Bassam - The Root Canal Morphology

THE ROOT CANAL MORPHOLOGY
Endodontics
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ENDODONTIC ANATOMY We often think of pulp canal anatomy as a simple tapering, tunnel-like system, misled by the two dimensional view of a radiograph. Actually, it is often quite complex. We must be able to visualize root canal systems in realistic, three-dimensional terms, in order to better perform endodontic therapy. Canals can often have different shapes at different levels. ENDODONTIC ANATOMY OBJECTIVES Understand the patterned endodontic anatomy of each tooth very well Realize that important, common anatomical variations exist also Know how to diagnose and manage these Adopt a detective-style curiosity for each endodontic case When you expect to find a single canal within a root, you will likely stop searching for more canals (or additional anatomy) after your expectation is met Understand three-dimensional, endodontic anatomy concepts Apply these during canal debridement and obturation It is useful to examine extracted teeth Be continuously vigilant and suspicious for evidence suggesting anatomical variation. Recognizing radiographic clues for additional canals is essential, as is the ability to apply the buccal object rule clinically. Apical anatomy must also be appreciated. The apical constriction (occasionally referred to as the minor diameter) is rarely located at the radiographic apex; rather the constriction averages 0.89 mm short of the apex (at the DCJ). This position can vary greatly however, between 0-3 mm. Many anatomical studies confirm the distance 0.5-1 mm from the apex, as an empirical guide for canal debridement and obturation. WEINE CLASSIFICATION We have several systems for communicating the canal configuration within a root. A very well known and simple system, proposed by Dr. Weine, is shown here:
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III
IV
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Type I - one orifice/one canal/one foramen Type II - two orifices/two canals/one foramen Type III - two orifices/two canals/two foramina Type IV - one orifice/two canals/two foramina
MORPHOLOGY OF THE ROOT CANAL SYSTEM AND ACCESS GUIDELINES, TOOTH BY TOOTH CONSIDERATIONS External anatomy-crown/root Number of roots/canals Canal configurations Root curvatures/dilacerations Position of foramen/foramina Lateral/accessory canals
1- MAXILLARY
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MAXILLARY CENTRAL INCISOR

The root canal morphology of the upper central incisor is optimal from an endodontic 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. From a proximal view, the long axis of the canal meets the incisal area at the incisal edge or slightly palatally. This means that, while access to the pulp chamber 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 canals in lower incisors.
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Central Incisor Average length - 22.5 mm Morphology - Type I. Canal is slightly triangular at the cervical area, gradually becoming round in the apical area. Root may have a slight distal and lingual curvature. Access - triangular (if pulp horns present) lingual access just above cingulum; lingual shoulder may prevent direct access and should be removed.
MAXILLARY LATERAL INCISOR

The upper lateral incisor has both similarities and differences to the upper central incisor. It has, practically always, one canal with an oval or round cross-section. However, the apical canal often curves distally, which makes the preparation 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
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the palatal roots of upper molars, which appear straight radiographically but typically have a buccal apical curvature.
Lateral Incisor : Average length - 22.0 mm Morphology - Type I. Canal is ovoid in the cervical area and round in the apical area. Root apex commonly has a distal dilaceration. Access - triangular to ovoid; beware of dilacerations and dens in dente.
MAXILLARY CANINE
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 crosssection. The root canal is typically 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
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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 careful assessment of root canal anatomy are essential in order to avoid complications in therapy.
Canine
Average length - 27.0 mm Morphology - Type I. Canal is ovoid in shape. Root can curve in any direction in the apical third, but is usually to buccal. Apical foramen frequently not located at anatomic apex. Access - ovoid above cingulum; beware of buccal apical dilaceration.
MAXILLARY FIRST PREMOLAR

The upper first premolar normally has two roots and two root canals. Occasionally 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 in the mesio7|Page http://dentalbooks-drbassam.blogspot.com/
distal or bucco-palatal dimensions. Rarely, the upper first premolar has three roots and three root canals (= molarization) as with upper molars, although the roots are much finer and smaller.
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First PREMOLAR :
Average length - 20.5 mm Morphology Carns EJ, Skidmore AE. Configuration and deviation of root canals of maxillary first premolars. One canal - 9% Two canals - 85% Three canals - 6% One root - 37% Two roots - 57% Three roots - 6%
Access - oval preparation with greater extension to buccal and lingual; beware of mesial concavity and potential for perforation
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MAXILLARY SECOND PREMOLAR

