SCANNING VOL.

9999, 16 (2016)
Wiley Periodicals, Inc.

A Micro-Computed Tomography Study of the Negotiation and

Anatomical Feature in Apical Root Canal of Mandibular Molars
YI MIN,1,2 JING-ZHI MA,3 YA SHEN,4 GARY SHUN-PAN CHEUNG,5 AND YUAN GAO6
1

State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral
Biomedicine Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, China
2
Department of Second Clinical Branches, School and Hospital of Stomatology, Wuhan University, Wuhan, China
3
Department of Stomatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, China
4
Division of Endodontics, Faculty of Dentistry, Department of Oral Biological and Medical Sciences, University of
British Columbia, Vancouver, Canada
5
Faculty of Dentistry, Area of Endodontics, Comprehensive Dental Care, University of Hong Kong, Hong Kong, China
6
State Key Laboratory of Oral Diseases, West China College and Hospital of Stomatology, Sichuan University,
Chengdu, China

Summary: The aim of this study was to investigate the

clinical negotiation of various apical anatomic features
of the mandibular first molars in a Chinese population
using micro-computed tomography (micro-CT). A total
of 152 mandibular first molars were scanned with microCT at 30 mm resolution. The apical 5 mm of root canal
(ARC) was reconstructed three dimensionally and
classified. Subsequently, the access cavity was prepared
with the ARC anatomy blinded to the operator. The
ARC was negotiated with a size 10 K file with or without
precurve. Information on the ability to obtain a
reproducible glide path was recorded. The anatomical
classification of ARC was Type I with 68.45% in
mandibular first molars. The negotiation result of ARC
with Category i was 387 canals (74.00%). With a bent
negotiating file, 96 canals were negotiated, including 88
reproducible glide paths (Category ii) and 8 irregular
glide paths (Category iii). About 7.65% canals could not
be negotiated with patency successfully (Category iv).
Contract grant sponsor: National Natural Science Foundation of
China; Contract grant number: 81200781.
Address for reprints: Gary Shun-Pan Cheung, MDS, MSc, PhD,
Faculty of Dentistry, Area of Endodontics, 3/F, Prince Philip Dental
Hospital, 34 Hospital Road, Saiyingpun, Hong Kong, China.
E-mail: spcheung@hku.hk
Address for reprints: Yuan Gao, Department of Operative Dentistry and
Endodontics, State Key Laboratory of Oral Diseases, West China
College and Hospital of Stomatology, Sichuan University, 14#, 3rd
Section of RenMin South Road, Chengdu, China 610041.
E-mail: gaoyuan@scu.edu.cn
Received 18 April 2016; Accepted with revision 27 May 2016
DOI: 10.1002/sca.21331
Published online XX Month Year in Wiley Online Library
(wileyonlinelibrary.com).

The statistical analyze shown the anatomic feature of

ARC had effect on the negotiation of ARC (p < 0.05). In
conclusion, ARC anatomic variations had a strong
potential impact on the negotiation. The category of
negotiation in ARC would be helpful in the using of
NiTi rotary instruments. Negotiation of ARC to the
working length with patency should be careful and
skillful because of the complexities of ARC. SCANNING 9999:16, 2016. 2016 Wiley Periodicals, Inc.
Key words: mandibular first molar, anatomical feature,
apical root canal, negotiation, micro-computed
tomography

Introduction
The most important objective of root canal preparation is the removal of all pulp tissue, debris, and bacteria
from the root canal system (Schilder, 67, 74). The only
way to achieve this fundamental endodontic goal is to
firstly negotiate the canal from the orifice to the canal
terminus. Negotiation involves establishing canal
patency and creation of a smooth, reproducible glide
path. Patency was defined by the American Association
of Endodontists (2012) as a canal preparation
technique where the apical portion of the canal is
maintained free of debris by recapitulation with a small
file through the apical foramen. The ability to pass a
small K-file through the apical foramen is essential to
assure that the canal is predictably negotiable
(Buchanan, 89). Maintenance of patency implies
having eliminated debris accumulation in the apical
portion of the canal, as well as prevented the occurrence

