C-shaped root canals in mandibular second molars

in a Saudi Arabian population

K. S. Al-Fouzan
Dental Department, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia

Abstract
Al-Fouzan KS. C-shaped root canals in mandibular second
molars in a Saudi Arabian population. International Endodontic Journal, 35, 499^504, 2002

Aim The aim of this study was to determine the frequency of C-shaped canals in mandibular second
molars in a population in Saudi Arabia and to establish a classication for the most common congurations.
Methodology One hundred and fty-one mandibular second molars scheduled for root-canal treatment
were examined over a 1-year period. The C-shaped
canals were detected by radiographic and clinical
examination. Teeth with C-shaped canal systems were

Introduction
A thorough knowledge of the anatomy of teeth involved
in root-canal treatment is essential for successful debridement and obturation of the root-canal system. Recognition of unusual canal congurations and variations
are paramount, because it has been established that
the root with a single tapering canal and apical foramen
is the exception rather than the rule (Abou-Rass et al.
1980).
Of particular interest is the canal conguration of
the mandibular second molar as a great deal of variation can occur, C-shaped canals are common (Cooke &
Cox 1979) with the presence of a thin n connecting
the root canals being the main anatomical feature
(Barril et al. 1989). Once recognized, the C-shaped
canal provides a challenge with respect to debridement and obturation, especially because it is unclear
whether the C-shaped orice found on the oor of the

Correspondence: Dr Khalid S. Al-Fouzan, Associate Consultant, Dental

Department, King Fahad National Guard Hospital, PO Box 22490, Riyadh
11426, Riyadh, Kingdom of Saudi Arabia (fax: 966 14821704).

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categorized by using a modication of the classication of Melton.

Results Of the 151 molars, 16 (10.6%) exhibited Cshaped canals. Five molars were classied as category
I, and three were considered category II. The remaining eight cases were classied as category III, with
two in subdivision I, two in subdivision II, and the
remaining four in subdivision III.
Conclusions The C-shaped canals in mandibular
second molars vary considerably in their anatomical
conguration with the result that debridement,
obturation, and restoration may be dicult.
Keywords: C-shaped canal, mandibular second molar.
Received1May 2001; accepted 5 September 2001

pulp chamber actually continues to the apical third of

the root.
The shape and the number of roots are determined by
Hertwigs epithelial sheath, which bends in a horizontal
plane below the amelocemental junction and fuses in
the centre leaving openings for roots (Orban & Mueller
1929). Fused roots may form either bycoalescence owing
to cementum deposition with time, or as a result of failure of Hertwigs epithelial sheath to develop or fuse in
the furcation area (Pederson 1949). A C-shaped canal
appears when fusion of either the buccal or lingual
aspect of the mesial and distal roots occurs. This fusion
remains irregular, and the two roots stay connected by
an interradicular ribbon (Barnett 1986, Barril et al.
1989). The pulp chamber has a single ribbon-shaped orice with a1808 arc from the distal to mesial canal (Cohen
& Burns 1994). The oor of the pulp chamber is deep
and has an unusual anatomical appearance (Barnett
1986). Two or three canals may be found in the C-shaped
groove, or the C-shape may be continuous throughout
the length of the root.
The mandibular second molars with C-shaped
canals vary in their conguration (Yang et al. 1988,

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C-shaped root canals Al-Fouzan

500

Melton et al. 1991). Clearly, the recognition of these congurations facilitates cleaning, shaping, and obturation
(Rice & Gilbert 1987). Preoperative radiographs demonstrate close fused roots or images of two distinct roots.
This occurs when the n is thin and thus, not visible
on the X-ray and makes clinical recognition of the
C-shaped canal unlikely until access to the pulp chamber has been achieved (Barril et al. 1989). Radiographs
taken whilst negotiating the root-canal system may suggest such anatomyas theycan reveal two characteristics:
instruments tending to converge at the apex (Rice & Gilbert 1987) or instruments appearing both clinically
and radiographically to be centered and appearing to
be exiting the furcation (Fig. 1).This can cause confusion
and initiate a search for a perforation (Barril et al. 1989,
Melton et al. 1991).
The C-shaped canals were rst documented by Cooke
& Cox (1979) in three case reports. Similar reports have

