO size #10 or 15 was carefully inserted into each canal orifice until the tip of the file could be seen at the
apical foramen. The number of files inserted into the canal system was guided by the shape of orifice with a procedure akin to the clinical situation described by
Fan et al.[12] In case the two files were very close and binding each other from orifice to the apex, only one file was selected. The files so inserted were fixed in
root canals with wax on the occlusal surface.

All teeth were then subjected to CBCT scan (Carestream Inc., Rochester, NY) (80 kVp, 8 mA, 0.09 mm3 voxel size) and studied from orifice to the apex at an
Negotiation
interval of 0.09 mmofinC-shaped canalwith
consultation systems
dentalinradiologist so as to obtain more accurate results [Figure 2]. The number of the initial files in different canals and
mandibular second molars.[J Endod.
number of missed canals were analyzed using 2009]cross-sectional and 3-dimensional (3D) images of each specimen (Xelis Dental 3D-Infinitt Inc., Seoul, Korea).
Fan B, Min Y, Lu G, Yang J, Cheung GS, Gutmann
JL
An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g002.jpg
Open inJ Endod. 2009
a separate Jul; 35(7):1003-8.
window
Figure 2
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Negotiation of C-shaped canal systems. Type-I: a-c, Type-II: d-f, Type-III: g-i and Type-IV: j-l. (a-Coronal, b-Middle and c-Apical level)

The missed canals were classified as below:

1. Missed main canal-canal missed entirely from orifice to the apex [Figure 3] and

An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g003.jpg
Open in a separate window
Figure 3

Missed canals (complete): 3D sagittal views (a-d), 2D and 3D cross-section views-coronal (e and f), middle (g and h) and apical level (3i and j)

2. Partially missed canal-canals missed at any level between orifices to the apex [Figure 4].

An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g004.jpg
Figure 4

Missed canals (partial): 3D sagittal views (a-d), 2D and 3D sagittal and cross section views-coronal (e-g), middle (h-j) and apical level (k-m)

The minimum distance between the external root surface on the groove and the file placed in the canal was measured at coronal, middle and apical third
respectively using CS 3D imaging software.

The statistical analysis was performed using one-way analysis of variance (ANOVA) and t-test to determine whether significant differences in the minimum
distance existed among various types of pulp floors. All statistical operations were carried out through Statistical Presentation System Software (SPSS Version
8) for Windows (SPSS Inc, Chicago, IL).

Go to:

RESULTS
Classification of C-shaped canal system (Min's method)

Out of total 42 samples of teeth observed under surgical operating microscope, there were 33 teeth (78.57%) with C-shaped floor and remaining 9 samples
(21.43%) presented with non-C-shaped configuration (Type-IV). Among 33 C-shaped teeth, 7 (16.66%) samples depicted Type-I, 15 (35.72%) Type-II and
remaining 11 (26.19%) Type-III configuration [Table 1].

Table 1

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Classification of C-shaped canal system at pulp floor level (Min's method)

An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g005.jpg

Initial files in different orifices

A total of 100 files were inserted in 86 orifices of various types in all 42 specimens. Pulp chamber floors displaying Type-I configuration (continuous C-shaped)
had 11 files with 1 file (4 orifice), 2 files (2 orifices) and 3 files (1 orifice). Types-II, III and IV specimens had a total number of 39, 31 and 19 initial files
respectively.

Missed canals at various levels

CBCT scan images revealed that a total of 21 canals were missing completely or partially from orifice to the apex. 4 (19.05%) canals were found to be missed
completely (2 in Type-I, 1 each in Type-II and Type-IV). Seventeen canals (80.95%) were observed as partially missed canals at various levels. Two specimens
(4.76%) were observed with partially missed canals at coronal and middle third level (1canal each in Type-IV) and 15 (35.71%) at apical third level (2 in Type-
I, 11 in Type-II, 1 each in Types-III and IV) [Table 2].

