CLINICAL RESEARCH

e-ISSN 1643-3750
© Med Sci Monit, 2021; 27: e928758
DOI: 10.12659/MSM.928758

Received:
Accepted:
2020.09.23
2020.10.29 Analysis of Root Canal Curvature and Root Canal
Available online:
Published:
2020.11.14
2021.01.13 Morphology of Maxillary Posterior Teeth in
Guizhou, China

Authors’ Contribution: CDEF 1,2,3 Xin Qiao 1 Department of Endodontics, Stomatological Hospital of Chongqing Medical
Study Design A BC 4 Tingting Xu University, Chongqing, P.R. China
Data Collection B 2 Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing,
Statistical Analysis C D 1,2,3 Liang Chen P.R. China
Data Interpretation D AG 1,2,3 Deqin Yang 3 Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher
Manuscript Preparation E Education, Chongqing, P.R. China
Literature Search F 4 Hospital/School of Stomatology, Zunyi Medical University, Zunyi, Guizhou,
Funds Collection G P.R. China

Corresponding Author: Deqin Yang, e-mail: [email protected]

Source of support: This study was supported by the National Natural Science Foundation of China (NSFC) (grant 31970783) and the Key Medical
Discipline Construction Project in Chongqing (YU-WEI-KE-JIAO, 2011, No. 55, Cardiology and Endodontics)

Background: We investigated the root canal curvature and morphology of maxillary posterior teeth in Guizhou, China, to
provide references for clinical practice.
Material/Methods: We collected 274 maxillary posterior teeth in Guizhou Province, China. The root canal curvature was observed
by X-ray film measurement. Two hundred teeth were selected to make transparent tooth models, and root ca-
nal configuration was recorded according to Vertucci classification criteria. The position of the MB2 root canal
orifice and the mesiobuccal root canal configuration were observed by micro-computed tomographic (micro-
CT) scanning. The t test and the chi-square test were used for statistical analysis.
Results: The root canals of the maxillary posterior teeth showed more significant curvature in the mesiodistal direction
than in the buccolingual direction (P<0.05). The MB2 root canal of maxillary molars showed severe bending in
the mesiodistal direction: 25.16±6.6 degrees and 28.05±8.65 degrees in first and second molars, respective-
ly. The detection rate of MB2 was 48% in maxillary first molars and 32% in maxillary second molars. The re-
sults of micro-CT showed that the vertical distances between the MB2 and MB-P line were 0.64±0.34 mm and
0.57±0.28 mm in first and second molars, respectively.
Conclusions: The root canal morphology and curvature of maxillary posterior teeth varied greatly in the Guizhou population,
which increases the difficulty of treatment. It is necessary for clinicians to gain understanding of the root ca-
nal and to improve the success rate of root canal therapy.

MeSH Keywords: Dental Pulp Cavity • Root Canal Therapy • Tooth Root • X-Ray Microtomography

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 Qiao X. et al.:
CLINICAL RESEARCH Root canal curvature and root canal morphology of maxillary posterior teeth
© Med Sci Monit, 2021; 27: e928758

