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ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 345-349

Radiographic variations of maxillary and mandibular premolars with type V canal configuration – A cone-beam computed tomographic study


1 Department of Restorative Dental Sciences, College of Dentistry, Majmaah University, Almajmaah, Saudi Arabia
2 Department of Endodontics, College of Dentistry, Qassim University, Buraydah, Saudi Arabia
3 Department of Endodontics, Eastern Riyadh Dental Center, Second Health Cluster, Ministry of Health, Saudi Arabia

Date of Submission12-Aug-2020
Date of Decision24-Aug-2020
Date of Acceptance21-Oct-2020
Date of Web Publication3-Sep-2021

Correspondence Address:
Dr. Faisal Alnassar
Department of Restorative Dental Sciences, College of Dentistry, Majmaah University, Almajmaah 11952,
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_204_20

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  Abstract 

Introduction: Cone-beam computed tomography (CBCT) image properly provides enhanced and accurate information of root morphology, canal configuration, and its possible variations. The aim of this study was to calculate the average distance from the cementoenamel junction (CEJ) up to the canal terminus and the width of the canal at the area of the division of type V configuration (Vertucci's classification) in premolar teeth using CBCT.
Materials and Methods: Sevend hundered and seven CBCT images of the mandibular and maxillary premolars were screened for having type V configuration. The distance from CEJ to canal terminus and the width of the canal in the area of the division were measured. Age and gender were also recorded. Data were statistically analyzed. The statistical significance level was set at P < 0.05.
Results: Maxillary second premolar teeth exhibited the shortest median distance from CEJ to the point of separation of the canal (3.86 mm) and the smallest width at the area of division (mean 1.86 ± 0.33 mm). No significant differences were observed in the distance nor width between genders in all teeth (P = 0.662 and 0.465, respectively). Moreover, no correlation was found between age and distance nor age and width of the canal (P = 0.89 and 0.95, respectively).
Conclusion: The measurements give a general guideline for a more quantitative approach to endodontic access preparation for premolar teeth with type V configuration.

Keywords: Cone-beam computed tomography, measurement, premolars, root canal morphology, type V canal configuration


How to cite this article:
Alnassar F, Almutairi W, Al-Dahman Y. Radiographic variations of maxillary and mandibular premolars with type V canal configuration – A cone-beam computed tomographic study. Saudi Endod J 2021;11:345-9

How to cite this URL:
Alnassar F, Almutairi W, Al-Dahman Y. Radiographic variations of maxillary and mandibular premolars with type V canal configuration – A cone-beam computed tomographic study. Saudi Endod J [serial online] 2021 [cited 2021 Dec 4];11:345-9. Available from: https://www.saudiendodj.com/text.asp?2021/11/3/345/325395


  Introduction Top


The complex anatomy of the root canal system can be a significant cause of technical errors and treatment failure.[1],[2] An unexpected additional or missing canal was reported as the most prevalent cause for failure.[3] Therefore, clinicians need to have enough knowledge and skills to deal with different morphological variations.[4]

Many variabilities, such as different canal configuration and number of roots, can be seen in premolar teeth. Studies of maxillary and mandibular teeth have reported the presence of Vertucci's type V, one canal that leaves the pulp chamber and divides short of the apex into two separate canals,[5] ranged from 0.5% to 24%. Modifying access opening and enlarging the coronal third sufficiently will help in the detection of bifurcation for these canals.

The root canal anatomy has been utilized using different assessment techniques including clinical evaluation during root canal treatment, retrospective assessment of patient records, conventional radiographic evaluation, cone-beam computed tomography (CBCT), canal staining and tooth clearing, root sectioning, microscopic examination, interpretation of conventional radiographs, and microcomputed tomography.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]

CBCT technology has become a useful tool to explore the morphology of root canals and was reported to be comparable in precision to other techniques such as root canal staining and clearing techniques due to its ability to produce a nondestructive three-dimensional (3D) visualization of morphological details.[12],[16]

There is a lack of a quantitative approach describing the access cavity management of premolar teeth presenting with type V Vertucci's classification; thus, the aim of the presented study was to calculate the average distance from the cementoenamel junction (CEJ) up to the canal terminus and the width of the canal in the area of the division of type V classification using a CBCT.


  Materials and Methods Top


The study protocol was designed and approved by the Institutional Review Board at King Saud University (No. E-18-3472) and conducted in full accordance with the World Medical Association Declaration of Helsinki.

