Journal of Dental Sciences (2013) 8, 321e327

Available online at www.sciencedirect.com

journal homepage: www.e-jds.com

ORIGINAL ARTICLE

A study on the root canal morphology of

primary molars by high-resolution computed
tomography
Yin-Lin Wang a,b,c, Hsiao-Hua Chang a,c, Ching-I Kuo c,
Ssu-Kuang Chen b,d, Ming-Kuang Guo a,b,c, Guay-Fen Huang a,b*,
Chun-Pin Lin a,b,c

a
Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
b
School of Dentistry, College of Medicine, National Taiwan University, Taipei, Taiwan
c
Graduate Institute of Clinical Dentistry, College of Medicine, National Taiwan University, Taipei,
Taiwan
d
University of Washington, Seattle, WA, USA

Received 15 December 2011; Final revision received 27 March 2013

Available online 30 May 2013

KEYWORDS Abstract Background/purpose: High-resolution computed tomography (mCT) was used to

high-resolution construct three-dimensional (3D) morphology of root canal systems of primary molars.
computed Materials and methods: Twenty-nine extracted primary molars, including eight maxillary first
tomography; molars, 10 maxillary second molars, two mandibular first molars, and nine mandibular second
primary molars; molars, without obvious root resorption were used. A mCT device was used to scan the teeth.
root canal Data were processed to reconstruct 3D images. Roots and root canal systems were analyzed
morphology from 3D images of the teeth and cross-sectional mCT images at different root levels.
Results: In primary molars, numbers of roots and root canals varied from two to three and
three to four, respectively. Maxillary molars exhibited more one-canal than two-canal roots,
yet there were equal numbers in mandibular molars. Fusion between the distobuccal and
palatal roots in maxillary molar was common with a greater prevalence in maxillary first mo-
lars. More ovoid root canal outlines were found apically. Root canal outlines remained consis-
tent from one level to the next in 76% of the roots.
Conclusion: This study showed the complexity of root canal system in primary molars. Under-
standing variations in root canal systems would improve the interpretative capability for cor-
rect diagnoses.

* Corresponding author. School of Dentistry, College of Medicine, National Taiwan University, 1 Chan-Te Street, Taipei 100, Taiwan.
E-mail address: 000841@ntuh.gov.tw (G.-F. Huang).

