3-Dimensional Analysis and Literature Review of The Root Canal Morphology and Physiological Foramen Geometry of 125 Mandibular Incisors by Means of Micro-Computed Tomography in A German Population
3-Dimensional Analysis and Literature Review of The Root Canal Morphology and Physiological Foramen Geometry of 125 Mandibular Incisors by Means of Micro-Computed Tomography in A German Population
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configuration of mandibular anterior teeth Bru€ttisellen, Switzerland) with a previously 1 physiological foramen is present. The
(60%) is a single root canal from the coronal established methodology18 at settings of 70 kV number and mean of accessory canals
to the apical terminus (1-1-1); however, scarce and 114 mA, resulting in 800 to 1200 slices observed in all root canal thirds and
concise information is found concerning the (0.016 mm) per tooth. The different resulting connecting canals (when present) according to
morphologic characteristics of the tooth structures in the 3D reconstructions of their root canal configuration are shown in
physiological foramen2,17. Although there are the micro-CT scans were visualized with Table 3. The physiological foramen observed
several ex vivo root canal anatomy research rendering software (VGStudio Max 2.2; shapes were oval in 56.0%, round in 28.8%,
methods, micro–computed tomographic Volumegraphics, Heidelberg, Germany) by and irregular in 15.2% of the samples. Table 4
(micro-CT) imaging has been defined as the displaying them with dummy colors. The pulp shows a mandibular anterior teeth literature
gold standard for this type of investigation18–21. chamber and the root canal system were summary depicting the root canal
Micro-CT imaging offers, in combination with colored with red, the enamel/crown area with configurations proposed by Weine et al30,
rendering and imaging software, the possibility white, and the root/dentin area with Vertucci4, and Brisen~o Marroquín et al18,
of 3D visualization and analysis of the transparent gray. The roots were divided into publication year, population, investigated teeth
endodontic morphology. A large number of thirds, and the root canal configuration was number, and position as well as the
reports have confirmed that extensive determined as described in a previous investigative methods used.
information on the complex root canal system report18. The first, second, and third root canal
can be obtained by the possibility of displaying configuration digits describe the root canal
and evaluating minute structures because of number at the respective coronal boundary of DISCUSSION
the high resolution of micro-CT imaging18,20,21. the coronal, middle, and apical thirds,
The root canal configuration of 125 single-
The aim of this study was to summarize the respectively. The fourth digit, separated by a
rooted mandibular incisors was investigated by
root canal morphology of mandibular anterior slash, describes the main foramina number.
means of micro-CT imaging. An oval shape
teeth reported in the literature as well as to The number of accessory and connecting root
was defined when the difference between the
investigate the root canal configuration and canals (one that loops within the same root
major and minor diameter was equal or greater
morphology of the physiological foramen of canal or that connects with another root canal
than 0.02 mm. An oval shape was defined
125 mandibular incisors in a German without connecting with the periapical tissues)
when the difference between the major and
population by means of micro-CT imaging. It is and the number of apical accessory foramina
minor diameter was 0.02 mm or more than
an attempt to provide a clinical observed with micro-CT imaging were also
0.02 mm1. To the best of our knowledge, there
recommendation on the final preparation size investigated. The determination of the
has been no attempt to determine the shape of
of the physiological foramen based on the physiological foramina forms and sizes was
the physiological foramen of mandibular
results obtained in this investigation. performed according to an established
anterior teeth; Bianchi Leoni et al17, in a
method1. The length between the
different investigative approach, described the
physiological foramen and the anatomic apex
MATERIALS AND METHODS “roundness” approximation of the foramina of
as well as the lengths of the narrowest and
mandibular incisors. Weine31 recommended to
A total of 125 extracted human permanent first widest diameter were determined with the 3D
enlarge the apical foramen 2 sizes more after
and second mandibular incisors were imaging software18,22. The results were
having determined the diameter of the original
collected from a university medical center in analyzed and descriptively expressed (mean,
physiological foramen. However, the clinical
southwest Germany. They were extracted for maximum, minimum, and standard deviation)
significance of the physiological foramen
reasons unrelated to this study; thus, they are with absolute and relative values. The final
shape, particularly when taking into
related to so-called excess material, making preparation size of the physiological foramen,
consideration that 56% of the samples had an
institutional review board approval for the and thus the corresponding master apical file
oval one, resides in the difficulty to clinically
purposes of this investigation unnecessary. size, was defined as 2 sizes larger than the
determine its initial preparation size (initial
The teeth were examined according to their calculated mean of the major physiological
apical file); this explains the decision-making
morphologic criteria; however, an unbiased foramen diameters measured.
