DR.

HANY MOHAMED ALY AHMED (Orcid ID : 0000-0003-0776-9288)

Accepted Article
Article type : Review

A new system for classifying accessory canal morphology

HMA Ahmed1, P Neelakantan2, PMH Dummer3

1
Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur,

Malaysia, 2Faculty of Dentistry, The University of Hong Kong, Hong Kong. 3School of Dentistry,

College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK.

Keywords: Accessory canals, classification, accessory canal morphology.

Running title: New classification for accessory canal morphology

Correspondence

Hany Mohamed Aly Ahmed,

Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, 50603, Kuala

Lumpur, Malaysia

Email: hany_endodontist@hotmail.com).

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/iej.12800

This article is protected by copyright. All rights reserved.

 Abstract

Thorough knowledge of the anatomical complexities of the root canal system has a direct impact on
Accepted Article
the effectiveness of canal preparation and filling, and is an essential prerequisite for successful root

canal treatment. A wide range of complex variations in root canal anatomy exists, including root canal

configuration type, developmental anomalies and more minor canal morphology such as accessory

canals and apical deltas. Accessory canals and apical deltas have been associated with pulp disease,

primary canal infection, canal reinfection and post-treatment disease. The current definitions of

accessory canal anatomy are not standardised and potentially confusing. Given their role in

endodontic disease and their impact on treatment outcomes, there is a need to have a simple

classification of their anatomy to provide an accurate description of their position and path from the

canal to the external surface of the root. The purpose of this article is to introduce a new system for

classifying accessory canal morphology for use in research, clinical practice and training.

Introduction

Adequate knowledge of the complexity of root canal systems is essential for successful root canal

treatment (Vertucci 2005). This topic has been the subject of numerous studies and clinical reports,

and several systems for classifying root canal configurations have been proposed (Weine et al. 1969,

Vertucci et al. 1974, Vertucci 2005, Versiani & Ordinola-Zapata 2015). With an increasing range of

imaging methods being used, many previously unreported anatomical complexities are being

identified (Leoni et al. 2014, Zhang et al. 2014, Filpo-Perez et al. 2015, Gao et al. 2016, Xu et al.

2016). To address the shortcomings of previous systems and to provide a logical and simple solution,

a new system for classifying root and canal morphology was recently proposed, which provides

detailed information on tooth notation, number of roots and root canal configuration (Ahmed et al.

2016).

Root canal infections are biofilm mediated, and the presence of residual microbes within the

root canal system is an important cause of persistent infection and post-treatment endodontic disease

(Nair 2006). The propagation of microbes and their by-products occurs not only within the main root

canal but also in complex anatomical features that communicate with periradicular tissues, resulting in

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 periodontitis anywhere along the length of the root, apex or furcation (Nicholls 1963, Seltzer et al.

1963, Weine 1984, Zolty 2001, Dammaschke et al. 2004, Iqbal et al. 2005, Silveira et al. 2010,
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Ahmed 2012, Jang et al. 2015). Such anatomic features include accessory canals, apical

delta/ramifications as well as dentinal tubules (Nicholls 1963, Gutmann 1978, Dammaschke et al.

2004, Ricucci & Siqueira 2008a, b, Ricucci & Siqueira 2010, Vieira et al. 2012, Arnold et al. 2013,

Versiani & Ordinola-Zapata 2015).

Justification for a new classification system

Existing terminology of accessory canal morphology

The terminology of accessory canals is inconsistent. De-Deus (1975) categorised accessory canal

morphology into:

a) the lateral canal which extends from the main canal to the periodontal ligament (mainly in the

body of the root);

b) the secondary canal which extends from the main canal to the periodontal ligament in the apical

region; and

c) the accessory canal which is derived from the secondary canal branching off to the periodontal

ligament in the apical region.

Other terms, such as auxiliary, reticular and recurrent canals, have also been used (Rubach &

Mitchell 1965, De-Deus 1975, Barbosa et al. 2009).