The upper second premolar has a single root more often than the first premolar. 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.
Second PREMOLAR :
Average length - 21.5 mm Morphology Vertucci FJ, Seelig A, Gillis R. Root canal morphology of the human maxillary second premolar 10 | P a g e http://dentalbooks-drbassam.blogspot.com/
One canal/one foramen - 48% Two canals/one foramen - 27% Two canals/two foramina - 24% Three canals - 1% Access - ovoid
MAXILLARY FIRST MOLAR

Maxillary molars have from one to three roots and from two to four root canals. From an occlusal view the pulp chamber is situated rather mesially, which has to be taken into account when cutting the access cavity. The upper first molar 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 three or four root canals. Dentists are quite familiar with the mesiobuccal, distobuccal and palatal canals, but not with the fourth canal, which is known as the mesiocentric or mesiopalatal, mb2 or accessory mesiobuccal canal. This fourth canal is usually difficult to find just by clinical inspection and is not apparent in the radiograph. However, finding all canals is necessary for successful therapy. The distobuccal canal is often easy to locate and instrument. It is typically rather straight or curves only slightly mesially, or sometimes distally. The palatal canal always looks straight radiographically but often has a buccal curvature. 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 file will still appear to be in the canal but in reality it is only superimposed onto 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 literature. The mesiobuccal root is the most challenging to treat. The root is usually curved all the way to the apex, which increases the risk of tip perforation and strip perforation. The distal surface of the root is concave which increases the risk of strip perforation. 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 looked for with suitable instruments. The orifice is usually located 1 - 3 mm palatally from the mesiobuccal canal. In most cases the mesiopalatal canal joins the mesiobuccal canal before the apex.
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First molar Average length - 21 mm Morphology - Usually 3 rooted with 3-4 canals. Palatal canal often curves to buccal direction in apical third. Second MB (MB 2 ) canal orifice usually located between the primary MB (MB 1 ) canal orifice and the palatal root (1.8 mm) and may exit 2 mm from the root end. MB 1 canal is the straighter canal.
Neaverth EJ, Kotler LM, Kaltenbach RF. Clinical investigation (in vivo) of endodontically
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Mesiobuccal root: One canal - 20% Two canals - 77% Three canals 3% One foramen 36% Two foramina 62% Three foramina 2% Higher occurrence of MB 2 discovery in ages 20-40 Access - Rhomboidal (heart shaped) to facilitate locating MB 2 . The MB 1 1 canal orifice typically exists directly beneath the MB cusp tip. The DB canal orifice usually lies below the mesial cuspal slope of the DF cusp.
MAXILLARY SECOND MOLAR

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 found (two canals in the mb root). A typical upper second molar resembles the first molar, the difference being that the orifices of the mb and db canals are closer 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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Second Molar
Average length - 20 mm Morphology - usually 3 rooted with 3 canals but can exhibit a 4th canal. Three orifices may be configured in a straight line. Pomeranz HH, Fishelberg G. The secondary mesio-buccal canal of maxillary molars. Mesiobuccal root: One canal - 63% Two canals - 37% Type II - 13% Type III - 24% Access - quadrilateral (to locate 4th canal). The DB canal orifice typically exists beneath the central occlusal pit (unlike in the first molar).
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MAXILLARY THIRD MOLAR

The upper third molar is often a "reduced version" of the second molar. There are usually two or three root canals, and the orifices of the buccal canals may be very close to each other. Some upper third molars have a root canal anatomy 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 also occur in the second molar). Some upper third molars have additional roots and/or root canals.
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MANDIBULAR
MANDIBULAR CENTRAL INCISOR

The mandibular central incisor always has one root, but often (20 %) has two root canals. Usually (75 %), the two canals join before the apical foramen. The 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 lingual 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 canal(s) of the lower central incisor is almost always straight unlike in the lower lateral incisor, where the root tip and canal often curve sharply distally.
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MANDIBULAR LATERAL INCISOR