Background Therefore, the present study collected data on the maxillary

posterior permanent teeth (including all maxillary premolars
Dental caries is the most widespread chronic infectious dis- and molars, except the third molars) of people in Guizhou, China
ease of humans. Inflammation in pulp tissues caused by den- and observed the buccolingual and the mesiodistal root canal
tal caries leads to periapical granulomas, bone erosion, tooth curvature with Schneider’s X-rays method [14]. We also stud-
loss, and severe pain [1]. Root canal therapy is the most com- ied root canal morphology of various teeth using transparent
monly used and effective treatment for pulp and periapical tooth staining technology according to Vertucci’s classifica-
disease [2], involving the removal of inflamed or necrotic pulp tion. Then, we used micro-computed tomography (micro-CT)
tissues and cleaning and shaping of the root canals, followed to analyze the location of the MB2 root canal orifice in maxil-
by obturation of the prepared canals. The wide range of vari- lary molars in order to provide a meaningful reference for the
ations in root canal morphological configuration complicate root canal treatment in people in Guizhou, China.
endodontic treatment if any of the root canal is left [3–5]. An
untreated missed root canal can lead to persistent presence of
microorganisms and necrotic tissue inside the canal, account- Material and Methods
ing for the high rate of root canal failure [6]. The prevalence
of untreated maxillary first molar MB2 canals in endodon- Main experimental materials
tic treatment failures was reported to be 66.0%, whereas the
prevalence of MB2 canals in primary treatments was 57.9%. In Guizhou Province, China (including Zunyi City, Guiyang
This difference was statistically significant and suggested the City, Renhuai City, Duyun City, Kaili City, Jinsha County, Tongzi
cause of persistent disease [7]. County, Suiyang County, Yaxi Town, and Tuanxi Town), maxil-
lary posterior molars were collected from stomatological hos-
One of the important indices to evaluate the difficulty of root pital and stomatological clinic. This procedure has been con-
canal therapy is root canal curvature [8]. The preparation of a firmed by the Ethics Committee of the Stomatological Hospital
curved root canal is particularly complex and is more likely to Affiliated with Chongqing Medical University.
cause complications such as root canal deviation, formation
of steps, and separation of instruments [9]. In clinical practice, Inclusion criteria were: no caries, completed root formation,
it is common to take X-rays film to observe the curved shape no pulp treatment, and no internal and external absorption of
of the root canal and evaluate difficulties of root canal treat- the collected maxillary posterior teeth.
ment before surgery. There have been few studies on root ca-
nal curvature of the maxillary posterior teeth in Guizhou, China. Exclusion criteria were: incomplete apical development, api-
cal absorption, and any pulp treatment.
Maxillary posterior teeth have a highly diverse canal con-
figuration that varies among races and geographic regions. Experimental method
Mohara et al. reported that the incidence of MB2 in the first
permanent molar and the second permanent molar of the X-ray measurement of root canal curvature
maxillary in Brazilians is 64.2% and 33.5%, respectively [10].
Buchanan et al. reported that according to the Vertucci classi- We selected 274 teeth (including 172 premolars and 102 mo-
fication of the root canal, type IV root canal is the most com- lars) according to the inclusion criteria. The sample size was es-
mon in the maxillary first molar in South Africa, and type I timated and calculated. After ultrasonic (NEWTRON® P5 BLED,
root canal is the most common in the maxillary second mo- SATELEC, Paris, France) removal of the soft tissue and stones
lar [11]. Li et al. found that the most common anatomy of adhered to the surface of the teeth, the top of the whole pulp
maxillary first premolars is 1 root with 2 canals (58.0%), and chamber was uncovered, the contents of the pulp chamber
the typical canal morphology is type IV (42.7%) in the Chinese and the calcification in the pulp chamber were removed by
population [12]. In addition, Guo et al. performed an evalua- dental fissure bur (Dentsply, New York, Pennsylvania, USA),
tion of maxillary first molar morphology in a North American the pulp chamber bottom and the root canal orifice were ful-
subpopulation, found that Asians presented a higher preva- ly exposed, and the root canal was inserted with a 15# K-file.
lence of Vertucci type I (35.0%) and type IV (45.0%) config- When the K-file just exposed the apical foramen, the opera-
urations when compared with white people (type I: 23.4%, tion was stopped to try to preserve the original appearance
type IV: 36.3%) [13]. Thus, there are some regional differenc- of the root canal. The method of parallel projection was used:
es of root canal morphology. Relevant research in local popu- the buccal surface of the tooth was fixed with the K-file on the
lations can help clinicians to increase understanding and eval- cardboard with double-sided tape, the plane of the cardboard
uation of root canal therapy and enrich the body of research was parallel to the long axis of the tooth, the cardboard was
on human root canals. then placed on the receiver, and the receiver was fixed 30 cm

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Root canal curvature and root canal morphology of maxillary posterior teeth
© Med Sci Monit, 2021; 27: e928758
CLINICAL RESEARCH

below the ball tube mouth of the Kodak 2100 integrated X-ray
system (Kodak, Rochester, New York, USA), and the mesiodis-
tal (form mesial to distal) and buccolingual (from buccal to lin-
gual) areas were photographed for the same tooth. Under the
condition of 60 kV, 7 Ma, and 0.16 s, the obtained X-ray den-
tal film was saved as a digital image, and then it was import-
ed into the electronic measuring ruler software (CASS, SOUTH
DIGITAL TECHNOLOGY COMPANY, Guangzhou, China) to mea-
sure the root canal curvature of the maxillary posterior teeth.