Cheung et al. (2007) defined an accessory canal as a fine branch of the pulp canal that

diverged at an oblique angle from the main canal to exit into the periodontal ligament space, whilst a

lateral canal was defined as a branch diverging at almost right angles from the main canal. According

to the AAE Glossary of Endodontic Terms (AAE 2016), “an accessory canal is a branch of the main

pulp canal or chamber that communicates with the external root surface”. By this definition, a lateral

canal is also a type of accessory canal, located in the coronal or middle third of the root, usually

extending horizontally from the main canal space, whilst a furcation canal is an accessory canal

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 located in the furcation. Others have defined lateral canals as accessory canals located in the coronal,

middle as well as apical third of the root (Çalişkan et al. 1995, Sert et al. 2004, Al-Qudah &
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Awawdeh 2006).

Green (1955) referred to “accessory apical foramina” for those within 3.5 mm of the apex

(more than three accessory foramina were considered as “multiple foramina”). Foramina located

beyond this limit were referred to as “lateral canal foramina”. Cheung et al. (2007) defined an

auxiliary/accessory foramen as the exit of any accessory and lateral canal, or of an apical delta. An

‘apical delta’ was defined as a complex ramification of branches of the pulp canal located near the

anatomical apex with the main canal not being discernible (Cheung et al. 2007). According to the

AAE glossary of terms (AAE 2016), “an accessory foramen is an orifice on the surface of the root

communicating with a lateral or accessory canal”, “an apical delta is the multiple accessory canals

that branch out from the main canal at or near the root apex. The term “ramification” includes

furcation, lateral and apical accessory canals as well as any unusual intracanal anatomy formed by the

localized fragmentation of the epithelial root sheath (AAE 2016).

Existing classifications of accessory canal morphology

The anatomy of root canals in the human dentition including the finer, accessory branches of the root

canal system has been appreciated for some time (Hess 1917). At first, there was no system to define

accessory canal morphology but then Yoshiuchi et al. (1972), with the aid of a staining and clearing

method, created a system based on their position along the root length. They divided the root length

into tenths from the root apex to the cervical margin (Figure 1a). When the level of an accessory canal

was at 5/10 to 9/10, 4/10 to 2/10, 1/10 or less of the root length, it was defined as being in the

cervical, middle or apical location, respectively (Figure 1a). The authors also defined the orientation

of the accessory canals. With the use of a hypothetical cross-section of a root with an accessory canal,

the centre of the buccal (labial) surface was defined as 12 o'clock and the centre of palatal (lingual)

surface as 6 o’clock. The buccal (labial) surface was defined as the span between 11 and 1 o'clock; the

mesio-labial – between 1 and 2 o'clock, the mesial between 2 and 4 o'clock, and so on (Figure 1b).

Others have also proposed similar concepts of categorisation based on the region of the root

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 (Kasahara et al. 1990, Miyashita et al. 1997, Adorno et al. 2010) (Figure 1c). However, the

practicality of defining the location of accessory canals according to tenths or sixths of the root length
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in clinical situations is a concern.

Vertucci et al. (1974) and Vertucci (1984) categorised lateral canals according to their

location (coronal, middle, apical or furcation) (Figure 1d), which was also adopted in other reports

(Gulabivala et al. 2002, Sert et al. 2004, Al-Qudah & Awawdeh 2006). De-Deus (1975) examined the

accessory canal morphology of 1140 human teeth and categorised lateral, secondary or accessory

canals according to their location (base of the root and furcation, body of the root and apical portion

of the root) (Figure 1e). Others added details on the concurrent existence of lateral canals in the

coronal/middle, coronal/apical, middle/apical, coronal/middle/apical thirds of the root to the existing

systems (Çalişkan et al. 1995).

A classification for accessory canals in the furcation region has also been proposed (Yoshida

et al. 1975) (Figure 2):

Type 1 (periodontium and pulpal chamber communicate through patent accessory canals);

Type 2 (accessory canals that originate from the pulp chamber and end in dentine);

Type 3 (accessory canals that originate from the periodontium and end in dentine);

Type 4 (accessory canals that originate from the pulp chamber go through dentine, and return to the

pulp chamber);

Type 5 (accessory canals that originate from the periodontium go through dentine and cementum, and

return to the periodontium); and

Type 6 (accessory canals found in dentine and/or cementum, but with no exit).