A total of seven hundred and seven CBCT images of maxillary and mandibular premolars were screened. The patients were distributed as 396 females and 311 males. Their ages ranged between 16 and 71 years, with an average age of 41.5 years. The images were taken as a part of evaluation of patients referred to the Radiology Department of the College of Dentistry, King Saud University, for routine dental treatment between 2015 and 2017 and not related to the study.

The presence of at least one maxillary or mandibular first or second premolar with completely developed roots and type V canal configuration, according to Vertucci's classification, is the critical point in the selection of the inclusion criteria. Unclear or distorted CBCT images, previous root canal initiated or treated teeth, the existence of coronal restoration, posts or crowns, periapical lesions, and any physiological or pathological process such as immature apex and caries were excluded.

Samples with type V canal configuration were evaluated to measure the distance from CEJ to canal terminus and the width of the canal in the area of the division. Furthermore, the age and gender of the patients were recorded.

Two endodontists analyzed the CBCT images using the Planmeca Romexis Viewer software (PLANMECA, Roselle, IL, USA). The images were obtained from two different CBCT machines: CS9300 3D digital imaging system (Carestream, Rochester, NY, USA) with a voxel size of 90–300 μm and Planmeca ProMax 3D (PLANMECA, Roselle, IL, USA) with a voxel size of ≤ 200 μm. The exposure time was < 15 second, and the sample comprised either small or large field-of-view CBCT images. The cross-sections of the CBCT images were 0.2 mm thick, viewed from the coronal to apical levels on HP Z400 workstation (HP, Palo Alto, CA, USA) with a 30-inch monitor with a resolution of 3280 × 2048 pixels in a dark room. The contrast and brightness of the images were calibrated with the software to ensure maximum visualization.

The distance was measured from CEJ to the canal terminus of the canal in the sagittal view of the CBCT image by adjusting the starting point at CEJ level (Point A) and the endpoint at the furcation area (Point B), then calculating the distance between the two points. For the measurement of the width of the canal at the area of division, two points were adjusted on the inner buccal wall (Point A) and the inner lingual wall (Point B) of the main canal at the area of the division on the axial view of the CBCT image, then calculating the distance between the two points [Figure 1]a and [Figure 1]b.
Figure 1: (a) sagittal view of the cone-beam computed tomography image with the measurement of the distance from cementoenamel junction to the canal terminus. (b) Axial view of the cone-beam computed tomography image cementoenamel junction with the measurement of the width of the canal at the area of the division

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Both inter- and intraexaminer reliabilities were calculated using the interclass correlation coefficient (ICC). The data were analyzed using version 22 of SPSS software (SPSS Inc., Chicago, IL, USA). The statistical significance level was set at P < 0.05.


  Results Top


The ICC for the interexaminer reliability was 0.868 (excellent) for the distance and 0.822 (excellent) for the width of canal division, while the ICC for the intraexaminer reliability was 1 for the first examiner regarding the distance and width and 1 and 0.95 for the second examiner with regard to distance and width, respectively. The values of ICCs confirmed that the procedure was reliable for the observers' evaluations and measurements.

Vertucci's type V classification was found in 39 out of 707 CBCT images examined, in which 20 teeth (59%) were in females and 19 teeth (41%) were in males. The distribution among each tooth group was as follows: 14 (36%) in the maxillary first premolar, 16 (41%) in the maxillary second premolar, 6 (15%) in the mandibular first premolar, and 3 (7%) in the mandibularsecond premolar teeth. The age range was from 17 to 54 years (mean age = 28 years).

The median distance from CEJ to the point of separation of the canals was 3.95 mm in the maxillary first premolar, 3.86 mm in the maxillary second premolar, 4.55 mm in the mandibular first premolar, and 4.2 mm in the mandibular second premolar with no statistically significant difference (P = 0.19). In addition, no significant differences were observed in the distance between females and males in all teeth groups (P = 0.662).

In comparing the width of the canal at the area of division, the largest was observed in the mandibular second premolar teeth (mean 2.30 ± 0.26 mm), while the smallest was in the maxillary second premolar teeth (mean 1.86 ± 0.33 mm) with no statistically significant difference [Table 1]. In addition, there were no statistically significant differences observed in mean width between females and males in all teeth groups (P = 0.465).
Table 1: The mean width of canal at area of division in different teeth groups

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Moreover, no correlation was observed between age and distance from CEJ to the point of division of the canals, nor age and width of the canal at the area of division (P = 0.89 and P = 0.95, respectively).