Measurements were performed using the method of

Schneider [14], in which a line was scribed from the root canal
orifice (Figure 1 Point A) on the X-ray parallel to the long axis
of the canal. A second line was drawn from the apical foramen
(Figure 1 Point C) to intersect with the first at the point where
the canal began to leave the long axis of the tooth (Figure 1
Point B). The acute angle formed was measured and recorded.

The same experimenter measured the root canal curvature ac-

cording to the above method, and took the average value of 3
measurements to reduce bias between observers.

According to the Schneider method [14,15], the calculated cur-

vature of root canal can be divided into 3 categories: 0–5 de-
grees of root canal curvature is category I (also known as ba-
sically no curvature), 5–20 degrees of root canal curvature is
category II (moderate curvature of root canal), and more than Figure 1. Root canal curvature measurement (Point A) the root
20 degrees of root canal curvature is category III (severe cur- canal orifice (Point B) the canal began to leave the long
vature of root canal). The combination of class II and class III axis of the tooth (Point C) the apical foramen
is indicted a curved root canal.
the liquid every 6 h, and then put them into a glass bottle con-
Observation of root canal morphology by transparent tooth taining methyl salicylate (Holly oil) (Merck, Shanghai, China)
method for sealing and preservation. After 5 h, the root canal morphol-
ogy could be observed transparently.
We selected 200 teeth (100 premolars and 100 molars) accord-
ing to the inclusion criteria. The sample size was estimated and Root canal morphology was classified according to the Vertucci
calculated. The adhered soft tissues and stones on the surface classification standard (Figure 2). The mesiobuccal root ca-
of the teeth were removed in vitro by ultrasound (NEWTRON® nals of maxillary molars vary greatly, so the mesiobuccal root
P5 BLED, SATELEC, Paris, France), followed by 24-h fixation in was chosen for observation and analysis in maxillary molars.
4% formaldehyde solution (Solarbio, Beijing, China), washing
with water for 2 h, opening the pulp with unaided vision, un- Micro-CT observation of root canal orifice position
covering the whole pulp chamber top, immersing in 5.25% so-
dium hypochlorite solution (Merck, Shanghai, China) for 24 h, We randomly selected 21 maxillary first molars and 21 maxil-
dissolving the residual pulp tissue in the root canal, washing lary second molars from the teeth that met the inclusion cri-
with water for 4 h, and drying at room temperature. The teeth teria. The sample size was estimated and calculated. In vi-
were immersed in a container full of carbon ink, and the ink tro, the experimental teeth were put into the micro-CT device
was fully infiltrated into the root canal by vacuum negative- (Micro CT inveon; Siemens Medical Solutions, Knoxville, TN).
pressure pump for 1 h. Then, teeth were placed in 10% nitric The scanning track was perpendicular to the long axis of the
acid (Merck, Shanghai, China) for decalcification, replaced ev- teeth, and the three-dimensional accuracy was 15×15×15 μm.
ery 24 h to maintain the constant concentration of nitric acid. We imported the two-dimensional data (DICOM format) ac-
After 3 days, the teeth were removed and washed with water quired after scanning into MICs 10.01 software (Materialise,
for 24 h. Teeth were dehydrated in 25%, 50%, and 75% etha- Leuven, Belgium) for digital simulation three-dimensional re-
nol and anhydrous ethanol (Merck, Shanghai, China), changing construction. To evaluate the distribution of MB2 orifices,

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Type I (1) Type II (2–1) Type III (1–2–1) Type IV (2) Type V (1–2) Type VI (2–1–2) Type V0I (1–2–1–2) Type VIII (3)

Figure 2. Illustration showing the categories of root canal morphologies in human permanent teeth according to the method by
Vertucci.