The lower lateral incisor is quite similar to the lower central incisor. However, the lateral incisor is approximately 2 mm longer and the apical root and canal often curve distally, which must be taken into consideration during instrumentation.
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Central/lateral incisors
Average length 20.5 mm Morphology - Canal shape can be broad bucco-lingually and ribbon shaped. Frequently, there is a dentinal bridge separating the buccal and lingual canals. Benjamin KA, Dowson J. Incidence of two root canals in human mandibular incisor teeth. Oral Surg 1974;34:122-6. One canal/one foramen - 57.3% Two canals - 42.7% Type II - 41.4% Type III - 1.3% Thus, 98.7% have a single foramen at apex Access - triangular to ovoid. Lingual shoulder of dentin may hide lingual canal. Extend access to lingual and incisal. Mesio-distal thinness of root invites perforations.
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MANDIBULAR CANINE
The mandibular canine is the second longest tooth in the dentition, it is only 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, quite large and usually does not cause any technical problems during instrumentation. 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 incisal 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 the 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 the canal curve distally and/or labially.
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Canine
Average length - 25 mm Morphology - Canal is ovoid at cervical and round apically from midroot. Lingual dentinal shoulder may be present. Vertuccci FJ. Root canal anatomy of the mandibular anterior teeth One canal/one foramen - 78% Two canals - 22% Type II - 16% Type III - 6% Access - Ovoid in shape.
MANDIBULAR FIRST PREMOLAR

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 quite easy to instrument, the canal is oval in cross-section and seldom curves severely. When there are two canals, the files usually easily find the buccal canal, while the lingual canal often requires bending of the instrument tip. Molarization in the lower first premolar is very rare.
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First premolar
Average length 21.5 mm Morphology - Second canal may project off primary canal (Type IV) sharply to lingual. Broad B-L canal space tapers to a small, ovoid shape in the apical area. Vertucci FJ. Root canal morphology of mandibular premolars. One canal - 75% Two canals - 24% (Type IV) Three canals - 1% Access - ovoid access centered over central groove. Caution re: coronalradicular long axis disagreement, and risk of facial surface perforation
MANDIBULAR SECOND PREMOLAR

The mandibular second premolar resembles the first premolar, but the lingual canal is present only occasionally. Instead, molarization is more frequent than in the first premolar, yet still quite rare. The root canal is oval in cross-section and rather straight with only a slight distal curvature in some canals.
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Second Bicuspid
Average length - 22.5 mm Morphology - The canal shape and variability can mimic that of the mandibular first bicuspid.
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Vertucci FJ. Root canal morphology of mandibular second premolar. One canal - 97.5% Two canals - 2.5% (Type IV) Access - ovoid access, with a little more of a M-D extension than the mandibular first bicuspid.
MANDIBULAR FIRST MOLAR

The mandibular first molar is perhaps the most frequently endodontically treated 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 two in the distal root. The Distal canal(s) is normally straight all the way to the apex, oval or flattened in cross-section, but quite large, which makes instrumentation easy. Often the most apical 1 - 2 mm of this canal curves up to 90 degrees distally, but this is seldom a clinical problem. The distal canal may also curve mesially, but the curvature is not sharp and usually remains easy to instrument. 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 whole length, and the curvature is typically greatest in the apical region. The canals curve distally, but they also curve buccally or lingually at the same 14 time. Bucco-lingual curvatures are not readily seen in the radiograph, which emphasizes the importance of the dentist's knowledge of possible variations in canal 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 the pulp chamber floor. Both distal and mesial canals can join before the apex. This is important to detect before obturation, to gain optimal results. Mandibular first molars with two canals are rare. Usually, finding only two canals indicates that the mesiobuccal canal has not yet been located.
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First Molar Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first molar. Oral Surg 1971;32:778-84. Two canals - 7% Three canals - 64% Four canals - 29% Mesial root - Type III - 60% Type II - 40% Distal root - Type II - 60% Type III - 40%
Access - trapezoidal access is recommended to locate all the canals. The MB canal orifice typically exists directly beneath the MB cusp tip, whereas the ML orifice is typically more centered on the occlusal table.
MANDIBULAR SECOND MOLAR