since been published (Wells & Bernier 1984, Rabie 1985,

Barnett 1986). Endodontic textbooks state that the Cshaped canal is not uncommon (Walton & Torabinejad
1996) and this is conrmed by studies in which frequencies ranging from 2.7 to 8% have been reported (Cooke
& Cox 1979,Weine et al. 1988). Although it is not specically stated, these gures probably relate to teeth of Caucasoid origin with an absence (Ainamo & Loe 1968,
Tamse & Kae1981,Vertucci1984) or nearabsence (Weine
et al.1988) of C-shaped canals. Investigations of the rootcanal anatomy of mandibular second molars conducted
on Japanese (Kotoku1985), Chinese (Yang et al.1988) and
Hong Kong Chinese (Walker 1988) populations showed
a high incidence of C-shaped canals (31.5%). It has thus
been established that this particular anatomy is more
frequent in Asians than in other racial groups (Manning
1990). No data are available on the incidence of this canal
conguration in the Saudi Arabian population.

Figure 1 Radiograph with instruments in root canals for

working length determination. (A) Instruments tend to
converge at the apex and (B) instruments appear to perforate
the furcation.

Figure 2 Category I: (A) preoperative radiograph of the

mandibular second molar showing fused roots and (B)
completed root lling using lateral condensation of guttapercha showing true C-shaped canal.

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Al-Fouzan C-shaped root canals

This study was undertaken to provide information on

the distribution of C-shaped canal anatomy, to establish
a classication for the most common congurations,
and to determine its frequency in a sample representing
the Saudi population.

Materials and methods

One hundred and fty-one mandibular second molars
scheduled for root-canal treatment were examined over
a 1-year period in the Endodontic Department, King
Fahad National Guard Hospital, Riyadh, Saudi Arabia.
The incidence of C-shaped canals was revealed following
radiographic and clinical examination. Three preoperative radiographs were taken at a constant target-lm distance and angulation by utilizing the extension cone
paralleling device (Rinn Corp., Elgin, III, USA): one with

Figure 3 Category II: (A) preoperative radiograph showing a

radicular fusion, a large distal canal, a narrow mesial canal,
and a blurred image of a third canal in centre; (B) postoperative
radiograph. Note the presence of dentine separating a mesial
canal from the rest of the C-shaped canal.

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a 908 angulation to the tooth in a buccolingual direction

and another two at a mesial and distal angulation of
approximately 208 to allow better visualization of the
buccolingual anatomy. The radiographs were examined
on a viewer using a peripheral block and a 6 magnifying lens.The number and the position of root canals were
noted. Three postoperative radiographs using the same
exposure geometry were taken to conrm canal conguration.
Clinical examination of the pulp chamber and canal
orices was carried out and root canals were investigated with size 10 K-les (Kerr Co., Romulus, MI, USA);
radiographs were taken to conrm canal morphology.
Once C-shaped anatomy was recognized, teeth were
categorized using a modication of an existing classication (Melton et al. 1991).
 Category I: continuous C-shaped canal running from
the pulp chamber to the apex (Fig. 2).

Figure 4 (A) Preoperative radiograph of a mandibular second

molar and (B) postoperative radiograph. Note the apical fusion
of the three canals.

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C-shaped root canals Al-Fouzan

Figure 5 (A) Preoperative radiograph of a mandibular second

molar and (B) postoperative radiograph. Note the main Cshaped canal splits near the mid-root into three canals.

Figure 6 (A) Preoperative radiograph of a mandibular second

molar and (B) postopertive radiograph. Note the main C-shaped
canal splits in the coronal third into three canals.

 Category II:semicolon (;) shaped orice in which dentine separated a main C-shaped canal from one mesial
distinct canal (Fig. 3).
 Category III: subdivision I, C-shaped orice in the coronal third that divided into two or more discrete and
separate canals that joined apically (Fig. 4); subdivision II, C-shaped orice in the coronal third that
divided into two or more discrete and separate canals
in the mid-root to the apex (Fig. 5); and subdivision
III, C-shaped orice that divided into two or more discrete and separate canals in the coronal third to the
apex (Fig. 6).

side (depending on where the fusion occurred). In one

instance, this canal swung back and merged with the
distal canal, thus yielding a single foramen; in the other
two cases, it remained distinct with its own portal of exit.
The remaining eight were considered as category III,
amongst those: two were subdivision I; two were subdivision II; and the remaining four were subdivision III.

