Clinical Research

Analysis of C-shaped Canals by Panoramic Radiography

Abstract
Introduction: The purpose of this study was to docu-
ment the characteristics of C-shaped canal systems in
permanent mandibular second molars using a combi-
T he term C-shaped canal was first introduced by Cooke and Cox (1) in 1979 to
describe the cross-sectional morphology of roots that resembled the letter C. The
characteristic feature of such roots is the connection of the root canals by a fin or
nation of orthopantomogram (OPT) and cross- weblike structure to form a C shape at the root canal orifice (2). The complexity of
sectional cone-beam computed tomographic (CBCT) C-shaped canals makes them difficult to clean, shape, and obturate effectively (3, 4).
imaging. Methods: Two hundred participants (94 The thin dentinal wall of the buccal or lingual groove may lead to strip perforation,
men and 106 women, mean age = 35 years) who which poses a considerable threat to tooth prognosis (5). To maximize a successful
underwent both routine CBCT and OPT examinations treatment outcome, it is necessary to have a good understanding of the C-shaped canal
were enrolled. One endodontist and 1 oral radiolo- anatomy and to perform a careful interpretation of its radiographic features. A high
gist examined the images of 339 mandibular prevalence of C-shaped canals has been reported in mandibular second molars (6).
second molars and described the radiographic features However, they can also be found in other maxillary and mandibular molars (7–10),
of C-shaped canals from OPT images as confirmed by mandibular premolars (11), and maxillary lateral incisors (12).
CBCT imaging. Root morphology was classified as Proper diagnosis and recognition of this morphology by radiographic examination
nonfused (NFRI–II) or fused (FRI–III) based on OPT is critical for effective endodontic management. Recent studies have investigated
images. Cross-sectional root canal configurations C-shaped canals using cone-beam computed tomographic (CBCT) imaging and
(C1–C5) were identified from CBCT imaging at 3 reported that it is a potentially effective tool for the detection of this morphology
different levels (coronal, middle, and apical). Fre- (13–15). Although CBCT imaging has a role in the identification of root canal
quency distributions of root morphology and root canal systems, it is not indicated as a standard method for routine demonstration of root
configurations were compared at each level, and inter- canal anatomy. The use of CBCT scanning in endodontics has been limited to
observer reliability was tested using the Cohen kappa selected cases in which conventional intraoral radiographs provide information on
test. Results: Of the 339 teeth, 29 (8.6 %) had the root canal anatomy that is equivocal or inadequate for planning treatment (16).
C-shaped root canal systems. Most of the root canals These complex endodontic conditions involve the identification of root canal system
were NFR type (86%); only 2% had C-shaped root anomalies and the determination of root curvature, an indication related to C-shaped
canals (all NFRII). In the FR category, 23 teeth with canals (17).
C-shaped canals were equally distributed between Radiographic features of C-shaped root canals have been described in various
the FRI and FRII subtypes. Interobserver agreement studies. C-shaped canals can have different shapes if evaluated longitudinally
was almost perfect (k = 0.89 and k = 0.91; right and (18, 19). Haddad et al (20) considered C-shaped canals a third canal that was in be-
left second molars, respectively). Per CBCT imaging, tween a large distal canal and a narrow mesial canal on a periapical (PA) radiograph.
the most common configuration was C3 at all levels; Furthermore, Wang et al (21) showed that teeth with C-shaped root canals had a more
no C5 case was detected. Conclusions: OPT usage apically positioned furcation with a longitudinal groove separating the root into mesial
can assist in recognizing and diagnosing C-shaped and distal parts revealed by preoperative, postoperative, and working length PA radio-
root canal systems. Radicular fusion or proximity is a graphs. It has also been reported that the radiographic evaluation of C-shaped canals
characteristic feature of C-shaped canal systems. How- with preoperative PA radiography is challenging if the fin connecting the roots is thin
ever, nonfused root appearances should also be and not visible (22). Although it is more accurate to assess root shape on PA radiog-
considered suspicious. (J Endod 2014;40:917–921) raphy (23), orthopantomogram (OPT) is often the first diagnostic image of choice for
routine radiologic examination and is widely used for screening at various institutions
Key Words (24). The recognition of C-shaped canals by means of OPT was suggested to be a good
Cone-beam computed tomography, C-shaped canal, surveying modality (25). Nonetheless, preoperative radiographs, whether OPT or PA,
mandibular second molars, panoramic radiography have limitations. They are 2-dimensional images with anatomic noise and geometric