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 second molars have a special root canal anatomy; two or
more of the canal openings in the pulp chamber floor join to form a C-shaped groove. This has occasioned the name "C-shaped canals". Usually the mb or ml canal joins the distal canal, sometimes both mesial canals join the distal canal. Deeper in the root there sometimes are further ramifications.
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Second Molar Average length - 20.0 mm Morphology - Usually 2 roots with 3 canals. MB and ML canals more often merge. Mesial roots have a gentle distal curvature. Watch for C-shaped canal configuration. Canal configuration of the mandibular second molar using a clinically oriented in vitro method. One canal - 1.3% Two canals - 4.0% Three canals - 81.0% Four canals - 11.0% C-shaped canal - 2.7% Mesial Root Type I - 4% Type II - 52% Type III - 40% Distal Root: Type I - 85% Type II - 9% Type III - 1% Access trapezoidal, similar to mandibular first molar. Tooth most susceptible to functional crown/crown-root fracture. Cooke HG, Cox FL. C-shaped canal configurations in mandibular molars. A single, ribbon-shaped orifice with a 180o arc Second molar incidence - 8%
Canal morphology can be highly variable Usually begins at ML line angle, and extends around the buccal aspect to the distal Inner arc of C oriented lingually
The configuration of C-shaped canals changes at different levels along the root. This irregular and changing configuration makes these systems extremely difficult to debride and obturate. Copious irrigation with NaOCl, placement of interim Ca(OH) 2 and the use of sonic/ultrasonic debridement can help. Consider extractionreplantation therapy in refractory nonsurgical cases. Access - generally rectangular or oval, depending on configuration found
MANDIBULAR THIRD MOLAR

The lower third molar resembles the first and second molars, but the probability of teeth with four canals is again less and of teeth with two canals greater. 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

