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DOI 10.1007/s40368-014-0117-0
Abstract
Aim This was to investigate the root canal morphology of
primary molar teeth using micro-computed tomography.
Methods Primary maxillary (n = 20) and mandibular
(n = 20) molars were scanned at a resolution of 16.7 lm
and analysed regarding the number, location, volume, area,
structured model index (SMI), area, roundness, diameters,
and length of canals, as well as the thickness of dentine in
the apical third. Data were statistically compared by using
paired-sample t test, independent sample t test, and oneway analysis of variance with significance level set as 5 %.
Results Overall, no statistical differences were found
between the canals with respect to length, SMI, dentine
thickness, area, roundness, and diameter (p [ 0.05). A
double canal system was observed in the mesial and mesiobuccal roots of the mandibular and maxillary molars,
respectively. The thickness in the internal aspect of the
roots was lower than in the external aspect. Cross-sectional
evaluation of the roots in the apical third showed flatshaped canals in the mandibular molars and ribbon- and
oval-shaped canals in the maxillary molars.
Conclusions External and internal anatomy of the primary first molars closely resemble the primary second
molars. The reported data may help clinicians to obtain a
thorough understanding of the morphological variations of
root canals in primary molars to overcome problems related to shaping and cleaning procedures, allowing appropriate management strategies for root canal treatment.
Keywords Deciduous teeth Dental pulp cavity Microcomputed tomography Primary molars
Introduction
The premature loss of primary teeth may cause changes in
the chronology and sequence of eruption of permanent
teeth; thus, saving teeth in children is an important concept
and frequently involves endodontic treatment (Cleghorn
et al. 2012). Root canal treatment in primary teeth includes
the removal of the pulp tissue, debridement and preparation, irrigation, and filling of the canals. The main objective
of pulp therapy in primary teeth is to maintain the integrity
and health of the teeth and their supporting tissues (Cleghorn et al. 2012). To accomplish this goal, a comprehensive understanding of the root and the root canal
morphology of primary teeth is of utmost importance
(Hibbard and Ireland 1957; Goodacre 2003; Zoremchhingi
et al. 2005; Aminabadi et al. 2008; Bagherian et al. 2010;
Cleghorn et al. 2012).
The external and internal morphology of primary teeth
are different in many aspects from permanent successors
(Kavanagh and OSullivan 1998; Goodacre 2003; Johnston
and Franklin 2006; Cleghorn et al. 2012). Generally, primary teeth with fully developed roots exhibit a less complex root canal system compared to permanent teeth, with
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were selected. For each group of teeth, ten first and ten
second primary molars were evaluated. The inclusion criteria comprised only molars with no physiological root
resorption or at its initial stages, i.e. in which resorption did
not exceed 1/3 of root length.
Micro-CT scanning and reconstruction
Each tooth was slightly dried, mounted on a custom
attachment, and scanned in a micro-CT scanner (SkyScan
1174v2; Bruker-microCT, Kontich, Belgium) at an isotropic resolution of 16.7 lm. The X-ray tube was operated at
50 kV and 800 mA, and the scanning was performed by
180 rotation around the vertical axis with a rotation step of
1, using a 0.5-mm-thick aluminium filter. Images of each
specimen were reconstructed with dedicated software
(NRecon v.1.6.6; Bruker-microCT) providing axial cross
sections of the inner structure of the samples.
Quantitative analysis
DataViewer v.1.4.4 software (Bruker-microCT) was used
to evaluate the length (in millimetres) of the root from the
apex, and the length of the main root canals from the apical
foramen to the level of the cementoenamel junction. Threedimensional evaluation of the root canals (volume, surface
area, and structure model index) was performed from the
apex to the canal orifice using CTAn v.1.12 software
(Bruker-microCT). Volume was calculated as that of binarised objects within the volume of interest. For the
measurement of the surface area of the 3D multilayer
dataset, two components to surface measured in 2D were
used: first, the perimeters of the binarised objects on each
cross-sectional level, and second, the vertical surfaces
exposed by pixel differences between adjacent cross sections. Structure model index (SMI) involves a measurement of surface convexity in a 3D structure. SMI is derived
as 6.(S.V)/S2), where S is the object surface area before
dilation and S is the change in surface area caused by
dilation. V is the initial, undilated object volume. An ideal
plate, cylinder and sphere have SMI values of 0, 3 and 4,
respectively (Peters et al. 2000).
The smallest thickness of dentine in the internal and
external aspects of the roots, at 1, 2 and 3 mm from the
apical resorption bevel, were also recorded. Measurements
of the dentine thickness were taken from the external limit
of the root canal to the surface of the root. At these same
levels, CTAn v.1.12 software (Bruker-microCT) was used
for the two-dimensional evaluation (area, roundness,
major diameter, and minor diameter) of the root canal.
