Cumhuriyet Dental Journal, 25(Suppl): 7-12, 2022

DOI: [Link]

Cumhuriyet Dental Journal

│ [Link] │ Founded: 1998 Available online, ISSN: 1302-5805 Publisher: Sivas Cumhuriyet Üniversitesi

Radicular Groove of Maxillary Premolar: is a “Danger Zone”?#

Deniz Yanık1,a,*, Ahmet Mert Nalbantoğlu2,b
¹Department of Endodontics, School of Dentistry, Antalya Bilim University, Antalya, Turkey
2Department of Periodontology, School of Dentistry, Antalya Bilim University, Antalya, Turkey

*Corresponding author
Research Article ABSTRACT
Objectives: To evaluate the presence of radicular groove and dentin thickness on the palatal aspect of the buccal
Acknowledgment root of maxillary first premolars using cone-beam computed tomography (CBCT).
#This study was presented as an Materials and methods: Images of 312 maxillary first premolars belonging to 187 patients (between 18-69
oral presentation at the ‘‘Sivas years, 94 females and 93 males) who were referred to the clinic were retrospectively reviewed. Root canal
Cumhuriyet University 1st treatment, periapical lesion, and post-core were excluded. One and three-rooted premolars were also excluded.
International Dentistry Congress’’ CBCT images were viewed on the axial plane to detect grooves. The concave area on the palatal aspect of the
held between 23-25 November buccal root was recorded as a groove. Buccal and palatal dentin thicknesses were measured by two observers at
2021.
the level of 3 mm below furcation. Statistical analyses were performed.
Results: Buccal and palatal thicknesses were 1.28(±0.25) and 0.87(±0.13) mm, respectively. According to
Student’s t-test, buccal dentin thickness was statistically higher than palatal dentin. The prevalence of groove
History
was 82.05%. While palatal thickness without groove was 0.93(±0.14) mm, palatal thickness corresponding to
Received: 16/11/2021 groove was 0.82(±0.12) mm. One-way ANOVA showed palatal and buccal thickness in group 1 (18-35 years) was
Accepted: 09/02/2022 statistically lower than group 3 (>65 years). No statistical difference in thickness was observed between sex and
left or right side.
Conclusions: Palatal thickness related to groove can be considered a “danger zone” for post-core and
endodontic treatment. Considering the high prevalence (82.05%) and thin dentin of the groove, more
conservative canal and post space preparation and CBCT examination are recommended to avoid perforation.

Keywords: CBCT, Dentin, Endodontics, Root Canal Preparation, Root Canal Therapy.