Dentine structure:
Evaginations:
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Evaginations are morphological anomalies where the pulp has made an extension towards the tooth surface. Dentine and enamel follow the pulpal extension which may be seen as an extra cusp or enamel pearl on the tooth surface. Evaginations are rare, and are usually seen in lower premolars. They typically cause occlusal interference. If eliminated by grinding in one appointment, pulpal exposure and damage will follow. Gradual grinding of 0.1 mm per month before occlusal contact is established may help to avoid pulpal inflammation.
Invaginations:
Invaginations are shallow or deep developmental cavities in tooth crowns, covered partly or totally by enamel walls. Their frequency has been reported to be between 0.1 and 10%. They are most frequent in upper lateral incisors, but can be found in any tooth. Invaginations are divided into four main types (see drawing). Invaginations often increase the risk of pulp infection, and they should be well 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.
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Pulp stones :
Pulp stones are calcified structures that may form within vital pulpal tissue They 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. Size and morphological features have been used for classification of intrapulpal calcifications, but classifications have little significance in endodontics. Previously, 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 reasons, pulp stones may complicate gaining access to the root canals or obtaining correct working length. Use of ultrasound often helps to remove pulp stones during root canal preparation.
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TABLES
Table 1
The average length of teeth in the upper jaw varies from 19mm to 26 mm. The canine is the longest tooth in the upper jaw followed by the central incisor. The central 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 premolar and molar regions have curved roots. Double canals are practically never found 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 canine is the longest tooth in the lower jaw and only slightly shorter than the upper canine. The central incisor is usually straight, down to the root tip. Most lower premolars and canines are also quite straight, while lateral incisors and molars typically have curved roots. All teeth in the lower jaw can have double canals. Double canals are located in the bucco-lingual direction. In the molars, double canals are typically found in mesial canals, but may be also found in distal canals, particularly in the first molar.
Terminology
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Apical canal
Apical preparation assumes a key role in successful therapy of apical periodontitis, because it is the bacteria, particularly in this area of the root canal, that are responsible for the development of the periapical lesion. The technical goal of treatment of apical periodontitis is to reach the apical constriction and all regions of the root canal system with preparation instruments, intracanal medicaments and the root filling. If this can be done successfully, prognosis of the therapy is good. Variations in apical root canal morphology, however, may complicate 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 cannot 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 because of secondary dentine produced by odontoblast cells in the pulp. Also the crown becomes shorter because of occlusal wear. It is important to understand the effects 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 treatment. 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 practice, however, many root canals are flattened and asymmetric in shape. The cross-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 round. 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.
Curved canals
Up to 90% of all root canals are curved to some degree. Canal curvatures are a challenge 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 bucco-lingual dimension, which can only occasionally be detected in radiographs. For optimal clinical results it is important to detect all curvatures in order to select the correct instruments and avoid complications. The type of curvature dictates the ease or difficulty of instrumentation. Even curvatures 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 always very demanding and easily result in transportation, ledges and even perforations. Even up to 90% of all root canals are more or less curved. Canal curvatures are a challenge to preparation and can cause different kinds of technical complications (see preparation of curved canals). Canals that curve in the mesio-distal direction are usually easily detected in radiographic pictures. However, many canals curve also in the bucco-lingual direction, which can only occasionally be detected in radiographs. For optimal clinical results it is important to detect all curvatures in order to select the correct instruments and avoid complications. The type of curvature dictates the ease or difficulty of instrumentation: even curvatures 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 always very demanding and easily result in transportation, steps and even perforations.
Double canals
Double canals means two canals in one root. Double canals can be separate from the 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 before the apex. Double canals are almost always situated as buccal and lingual canals in the root, which makes their detection in radiographs difficult. However, knowing the possibility of their existence together with careful analysis of radiographs and clinical examination helps to find double canals. From the clinical 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 palatal 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 first 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
Double canals are almost always located bucco-lingually, so that they may be difficult to detect in radiographs. However, a reliable way to identify double canals is to follow the radiographic shadow of the canal; if the shadow suddenly almost disappears, it is a strong indication of canal ramification. Taking the radiograph 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
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Sometimes premolars have a root morphology similar to that of molars, a phenomenon known as molarization. Thus lower premolars will have a mesial and a distal root just like lower molars, and upper premolars have two buccal roots and one palatal root just like upper molars. The crowns in these premolars with molarization usually look quite normal, particularly in the upper premolars. Sometimes there may be an extra cusp present and the crown may be slightly longer mesio-distally. The frequency of molarization in premolars is approximately 1%. In the maxilla 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, but mandibular premolars can sometimes have only two.
C-shaped canals
The C-shaped canal is a special feature of some lower second molars. Approximately 1% of lower second molars have C-shaped canals. The name comes from the appearance 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 letter 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 area near the pulp chamber floor. The canals may later, closer to apex, separate again to leave the tooth via separate foramina.
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Taurodontism
Taurodontism is a special anatomic variation occasionally seen in molars. The pulp chamber continues apically far beyond the normal height: often the root canals start only a few millimeters before the apex. Taurodontism makes root canal treatment more difficult because localization of canal orifices is more complicated. In cases of pulpitis, control of bleeding can also take a lot of time and effort compared to teeth with normal anatomy.
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CORONAL ACCESS PREPARATION
In the scope of endodontic treatment, the removal of pulp contents, the cleaning and shaping of the chamber and root canal system, and subsequent obturation, (the sum total of our major objectives in endodontics), totally depend on the initial step of proper coronal access preparation. The cleaning, shaping, and filling of the canal system can only be accomplished well by having an adequately designed access through which to accomplish our task. A good access preparation gives us the ability to better visualize the internal anatomy, with any variations in orifice or canal configuration. It allows instruments to reach the apical region of the canal with minimal binding and stress, and allows placement of instruments and obturation materials in a faster, more efficient manner. Access shape is dictated by canal configuration and must be modified to allow unencumbered debridement, with straight-line access as deep into the canals as possible. Access preparation is a dynamic process. The final outline form of the access cavity will evolve and enlarge as debridement progresses, and often is not established until a significant amount of preparation has occurred. MAJOR OBJECTIVES OF THE ENDODONTIC CORONAL ACCESS PREPARATION Combined with radicular access procedures, coronal access should help to establish unimpeded, direct-line access to the apical foramen. You should balance the need for visual, instrument and material access with the need for conservation of tooth structure Straight-line access Affords good vision of pulp chamber and canal orifices Reduces coronal curvature for easier debridement and obturation Allows improved instrument control and reduces canal transportation Make access preparation confluent with the canal orifices Create divergent walls for a positive seat of the temporary restoration and to improve orifice visualization Debride the entire contents of the pulp chamber Removal of pulp horns In anterior teeth, undebrided pulp horn tissue leads to coronal discoloration
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FACTORS TO CONSIDER PRIOR TO CORONAL ACCESS PREPARATION
Shape of the tooth Position of the tooth Rotation Tipping Radiographic chamber and root morphology Calcifications Unusual variations Depth of necessary bur penetration can be judged by measurements made from pre-operative radiographs (BWXRs are more accurate), and by viewing the bur held over the radiographic crown. A preoperative radiograph taken by you is critical to assess any damage created during previous endodontic procedures, or to detect other dental changes which may have occurred since the previous radiograph was made.
STEPS IN CORONAL ACCESS PREPARATION