Figure 3. Diagram of MB2 root canal orifice positioning measurement.

we adjusted the transparency and magnification of the mod- Results

el, measured the distance MB-MB2, the vertical distance be-
tween the MB2 and MB-P lines, and the acute angle between X-ray measurement of root canal curvature
the MB-MB2 and MB-P lines (Figure 3) with the measurement
function attached to the software. The root canal morpholo- As shown in Table 1, the mean curvature of the maxillary sec-
gy of mesiobuccal roots was observed and classified accord- ond premolar was slightly higher than that of the first premo-
ing to Vertucci method. lar, and all of them had moderate curvature (5-20 degrees)
in mesiodistal and buccolingual directions. However, we not-
Data analysis ed that the maximum curvature generally reached category
III (more than 20 degree) in maxillary premolars, regardless
SPSS 19.0 (SPSS, Chicago, IL, USA) software was used to cal- of direction, indicating that root canal curvature varies great-
culate the mean and standard deviation of the curvature of ly among individuals. There was a significant difference in pal-
each root canal. We performed t tests to compare the curvature atal roots between mesiodistal (7.73±5.30 degree) and buc-
of the root canal in mesiodistal and buccolingual directions, colingual (9.42±7.16 degree) directions of the first premolars
and the chi-square test was used to compare the incidences (P<0.05) (Table 1).
of MB2 detected by transparentizing teeth and micro-CT. The
difference was statistically significant when P<0.05. Table 2 shows the root canal curvature of maxillary molars.
Except for MB2 of the second molar, all the root canal curvatures

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Root canal curvature and root canal morphology of maxillary posterior teeth
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CLINICAL RESEARCH

Table 1. Root canal curvature of maxillary premolar.

Mesiodistal direction Buccolingual direction t test

Tooth Number of Cate- Cate- Cate- Cate- Cate- Cate-
position root canal Maximum X±S Maximum ‘X±S
gory gory gory gory gory gory t value P value
(degree) (degree) (degree) (degree)
I II III I II III

First Double B 34 73 6 26.45 8.73±6.56 37 71 5 25.82 7.63±6.06 1.508 0.134

premolar root canal
(113) P 37 73 3 23.96 7.73±5.30 31 73 9 34.58 9.42±7.16 –2.01 0.047

Single root
4 8 0 16.91 5.72±5.19 5 7 0 16.33 7.18±4.70 –0.723 0.477
canal (12)

Second Double B 10 34 3 37.97 10.27±7.51 9 31 7 27.19 11.78±7.62 –1.051 0.299

premolar root canal
(22) P 8 11 3 26.85 9.2±7.57 2 17 3 33.48 12.71±7.7 –1.838 0.08

Single root
3 20 2 31.96 9.19±5.72 4 20 1 22.21 10.35±6.59 –0.665 0.509
canal (25)

B – buccal root canal; P – palatal root canal.

Table 2. Root canal curvature of maxillary molar.

Number of Mesiodistal direction Buccolingual direction t test

Tooth
root Type Type Type Maximum X±S Type Type Type Maximum ‘X±S
position t value P value
canal I II III (degree) (degree) I II III (degree) (degree)
First MB (64) 2 31 32 35.95 20.84±7.16 5 59 1 30.66 11.33±6.53 3.755 0.001
molar
MB2 (21) 0 16 5 27.33 25.16±6.6 1 19 1 22.68 11.05±6.08 6.418 0

DB (64) 4 56 4 25.48 13.75±6.65 13 51 0 15.62 6.87±5.13 6.291 0

P (64) 21 43 1 21.41 9.92±7.67 7 55 3 24.96 4.30±4.35 5.197 0

Second MB (38) 2 19 20 48.06 19.48±9.64 7 27 7 33.72 10.97±8.34 5.722 0

molar
MB2 (2) 0 0 2 34.16 28.05±8.65 0 2 0 16.32 11.02±7.5 1.491 0.376

DB (38) 1 34 6 29.95 13.36±6.35 12 29 0 18.11 7.81±5.91 4.592 0

P (38) 22 19 0 17.68 9.12±7.98 16 20 5 24.55 4.42±4.77 3.111 0.003

P – palatal root canal; MB – mesiobuccal root canal; MB2 – the second mesiobuccal root canal; DB – distobuccal root canal.