Maksiller Premolar Radiküler Oluğu: “Tehlikeli Bölge”midir?#

Bilgi ÖZ
#Bu çalışma 23-25 Kasım 2021 Amaç: Bu çalışmanın amacı maksiller birinci premolardaki bukkal kökün palatinalinde bulunan oluğun
tarihleri arasında düzenlenen ‘Sivas prevalansının ve ayrıca bukkal ve palatinal dentin kalınlığının konik-ışınlı bilgisayarlı tomografi kullanarak (KIBT)
Cumhuriyet Üniversitesi 1. incelenmesidir
Uluslararası Diş Hekimliği
Yöntem: Çalışmaya, kliniğe başvuran 187 hastaya ait (18-69 yaş arası, 94 kadın ve 93 erkek) 312 premolar dişin
Kongresi’nde sözlü bildiri olarak
KIBT görüntüsü dahil edildi. Kanal tedavili, post uygulanmış, tek veya üç köklü premolar dişler çalışma dışı
sunulmuştur.
* Sorumlu yazar
bırakıldı. Kök oluğunu tespit edebilmek için KIBT görüntüleri aksiyel kesitte incelendi. Bukkal kökün
palatinalindeki konkav alanlar oluk olarak kaydedildi. Bukkal ve palatinal dentin kalınlıkları iki gözlemci
Süreç tarafından, furkasyonun 3 mm altından ölçüldü. İstatistiksel analiz yapıldı.
Bulgular: Bukkal ve palatinal dentin kalınlıkları sırasıyla 1,28(±0,25) ve 0,87(±0,13) olarak bulundu. Student’s t-
Geliş: 16/11/2021 testine göre, bukkal dentin kalınlığı palatinaldeki dentin kalınlığına göre istatistiksel olarak anlamlı derecede fazla
Kabul: 09/02/2022 bulundu. Bukkal oluk prevalansı %82,05 olarak kaydedildi. Oluk bulunmayan palatinal dentin kalınlığı 0,93(±0,14)
mm iken oluk bulunan palatinal dentin kalınlığı 0,82(±0,12) mm olarak tespit edildi. Tek yönlü ANOVA testine
göre, palatinal ve bukkal kalınlık grup 1(18-35 yaş)’de istatistiksel olarak anlamlı derecede grup 3 (>65 yaş)’e göre
daha inceydi. Cinsiyet ve sağ-sol arasında dentin kalınlığı açısından bir farklılık gözlenmedi.
Sonuçlar: Kök oluğu bulunan bölgedeki dentin kalınlığı kanal tedavisi ve özellikle kök dentininde kayba sebep
olan post uygulamaları açısından “tehlikeli bölge” olarak düşünülebilir. Kök oluğunun yüksek prevalansı ve kök
oluğundaki ince dentin varlığı düşünüldüğünde, klinikte perforasyon oluşumu engellemek için, işlem öncesi üç
boyutlu inceleme ve ayrıca daha konservatif kanal şekillendirmesi ve post boşluğu hazırlığı önerilir.

License

This work is licensed under Creative

Commons Attribution 4.0
International License Anahtar Kelimeler: KIBT, Dentin, Endodonti, Kök Kanalını Hazırlama, Kök Kanal Tedavisi.

a [Link]@[Link] [Link] b [Link]@[Link] [Link]

How to Cite: Yanık D, Nalbantoğlu AM.(2022) Radicular Groove of Maxillary Premolar: is a “Danger Zone”?, Cumhuriyet Dental Journal, 25(Suppl): 7-12.

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 Yanık et al. / Cumhuriyet Dental Journal, 25(Suppl): 7-12, 2022