From the Departments of *Oral and Maxillofacial Radiology and †Endodontics, Faculty of Dentistry, Kocaeli University, Kocaeli, Turkey.
Address requests for reprints to Dr Alper Sinanoglu, Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Kocaeli University, Yuvacik Yerleskesi,
Basiskele, Kocaeli, Turkey. E-mail address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.03.014

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Clinical Research
distortion (26). In such complex cases, before the decision to perform distal and mesial canals that appear to continue on their own pathway
advanced imaging, these preoperative radiographs should be well inter- toward the apex; and FRIII, fused root type with separate distal and mesial
preted in order to justify the need to expose a patient to radiation. The canals (1 canal was curved to and superimposed on a radiolucent line
aim of this study was to document the presence of C-shaped canals and that separated the root into distal and mesial regions, and the other canal
their different variants in permanent mandibular second molars by us- appeared to continue on its own path toward the apex). The 2 investiga-
ing the longitudinal resolution of OPT images along with confirmation tors independently scored the right and left mandibular second molars
by CBCT imaging among members of a Turkish population. according to root morphology classification on OPT images, and a final
consensus was reached for each tooth afterward.
Materials and Methods
The Ethics Committee of Kocaeli University (KOU KAEK 2013/78) CBCT Evaluation
approved this retrospective study. The participants were referred to the The mandibular second molars were evaluated for the presence of a
University of Kocaeli, Faculty of Dentistry, Kocaeli, Turkey, between C-shaped canal. The canal system was defined as C-shaped according to
March 2010 and December 2012 and required both CBCT and OPT ex- the following criteria stated by Fan et al (2):
aminations as part of their routine examination. The aim of the CBCT 1. Fused roots
scans was for the diagnostic imaging of maxillofacial tumors and cysts, 2. A longitudinal groove on the lingual or buccal surface of the root
presurgical assessment of impacted teeth, and proposed implant sites. 3. At least 1 cross-section of the canal showed a C1, C2, or C3 config-
The OPT and CBCT images from these patients were retrieved from the uration
database in the oral and maxillofacial radiology department and were
investigated retrospectively. Configuration of the C-shaped canal was categorized in cross-
The inclusion criterion was the presence of at least 1 well- sections of the roots at 3 different levels: coronal, middle, and apex.
developed mandibular second molar with complete root formation. The following 3 levels were selected:
The exclusion criteria were the existence of root canal fillings, PA le-
Coronal: C = 2 mm from the orifice
sion(s), or deep caries. CBCT images were acquired using an i-CAT
Middle: M = root length/2
scanner (Xoran Technologies, Ann Arbor, MI, and Imaging Sciences In-
Apical: A = 2 mm from apex
ternational, Hatfield, PA) according to the manufacturers’ protocol. All
CBCT images were obtained at a 0.25-mm voxel size and were recon- After segmentation into 1-mm slices, the configuration of the root
structed to be a 1-mm-thick slice. To investigate the mandibular canal at each level of the root was categorized into the following types in
second molars, the i-CAT Vision viewer software was used to reconstruct accordance with the classification of Fan et al (2) (Fig. 2):
the cross-sectional images. The OPT images were obtained with Vera-
viewpocs (Morita, Kyoto, Japan) that was operated at 70 kVp and C1: Continuous C-shaped canal
10 mA. C2: Semicolon shaped because of a discontinuation in the ‘‘C’’
After evaluation, 339 mandibular second molars in 200 CBCT im- outline; however, either angle, a or b, should be no less than 60
ages fulfilled the previously mentioned inclusion criteria. The study C3: 2 (C3a) or 3 (C3b) separate canals, and both angles, a and b,
group consisted of 94 male and 106 female patients with a mean age were less than 60
of 35 years. One endodontist and 1 oral radiologist investigated all im- C4: Single round or oval canal
ages independently. C5: No canal lumen
To confirm the canal shapes, C2 and C3, Image ProPlus 4.0 (Me-
dia Cybernetics Inc, Silver Spring, MD) was used for measurement of the
OPT Evaluation angles, a and b (2, 14) (Fig. 3A and B). The frequency of each type of C-
The mandibular second molar root morphology was classified ac-
shaped canal and the distribution of the canal configurations at each
cording to whether the root shape was considered a fused root (FR) or a
level were analyzed.
nonfused root (NFR) as presented in Figure 1. FR and NFR types were
divided into the following subgroups as modified from the classification
of Fan et al (18): NFRI, nonfused type with 2 divergent or parallel separate Data Analysis
roots; NFRII, nonfused type with 2 convergent separate roots with trabec- The roots were analyzed for morphology (NRFI, NRFII, FRI, FRII,
ular patterns between them; FRI, fused root type with distal and mesial and FRIII) by longitudinal OPT images and the different types of
canals merging at the apical level; FRII, fused root type with separate C-shaped canals (C1–C5) by using cross-sectional CBCT images