of maxillary molars showed significant differences in mesiodis- Figure 4 shows the types of root canal curvature in different
tal and buccolingual directions (P<0.01). According to our re- tooth positions and different projection directions.
sults, the root canals of the maxillary posterior teeth showed
a greater curvature in the mesiodistal direction than in the Observation of root canal morphology by transparent
buccolingual direction, and the MB and MB2 of maxillary first tooth method
molars and MB2 of maxillary second molars showed severe
bending (more than 20 degrees) in the mesiodistal direction The representative types of root canals observed by the
(20.84±7.16 degrees, 25.16±6.6 degrees, and 28.05±8.65 de- transparent tooth method are shown in Figure 5. In the first
grees, respectively). All root canals of maxillary posterior teeth premolar, the detection rate of type IV root canal was the
showed moderate curvature (more than 5 degrees and less highest, accounting for 44%, followed by type II root canal,
than 20 degrees) in the buccolingual direction, while palatal accounting for 26%. In the second premolar, the detection
roots showed slight bending in mesiodistal directions, i.e., a rate of type I root canals was the highest (44%), followed
straight root canal (less than 5 degree) (Table 2). by type II and type IV root canals (28% and 22%). The re-
sults showed that the detection rate of MB2 (type II, IV, and
VI) in maxillary first molars was 48%, while it was 32% in

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A B C

D E

F G

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Root canal curvature and root canal morphology of maxillary posterior teeth
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CLINICAL RESEARCH

H I J

Figure 4. Representation of root canal curvature in different tooth positions and different observation directions. (A–C) Buccolingual
direction of premolar (A) straight root canal (category I). (B) Moderately curved root canal (category II). (C) Severely curved
root canal (category III). (D, E) Mesiodistal direction of premolar. (D) Straight root canal (category I) and severely curved root
canal (category III). (E) Moderately curved root canal (category II). (F, G) Buccolingual direction of molar. (F) Straight root canal
(category I) and severely curved root canal (category III). (G) Moderately curved root canal (category II). (H–J) Mesiodistal
direction of molar. (H) Straight root canal (category I). (I) Moderately curved root canal (category II). (J) Severely curved root
canal (category III).

A B C D

E F G H

Figure 5. Representation of root canal types observed by transparent tooth method (A) Type I (1-1 double roots) (B) type I (1-1 single
root) (C) type II (2-1) (D) type III (1-2-1) (E) Type IV (2-2) (F) type V (1-2) (G) type VI (2-1-2) (H) type VII (1-2-1-2).

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Table 3. Distribution of main root canal configuration of 200 maxillary posterior teeth (n %).

Type I Type II Type III Type IV Type V Type VI Type VII Type VIII
Tooth position Number
(n %) (n %) (n %) (n %) (n %) (n %) (n %) (n %)

First premolar 50 6 (12%) 13 (26%) 4 (6%) 22 (44%) 3 (6%) 1 (2%) 1 (2%) 0 (0%)

Second premolar 50 22 (44%) 14 (28%) 0 (0%) 11 (22%) 2 (4%) 1 (2%) 0 (0%) 0 (0%)

MB root of the
50 14 (28%) 6 (12%) 5 (10%) 16 (32%) 7 (14%) 2 (4%) 0 (0%) 0 (0%)
First molar

MB root of the
50 24 (48%) 5 (10%) 7 (14%) 9 (18%) 2 (4%) 2 (4%) 0 (0%) 1 (2%)
Second molar

Table 4. Measurement results of MB2 orifice in micro-CT.

MB2-MB distances MB2-(MB-P line) Angles between (MB-MB2 line) and

Tooth position
(mm) (mm) (MB-P line) (degree)
The first molar 1.37±0.48 0.64±0.34 25.18±18.32

The second molar 1.29±0.54 0.57±0.28 23.31±15.86

Table 5. Comparison of MB2 detection rate by micro-CT and tooth transparent method.