Introduction Materials and Methods

Dentin thickness is a crucial parameter to maintain The present study was approved by the ethics
root integrity in the case of excessive removal during committee on human research of the university
preparation in endodontic therapy.1 Concave and thin (#70904504/616). The protocol of our retrospective
dentin areas that have jeopardy for strip perforation are study was accomplished in accordance with the
termed as "danger zone", especially the distal region of guidelines outlined in the Declaration of Helsinki. For the
mesial root in mandibular molars. 2 Numerous studies study, CBCT images of 312 maxillary first premolars
focused on the dentin thickness of the danger zone in belonging to 187 patients (94 females and 93 males)
mandibular molars, however mandibular molars are not aged between 18-69 years (mean age 33.4±3) who were
the only teeth with compromised roots because of referred to the clinic were selected and retrospectively
dentin thickness.1,3-5 Radicular groove located on the reviewed. CBCT images were collected from the database
palatal aspect of the buccal root of the maxillary of the university clinic from May 2019 to August 2020.
premolar also can create a risky area for perforation or CBCT images included in our study were obtained as a
fracture because it causes the presence of concave and part of routine dental treatment planning. Patients with
thin dentin area. Radicular groove, also called no systemic disease and no previous orthodontic
"developmental depression”, “buccal furcation groove”, treatment were included. Exclusion criteria were teeth
or “furcal concavity”, is located in many types of teeth with endodontic treatment, filling, post-core and carious
most notably mandibular premolar, maxillary lateral, and lesion, periapical lesion, horizontal or vertical root
maxillary first premolar.6,7 Radicular groove generally fracture, external or internal root resorption, under-
starts at the level of furcation, reaches throughout the develop roots with a wide-open apex, and periodontal
surface of the root, and disappears towards the apical disease. Patients with a history of trauma were excluded
part of the root.8 In maxillary premolars, it is found at the from the study. CBCT images with low or poor quality
palatal aspect of the buccal root. According to literature, and artifacts were also excluded. To detect the minimum
the prevalence of the radicular groove in the maxillary sample size for Student's t-test, we performed a power
premolar was reported between 58%-100%.8-19 It was analysis based on the data of 30 samples that we
thought that the radicular groove located on the palatal measured as a pilot study, with a power of 95%, alfa
aspect of buccal root in maxillary first premolars means error of 0.05, effect size f value of 0.36 using the
the precursor of two separate buccal roots.20 software of G*Power 3.1 (Heinrich–Heine–Universität,
Dentin thickness related to a root variation such as Düsseldorf, Germany). We needed a total of 100 samples
radicular groove requires a more detailed understanding (50 in each group) as a minimum necessary sample size,
to avoid complications and estimate the long-term likewise, for the one-way ANOVA, we obtained a partial
prognosis of endodontic treatment. The amount of dentin n2 value of 0.063 according to the data of the pilot study
removed during instrumentation can reach 2-3 mm3, as and calculated the effect size of f value as 0.25. With the
concluded in previous studies that mean approximately alfa error of 0.05 and the power of 0.95, the required
%10 - %30 of dentin reduction.21,22 Besides, according to minimum sample size was 252 (84 in each group).
the literature, the minimum dentin thickness to resist For our study, 312 maxillary first premolars were
compaction forces during obturation without fracture has selected. All maxillary first premolars in our study had
occurred was 0.2 - 0.3 mm.21 In the case of post-core two roots. Maxillary first premolars with single or three
treatment, the required dentin thickness is 1 mm to roots were excluded from the study. Patients are divided
prevent fracture.23 These calculations become important into three age groups; group 1: 18-35 years, group 2: 36-
particularly in the areas that have anatomically thin dentin 65 years, group 3: >65 years.
as in roots with radicular grooves to prevent vertical root CBCT images of patients were obtained from
fracture or strip perforation. Orthophos (Sirona Dental Systems, Bensheim, Germany).
To sum up, the root dentin thickness related to the Imaging parameters were set as 85 kVp, 6 mA, 14.1 sn
radicular groove on the buccal root of the maxillary first exposure time, 0.16 mm voxel size, and 80 x 40 mm field
premolar has clinical importance and needs careful of view according to the “as low as reasonably achievable”
instrumentation. Knowledge of dentin thickness and root (ALARA) principle. Images were exported in DICOM format
structure in regions that have variations can decrease to the Horos 3.0 software (Horos Project, Annapolis,
complications related to over-preparation such as strip Maryland, USA) and analyzed. Before measurements, to
perforation or fracture of the root. Therefore, the aim of adjust optimal visualization, contrast and brightness values
the present study is to evaluate the dentin thickness and were regulated by image tools of the Horos software, and
presence of radicular groove on the palatal and buccal all examinations were made in a dark room.
aspects on the buccal root of maxillary first premolar Examinations were performed by two observers (a 10-
using cone-beam computed tomography (CBCT). The null year experienced periodontist and a five-year experienced
hypothesis of our study is dentin thickness related to the endodontist) independently blind to the patient's data.
radicular groove is thinner than the dentin without Before the measurement process, two observers were
radicular groove. calibrated. For calibration, 10% of the images were
evaluated, and the kappa score was stated (range from

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0.91 to 0.93). Moreover, all measurements made by dentin thickness of the concave area on the palatal
observers were performed twice, and the average values aspect (in our study, it is considered as danger zone) and
were accepted for statistical analysis. The measurements the dentin thickness on the buccal aspect (in our study, it
of three maxillary first premolars were performed at one is considered as safety zone) of the buccal root were
time, after every three measurements, a break was made measured at the level of 3 mm below furcation (Figure
to eliminate eye fatigue of two observers. 1). The presence of radicular groove and dentin
CBCT images were evaluated on the axial plane to thicknesses of the palatal aspect (danger zone) and
detect the presence of the radicular groove. The buccal aspect (safety zone) on the buccal root were
presence of the groove in all samples was recorded. The recorded according to gender and age groups.