SCANNING VOL. 9999, 9999 (2016)

of ledge formation or transportation. In addition, it could

improve tactile sensation and will facilitate irrigation in
the apical thirds of canal (West, 2011). Once apical
patency is established, a glide path can be created, i.e.
essential prior to the safe use of NiTi rotary instruments
(West, 2011; Alves Vde et al., 2012; Sung et al., 2014).
Canal negotiation can be quite a challenge, particularly in the apical portion of the root canal. Stainless steel
#10 K-file is commonly employed to explore the canal for
curvature, calcification, ease of insertion (hence diameter), length, and finally, patency. Canal negotiation is a
process of exploration and discovery of the internal
anatomy of the root canal system. Successful negotiation
is influenced by several factors, including operator
experience and apical canal anatomy. It has been reported
that dentists performing endodontic therapy on 10 molars
would run into at least one anatomic impediment
(Buchanan, 2013). Iatrogenic aberrations (apical blockage, apical ledging, separation of instrument) may form
when the anatomic impediments cannot be negotiated
and shaped. Access of instruments to the apex would thus
be prevented. Incomplete instrumentation and obturation
might contribute to ongoing periapical pathosis after root
canal treatment. Various experimental methods have
been used to study the root canal configuration of the
mandibular first molar, all of which have demonstrated
tremendous variations in the apical morphology of
this tooth (Tratman, 38; Skidmore and Bjorndal, 71;
Fabra-Campos, 89; Oi et al., 2004). The clearing
technique (Skidmore and Bjorndal, 71) would destroy
the tooth structure, limiting further use of the specimen
for experimentation. Micro-computed tomography
(micro-CT) is able to provide dimensionally accurate
morphological information about the apical area of the
root canal in a non-destructive manner (Oi et al., 2004).
Fan et al. (2009) investigated the negotiation of C-shaped
canals in mandibular second molars using micro-CT.
However, there is a lack of study that examined the
negotiation of mandibular first molars, especially for the
influence of apical canal anatomy. Hence, the purpose of
this study was to investigate the negotiation of various
anatomical features in the apical root canal (ARC) of
mandibular first molars. An attempt was made to
correlate the influence of ARC anatomy on negotiating
the ARC.

Materials and Methods

Preparation of Specimen and Classification
of Apical Anatomy

One hundred and fifty-two mandibular first molars

extracted for periodontal reasons were cleaned to
remove adherent soft tissues, before storage in a 10%
formalin solution until use. These teeth had fully formed
apices and had not been endodontically treated. The age

and gender of the patients were unknown. Each tooth

was scanned at an istropic resolution of 30 mm in a
micro-CT scanner (mCT-50; Scanco Medical, Bassersdorf, Switzerland) at 90 kV and 112 mA.
Images of the apical 5 mm of the roots were imported
into a 3-D visualization software package (Mevislab;
MeVis Medical Solutions AG, Breman, Germany) for
rendering of the external surface of the root and the
internal root canal wall. During reconstruction, the
dentine of the tooth image was rendered transparent so
that the internal root canal morphology could be viewed.
Areas of interest were magnified to allow visualization
of the apical root canal (ARC) morphology.The
morphology of the apical 5 mm were examined and
classified into five types according to the anatomical
feature (including accessory and lateral canal, or of
apical delta, isthmus, and fin) and curvature (based on
Schneiders method of measurement) (Fig. 1):
Type I: ARC with a curvature <20, without apical
irregularity, or apical irregularity on the inside wall
of the curved canal (apical irregularity means
accessory or lateral canal, or of apical delta, isthmus
and fin of the apical 5 mm);
Type II: ARC with a curvature <20, with some
irregularity on the outside wall of the curve; or ARC
with a curvature between 20 and 45, but without
apical irregularity (or apical irregularity on the
inside wall of the curved canal);
Type III: ARC with a curvature between 20 and
45, and with apical irregularity on the outside wall
of the curved canal;
Type IV: abruptly curved ARC (curvature >45)
with or without irregularity;
Type V: calcified canal.