Figure 1. Root morphology classification. Nonfused root types (NFRI and NFRII) were added to the classification of Fan et al (18). FR refers to the fused root type.
(Adapted from Fan B, Cheung GS, Fan M, et al. C-shaped canal system in mandibular second molars: part II–radiographic features. J Endod 2004;30:904–8.)

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 Clinical Research
roots, the most common canal configuration was C3, whereas the C5
configuration was not detected in any of the sections. Chi-square anal-
ysis showed that the cross-sectional radiographic images of the middle
or apical regions could equally detect all 4 types of C-shaped root ca-
nals, whereas examination of the coronal region did not detect any
C4 types. In addition, the ability to identify each type of C-shaped root
canal depends on the position of the radiographic scan along the length
of the tooth (Table 2). These data show that cross-sectional analysis
must be conducted in all 3 levels of each tooth in order to avoid false
negatives regarding the existence of a C-shaped root canal.

Discussion
Radiographic identification of the variations of root canal
morphology is a basic requirement for successful endodontic treatment.
Preoperative radiographs are important diagnostic tools in the evaluation
process of various root canal configurations, particularly for complex
ones, such as C-shaped root canal systems (18, 20, 21, 25). The use
Figure 2. Classifications of C-shaped canal configurations. (From Fan B, of conventional radiography for the detection of this morphology has
Cheung GS, Fan M, et al. C-shaped canal system in mandibular second molars: been investigated in various studies. Cooke and Cox (1) emphasized
part I–anatomical features. J Endod 2004;30:899–903.) the difficulty of diagnosing C-shaped root canals with preoperative radio-
graphs. Difficulty in recognition of C-shaped canals in OPT was also re-
(Fig. 4). All data were compiled as absolute counts and percentages.
ported for hypertaurodont mandibular molars (27). Lambrianidis et al
They were analyzed for regional differences in frequency distributions
(28) suggested that working length PA radiographs were more helpful
by the chi-square and Fisher exact tests using SPSS 15.0 software for
than that of preoperative ones and that clinical diagnosis can only be es-
Windows (SPSS Inc, Chicago, IL). A P < .05 was considered significant.
tablished after access to the chamber. Nonetheless, numerous studies re-
Interobserver reliability was calculated using the Cohen kappa test.
ported that the existence and configuration of C-shaped canals could be
predicted from preoperative radiographs according to the appearance of
Results the roots (18, 20–22, 25). As a common approach, these studies stated
A total of 200 cases were included in the study group (94 men and that a C-shaped canal must be suspected if the preoperative radiographs
106 women, mean age = 35 years). General root morphology was first display radicular fusion or proximity. A classification was developed by
assessed longitudinally by using OPT images. The frequency distribution Fan et al (18) for the radiographic appearance of C-shaped roots accord-
of the different types of root canals is given in Table 1. Among the 339 ing to the pathways of the mesial and distal canals. They used PA radio-
teeth evaluated, the vast majority of the root canals exhibited NFR graphs of extracted teeth; therefore, the images did not present any
morphology, and a total of 29 teeth (8.6%) exhibited a C-shaped canal. anatomic noise (ie, presence of surrounding bone), facilitating a detailed