Figure 1. CBCT images of radicular grooves (black arrows) on axial sections.

Statistical analysis was performed by SPSS version 22.0 Buccal dentin thickness was statistically higher than
(IBM Corp., Armonk, NY, USA). The normality distribution the palatal thickness (p=0.016). Buccal thickness was
of the data of our study was analyzed by Levene’s test. 1.28 (±0.25) mm, and the palatal thickness was 0.87
Student’s t-test was used to compare the dentin (±0.13) mm in all maxillary first premolars (with or
thicknesses of the palatal aspect (danger zone) and buccal without radicular grooves). The palatal dentin thickness
aspect (safety zone) in maxillary first premolars. Student's of teeth that have grooves was 0.82 (±0.16) mm, while
t-test was also used to compare the dentin thicknesses the dentin thickness of teeth without grooves was 0.93
between genders. The dentin thicknesses according to age (±0.21) mm. Dentin thickness with the radicular groove
groups were examined by one-way ANOVA and posthoc was statistically thinner than dentin without the radicular
Tukey test. Chi-square test was used to examine the groove (p=0.00043). The prevalence of the dentin
prevalence of the radicular groove between the right and thickness <1 mm was 100% in roots with radicular
left premolars, and genders. The level of significance was grooves. The prevalence of dentin thickness <1 mm was
set at p<0.05 for Levene's, Student's t-test, one-way 76.4% in roots without grooves.
ANOVA, and Chi-square test. Interclass correlation The descriptive data about dentin thicknesses
coefficient (ICC) was performed to determine according to age and gender was shown in Table 1. There
interobserver reliability. A p-value <0.001 was considered was no statistical difference among gender (p=0.051),
statistically significant for the ICC. and right and left sides (p=0.052) in buccal and palatal
dentin thicknesses.
Results According to the one-way ANOVA test, there were
differences between age groups in dentin thicknesses
We found the prevalence of radicular groove on the (p<0.05). Group 3 has higher dentin thickness than group
palatal aspect was 82.05%. No radicular groove was 1 in palatal dentin thickness (p=0.012). Buccal dentin
detected on the buccal aspect of the buccal root (0%). A thickness of group 3 was higher than both group 1
total of 312 maxillary first premolars were examined, and (p=0.001) and group 2 (p=0.003).
the radicular groove was detected in 256 teeth. According The ICC for the measurements by two observers of
to the chi-square test, there was no statistical difference in dentin thicknesses of maxillary first premolars were
the presence of the radicular groove between the right and 0.979 and 0.977, respectively (p<0.001 for ICC values).
left sides (p=0.13) and between genders (p=0.172).

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Table 1. Buccal and palatal dentin thickness of maxillary first premolar by gender and age groups (G1: between 18-35
years, G2: between 36-65 years, G3: >65 years).
Palatal thickness (mm) Buccal thickness (mm)
Mean(±Std) Minimum Maximum Mean(±Std) Minimum Maximum P value
G1 0.84 (±0.11)a 0.64 1.15 1.25 (±0.23)a 0.75 1.81
G2 0.88 (±0.23) 0.71 1.13 1.27 (±0.19)b 0.76 1.84
G3 0.91 (±0.15)a 0.66 1.19 1.58 (±0.25)a,b 0.81 1.85
Max. first
Male 0.90 (±0.26) 0.72 1.19 1.31 (±0.23) 0.78 1.85
premolar 0.016*
Female 0.84 (±0.18) 0.64 1.11 1.23 (±0.18) 0.75 1.79
(n=312)
Left (#24) 0.87 (±0.21) 0.64 1.05 1.16 (±0.25) 0.81 1.77
Right (#14) 0.87 (±0.18) 0.67 1.19 1.38 (±0.29) 0.75 1.85
Total 0.87 (±0.13) 0.64 1.19 1.28 (±0.25) 0.75 1.85
*Presented statistically significant difference (According to Student’s t-test; p<0.05). Values presented with the same letter vertically means
statistically significant differences between groups (According to one-way ANOVA test; P<0.05).