Micro CT tooth transparent method

c2 P
MB2 (number) Total Detection rate MB2 (number) Total Detection rate

The maxillary
10 21 47.62% 24 50 48% 0.001 0.592
first molar

The maxillary
8 21 38.10% 16 50 32% 0.246 0.408
second molar

maxillary second molars. The proportion of type I root ca- The representative root canal morphology observed by micro-
nal in the mesiobuccal root of the second permanent mo- CT of the first and second maxillary molars mesiobuccal root is
lars was highest, accounting for 48%. The detailed classifi- shown in Figure 6. According to the Vertucci method, the inci-
cation of root canal configuration in different tooth positions dences of MB2 were 47.62% and 38.10%, respectively. When
is shown in Table 3. the allowable error is 20%, we compared the incidence of MB2
between micro-CT and transparent teeth method, and the chi-
Micro-CT observation of root canal orifice position square test showed that there were no statistically significant
differences (P>0.05) (Table 5).
MB2 orifice was found in 10 maxillary first molars and 8 max-
illary second molars. The results of micro-CT showed that all In this study, although the sample size was not large, a tooth
the MB2 orifices were located at the lingual side of the MB, with a relatively rare shape was found. The report was as fol-
and the MB2-MB distances of the first molar and the second lows: the first permanent molar of the maxillary had 2 mesio-
molar were (1.37±0.48) mm and (1.29±0.54) mm, respective- buccal roots, which were type I root canal type (Figure 6H).
ly. Most of the MB2 orifices were located at mesial position Micro-CT clearly showed that the branches of the root ca-
of the line of MB-P, but in 1 case, the MB2 orifices were lo- nal were complex and highly variable, especially in 1/3 of the
cated at the distal position. In maxillary first molars and sec- apex (Figure 6).
ond molars, the vertical distances between MB2 and the line
of MB-P were (0.64±0.34) mm, (0.57±0.28) mm, and the angles
between the MB-MB2 line and MB-P line were (25.18±18.32)°
and (23.31±15.86)°, respectively (Table 4).

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Root canal curvature and root canal morphology of maxillary posterior teeth
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CLINICAL RESEARCH

A B C D

E F G H

Figure 6. Representation root canal morphology by micro-CT (A) Type I (1-1) (B) Type II (2-1) (C) Type III (1-2-1) (D) Type IV (2-2)
(E) type V (1-2) (F) type VI (2-1-2) (G) type VII (1-2-1-2) (H) Double root of mesial buccal (1-1 root canal).

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CLINICAL RESEARCH Root canal curvature and root canal morphology of maxillary posterior teeth
© Med Sci Monit, 2021; 27: e928758

Discussion Commonly used methods to observe the root canal system

include X-ray, transparent tooth, CBCT, and micro-CT. At pres-
To improve the success rate of root canal therapy, it is neces- ent, CBCT is often used in the study of root canal morpholo-
sary to understand the root canal curvature. In clinical practice, gy [21–23]. However, transparent teeth can directly and com-
X-ray film is mainly used to evaluate the root canal curvature prehensively observe the three-dimensional morphology of
before root canal surgery, that can show root canal curvature the root canal system, which helps find subtle structures
in the mesiodistal direction. However, when there is curvature such as lateral branch root canal and apical divergence. Zhang
in the buccolingual direction, clinical X-ray films show little Zhiyong et al. showed that the display of transparent teeth on
useful information to the dentist because of the limitation of the branch structure of root canal was significantly higher than
a single-projection direction; moreover, the curvature of the that of CBCT [24]. In the present study, we used transparent
palatal root canal is often not reflected due to buccal root ob- tooth method to observe the root canal morphology. The cur-
struction. These undiscovered bends may result in poor root rent study showed that maxillary posterior teeth among resi-
canal preparation, such as inaccurate measurement of work- dents of Guizhou, China, presented with a variety of Vertucci
ing length, deviation during root canal expansion, and lateral types of canal configurations, with similarities and differences
or zonal perforation [16]. In this study, the digital X-ray den- to other reported studies [10,25,26] in different populations.
tal film machine was used to project the maxillary posterior
teeth in vitro with the buccolingual and mesiodistal directions, We revealed that the incidence of single root canal (type I) in
so as to avoid the negative reflection of single-projection di- maxillary first premolar was only 12%, and the 2-canal con-
rection and more accurately analyze the root canal curvature. figuration was the most prevalent observation (88%), which
Electronic measuring ruler software was used to measure the is similar to that of the Shandong population (89%) assessed
buccolingual and mesiodistal photographs, which reduced by Wu et al. [6]. According to Vertucci classification, type IV
the artificial deviation and provided detailed information on had the highest detection rate (44%) in maxillary first pre-
the root canal bending shape of the maxillary posterior teeth. molars, slightly higher than that reported by Wolf et al. in a
Swiss-German population (30%) [27]. Previous studies [28,29]
Importantly, endodontic instruments have the tendency to suggested that type I was the most prevalent in the second
conform to a straight canal, causing over-preparation of the premolars in Brazil (49.9%) and Saudi Arabia (49.4%), which
outer curvature in their apical portion and the inner curve of is consistent with the present study (44%) in Guizhou, China.
the root canal in the coronal parts of the curved roots [17].
With the increase of root canal curvature, this negative effect In maxillary molars, MB2 exists in type II, IV, and VI root ca-
is especially obvious, which leads to more errors in root canal nal configurations of the mesiobuccal root, which was esti-
preparation. Furthermore, canal preparation errors hinder ad- mated to be 48% in first maxillary molars and 32% in maxil-
equate cleaning, irrigation, and filling of root canals, and are lary second molars, consistent with a study on MB2 incidence
thus likely to negatively affect treatment outcomes [18,19]. of maxillary second molars (35.97%) in Taiwan [25]. These re-
Therefore, root canal curvature is one of the important index- sults are higher than the incidence of MB2 (in maxillary first
es used to evaluate the difficulty of root canal therapy. In our and second molars were 36.3% and 8.5%, respectively) in a
study, the root canals of maxillary premolars all showed moder- Malaysian subpopulation [30], but lower than that in a white
ate curvature, either in mesiodistal or buccolingual directions. population (71% in maxillary first molars and 44% in second
However, the curvature in mesiodistal directions was signifi- molars) [31] and in a Brazilian subpopulation (85.7% in max-
cantly greater than that in buccolingual direction (except for illary first molars) [32]. These differences suggest that the in-
MB2 of maxillary second molar) in maxillary molars, and the cidence of MB2 varies by region and race. No C-shaped roots
difference was statistically significant, which was consistent or canals were found in the present study, although cases
with the root anatomy. As is well known, the root of maxillary have been reported [33], and the incidence of C-shaped roots
molars is mostly distally oriented [20], which explains why the in maxillary molars in China is low.
flexion angles in the mesiodistal direction were significantly
greater than that in the buccolingual direction. In addition, the In the present study, we used micro-CT technology to recon-
bending angles were mostly moderate-to-severe in maxillary struct the first and second maxillary molars in three-dimen-
molars, which undoubtedly increases the difficulty and chal- sional digital simulation. According to the measured related
lenge for root canal therapy. When preparing the root canal values to locate the MB2 orifice, the approximate position of
of maxillary posterior teeth, we suggest that clinicians should MB2 can be inferred: most MB2 are located at the lingual side
use a softer nickel-titanium file to reduce complications such of the root canal orifice of MB, and the mesial of the line of
as needle breakage and apical deviation. MB-P (occasionally in the distal), the length from MB2 to MB-P
line is about 0.6 mm, the distance between MB and MB2 is
about 1–1.5 mm, and the angle between MB-P and MB-MB2