  Discussion Top


No previous studies were published that compared between distance from CEJ to the point of separation of the canals and width of the canal at the area of division in type V Vertucci's classification in the maxillary and mandibular premolars. This makes it difficult to compare the findings of the present investigation with any relevant study.

A detailed understanding of the root canal morphology and its variations along with adequate preoperative evaluation is essential in determining the proper access, shaping and cleaning, and obturation procedures, which also affects the success of endodontic treatment.[16],[17] The morphological pattern of the premolar teeth had certain typical variations that make them difficult to treat endodontically and also their apical configuration found to be complex.[18],[19]

Slowey[20] states that the anatomy of the root canal of each tooth has some common occurring characteristics with several atypical ones, which may be road maps for effective endodontic procedures. The expected anatomy of the root canal determines the location of the initial entry of access and the size of the first files used, and it contributes to a sensible approach to addressing the problems that arise during the treatment procedure. Therefore, a comprehensive knowledge of the root canal anatomy from access to obturation is crucial to give the highest possible chance for the overall success of root canal treatment.

Maxillary first premolars with type V canal configuration have been reported to be 7%,[21] while 6% in the maxillary second premolars.[18] For mandibular premolars, it has been reported to be 24% and 2.5% in mandibular first and second premolars, respectively.[22] The percentages of type V canal configuration in the present study was 5.52% (39 teeth out of 707) in general. This type of canal configuration necessitates access cavity extension toward the lingual to achieve an unobstructed pathway of instruments into the lingual canal division.[20]

The pulp chamber is relatively large in young teeth, but age-related changes occur mainly in direct influence on the reduction in the pulp chamber space because of the deposition of minerals in the lumen of dentinal tubules, which occurs concomitantly with the formation of secondary dentine in the dentine/pulp interface. This reduction occurs mainly in the mesial–distal direction.[23],[24],[25] Due to a smaller number of type V canal configuration in the sample, there were no statistically significant differences. Further investigations are required to find if there is any statistically significant difference.

Clinically, several techniques could aid in the detection of extra canals starting with at least two preoperative radiographs, with the second one angulated from 15° to 20°, either mesial or distal from the long horizontal axis of the root. A sudden narrowing of the main canal on the radiograph usually indicates that more than one root canal should be suspected.[26] Furthermore, an additional canal should be suspected if the pulp chamber space appears to deviate from normal configuration and tend to be more oval or triangular in shape.[27]

The American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology and the Position Statement of the European Society of Endodontology recommended an intraoral radiograph as the imaging modality of choice. Furthermore, they stated that CBCT should be considered as an adjunct in certain situations such as investigation of teeth with complex anatomy or inconclusive interpretation of two-dimensional radiographs.[28]

Because of its precision, reliability, and 3D imaging capabilities, CBCT has emerged as an invaluable tool in the field of endodontics.[29],[30] In the current study, CBCT images were examined to investigate the root canal morphology further. The sagittal view shows the distance from CEJ up to the point of separation of the canals, while the axial view will show the width of the canal at the area of division in type V canal configuration.

Proper access cavity preparation, avoidance of over-instrumentation of the root canal system, using a small precurved k-file tip to examine all main canal walls for catching the opening of the extra canal, dyes, fiberoptic transillumination, sodium hypochlorite bubbling, and using magnifying tools such as loupes and dental operating microscope could aid in locating extra root canals.[31]

The results of this study can not be applied to the entire population because data from this study were gathered from one governmental dental center. Furthermore, the preexisting CBCT images were accessed regardless of the size of the voxel. One more limitation of this study is that no sample size calculation was done before the conduction of the study. Further studies are recommended with a larger samples and fixed voxel size.


  Conclusion Top


Within the limitation of this study, maxillary second premolar teeth exhibited the shortest median distance from CEJ to the point of separation of the canal and the smallest width in the area of the division of the canal. The reported measurements in this study give us a general guideline for a more quantitative approach to endodontic access preparation for premolar teeth with type V canal configuration.

Acknowledgment

The authors thank King Saud University, College of Dentistry Research Center, for their support in conducting the study (E-18-3472), and Professor Saad Al-Nazhan for his valuable comments on the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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