Results
Of the 151 molars,16 (10.6%) exhibited C-shaped canals.
Five molars presented a continuous C-shaped canal
(category I), and three had a semicolon shape (category
II) with a mesial canal located on the buccal or lingual

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Discussion
Previously reported dierences in the root-canal anatomy of mandibular second molars may be owing to the
population from which the teeth were chosen. If a Caucasian population were studied, then predominantly tworooted mandibular second molars could be expected
(Ainamo & Loe 1968, Tamse & Kae 1981, Vertucci 1984,
Weine et al. 1988), whereas if an Asian or Mongoloid
population were examined then a higher number of
teeth would be single-rooted (Kotoku 1985, Walker

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Al-Fouzan C-shaped root canals

1988). Single-rooted mandibular second molars have

been reported less frequently (Kotoku 1985, Yang et al.
1988,Walker 1988,Weine et al.1988), and the canal types
have not been fully investigated.
A radiographic study (Weine et al. 1988) of three single-rooted specimens found one to have a single canal
and two to be C-shaped, and photographs from another
study (Walker 1988) of selected specimens that were
cleared showed the complex anatomy characteristic of
single-rooted specimens. In the current investigation, a
variety of canal types was found, with category I representing almost one-third of the sample.
Cooke & Cox (1979) stated that it was impossible to
diagnose C-shaped canals on the preoperative radiograph. In this study, almost all preoperative radiographs
of category I, II, and III (subdivision I) showed common
characteristics that provided a typical image and
allowed identication of this anatomical condition. In
fact, most radiographs revealed radicular fusion or proximity, a large distal canal, a narrow mesial canal, and a
blurred image of a middle third canal (Fig. 3A).
Weine et al. (1988) advised placing les in the canals to
determine canal conguration of the mandibular second molar. However, using a radiograph showing les
set to the canal terminus to diagnose and to determine
canal morphology may not give the results expected.
In some instances, it may be dicult to distinguish
between C-shaped canal or one with single or three
canals joining apically.Thus, it was necessary to conrm
the diagnosis by exploring the access cavity. Two types
of root-canal orices were observed.
1 A complete C-shaped orice located either on the
buccal or lingual aspect of the oor, that extended from

Figure 7 C-shaped chamber oor showing a complete Cshaped root-canal orice in the form of a deep trough
connecting the distal, mesiobuccal and mesiolingual canal
orices.

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Figure 8 C-shaped chamber oor of mandibular second molar

with mesial, distal, and midbuccal canal orices are seen.

the usual location of the distal canal to the usual location

of the mesial canals (Fig. 7).
2 Two or three orices: a C-shaped orice extending
from distal to mesiobuccal in a buccal position separated
with dentine from an independent mesiolingual orice,
or from distal to mesiolingual in a lingual position with
an independent mesiobuccal orice. Some teeth had
one mesial and one distal orice, and one orice between
the two (Fig. 8).
In the present study, all root canals that conformed to
the general structure of aCand occurred in a C-shaped
root were described as C-shaped root canals, whether
or not a separate canal or orice was observed. The classication system of canal types described by Melton
et al. (1991) was modied and used to describe the canal
system in C-shaped roots. In type I canal, a single canal
is present from orice to the apex; this has been described
as a true C-shaped canal. Other more complex canal
types were found in C-shaped roots; category III (subdivision III), the type with three canals, which did not
necessarily combine, occurred most frequently.
The root-canal anatomy of teeth from a Chinese population with the C-shaped canals has been reported previously (Yang et al. 1988), when rst and second molars
were examined using a transparent technique (Robertson et al. 1980). The C-shaped roots occurred in 31.5%
of second molars. They found that roots with separate
canal orices formed separate canals as well as true Cshaped canals. The latter, which were described as roots
having a C-shaped canal from the orice to the apex,
occurred in 7.4% of the sample of mandibular second
molars. Manning (1990) found that, amongst 19 teeth,
three (10%) had true C-shapes. Haddad et al. (1999)
reported that true C-shaped canals with a single swath