Others (Paras et al. 1993) have re-categorized the above-mentioned 6 types into 4 categories (true,

blind, loop or sealed accessory canals) (Figure 2). There are some concerns, however, when using a

single term “accessory canals” to define canals originating from either the pulp or periodontal tissues

because the origin comes from two different tissue types.

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 High resolution micro–computed tomography (micro-CT) has been widely used for the three-

dimensional analysis of anatomical variations within the root canal system (Verma & Love 2011,
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Matsunaga et al. 2014, Versiani et al. 2016). Matsunaga et al. (2014) introduced a classification for

minor canal morphology to supplement Weine’s classification for root canal morphology (Weine

1982). The authors divided each root canal configuration type into four subtypes:

a) no accessory root canals;

b) with apical ramifications;

c) with lateral canals;

d) both apical ramifications and lateral canals observed at the same time (Figure 3).

However, no information was provided on the location, number, or configuration of the

accessory/lateral canal(s).

New classification system for accessory canal morphology

Despite previous efforts, a simple and practical classification addressing the number, location and

configuration of accessory canals has not been achieved. The new system suggested in this article

provides students/trainees, clinicians and researchers with a standardised approach to classify

accessory canal morphology. For simplicity, the classification does not address the diameter, length

nor the orientation of accessory canals. In addition, it does not address complex characteristics of

accessory canals (such as tortuosity) investigated in recent studies (Gao et al. 2016, Xu et al. 2016).

New classification – Terminology

Pulp chamber:

The portion of the pulp space within (or extending to just below) the anatomic crown of the tooth. In

single-rooted teeth and double/multi-rooted teeth with middle or apical root bifurcations with a single

canal coronally, it extends to the most apical portion of the cervical margin of the crown, and in

double/multi-rooted teeth with coronal root and/or canal bifurcations (no single canal coronally), it

extends to the floor of pulp chamber located in the coronal third of the root (Figure 4).

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 Chamber canal:

A small canal leaving the “pulp chamber” that (usually) communicates with the external surface of
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the root (including the furcation) (Figure 5). It can be of any type (patent, blind or loop).

Root canal:

A passage or channel in the root of the tooth extending from the most apical portion of the pulp

chamber (i.e. root canal orifice) to the major apical foramen (Figure 4).

Accessory canal:

A small canal leaving the “root canal” that (usually) communicates with the external surface of the

root or furcation (Figure 5). Hence, it can be located anywhere along the length of the root (coronal,

middle or apical third), and can be any type (patent, blind, loop). It also includes what have been in

the past termed lateral canals. For simplicity, only the term ‘accessory’ should be used for such canals

and terms such as ‘lateral’ are not necessary and have the potential to cause confusion.

Accessory foramen:

The opening of an accessory or a chamber canal on the external surface of the root or furcation. It is

essential to appreciate that not all accessory canals terminate in accessory foramina as they may be

blind, looped etc. (Figure 2).

Apical delta (or apical ramifications):

The region at or near the root apex where the main canal divides into multiple accessory canals (more

than two) (Figure 5).

Tooth number and root configuration

The tooth number (TN) can be written using any numbering system; root abbreviations and

configurations should be written as described previously (Ahmed et al. 2016) (Table 1).

Location of accessory/chamber canals

Accessory canals: the length of the root is divided into thirds (T): the coronal third (C), which starts

from an imaginary line from the most apical portion of the pulp chamber, middle third (M) and apical

third (A) ending at the root apex (Figure 6). Each third is identified as a superscript within parenthesis

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 after the tooth number [TN(T)], e.g. [TN(C), TN(M), TN(A)], or after the individual roots if the tooth is

double/multi-rooted, e.g. [2TN R1(T) R2] (R: Root). If the accessory canal branches from a single
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canal coronal to a root bifurcation, then the superscript is written before the root notation, e.g. 2TN
(T)
R1 R2 (Figure 7).

Chamber canals: the superscript is written before the root notation, e.g. 3TN (-)
R1 R2 R3. Since

chamber canals originated from the pulp chamber, the description of the thirds (C, M, A) is not

required (Figure 7).