differentiation between central and lateral
mandibular incisors was not possible. All TABLE 1 - Root Canal Configuration of Mandibular
included teeth were single rooted. According
RESULTS
Incisors by Means of Micro–computed Tomographic
to their morphologic appearance, the selection The root canal configuration frequency results Imaging (N 5 125)
criteria were a complete coronal and root for 125 mandibular incisors (absolute/mean)
development, no signs of root fracture or are shown in Table 1. The most frequently Frequency
Root canal
resorption, no radicular or coronal caries, and observed root canal configurations (Figs. 1 configuration Absolute Mean
no endodontic treatment. Attached hard and and 2) were 1-1-1/1 (56.0%), 1-2-1/1 (17.6%),
1-1-1/1 70 56.0
soft tissues and calculus were cleaned from and 1-1-1/2 (10.4%); yet, in 19 teeth (15.2%),
1-1-1/2 13 10.4
the teeth with an ultrasonic scaler. They were another 9 different root canal configurations 1-2-1/1 22 17.6
then placed in a 3% hydrogen peroxide were observed. The narrow and wide diameter 1-2-1/2 5 4.0
ultrasonic bath for 1 hour and subsequently sizes of a total of 146 physiological foramina, 1-2-1/3 4 3.2
stored in 70% alcohol. A physiological (main) according to their frequency, are shown in 1-2-2/1 1 0.8
foramen was defined as one with a diameter of Table 2. Furthermore, a master apical file size 1-2-2/2 1 0.8
0.20 mm or more; smaller foramina diameters (ISO size/tip diameter) recommendation is 1-2-2/3 1 0.8
were defined as accessory foramina1. The given based on the physiological foramina 1-3-1/1 1 0.8
teeth were scanned at an isotropic resolution diameter results obtained (Table 2). According 2-2-1/1 4 3.2
2-2-1/2 1 0.8
of 20 mm in a desktop microcomputer to our results, the final apical preparation size
2-2-2/1 1 0.8
tomography unit (mCT 40; Scanco Medical, of incisors should be at least ISO 35 when only
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different tooth position, and their origin.
Although parameters such as age, sex, and
tooth position are, in our opinion, not relevant
when explaining discrepancies between the
different results of the summarized studies,
they cannot be completely discarded as
possible causes. Another possible cause of
result discrepancies could be the patient/tooth
age at the time of extraction. Possible
morphologic dimension changes, especially in
the apical portion of a root canal, could happen
over time; unfortunately, the inclusion of the
age parameter could not be included in this
investigation. The root canal configuration 1-1-
1/1 (type I) is the most commonly reported root
canal configuration in mandibular incisors, and
its frequency reported in the literature varies
FIGURE 1 – Micro-CT imaging of a mandibular incisor. The dental structures are color coded (pulp and root canal from 30%25 in a Turkish population up to
system with red, enamel with white, and dentin with transparent gray). The most frequent 1-1-1/1 (56.0%) root canal 91.1% in a Chinese population10. It represents
configuration without any accessory canals or foramina can be observed (n 5 125). a single root canal from the coronal pulp orifice
up to the physiological foramen. Only 2
investigations25,26 reported a 1-1-1/1
configuration lower than 50%17; our results
process of the final preparation size (master radiology3,9,19, microscopy23,26, cone-beam
show that this configuration type was
apical file). To the best of our knowledge, only computed tomographic (CBCT)
observed in 56.0%. Only 3 of 16 studies9,16,17
Milanezi de Almeida et al12 studied a higher imaging3,6,7,9,10,14,16,27,28, and micro-CT
reported a higher difference than 10%
number (N 5 340) of anterior mandibular teeth imaging3,12,17. Solely radiographic
between mandibular central and lateral incisors
by means of micro-CT imaging. However, the investigations were performed in the
within a 1-1-1/1–type configuration. Two of
authors, using a different research approach, 1970s15,29; yet, CBCT investigations are
these studies were conducted by means of
reported buccolingual and mesiodistal increasingly found in the literature in recent
CBCT imaging9,16 and the third one by means
diameters at 1–3 mm from the “apical level.” years6,9,10,14,16,27,28. To the best of our
of micro-CT imaging17. Although unfortunately
The reported results of 22 previous knowledge, the micro-CT research method
in our study differentiation between central and
similar studies (Table 4) with different research has been used to investigate the morphology
lateral incisors was not possible because of the
methodologies support to a relatively high of mandibular incisors in only 3 studies
sample origin, in our opinion, the differentiation
extent the ones obtained in this investigation. (including the present one), but the other 2 only
between central and lateral incisors is not
To the best of our knowledge, Table 4 reported results obtained with a Brazilian
significant. This opinion can be supported by
summarizes all previous similar morphologic population3,12,17.