Negotiation of the ARC

One experienced operator, which is a specialist in

endodontics, carried out the simulated clinical treatment
of all teeth. This operator was not allowed to see the
reconstructed models of the teeth before performing the
procedure. Endodontic access cavities were completed
in all teeth under magnification. After locating the canal
orifices, attempt was made to negotiate the canal with a
straight, size #10 stainless-steel K-file placed 1 mm
beyond the working length to confirm patency with
Glyde File Prep (Dentsply, Maillefer, Ballaigues,
Switzerland). The coronal and middle thirds of the
root canal were enlarged by using ProTaper S1, S2
(Dentsply Maillefer, Ballaigues, Switzerland). The
procedure of negotiating the apical one-third was
summarized in Figure 1. Briefly, only straight file was
used in the first attempt. If that was unsuccessful, the last
12 mm of the file was precurved with an EndoBender

Y. Min et al.: Micro-CT study: Negotiation and anatomical feature

Fig 1. The anatomical classification of ARC: A1 is Type I with a curvature <20, without apical irregularity; A2 is Type I with a curvature
<20, with apical irregularity on the inside wall of the curved canal; B1 is Type II with a curvature <20, with apical irregularity on the
outside wall of the curved canal; B2 is Type II with a curvature between 20 and 45 without apical irregularity; C is Type III with a
curvature between 20 and 45, with apical irregularity on the outside wall of the curved canal; D1 is Type IV with abruptly curve (curvature
>45), with apical irregularity on the outside wall of the curved canal; D2 is Type IV with abruptly curve (curvature >45), without apical
irregularity; and E is Type V with calcified canal.

(SybronEndo), re-enter the canal with every chance of

finding a passive path around the impediment. Irrigation
was done with 1% NaOCl and 17% EDTA. When
impediment was met, attempts to negotiate the canal
were repeated with precurved #10 file until either: (i) the
canal was successfully negotiated with apical patency or
(ii) mishap occurred (including apical blockage, apical
ledging, calcification, or separation of instrument) to an
extent that it was considered impossible to negotiate
further. Impediment was defined as resistance to file
advancement by tactile sensation.
Successful negotiation was confirmed when a
reproducible glide path was obtained, i.e. the instrument
slid to the apical foramen in every attempt. If apical
patency was achieved initially, but when passing an
unprecurved #10 file to confirm the glide path and it met
some impediments, that was considered as an irregular
glide path. The result for the readiness to create a glide
path for these specimens was categorized into four
scenarios (Fig. 2): category (i) straightforwardthe
ARC was negotiable with unprecurved #10 K-file with a
reproducible glide path; (ii) predictablethe ARC was
negotiable with precurved #10 K-file and later a
reproducible glide path confirmed with straight #10
K-file; (iii) irregularthe ARC can be negotiable with

or without precurving the K-file, but the glide path was

irregular; (iv) non-negotiablethe ARC could not be
negotiable with patency not achieved.

Correlation Between Negotiability and

Anatomic Feature

After completing all specimens, the negotiability

of each canal was correlated to its ARC anatomic
feature. Frequency distribution was used to describe the
proportion of canals in each negotiability group for each
apical anatomic feature, with comparison between
groups using likelihood ratio x2 test. Kappa analysis
was used to describe concordance rate between
negotiation category and anatomic classification. The
statistical package (STATA 13.0; StataCorp, College
Station, TX) was employed, with the level of statistical
significance set at p < 0.05.

Results
Of the 152 mandibular first molars included in the
sample, the great majority had two separate roots

SCANNING VOL. 9999, 9999 (2016)

Fig 2.