Accessory/chamber canal configuration

Details of accessory canal(s) should define the continuous course of the accessory canal starting from

the accessory-orifice(s) (aO), through the canal (C) to the accessory-foramen (foramina) (aF) – (aO-

C-aF) (Table 2) (Figure 8). If the aO of an accessory canal is in one third of the root but the aF is
(M,AaO-C-
located in another third, then a comma is added between the two regions of the root (e.g TN
aF)
). An apical delta is identified by the letter “D” (Figure 7). In some instances, the

accessory/chamber canal may not end in a foramen and in that situation, the notation aO-C-0 will be

used, e.g. 1-0 describes an accessory/chamber canal that has one aO, one C but with no aF, while 2-1-

0 describes a looped accessory/chamber canal (Figure 8).

- Accessory canals located in one of the three thirds of the root

Single rooted teeth:

If the tooth has an accessory canal(s) in one of the three thirds of the root, then the code TN (TaO-C-aF)

will be used. For any accessory canal, if the numbers of aO, C and aF are the same, then a single code

is used. Thus, 111(A1) describes a single-rooted maxillary right central incisor having an accessory

canal located in the apical third of the root with one aO, one C and one aF (Figure 9a). 111(M2)

describes a single-rooted maxillary right central incisor having two accessory canals in the middle

third of the root with two aOs, two Cs and ending up with two aFs (Figure 9b), whilst 111(A1-2) refers

to the same tooth having one accessory canal in the apical third of the root starting with one orifice

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 (aO) and one C initially but then dividing into two and ending up with two accessory foramina (aF)

(Figure 9c). 111(D) describes the central incisor having an apical delta (Figure 9d).
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Double and multi-rooted teeth:

If one of the roots has an accessory canal(s) in one of the three thirds of the root, then the code 2TN

R1(TaO-C-aF) R2 or nTN R1(TaO-C-aF) R2 Rn will be used in double and multi-rooted teeth, respectively.

Indeed, if more roots have accessory canals, then the aO-C-aF will be applied as listed in Table 2. 233

B(A1) L (B: buccal, L: lingual) describes tooth 33 having one accessory canal in the apical third of the

buccal root with a configuration type 1 (Figure 9e). 233 B L(M1) means that tooth 33 has an accessory

canal in the middle third of the lingual root with a configuration type 1 (Figure 9f). 233 B(A1) L(D)

describes tooth 33 having one accessory canal configuration type 1 in the apical third of the buccal

root, whilst the lingual root has an apical delta (Figure 9g). 326 MB(M2-1) DB P describes tooth 26

having two accessory canals in the mesiobuccal (MB) root starting with two orifices (aOs) that

progress along two accessory canals (Cs) in the middle of the root initially, which then merge and end

in one foramen (aF) (Figure 9h). 326 MB(A1) DB P(M1) describes tooth 26 having one accessory canal

configuration type 1 in the apical third of the MB root and in the middle third of the P (palatal) root

(Figure 9i). 326 (1)MB DB P(A1) describes tooth 26 having one chamber canal configuration type 1, and

one accessory canal configuration type 1 in the apical third of the P root (Figure 9j).

- Accessory canals located in two of the three thirds of the root

Single rooted teeth:

If the tooth has accessory canal(s) in two of the three thirds of the root, then the code TNTaO-C-aF,TaO-C-aF

will be used. 111(M1,A1) describes tooth 11 having an accessory canal located in the middle third of the

root and another one in the apical third; both with a configuration type 1 (Figure 10a). 111(M2-3,A1)

describes tooth 11 having three accessory canals, two in the middle third and one in the apical third of

the root, with a configuration type 2-3 (2 canals, 3 foramina) and 1, respectively (Figure 10b).
1
11(M,A1) describes tooth 11 having an accessory canal with configuration type 1 located in both apical

and middle thirds of the root (Figure 10c).