the results reported in the other 13
investigations of mandibular incisors. The root Discrepancies observed within the
investigations4,6–8,10,11,14,15,24–28 in which the
canal morphology of mandibular incisors has summarized investigations themselves and the
difference between the central and lateral
been investigated by means of the staining and present one can be explained by the different
incisor was a mean of 3.6% (8.6% maximum,
clearing method4,5,8,11,13,23–26, conventional methods of investigation, sample number,
0.0% minimum).
The second most common root canal
configuration observed in this study was
1-2-1/1 and can be supported by the
results obtained in several similar
investigations4,8,9,12,14–17,23,27,28. Only 4
investigations5,6,9,10 reported a 1-2-1/1
configuration frequency lower than 7%. The
relatively low frequency of the configuration
2-2-1/1 observed in this investigation can be
supported by similar results obtained in
different investigations4,6,9,10,12,14,15,27,28. In
contrast to these results, different research
groups5,7,8,12,13,16,23–26,29 reported a relatively
higher incidence of this type of configuration. It
can be assumed that such differences could
be attributed to different populations, research
methodologies, and sample number; yet, it is
interesting to point out that almost all reports
that showed a relatively low frequency of this
FIGURE 2 – Micro-CT imaging of a mandibular incisor with the second most frequent root canal configuration 1-2-1/1 type of configuration, excluding the ones by
(10.4%); 1 connecting canal and 1 accessory foramen can be distinguished. Pineda and Kuttler15 and Vertucci4, were
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TABLE 2 - Statistical Analysis of the Narrow and Wide Diameter Sizes of the Physiological Foramen (mm) and Final occasionally were not easy to recognize in
Physiological Foramen Preparation Size (Master Apical File [MAF]) Recommendation (N 5 146/ISO Size/Instrument Tip some examined samples. Thus, our results,
Diameter) contrary to the previous ones1,37, support
the presence of a physiological foramen.
Foramina (n) 1 2 3 Such differences can be explained through
Diameter Wide Narrow Wide Narrow Wide Narrow the possibility of a minute area examination
by means of micro-CT imaging. The goal of
Ø 0.24 0.23 0.21 0.20 0.10 0.13
successful root canal treatment is to
SD 0.09 0.07 0.05 0.04 0.11 0.13
Maximum 0.73 0.65 0.29 0.26 0.25 0.30 eliminate vital and/or necrotic tissue from
Minimum 0.10 0.08 0.15 0.09 0.13 0.23 the entire root canal system and to provide
n 125 125 18 18 3 3 a preparation shape, which allows the
MAF* size 35 35 30 30 25 25 placement of a hermetic seal, especially on
all portals of exit. Therefore, adequate root
SD, standard deviation.
canal preparation, also of the physiological
*Recommendation to Table 2.
foramen, is mandatory. Clinical limitations of
conducted either with micro-CT12 or CBCT connecting canals are unlikely to be prepared the present study in which root canal
imaging6,9,10,14,27,28. The frequency of all other or even cleaned13, awareness of such system disinfection, preparation, and 3D
root canal configurations across all studies is morphologic difficulties will increase the root canal system filling were not
relatively low, which was also confirmed by the awareness of an operator about the purpose investigated must be taken into
present study. Only Sert and Bayirli26 and of cleaning such spaces in order to be able to consideration. Different morphologic
Aminsobhani et al7 reported a relatively high 2- fill them, providing a hermetic seal of the root aspects of the root itself and root canal
2-2/2 root canal configuration frequency (8.0– canal system. morphology could be a hindrance to
15.4%). To the best of our knowledge, there achieving a recommended apical
As early as 1917, Hess32,33 reported on is only 1 report17 with a detailed description preparation size. Moreover, because of a
the complexity of the root canal system and of the dimensions and shapes of the relatively low specimen number, the
showed different kinds of lateral and physiological foramen of mandibular anterior recommended physiological foramen
connecting canals as well as isthmuses. Since teeth using micro-CT imaging. The final preparation sizes in this report should
then, the presence of accessory and apical preparation size in clinical endodontic be population investigated and the
connecting canals has also been shown in treatment is considered to be an important high standard deviations calculated
different investigations2,8,26,34–36, reporting in factor for endodontic success. However, conscientiously on an individual
most studies that the highest incidence of the clinical determination of the basis.