Area was calculated using the Pratt algorithm (Pratt
1991). The cross-sectional appearance, round or more
ribbon shaped, was expressed as roundness. Roundness of
Root canal
Volume (mm3)
SMI
10
7.3 1.5
6.1 1.5
5.4 3.6
36.1 12.7a
2.0 0.4
28.0 15.6b
1.9 0.4
Mandibular
First molar
D
Second molar
10
6.4 1.9
4.7 2.5
4.6 4.4
8.5 1.1
7.0 1.8
6.6 2.7
58.7 20.3
1.7 0.5
8.9 2.0b
6.7 2.3
9.6 3.5b
65.9 18.3b
1.6 0.3
MB
7.9 1.1
6.5 2.3
2.8 2.1
24.5 7.9
2.1 0.6
DB
6.7 1.7
5.4 1.5
1.3 1.6
11.4 6.9a
2.1 0.5
5.9 1.8
4.6 1.9
2.9 2.5a
17.9 7.5a
2.7 0.3
Maxillary
First molar
Second molar
10
10
MB
8.5 1.4
6.3 1.9
3.2 1.6
31.0 12.0
1.8 0.6
DB
P
6.5 1.6
7.4 1.4
5.7 1.4
5.9 1.8
2.0 1.0
5.4 2.6b
22.2 11.5b
31.8 11.6b
2.0 0.5
2.5 0.4
Different superscript letters in the same column indicate statistical significant difference between root canals in the same group of teeth
(independent sample t test, p \ 0.05); within root, values with bold letters in the same line were statistically different (paired-sample t test,
p \ 0.05)
M mesial; D distal; MB mesio-buccal; DB disto-buccal; P palatal
Results
Quantitative analysis
Tables 1 and 2 show the mean (SD) of the three- and
two-dimensional data, respectively, in each root of the
primary molars. Overall, in both groups of teeth no statistical differences were found between root canals of the
first and second molars with respect to length, SMI, and the
two-dimensional analysed parameters (area, roundness,
major diameter, and minor diameter) (p [ 0.05). Distal and
palatal canals of the mandibular and maxillary molars,
respectively, presented a significant higher volume than the
other canals in the same group of teeth (p \ 0.05). Generally, root canals of the second primary molar canals had
higher surface area than the first molars (p \ 0.05).
Table 3 summarises the mean dentine thickness in the
apical third of each molar root. No statistical difference
was observed in the comparison of the dentine thickness, in
either internal or external aspect of each root, between the
first and second molars (p [ 0.05). The lowest mean values
of dentine thickness were observed in the internal aspect of
the roots, in both molar groups. In general, the highest
mean thickness of dentine was observed in the distal and
palatal roots of the mandibular and maxillary molars,
respectively, in all evaluated levels.
Qualitative analysis
The analysis of the external anatomy of the mandibular first
and second molars showed that all specimens had two
roots, wider in the buccallingual dimension, narrower
mesio-distally, and often fluted. Deep caries with no pulp
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Root
canal
10
Distance
(mm)
Area
(mm2)
Roundness
Major diameter
(mm)
Minor diameter
(mm)
Mandibular
First molar
Second molar
10
10
10
0.4 0.6
0.4 0.2
1.0 1.0
0.4 0.3
0.4 0.6
0.4 0.2
1.1 0.9
0.4 0.2
0.5 0.6
0.4 0.2
1.3 0.9
0.4 0.3
0.5 0.4
0.3 0.1
1.2 0.6
0.4 0.2
0.6 0.4
0.3 0.1
1.5 0.4
0.5 0.2
0.7 0.4
0.4 0.1
1.4 0.6
0.6 0.3
0.4 0.6
0.4 0.2
1.3 1.6
0.3 0.2
0.2 0.4
0.4 0.2
1.0 1.0
0.3 0.1
0.5 0.9
0.3 0.2
1.4 1.1
0.4 0.2
1
2
0.4 0.5
0.7 0.7
0.2 0.2
0.2 0.2
1.8 1.4
2.1 1.5
0.3 0.1
0.4 0.2
1.2 1.0
0.2 0.2
2.7 1.4
0.5 0.2
Maxillary
First molar
MB
DB
Second molar
MB
DB
10
10
10
10
10
10
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0.1 0.1
0.4 0.1
0.5 0.3
0.3 0.2
0.2 0.2
0.3 0.2
1.0 0.6
0.3 0.2
0.3 0.2
0.3 0.2
1.0 0.6
0.4 0.2
0.1 0.3
0.5 0.2
0.5 0.3
0.2 0.2
0.2 0.3
0.5 0.2
0.6 0.3
0.3 0.2
0.2 0.3
0.4 0.2
0.6 0.3
0.3 0.2
0.4 0.5
0.6 0.1
0.8 0.4
0.5 0.3
0.6 0.5
0.6 0.1
1.0 0.4
0.7 0.4
0.9 0.7
0.5 0.1
1.3 0.5
0.8 0.4
0.3 0.2
0.3 0.1
1.2 0.9
0.3 0.1
0.4 0.2
0.2 0.1
1.4 0.9
0.4 0.1
0.4 0.3
0.2 0.1
1.6 1.0
0.4 0.2
1
2
0.2 0.1
0.3 0.1
0.3 0.2
0.3 0.2
0.9 0.3
1.3 0.6
0.3 0.1
0.3 0.1
0.4 0.2
0.3 0.2
1.6 0.9
0.4 0.1
0.7 0.2
0.5 0.1