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 Double and multi-rooted teeth:

If one of the roots has an accessory canal(s) in two of the three thirds of the root, then the code 2TN
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R1(TaO-C-aF,TaO-C-aF) R2, nTN R1(TaO-C-aF,TaO-C-aF) R2 Rn will be used for double and multi-rooted teeth,

respectively. If more roots have accessory canals, then the aO-C-aF will be applied accordingly. 233

B(M1,A1) L describes tooth 33 having one accessory canal configuration type 1 in the middle and apical

thirds of the buccal root but none in the lingual root (Figure 10d). 326 MB DB P(M1,A2) means that

tooth 26 has three accessory canals in the palatal root – one in the middle third (configuration type

1) and two in the apical third (configuration type 2) (Figure 10e). 326 MB(M1-0,D) DB(A1) P(A1) describes

tooth 26 having one accessory canal configuration type 1-0 (1 orifice but ending in dentine with no

foramen) in the middle third and an apical delta in the MB root, whilst the DB (distobuccal) and

palatal roots have type 1 accessory canals in the apical third (Figure 10f).

- Accessory canals located in all thirds

Single rooted teeth:

If the tooth has accessory canal(s) in all thirds of the root, then the code TN TaO-C-aF,TaO-C-aF, TaO-C-aF will

be used (Table 2). 111(C1,M1,A2) describes a single-rooted tooth 11 having one accessory canal

configuration type 1 located in the coronal and middle thirds of the root and configuration type 2 in

the apical third (Figure 11a).

Double and multi-rooted teeth:

If one of the roots has an accessory canal(s) in all thirds of the root, then the code 2TN R1(CaO-C-aF,MaO-C-
aF,AaO-C-aF)
R2 or nTN R1(CaO-C-aF,MaO-C-aF,AaO-C-aF) R2 Rn will be used for double and multi-rooted teeth,

respectively. If more roots have accessory canals, then the aO-C-aF will be applied accordingly. 233
(C1) (M1,A1)
B L describes tooth 33 having three configuration type 1 accessory canals in the coronal

(branching from the coronal single canal in double/multi-rooted teeth), middle and apical thirds of

the buccal root (Figure 11b). 326 MB(C1,M1,D) DB(A1) P(A1) describes tooth 26 having two type 1

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 configuration accessory canals in the coronal and middle thirds of the root and an apical delta, whilst

the DB and P roots have type 1 accessory canals in the apical third (Figure 11c).
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Clinical implications, practicability and application

Dividing the root into thirds (coronal, middle and apical) has several clinical implications. Patent

accessory or chamber canals located in the coronal third of the root can cause pulp disease secondary

to periodontal disease, and vice versa (Rubach & Mitchell 1965, Weine 1984). It is also possible for a

blood vessel within accessory and chamber canals to be severed during periodontal treatment

procedures that may result in subsequent irreversible inflammatory changes in the pulp (Abbott &

Salgado 2009). Defining chamber canals is advantageous as they can be linked to bony lesions

occurring in the furcation area of posterior teeth in both permanent and primary dentitions (Weine

1984, Dammaschke et al. 2004, Vertucci 2005, Ahmed 2013).

Lateral radiolucent areas are related usually to accessory canals located in the middle third of the root

(Silveira et al. 2010). Accessory canals located in the apical third, as well as apical deltas, are one of

the main causes for persistent apical periodontitis (Iqbal et al. 2005, Arnold et al. 2013). Therefore, a

root-end resection of at least 3 mm has been advised in order to remove the majority of accessory

canals and any potential apical delta, thus, reducing the risk of periapical inflammatory responses and

eventual failure (Kim & Kratchman 2006). Defining the accessory canal configuration (aO-aC-aF)

reflects its complexity in a simple yet accurate manner.

For practicability and simplicity, the codes for accessory/chamber canal morphology presented in this

system can serve as complimentary codes to the recently described system for classifying root and

root canal morphology (Ahmed et al. 2016) (Figure 11). Combining both codes would provide more

detailed information on the root, root canal as well as accessory canal morphology of a given tooth

(Figure 12).

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 Appendix S1 shows several examples of codes allocated for several teeth having accessory canal with

various configurations.
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Conclusions

The proposed classification provides an accurate description of the position and configuration of

accessory and chamber canals. It consists of codes that can be used with the new system for

classifying root and root canal morphology to provide more detailed information on the tooth number,

number of roots and root canal configuration types as well as accessory canal morphology.