Table 2. Previous studies about the prevalence of radicular grooves.

Study Methodology Racial origin Sample size Teeth Prevalence
Lammertyn et al. (2009) Section analysis Argentinian 141 Maxillary first premolar 83%
Brooker et al. (1985) Section analysis North American 25 Maxillary first premolar 100%
Joseph et al. (1996) Section analysis Indian 100 Maxillary first premolar 62%
Awawdeh et al. (2008) Section analysis Jordanian 379 Maxillary first premolar 100%
Tamse et al.(2000) Section analysis Israeli 25 Maxillary first premolar 97%
Katz et al (2006) Section analysis Israeli 25 Maxillary first premolar 100%
Liu et al. (2021) Micro-CT Chinese 48 Maxillary first premolar 95.83%
Kfir et al. (2020) CBCT Israeli 246 Maxillary first premolar 58%
Li et al. (2013) Micro-CT Chinese 36 Maxillary first premolar 85.7%
Al-Shahrani et al. (2013) Micro-CT Arabian 23 Maxillary first premolar 100%
Gheorghiță et al. (2020) Section analysis Romanian 26 Maxillary first premolar 76.9%
Gher et al. (1980) Section analysis North American 45 Maxillary first premolar 78%
Our study CBCT Turkish 312 Maxillary first premolar 82.05%

Discussion
We found the prevalence of radicular groove was radicular groove is challenging for periodontal treatment
82.05%. In the literature, the radicular groove in different as well as for endodontic and restorative procedures.
populations was investigated by section analysis, CBCT, or Considering the high prevalence found in our study, it can
micro-CT, and reported the prevalence of radicular groove be thought that the long-term outcomes of periodontal
was range from 58% to 100% (Table 2).8-19 The radicular treatment of these teeth are compromised.
groove is thought of as a morphological or developmental We reported the dentin thickness in roots with grooves
formation.24 Embryologically, if that is the precursor of two was 0.82 mm. In our study, it was observed that the dentin
separate buccal roots, the same entity is expected to be thickness in roots with radicular grooves was lower than in
on the buccal surface. However, most of the previous roots without grooves (p<0.05). Therefore, the null
studies have reported no buccal groove on the buccal hypothesis was accepted. In previous studies using different
root.8,9,12-18 Likewise, our study indicates no buccal groove methodologies, the dentin thickness corresponding to the
in all maxillary premolars (0%). Only a few studies report radicular groove was reported as 0.78 mm-1.18 mm.8-
10,15,16,26
buccal groove on the buccal root in some cases of their Our results were within the range reported in the
study sample.25,26 In the development of maxillary literature. Differences reported in the literature can be
premolar with two separate buccal roots, the explained by the fact that different methodologies and
embryological diagram grows eccentrically and forms two racial factors. Above all, studies have examined dentin
epithelial layers that will merge afterward instead of thickness at different levels of root between furcation level
creating a developmental depression or groove from a and apex. Some studies divided the root between furcation
single unit.24 Further embryological studies that focused and apex into three or four, some of the studies divided
on this formation are needed to understand its biological only the length where the groove was located.8-10,15,16,26
and developmental factors in the process of development. However, in premolars, the furcation is located at different
In literature, it was found that teeth with radicular levels. The separation of roots can occur at the half of
grooves are more associated with advanced periodontal overall root length, at coronal third, or near apical portion.27
loss compared to teeth without grooves due to the Therefore, the cross-section in which the dentin thickness
difficulty of plaque control in the region corresponding to was measured corresponds to different levels at total root
the radicular groove.27 In the case of the 50% loss of length. Since the root has a taper angle throughout all
interproximal bone, the radicular groove complicates the lengths, the dentin thickness according to levels is also
treatment and healing of periodontal disease because of different. Consequently, the various results can be
the difficulty in reaching its location.28 The presence of the