Consider use/nonuse of rubber dam. Most clinical situations are amenable to rubber dam use, with the application of some ingenuity. Oftentimes, the RD should not be placed until the pulp chamber is accessed. The RD impedes visualization of the entire crown, exposed roots, radicular eminences and adjacent teeth. With the RD removed, long-axis orientation appreciation is greatly enhanced. Examples of instances to consider RD nonuse during access include: prosthetic coverage, altered axial inclination, crown-root axis deviation, calcified anterior teeth and risk of tooth misidentification. Reduce occlusion (if necessary). This step may reduce post-operative pain in teeth already sensitive to biting or percussion. If occlusion is relieved after working lengths have been established, reference areas may be altered and working lengths rendered inaccurate. Remove caries, unsupported enamel and defective restorations: Removes source of bacteria Reduces coronal leakage Allows visualization of fractures or weakened tooth structure Occasionally required to determine restorability
Facilitates endodontic access in certain situations It may be necessary to place a band and temporary restoration prior to making endodontic access, in order to provide a salivary/irrigant seal or to retain the RD clamp Establish defined reference areas for files. If necessary, prepare flattened reference areas prior to or in conjunction with making access. Initial penetration should be directed towards the greatest chamber dimension or the largest canal. Bur choices vary, and commonly include high speed tapered fissure, straight fissure, or round burs. Consider the material you are penetrating. The high speed 1958 (rounded end, fine crosscut design) is a practical access bur for most teeth, although too large for some mandibular incisors (#2 round bur more appropriate). A round diamond is quite useful in penetrating through porcelain, while minimizing the potential for porcelain fracture. Create an initially undersized, geometrically appropriate access cavity outline, while visualizing the pulp chamber space as you prepare. Once the chamber roof has been penetrated (as sometimes detected by the loss of resistance and a "dropping in" of the bur into the chamber), chamber "unroofing" procedures follow. Dentin cutting is performed only on the outward stroke, as detected by a bur catch. This protects the pulpal floor and limits over-reduction of tooth structure. Most texts recommend a slow speed round bur but individual choices vary between high and low speed as well as bur design. Caution: teeth having vertically compressed, calcified pulp chambers (due to age or pulp stressors) may not provide the dropping in sensation experienced in larger pulp spaces. This increases the potential for over-penetration, and gouging or perforation. Once the unroofing procedure is complete (no catch on the outward stroke), perform a gross chamber debridement and explore/locate all canal orifices. Delay further access enlargement or refinement until this step is complete.
CHAMBER DEBRIDEMENT
Slow speed round burs or spoon excavators Full-strength sodium hypochlorite Removes debris (and reduces potential for its apical extrusion) Improves visualization of orifices, pulp horns, remaining chamber roof Removes calcifications (and reduces potential for canal obstruction) Decreases bacterial contamination of canal system
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LOCATION OF ORIFICES Use endodontic explorer and #8 or #10 endodontic files Insert small files into canals observe angle of instrument exit Follow the dentin "roadmap" to interconnecting orifices on the chamber floor
REFINEMENT OF CORONAL ACCESS