Flow diagram of negotiation in the ARC with results: (i) straightforward; (ii) predictable; (iii) irregular; and (iv) non-negotiable.

(94.1%); about 6% had a third root. About two-thirds of

the sample (62%) had three main root canals, 32.2%
with four and 5.9% with five main canals. The apical
5 mm of a total of 523 ARC were reconstructed in three
dimensions. The anatomy varied a lot and could appear
rather complex or relatively straightforward (Fig. 3).
The most frequent anatomy encountered was Type I
(n 358, 68.5%), followed by Type II (13%) (Fig. 4).
All type I ARC, and about 43% of type II were
straightforward and could be easily negotiated without
any apical impediment using unprecurved files
(Table I). Ninety-six other canals were negotiated using
precurved files, producing 88 reproducible and 8
irregular glide paths. Finally, 40 canals (7.7%) could
not be negotiated and patency not attained.
The relationship between the apical anatomic feature
and the negotiability was examined and a significant
association was confirmed (p < 0.05; Table I). The
concordance rate was 80.69% with a Kappa coefficient
of 0.5832, suggesting that there was a high consistency
between negotiability and anatomical classification,
(p < 0.0001). Visualization of the reconstructed images
indeed confirmed the presence of anatomic impediments
in all 40 canals that could not be negotiated (Fig. 3).

as a smooth passage from the canal orifice to the apical

terminus (Pati~no et al., 2005), which is an important
requisite to minimize the chance of iatrogenic mishaps
when NiTi rotary instruments are used (Pasqualini et al.,
2012). All studies of root canal instrumentation, which
was performed on extracted teeth, were done on
specimens with initially patent canals, thus, little is
known about the negotiability of various apical canal
configurations. Micro-CT technique is a nondestructive
method that allows evaluation of root canal anatomy for
correlation with the ability to negotiate for canal
patency.
Many studies have shown that the root canal anatomy
is significantly more complex in molars than in anterior
teeth (Eleftheriadis and Lambrianidis, 2005; Jafarzadeh
and Abbott, 2007; Gekelman et al., 2009). The internal
feature of the apical portion of root canal is even more
complex. Study of canal morphology have demonstrated

Discussion
Root canal instrumentation is an important phase in
endodontic treatment (Ricucci, 98; Peters, 2004),
which facilitates canal disinfection and placement of
obturation material. Identifying, locating and negotiating the canal for patency is the first step of this process. If
patency cannot be achieved, ledge formation and canal
blockage may easily occur. Glide path has been defined

Fig 3. Reconstructed images of the ARC anatomy of a

mandibular first molar, mesial root with rather complex and
distal root with relatively simple anatomy.

Y. Min et al.: Micro-CT study: Negotiation and anatomical feature

Fig 4. The number distribution of anatomic classification and

negotiations category in each ARC. Mb, mesial-buccal canal; Ml,
mesial-lingual canal; Mm, canal between Mb and Ml; D, distal
canal; Db, distal-buccal canal; Dl, distal-lingual canal; Dm, canal
between Db and Dl.

that root canals are rarely conical or straight, and have

lateral canals, apical deltas, fins, webs, and transverse
anastomoses that are especially prevalent in the apical
third of the root (Vertucci, 84; Alshehri et al., 2015).
Many canals in this present study also showed the
presence of these, confirming the highly complex nature
of the ARC anatomy.
Traditional researches have focused on the complexity of the root canal system with little direct application
to the clinical situation (Forner Navarro et al., 2007).
This study aimed to correlate the negotiability of
different types of apical anatomy, in the hope to provide
a mental image of the three-dimensional morphology of
root canal system, to facilitate the bypass of such
anatomical features. Most canals can be negotiated by
skillful use of a small K-file. In this study, 74% root
canals could be negotiated with unprecurved file after
pre-flaring of the coronal part of the canal. Stainless
steel #10 files are extremely flexible and can negotiate
even a canal with a moderate apical curve. Resistance to
file advancement means that the file is caught either in
some types of irregularity (including accessory and
lateral canal, or apical delta, isthmus, or fin), or by pulp
and/or dentin mud. Or, its tip may be bumping into the
outer wall of an acutely curved canal. Precurving the
negotiating instrument is an effective method to bypass
impediments (see results in Table I), although it seems
TABLE I

unnecessary to precurve the file for many cases.