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Qiao X. et al.:
Root canal curvature and root canal morphology of maxillary posterior teeth
© Med Sci Monit, 2021; 27: e928758
CLINICAL RESEARCH

is about 23-25 degrees. When exploring maxillary molars, cli- Conclusions

nicians can look for MB2 in the above range, so as to improve
the success rate of root canal therapy. Within the limitations of the present report, complex structures
and large variation can be found in the root canal morphology
There is obvious variation of the root canal curvature and mor- of maxillary posterior teeth in Guizhou, China. The maxillary
phology of maxillary posterior teeth in Guizhou, China, which posterior teeth showed obvious root canal bending variation
is very complex and requires careful assessment for endodon- and root canal configuration differences. Mostly, the root ca-
tic treatment. Our study has certain limitations. For example, nals of maxillary premolars showed moderate curvature, while
the sample size was not large enough, and a study with a larg- the root canals of maxillary molars showed moderate-to-se-
er sample size may provide a more convincing and reliable re- vere bending. In the Guizhou population, the incidence of dou-
sult in the study of a specific population. In addition, this study ble root canals in maxillary premolars is high. The endodontic
only discussed the root canal anatomy, but not the root anato- doctors should carefully explore to avoid missing root canals
my. As an important structure of teeth, roots also play an im- when performing root canal therapy. The incidence of 2 ca-
portant role in clinical practice, not only for endodontic pur- nals in the MB roots in the first molars was higher than that
poses, but also when certain clinical procedures are planned. of the second molars. The root canal configuration of maxil-
Implant placement [34], miniscrew insertion [35], or complex lary second molars was more variable than those of the first
disinclusion orthodontic therapy [36] gain in predicability with molars. Before root canal treatment, doctors should be fully
deeper knowledge of variations in tooth anatomy. These is- aware of the possibility of root canal variation, and explore
sues need to be further studied in the future. carefully to avoid missing root canals, so as to improve the
success rate of treatment.

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