Conflict of Interest statement

The authors have stated explicitly that there are no conflicts of interest in connection with this

article.

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 Figures Legends

Figure 1 a, b) Location and orientation of accessory canals as described by Yoshiuchi et al. 1972. c)
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Similar approach was followed by Kasahara et al. 1990 and Miyashita et al. 1997 but with fewer

divisions of the root. d) Vertucci et al. 1974. e) De-Deus 1975.

Figure 2 Classification of furcation canals introduced by Yoshida et al. 1975 and Paras et al. 1993. a)

Type 1 canals (periodontium and pulpal chamber communicate through ‘‘real’’ accessory canals). b)

Types 2 and 3 canals (‘‘blind’’ accessory canals that originate from the pulp chamber (RED) and/or

periodontal surface (YELLOW) and end in dentine). c) Types 4 and 5 canals (‘‘loop’’ accessory canals

that originate from the pulp chamber (RED) and/or periodontium (YELLOW), go through dentine,

and return to the pulp chamber and periodontium). d) Type 6 canals (‘‘sealed’’ accessory canals

found in dentine and/or cementum, but with no exit).

Figure 3 Classification of accessory canals proposed by Matsunaga et al 2014 (accessory canals types

added to Weine’s classification). a) no accessory root canals; b) with apical ramifications; c) with

lateral canals; d) both apical ramifications and lateral canals observed at the same time.

Figure 4 Criteria for defining the borders of the pulp chamber; a, b) most apical portion of the

cervical margin (in case of single rooted teeth and double/multi-rooted teeth with middle or apical

root bifurcations with a common canal coronally). c, d) Floor of the pulp (double/multirooted teeth

with coronal root and canal bifurcations (no common canal coronally).

Figure 5 Diagrammatic representations showing accessory and chamber canals and the apical delta.

Figure 6 Criteria for defining the location of accessory canals in a) single rooted, b) double rooted,

and c) multirooted teeth.

Figure 7 Diagrammatic representations showing the codes for accessory and chamber canals and the

apical delta.

Figure 8 Codes for accessory canals having one aO, C and aF (configuration type 1), when do not end

in an aF (1-0), and when the accessory canal forms a loop (2-1-0).

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 Figure 9 Diagrammatic representations for the codes allocated for accessory canals in one of the three

thirds of the root.

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Figure 10 Diagrammatic representations for the codes allocated for accessory canals in two of the

three thirds of the root.

Figure 11 Diagrammatic representations for the codes allocated for accessory canals in all thirds of

the root.

Figure 12 Micro-CT 3D models of different groups of teeth classified according to the new system

for classifying the root and root canal (first column), accessory canal morphology (second column),

and combined codes (third column).

Appendix S1: Supplementary powerpoint presentation describing the new proposed classification for

accessory canal morphology.

Table 1 A summary of the codes of root and root canal morphology allocated for single-,

double- and multirooted teeth (Ahmed et al. 2016).

Tooth type Code

1
Single-rooted TNO-C-F

2
Double-rooted TN R1O-C-F R2O-C-F

n
Multirooted TN R1O-C-F R2O-C-F RnO-C-F

TN, Tooth number; R, Root; O, Orifice; C, Canal; F, Foramen. “n” refers to 3 roots or more.

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 Table 2 A summary of the codes for accessory canal morphology
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Configuration Code

Accessory canal(s) located in one of the three (CaO-C-aF) OR

thirds of the root
(MaO-C-aF) OR

(AaO-C-aF)

An accessory canal starts with an aO in one (C,MaO-C-aF) OR

third, and aF in another third of the root
(M,AaO-C-aF)

Accessory canals located in two of the three (CaO-C-aF,MaO-C-aF) OR

thirds of the root
(CaO-C-aF,AaO-C-aF) OR

(MaO-C-aF,AaO-C-aF)

Accessory canals located in all thirds of the (CaO-C-aF,MaO-C-aF,AaO-C-aF)

root

C: Coronal, M: Middle, A: Apical; aO: accessory-Orifice; C: Canal; aF: accessory-Foramen;

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