Table 2
Missed canals at various levels

An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g006.jpg

Minimum thickness between initial file and external surface on the groove

The mean values for the minimum thickness between the initial file and the external surface of root on the groove were highest at coronal third followed by
middle and apical third levels in all the categories. Lowest values were obtained for teeth with Type-III category at all three namely coronal, middle and apical
third levels. On the other hand, the highest mean of values were calculated in Type-I category at coronal third level and Type-IV category in middle and apical
regions [Table 3].

Table 3

Minimum thickness between initial file and external surface of the groove

An external file that holds a picture, illustration, etc. Object name is JCD-17-238-g007.jpg

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ANOVA results showed that there was no significant difference among various categories but minimum thickness values at coronal third were significantly
higher than middle and apical third levels (0.05 > P).

Statistical analysis by t-test revealed that there was a significant difference between Type-I and Type-III category at coronal third level, Type-II and Type-IV
category at middle third, Type-III and Type-IV at both coronal and middle third levels.

Go to:

DISCUSSION
It is a well-established fact that the prevalence of C-shaped canals is race dependent and more common in Asians. Although this canal variant has been reported
to range from 2.7% to 8% in mixed populations[1,7,13] and 4.7-34.6% in Asian ethnic groups in the mandibular second molar,[4,14,15] a few studies are
available in literature illustrating the canal anatomy of this particular tooth from Indian population which is hybrid of several ethnic groups with characteristics
of Caucasian, Mongoloid and Negroid races (Dravidian group).[2] Therefore, the present study evaluated the root canal anatomy of C-shaped canal system in
mandibular second molars collected randomly from Indian population.

Previous studies have reported that there are chances of C-shaped canal system in teeth having fused roots and longitudinal groove. Sutalo et al. in their study
have reported that C-shaped canals occurred in 42.9% of their sample of 14 fused mandibular second molars.[16] In the present study, presence of C-shaped
canal system was observed in 78.5% of the total number of 42 mandibular second molars with fused roots. The highest prevalence of C-shaped canal
configuration observed in this study belonged to Type-II followed by Type-III, Type-IV and Type-I category, which was close to the results obtained by Min et
al.[17] and Fan et al.[12]

It has been shown that the prevalence of detection of additional canals increased to 93% with an experienced clinician working on an operating microscope.[18]
Matherne et al. in their study have reported the superiority of CBCT over other diagnostic methods and suggested the simultaneous use of the operating
microscope and CBCT.[19] Although µCT has been compared to CBCT and reported to be more precise with up to 2 µm resolution,[20,21] however, the
limitations include amount of time required and its usage restricted to only ex vivo studies.[22,23] Accuracy of CT imaging is well-documented.[24] Major
advantages of CBCT over conventional CT scans include X-ray beam limitation,[25] rapid scan time[26] and effective dose reduction.[27] The approach offers
a non-invasive reproducible technique for 3D assessment of root canal systems and aids the clinician to visualize the internal anatomy precisely.[28]
Furthermore, use of this technique has been firmly advocated in the recent past for diagnosis of root canal aberrations.[29] Hence, 3D imaging may be an
interesting method for the study of canal configuration of the C-shaped teeth and in general for the teeth with morphological anomalies.[30] However, CBCT
makes use of ionizing radiation. Therefore, it is advised to keep the patient's exposure to radiation as low as reasonably achievable.[31] In view of the above, the
simultaneous use of operating microscope and CBCT was preferred to analyze the specimens.

A study by Weine et al. suggested the role of placing K-files in the canals to determine canal configuration of the mandibular second molar.[32] Jerome in the
year 1994 supported the fact that deep orifice preparation and careful probing with small files may facilitate a more accurate characterization of the C-shaped
canal system. Present study design also explored the canal anatomy below the orifices through insertion of small files.

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There were a total number of 100 initial files inserted in 86 orifices of various shapes, which is in accordance with the fact that number of canals below the
orifice varies from coronal to apical level in C-shaped canal system. However, in a study by Fan et al.,[12] a total number of 132 initial files could be inserted in
83 orifice. The difference could be attributed to various factors such as age changes in the pulpo-dentinal complex, sample source, size and method of
examination.