However, given that anatomic variations may not be
known prior to canal negotiation in the clinical situation,
only gentle exploration with straight, unprecurved file is
suggested. If the estimated working length cannot be
reached, or when the unprecurved file fails to advance
during canal negotiation, one must resort to the use of
precurved instrument. A #10 file with a curved tip is
used in a circumferential tip walking motion until the
tip slips past the impediment. Some shaping then
follows, in the hope to produce a smoothened canal wall.
A reproducible glide path is achieved when the #10 file
can advance uninterruptedly from the orifice through the
smooth canal walls to the apical terminus. It must be
emphasized that NiTi instruments cannot be precurved
and should not be taken into the canal, until after a size
10 stainless steel hand file goes easily to length
predictably, i.e. canals with reproducible glide path.
Once this is achieved, that path is much more likely to be
maintained with the rotary NiTi instruments. In the case
of Category iii (irregular glide path), as the precurved
file is retrieved from the terminus, its tip clicks past the
exit of an accessory canal or other internal structure or
impediments. It is advisable to gently advance the file
apically at this stage, to see if it may enter into another
canal path. As the original canal path can still be
maintained and the canal is patent, that canal is
considered as having an irregular glide path. NiTi
should not to be used there because its tip cannot be
precurved. Or, there would be a risk of canal
transportation, or instrument separation. Martn et al.
(2003) indicated that the separation rate of three rotary
NiTi instruments was significantly reduced when their
use was preceded by glide path preparation. Therefore,
even patency is established, manual instruments should
be suggested and great care must be taken if a
reproducible glide path cannot be created. In this study,
7.65% of all canals cannot be negotiated at the end,
because of blockage, ledge, or calcification. Such nonpatent canal would be a challenge for its management
due to risk of further blockade, ledge formation, and
inability to clean up to the apical end of the canal.
Micro-CT allows spatial analysis of the curvatures
and/or any transportation after instrumentation, as well

Column correlation analysis between negotiations and anatomical classification

Anatomical classification

Negotiation
i
ii
iii
iv
Total

Likelihood ratio

Type I

Type II

Type III

Type IV

Type V

Subtotal (% of total)

x2

358
0
0
0
358

29
38
1
0
68

0
28
4
17
49

0
22
3
22
47

0
0
0
1
1

387 (74.0)
88 (16.8)
8 (1.53)
40 (7.65)
523

670.7

<0.0001

Contingency coefficient: 0.5755.

SCANNING VOL. 9999, 9999 (2016)

as identification of anatomical anomalies. In this study,

the Kappa analysis was used to describe the concordance rate of anatomic classification and negotiation
category. A value of 80.69% indicated better agreement.
On basis of the present findings, the apical anatomy of
the canals was found to have a significant effect on the
negotiability of the canal. On the other hand, the
negotiation results provided a guideline for use of rotary
NiTi instruments in the mesial roots of mandibular
molars. The Type I ARC that could be easily negotiated
with unprecurved K-files were thus most suitable for
NiTi instruments used either manually or in a rotary
mode. When the patency file hit an impediment that
could not reached the desired length, rotary NiTi files
should not be used until a reproducible glide path was
obtained. Rotary NiTi instruments cannot be used in
about 10% of cases where an irregular glide path or no
patient could be achieved.

Conclusion
A strong impact of anatomic variations on the ability
to obtain patency and a reproducible glide path was
demonstrated in this study. Careful negotiation of root
canal to the working length with a size 10 K-file and
selection of the instrumentation method should be based
on the apical canal complexities.

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