The FR group presented a significantly higher frequency of C-shaped ca- assessment of the root morphology. In the present study, radiographic
nals than the NRF group (P = .001). The 2 observers reached a high appearances revealed by OPT were investigated, and specific evaluation
level of agreement regarding the classification of the different root types of root canal morphology was not a precedence. Our findings were in
that was considered almost perfect (k = 0.89 and k = 0.91; right and accordance with Fan et al (18), suggesting the high prevalence of C-
left second molars, respectively). Collectively, these data suggest that C- shaped canals in fused roots. The FRI type was the most commonly
shaped canals are rarely detected in the most common type of root canal seen radiographic appearance of roots with C-shaped canals and had
(NFRI) but should be expected in about half of the permanent mandib- a higher prevalence than that of prior studies (18, 21).
ular second molars presenting with FR morphology. Other than the characteristic feature, some additional radiographic
The cross-sectional characteristics of FR and NFR types are shown properties were also reported in teeth with C-shaped root canals. Gula-
in Table 2 for the coronal, middle, and apical regions. At all levels of the bivala et al (29) reported that C-shaped root canals might be present in

Figure 3. Measurements of the angles a and b to differentiate the C2 and C3 canal configurations. (A and B) Ends of one canal cross-section. (C and D) Ends of
the other canal cross-section. M, middle point of line AD; a, angle between line AM and line BM; b, angle between line CM and line DM (2). (A) C2 canal config-
uration, angle b > 60 ; (B) C3 canal configuration, a < 60 , b < 60 . (From Fan B, Cheung GS, Fan M, et al. C-shaped canal system in mandibular second
molars:part I–anatomical features. J Endod 2004;30:899–903.)

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Figure 4. Representative OPT images with corresponding CBCT cross-sections at the coronal (c), middle (m), and apical (a) levels.

not only fused roots but also 2 separate roots with a dentin fin that might TABLE 1. Frequency Distribution of the Different Types of Root Canals and
be difficult to recognize in PA radiographs. In a recent study, 76 of the Percentages of C-shaped Canals
1,146 cases with 2 separate roots were found to be C-shaped root canals NFR FR
on the basis of PA examinations (21). Therefore, in the present study, the Root morphology (n = 293) (n = 46)
classification by Fan et al (18), in which all 3 types were fused roots, was
modified, and the NFR types were added (Fig. 1). Interestingly, 6 NFRII- Types NFRI NFRII FRI FRII FRIII
type roots presented as C-shaped canals with CBCT evaluation. This Number of teeth 203 90 20 21 5
finding can be explained by the difficulty of recognizing root fusion Number of teeth with a 0 6 11 10 2
C-shaped canal (%) 6 (2%) 23 (50%)
with OPT, possibly related to the trabecular pattern of the alveolar
bone because of the deep grooves of the roots and the thin dentin fin FR, fused root; NFR, nonfused root.

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 Clinical Research
TABLE 2. Frequency Distribution of the C-shaped Canal Configurations at the References
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Acknowledgments ond molars. Part I: radiographic and anatomical features revealed by intraradicular
The authors deny any conflicts of interest related to this study. contrast medium. J Endod 2007;33:806–10.

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