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C-shaped root canals Al-Fouzan

of canal were the exception rather than the rule. In the

present study, from approximately the same number of
teeth, ve teeth exhibited this form.
In this study, all patients showing category III conguration were under 40 years of age. This is in contrast
to the observation of Manning (1990) that age-related
deposition of dentine formed separate canals. Manning
(1990) also reported that category III (subdivision III)
systems occurred most frequently, which is in agreement
with this study. Melton et al. (1991) reported that the Cshaped canals had various conguration at dierent
root levels; this was particularly true in all category III
canals.
The study of the incidence of C-shaped canals in the
mandibular second molars using radiographic techniques might appear to have certain disadvantages. Only
a 2D image of the tooth is seen and conceivably both
roots and root canals can be missed. However, clinically
it remains the only noninvasive method available, and
by strictlyadhering to the radiographic criteria for determining the incidence of C-shaped canals in the mandibular second molars, the ndings of this study were in
good accord with those of other recent studies using various techniques.
The frequency obtained in this investigation (10.6%)
lies between the 31.5% frequency reported byYang et al.
(1988) and the 2.7% frequency reported by Weine et al.
(1988). The geographical position of Saudi Arabia in particular and the Middle East, in general, may be the explanation for this phenomenon. However, further studies
would be necessary to conrm this phenomenon.

Conclusions
Mandibular second molars with C-shaped canals vary
in canal conguration. The early recognition of these
congurations facilitates cleaning, shaping, and obturation of the root-canal system. The possibility of CShaped canals has to be considered during the clinical
and radiographic examination of the patient.

References
Abou-Rass M, Frank L, Glick DH (1980) The anticurvature
method to prepare the curved root canal. Journal of the American Dental Association 101,792^4.
Ainamo J, Loe H (1968) A stereomicroscopic investigation of the
anatomy of the root apices of 910 maxillary and mandibular
teeth. Odontologiska ForeningensTidskrift 76, 417^26.
Barnett F (1986) Mandibular molar with C-shaped canal. Endodontics and Dental Traumatology 2,79^81.

504

International Endodontic Journal, 35, 499^504, 2002

Barril I, Cochet JY, Ricci C (1989) Le traitement des canaux presentant une conguration dite en C. Revue Francaise Dendodontie 8, 47^58.
Cohen S, Burns R (1994) Pathways of the Pulp,7th edn. St. Louis,
USA: CV Mosby, pp. 184^9.
Cooke HG, Cox FL (1979) C-shaped canal congurations in mandibular molars. Journal of the American Dental Association
99, 836^9.
Haddad GY, Nehme WB, Ounsi HF (1999) Diagnosis, classication, and frequencyof C-Shaped canals in mandibular second
molars in the Lebanese population. Journal of Endodontics
25, 268^71.
Kotoku K (1985) Morphological studies on the roots of the Japanese mandibular second molars. Shikwa Gakuho 85, 43^64.
Manning SA (1990) Root canal anatomy of mandibular second
molars. Part II. C-shaped canals. International Endodontic
Journal 23, 40^5.
Melton DC, Krell KV, Fuller MW (1991) Anatomical and histological features of C-shaped canals in mandibular second
molars. Journal of Endodontics 17, 384^8.
Orban B, Mueller E (1929) The development of bifurcation of
multirooted teeth. Journal of the American Dental Association
16, 297^319.
Pederson PO (1949) The East Greenland Eskimo dentition: Numerical variations and anatomy. Bianco Lunos Bogtrykkeri,
Copenhagen.
Rabie G (1985) Mandibular molar with merging mesiobuccal
and distal root canal. Endodontics and Dental Traumatology 1,
191^4.
Rice RT, Gilbert BO (1987) An unusual canal conguration in
mandibular rst molar. Journal of Endodontics 13, 513^5.
Robertson D, Leeb J, McKee M et al. (1980) A clearing technique
for the study of root canal systems. Journal of Endodontics 6,
421^4.
Tamse A, Kae I (1981) Radiographic survey of the prevalence of
conical lower second molars. International Endodontic Journal
14, 188^90.
Vertucci FJ (1984) Root canal anatomy of the human permanent
teeth. Oral Surgery, Oral Medicine and Oral Pathology 58,
589^99.
Walker RT (1988) Root form and canal anatomy of mandibular
second molars in a Southern Chinese population. Journal of
Endodontics 14, 325^9.
Walton R, Torabinejad M (1996) Principles and Practice of
Endodontics, 2nd edn. Philadelphia, USA: W.B. Saunders
Co., pp. 177^8.
Weine FS, Pasiewicz RA, Rice RT (1988) Canal conguration of
the mandibular second molar using a clinically oriented in
vitro method. Journal of Endodontics 14, 207^13.
Wells DW, BernierWE (1984) A single mesial canal and two distal
canals in a mandibular second molar. Journal of Endodontics
10, 400^3.
Yang ZP, Yang SF, Lin YL et al. (1988) C-shaped root canals in
mandibular second molars in Chinese population. Endodontics and Dental Traumatology 4, 160^3.

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