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explained by the differences in anatomical parameters of previous study investigating the three-dimensional shape
methodologies. of the root canal using micro-CT, it was concluded that a
In our study, the dentin thickness of group 3 (>65 deeper radicular groove results in a more irregular canal
years) was statistically higher than groups 1 and 2 morphology.16 The irregularity of the canal affects canal
(p<0.05). This can be explained by the fact that the instrumentation, irrigation, and filling.31 We found 85.02%
increase of secondary dentin deposition with age. 28 The of radicular grooves in maxillary premolars, the potential
dept of radicular groove diminishes depending on irregularity of canal morphology should be considered in
cementum deposition with age. A previous study showed the endodontic treatment of maxillary premolars.
the deposition of cementum is greater in concave areas Dentin thickness corresponding to radicular groove
compared to convex areas.19 was 0.82 mm, and it was <1 mm in all samples. This
Our study indicated that palatal dentin thickness in region can be assumed as a "danger zone", consequently,
buccal roots with radicular grooves is thinner compared it should be avoided too vigorous instrumentation. It is
to buccal dentin thickness. This result is in congruence recommended minimally invasive endodontics, for
with previous studies.9,10, 26 Dentin thickness relative to instance, anti-curvature preparation technique to
buccal groove creates a challenging situation for prevent strip perforation. For restorative procedures,
endodontic treatment. The remaining dentin thickness when the buccal root would receive post mandatorily,
after root canal preparation is closely associated with the more conservative post forms are recommended.
tendency to generate fracture. Considering that vertical The limitations of our study are low sample size and to
root fracture is one of the most common causes of tooth use of CBCT to determine the radicular groove and to
loss and that 56% of vertical root fractures occur in measure dentin thicknesses. However, the strength of our
premolars, the clinical importance of anatomical study is to be the first study to investigate radicular
formations in maxillary premolars is come out.29 grooves in the Turkish subpopulation. Further studies are
A minimum of 1 mm dentin thickness is required for needed to examine the prevalence of radicular grooves in
posts to preserve the integrity of the tooth.23,30 A kidney- the Turkish population with a larger sample size and more
shaped cross-section is seen in roots with furcation detailed methodologies like micro-CT or section analysis.
grooves and particularly in the deepest part, it cannot
provide adequate dentin for posts. As in our results, the Conclusions
dentin thickness of roots with groove is 0.82 mm that
less than the dentin thickness required for posts. A more Within the limitation of this study, we showed several
critical fact is the dentin thickness is already less than 1 conclusions; (1) radicular groove rate on maxillary first
mm before post space preparation and even canal premolars was high (82.05%), (2) palatal dentin thickness
instrumentation. After canal preparation, the dentin will relative to radicular groove was lower than dentin
be thinner and, subsequently, the tooth will be more thickness on roots without radicular grooves, (3) buccal
prone to vertical root fracture. Because 1 mm dentin dentin thickness is higher than the palatal thickness on
thickness is a critical threshold, we investigated the the buccal root, (4) buccal root of maxillary premolar was
dentin thickness according to this value. We found the considered "danger zone", for this root, anti-curvature
rate of the dentin thickness < 1 mm was 100% in roots preparation techniques, and more conservative post
with radicular grooves. The rate of the dentin thickness form should be considered.
<1 mm was 76.4% in root without radicular grooves. This
can be concluded that the roots with radicular grooves Conflicts of Interest
are riskier for fracture. However, in the clinic, endodontic
and restorative processes are not performed according The authors of the present study declare no conflict
to "the tooth in average features". Thin dentin thickness of interest.
in the root with or without a groove should be
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