It was observed that a total of four canals were missed completely (2 in Type-I, 1 each in Types-II and IV) mainly due to dentin fusion or calcification which
prevented the initial files from entering the canals. Although, bifurcation of canals was the main reason behind the partially missed canals specially at apical
third region, one specimen showed merging of canals immediately below the orifice in coronal third level and represented as partially missed canal in Type-II
configuration. This explained the reason of insertion of 23 initial files in 24 mesial orifices in the same category. Majority of the partially missed canals were
detected at apical third level which suggests that clinically it is more difficult to clean, shape and obturate this area in C-shaped canal system. Employment of
various methods such as use of sonics and ultrasonics, light activated disinfection, careful exploration by extravagant use of small files may help in achieving
more success in such cases.

Clinically, it is extremely important to perform root canal instrumentation cautiously during treatment as a lot of variation and anatomical diversity pertaining to
the shape and thickness exist at each level in teeth with C-shaped canal system. One should be aware of these danger areas so as to avoid the perforation during
treatment of such canal system. The lowest values of mean thickness obtained in the present study belonged to Type-III category at different levels and in apical
region for all categories which suggests that teeth with Type-III category and apical region are at a risk of strip perforation.

Caputo and Standlee suggested that there should be at least 1 mm of sound tooth substance present around a post in order to resist root fracture.[33] The mean
of values obtained in this study for all types was less than 1 mm at middle and apical regions. Hence, a root canal post is not advisable for such a root canal
system. A “corono-radicular”
Root amalgam,
canal anatomy of the human preferably
permanent dentin-bonded,
teeth. or resin composite might be a better choice as the core or as the final restoration for C-shaped
canal system.[34]
[Oral Surg Oral Med Oral Pathol. 1984]
Go to:Vertucci FJ
Oral Surg Oral Med Oral Pathol. 1984 Nov;
58(5):589-99.
CONCLUSION
A mandibular first molar with a C-shaped root
configuration.[J Endod. 1988]
Bolgerstudy
The present WL, revealed
Schindleranatomical
WG variations of C-shaped canal system in mandibular second molars. Clinically, when a C-shaped canal system is observed,
J Endod. 1988 Oct; 14(10):515-9.
one cannot assume that such a shape continues throughout its length. The prognosis of such complex canal anatomies can be improved by simultaneous use of
Identification
sophisticated
"C"-shaped of a configuration
techniques
canal C-shaped canal
of system
such as surgical in microscope and CBCT. More studies in future are required employing various other techniques to develop
mandibular
operating
mandibular
effective
second
methods second
permanent
to clean molars. Part
molar.[Coll III. Anatomic
and shape Antropol.
such canal1998]
system.
features
Sutalo J,revealed
Simeon P, byTarle
digital
Z,subtraction
Prskalo K, Pevalek J,
radiography.[J
Go to:Stanicić Endod.M2008]
T, Udovicić
Fan
Coll Antropol. Gutmann
W, Fan B, 1998 Jun;JL, Fan M
22(1):179-86.
J Endod. 2008
canalOct; 34(10):1187-90.
Footnotes
C-shaped system in mandibular second
molars Part III: The morphology of the pulp
See more ... floor.[J Endod. 2006]
chamber

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SourceEffect
Minof Support:
Y,ofFan
magnification
B, Nil
Cheung GS,on locating
Gutmann theJL,
MB2Fancanal
M
J Endod.
in maxillary
2006 molars.[J
Dec; 32(12):1155-9.
Endod. 2002]
Conflict of Interest:
Negotiation
Buhrley LJ, of None declared
Barrows
C-shapedMJ,canal
BeGolesystems
EA, Wenckus
in
mandibular second molars.[J Endod. 2009]
CS
Go to:JFanEndod.
B, Min2002Y, Lu
Apr;
G,28(4):324-7.
Yang J, Cheung GS, Gutmann
JL of cone-beam computed tomography to
Use
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