Use Endo Z bur (safe-ended) or safe-ended, diamond bur Goals = straight-line access, confluent chamber/canal walls Match access extensions with canal orifices Anticipate multiple re-entries of files and placements of gutta-percha Make necessary access extensions as soon as the need is recognized! Mentally envision the final access design early Access refinement may occur throughout the endodontic debridement process If you have repeated difficulty placing a file into an orifice, it is most likely true that you need to modify the access preparation immediately.
RADICULAR ACCESS Please refer to your Endodontic Cleaning and Shaping lecture handout and notes. CALCIFIED CHAMBERS AND CANALS As the pulp chamber and canals calcify, the pulp chamber becomes shortened vertically and the distance between the canal orifices decreases Aids in locating calcified canals: Aim for largest canal first Evaluate depth of penetration using periodontal probe Use caution not to over-penetrate and perforate Frequently wash/dry chamber floor to enhance visual appreciation of various color shades
Use magnification and fiberoptic transillumination Orifices show as dark dots Make check radiographs of coronal access as needed Use sharp endodontic explorer (D-16) If one canal is discovered but not identified, place a file Observe exit angle of instrument Make check radiograph(s) (apply buccal object rule) Follow the dentin roadmap (chamber floor dentin color changes) This interconnects orifices Use long latch round (#1 or #2) burs or Mueller burs Look for dust spots A combination of adjuncts is often required COMMON ERRORS/PITFALLS OF CORONAL ACCESS PREPARATION Too far lingual in lower molars Common when molars are tipped lingually Too far mesial in upper and lower molars Common when molars are tipped mesially Over-reduction (gouging) at chamber floor level Insufficient extension over D root in mandibular molars Final access form should usually be trapezoidal, not triangular Insufficient extension over MB canal in mandibular molars Access extension should usually approximate MB cusp tip Insufficient extension over MB 1 canal in maxillary molars Access extension should usually approximate MB cusp tip Insufficient extension over MB 2 canal in maxillary molars Final access form should usually be rhomboidal, (or heart shaped), not triangular
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Searching for the maxillary second molar DB canal orifice in the wrong location Usually lies beneath the central occlusal pit Insufficient F-L extension in bicuspid teeth Insufficient incisal extension in anterior teeth Too deep facially in anterior teeth Leaving a lingual shelf in anterior teeth
CONSEQUENCES OF CORONAL ACCESS ERRORS

Incomplete removal of pulp tissue or caries Coronal discoloration Mutilation of coronal tooth structure Missed, untreated canals Coronal or radicular perforation Canal transportation Inadequate canal system debridement and obturation Post-treatment discomfort Treatment of wrong tooth RCT failure
FINAL CORONAL ACCESS CONSIDERATIONS
Start small, find the canals, and the access will evolve and enlarge as debridement progresses. Spend the time needed to develop a proper access and it will save twice the time
during canal debridement and obturation. Access preparation is a dynamic process. The final outline form of the access cavity is often not established until a significant amount of canal preparation has occurred. Do not operate through insufficiently sized access openings. Inappropriate efforts to conserve tooth structure oftentimes lead to RCT failure and complications.
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Bassam - The Root Canal Morphology

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Bassam - The Root Canal Morphology

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THE ROOT CANAL MORPHOLOGY

MAXILLARY CENTRAL INCISOR

MAXILLARY LATERAL INCISOR

MAXILLARY FIRST PREMOLAR

MAXILLARY SECOND PREMOLAR

MAXILLARY FIRST MOLAR

MAXILLARY SECOND MOLAR

MAXILLARY THIRD MOLAR

MANDIBULAR CENTRAL INCISOR

MANDIBULAR LATERAL INCISOR

MANDIBULAR FIRST PREMOLAR

MANDIBULAR SECOND PREMOLAR

MANDIBULAR FIRST MOLAR

MANDIBULAR SECOND MOLAR

MANDIBULAR THIRD MOLAR

SPECIAL MORPHOLOGY FOR ROOT CANALS

CORONAL ACCESS PREPARATION

FACTORS TO CONSIDER PRIOR TO CORONAL ACCESS PREPARATION

STEPS IN CORONAL ACCESS PREPARATION

REFINEMENT OF CORONAL ACCESS

CONSEQUENCES OF CORONAL ACCESS ERRORS

FINAL CORONAL ACCESS CONSIDERATIONS

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