accessory canals was observed in the apical physiological foramen dimensions has been
third of the root. Such findings can be described as a difficult procedure to
CONCLUSIONS
confirmed by our results in which a similar accomplish because of the inherent
number of accessory root canals was morphologic difficulties of often missing The most frequent root canal configurations
observed in the middle and apical thirds. To clear physiological foramen (apical observed were 1-1-1/1 (56.0%), 1-2-1/1
the best of our knowledge, the present study is constriction) landmarks and/or shape (17.6%), and 1-1-1/2 (10.6%). Single-rooted
the second one35 to investigate the determination1,37. However, in the present mandibular incisors showed in 80% 1, in
occurrence of lateral and connecting canals by micro-CT study, the physiological foramen 16% 2, and in 4% 3 main physiological
means of micro-CT imaging. Although it is could be clearly determined in most foramina. Accessory canals were observed
generally known that accessory and samples, although the anatomic landmarks in 13.6% and connecting canals in 36% of
the investigated sample. The mean wide and
narrow diameters of the physiological
TABLE 3 - Absolute and Mean Values of Accessory and Connecting Canals of Mandibular Incisors Observed under
foramina were 0.24 mm (standard
Micro–computed Tomographic Imaging (N 5 125)
deviation 5 0.09 mm) and 0.23 mm
(standard deviation 5 0.07 mm) when
Accessory canals n Frequency (%) Connecting canals n Frequency (%)
only 2 physiological foramen was
Not observed 108 86.4 Not observed 80 64.0 present.
Coronal third 1 0.8 1-1-1/1 4 3.2
A final physiological foramina
Middle third 8 6.4 1-1-1/2 0 0.0
preparation size of 0.35, 0.30, and 0.25 mm in
Apical third 8 6.4 1-2-1/1 16 12.8
1-2-1/2 2 1.6 mandibular anterior teeth with 1, 2, and 3
1-2-1/3 2 1.6 foramina, respectively, is recommended. A
1-2-2/1 0 0.0 physiological foramen was observed in all
1-2-2/2 1 0.8 teeth; their shape was oval (56.0%), round
1-2-2/3 2 1.6 (28.8%), or irregular (15.2%).
1-3-1/1 3 2.4
2-2-1/1 9 7.2
2-2-1/2 4 3.2
2-2-2/1 2 1.6 ACKNOWLEDGMENTS
The authors deny any conflicts of interest
The presence of accessory canals is divided according to the root’s thirds. The connecting canals are shown according to
the different root canal configurations. related to this study.
JOE Volume 46, Number 2, February 2020 Root Canal Morphology and Literature Review of Mandibular Incisors 187
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TABLE 4 - A Literature Review Summary of Different Morphologic Investigations of Mandibular Incisors3–17,23–29 Including the Present One
188
Pineda & MEX 179 mci R 72.4 2.0 23.5 1.0 1.1
Kuttler, 197215 184 mli 76.2 3.2 19.3 1.3
Kartal & TUR 100 mi SC, Mi 55.0 16.0 20.0 4.0 3.0 2.0
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Almeida
et al, 201312
Paes da Silva BRA 40 mi m-CT, 60.0 40.0
Ramos CB, R
Fernandes
et al, 20143
Liu et al, 201410 CHN 786 mci CB 91.1 6.1 2.3
785 mli 82.5 3.9 10.4 2.8 0.3
Han et al, 20149 CHNs 1286 mci CB 84.3 3.4 6.6 1.8 3.9 0.3 0.4
1294 mli 72.6 4.02 15.6 2.3 5.1 0.2 0.2 0.1
(continued on next page )
TABLE 4 - Continued
JOE Volume 46, Number 2, February 2020
Wolf et al, 2020 GER 125 mi m-CT 56.0 3.2 17.6 4.0 18.4
(pending/in
press)
m-CT, micro–computed tomographic method; CB, cone-beam computed tomographic method; F, female; l, left incisor; M, male; mci, mandibular central incisor; Met, methodology used; mi, mandibular incisor; mli, mandibular lateral incisor; PP,
population; r, right incisor; R, radiographic method; SC, staining and clearing method; TP, tooth position.
~o
The summary depicts the sample origin (country), sample number, and teeth position. The data (mean values) are sorted according to the respective root canal configuration method proposed by Vertucci (1974/Ve)4, Weine et al (1969/We)30, and Brisen
Marroquín et al (2015/Br)18. “s” after country code 5 subpopulation.
*Configuration not given or different than the ones expressed in Table 4.
189
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