1.3 0.3
0.6 0.1*
0.9 0.4
0.5 0.1
1.5 0.4
0.7 0.1
1.1 0.4
0.5 0.1
1.7 0.5
0.8 0.1*
10
Distance
(mm)
Thickness
(internal)
Thickness
(external)
Mandibular
First molar
Second molar
Maxillary
First molar
MB
DB
Second molar
MB
DB
10
10
10
10
10
10
10
0.4 0.1
0.7 0.1
0.5 0.1
0.8 0.2
0.5 0.1
0.9 0.2
0.4 0.1
0.8 0.3
0.5 0.2
0.8 0.3
0.4 0.1
0.8 0.3
0.5 0.1
0.6 0.1*
0.6 0.1
0.7 0.1
0.6 0.1
0.8 0.1*
0.5 0.1
0.7 0.2
0.6 0.1
0.8 0.2
0.6 0.1
0.9 0.3
0.3 0.1
0.6 0.3
0.4 0.1
0.7 0.3
0.5 0.1
0.7 0.3
0.4 0.2
0.6 0.2*
0.6 0.2
0.7 0.2
0.6 0.3
0.9 0.2*
0.8 0.2
1.0 0.2
1.1 0.3
1.1 0.2
1.2 0.4
1.2 0.3
0.4 0.1*
0.6 0.1
0.5 0.1
0.8 0.2
0.6 0.1*
0.8 0.2
10
0.5 0.2
0.7 0.1
0.6 0.2
0.8 0.2
10
3
1
0.7 0.2
0.6 0.2
0.9 0.3
1.0 0.3
0.8 0.3
1.2 0.4
0.8 0.2
1.3 0.5
Discussion
Although detailed descriptions of the external and internal
anatomical configuration of primary molars have been
already reported using conventional methodologies (Hibbard and Ireland 1957; Simpson 1973; Badger 1982; Falk
and Bowers 1983; Ringelstein and Seow 1989; Salama
et al. 1992; Caceda et al. 1994; Winkler and Ahmad 1997;
Wrbas et al. 1997; Kavanagh and OSullivan 1998; Fuks
2000; Eden et al. 2002; Goodacre 2003; Zoremchhingi
et al. 2005; Aminabadi et al. 2008; Poornima and Subba
Reddy 2008; Song et al. 2009; Bagherian et al. 2010; Liu
et al. 2010; Cleghorn et al. 2012), no study has been
undertaken to evaluate quantitatively their root canal system using high-resolution micro-computed tomography.
Primary mandibular molars have been usually described
as having two grooved and divergent roots that flare to
accommodate the developing permanent premolars (Hibbard and Ireland 1957; Zoremchhingi et al. 2005; Bagherian et al. 2010). In the literature, a considerable variation
in number and shape of canal systems has been described
in this group of teeth (Hibbard and Ireland 1957; Salama
et al. 1992; Zoremchhingi et al. 2005; Aminabadi et al.
2008; Bagherian et al. 2010; Cleghorn et al. 2012). Anatomical anomalies, such as additional roots, dens invaginatus, and taurodontism, have also been reported, mostly in
mandibular second molars (Badger 1982; Falk and Bowers
1983; Winkler and Ahmad 1997; Eden et al. 2002; Zoremchhingi et al. 2005; Johnston and Franklin 2006; Song
et al. 2009; Bagherian et al. 2010; Liu et al. 2010). Overall,
it may be inferred that the external and internal anatomy of
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123
mesio-buccal root and one in the disto-buccal and palatal roots. The
presence of a bevelled resorption in the apex of the roots resulted in a
thinner thickness of the dentine walls and exposure of the root canal
(arrows in d)
123
Table 4 Percentage frequency of root canal shape in each root of the primary maxillary and mandibular molars
n
Root canal
Round
First molar
10
30
D
Second molar
10
Oval
Flat-oval
Ribbon
Irregular
10
50
10
30
10
10
40
10
30
60
10
40
20
40
MB
DB
10
10
50
20
50
50
10
20
80
MB
20
10
20
40
10
DB
40
60
30
70
Mandibular
Maxillary
First molar
10
Second molar
10
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123
Conclusion
Under the limitations of this ex vivo study, it was possible
to conclude that external and internal anatomy of the primary first molars closely resembles the primary second
molars. Considering the morphology of the canals in the
apical third, a careful selection of instruments including the
use of additional disinfection supplements such as passive
ultrasonic irrigation or negative apical pressure is advisable. The reported data may help clinicians to obtain a
thorough understanding of the variations in root canal
morphology of primary molars to overcome problems
related to shaping and cleaning procedures.
Conflict of interest
of interest.
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