1991-7902/$36 Copyright ª 2013, Association for Dental Sciences of the Republic of China. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jds.2013.04.002
322
Copyright ª 2013, Association for Dental Sciences of the Republic of China. Published by
Elsevier Taiwan LLC. All rights reserved.
Introduction
Pulpal therapy of primary teeth is frequently performed in
daily practice to preserve the function of the tooth and the
integrity of the dental arch.1 Familiarity with the
complexity of root canal systems dictates the parameters
that affect the probability of success of root canal ther-
apy.2,3 The root canal anatomy of the permanent dentition
has systemically been established.2e5 Histology and ground
sectioning have been used for studies of root canal sys-
tems.6e8 However, they are unable to obtain the entire
picture of tooth structures including the crown, roots, and
root canal systems. Three-dimensional (3D) models of teeth
and root canal systems have been produced by injecting
materials or dyes into the root canal system with subse-
quent demineralization etc.9e13 Unfortunately, those
methods have to destroy or alter dental hard tissues.
Dental periapical radiography is routinely used for
diagnostic and endodontic evaluations; however, radiog-
raphy yields only 2D images, which might encounter some
blind spaces in root canals and are generally unsatisfactory.
Computed-based techniques have been popularly used
for studying root canal morphology.14e20 High-resolution
computed tomography (micro-CT or mCT) is a 3D imaging
technique that possesses the ability to visualize morpho-
logical characteristics of a tooth and root canals in a
detailed and accurate manner without destroying the
teeth.17e20 The numbers of roots and root canals and the
root canal morphology are considered ethnic characteris-
tics.21 There are only a few radiographic studies on the
prevalence of three-rooted mandibular primary molars in
Taiwanese children.6,7 One report evaluating cross-
sectional images of root and root canal systems studied
mandibular permanent first molars in Taiwanese individuals
using cone-beam CT.22 However, no study has been con-
ducted on the characteristics of root canal morphology of
primary teeth in Taiwan. This study focused on evaluating
the numbers of roots and root canals, and 3D characteris-
tics of root canal systems of primary molars in Taiwanese
children using mCT.
Materials and methods
Twenty-nine extracted primary molars of patients aged
3e6 years were randomly collected from the pediatric
dental clinic of National Taiwan University Hospital for
study, including eight maxillary first primary molars, 10
maxillary second primary molars, two mandibular first
primary molars, and nine mandibular second primary
molars. This study was approved by the research ethics
committee of National Taiwan University Hospital. All
participants and their guardians enrolled in this research
appropriately responded to an informed consent
protocol.
Y.-L. Wang et al
The teeth collected were carious but without obvious
root resorption. The age and gender of the patients were
unknown. Soft tissues on the surface of the extracted pri-
mary molars were removed and cleaned with a toothbrush.
Debris on the tooth surface and in the carious cavities was
washed out with tap water and ultrasound. No attempt was
made to introduce burs or files into the inside structures of
the tooth, including the pulp chamber and root canal.
Specimens were stored in a 0.1% thymol solution until used.
Teeth were photographed in the buccolingual direction,
then mounted on acrylic stents for radiographic examina-
tion in the same orientation as that for routine intraoral
radiography.
The teeth were scanned with a commercially available
mCT scanner (MCT-CB100MF, Hitachi, Medical, Tokyo,
Japan) at 70 kV and 100 mA. On average, 180 slices with
voxel sizes of 100 mm
100 mm
100 mm were scanned for
each tooth at 1.2
magnification. The scanning time for
one tooth varied from 3 hours to 4.5 hours.
To visualize 3D images, all scanned slices were recon-
structed with Amira (2.2) software (Mercury Computer
Systems, Berlin, Germany). Scanned data were loaded into
the Amira software. Tooth structures were extracted using
the intensity threshold. A manual technique was used to
outline and segment the structures. Then a simplification
algorithm was applied to remove redundant vertices. Two
to five interactions of the smoothing algorithm were
applied to each surface. Color settings were selected to
show the root canal spaces (purplishered) in the 3D images
of the tooth structures (bluishegray). Cross-sectional im-
ages of roots were obtained using the Field Cut module of
Amira software at different levels from the cervical (pulp
floor), middle, and apical levels of the root. The dental
hard structure was rendered transparent, and the pulp
chamber and root canal system were made opaque to allow
visualization of the 3D model of these structures.
Photos of the tooth, x-ray images, and reconstructed 3D
tooth images in different directions were displayed. Cross-
sectional tomographic images of the shape of the roots and
root canals at various levels were evaluated by two dentists
to determine the shape of the roots and canals in these
teeth. Disagreement in identifying shapes of the roots and
canals were resolved by further discussion, and a consensus
was reached between the two dentists. Numbers of roots
and root canals, and cross-sectional shapes of the root
canals at different root levels were recorded.
The shapes of the root canals from the tomographic
images were further confirmed by the reconstructed 3D
images of the root and root canal. Data analyses were re-
ported as frequencies of the numbers of roots and root
canals, cross-sectional root canal outlines, and consistency
of the root canal morphology from the cervix to the apex of
respective primary molars. A Chi-squared test was used to
analyze differences in the prevalences of cross-sectional
root canal outlines at various root levels and differences in
Root canal morphology of primary molars 323

Figure 1 Images of the crown, roots, and root canal system of a maxillary second primary molar. Buccolingual projections of (A)
tooth photographs, (B) radiographs, and (C) reconstructed 3D images of the tooth. Red-colored areas in the reconstructed 3D
images represent root canal spaces on the (C) buccolingual, (D) mesiodistal, and (E) distomesial projections of the 3D image.
Intercanalicular communication and apical ramification are shown between the mesiobuccal (MB) and distobuccal (DB) roots, and
at the apex of the distobuccal root, respectively. The cross-sectional microcomputed tomographic images of the roots and root
canals corresponding to (a) apical, (b) middle, and (c) cervical levels of the roots are indicated on image A. B Z buccal; D Z distal;
M Z mesial; P, palatal.

the degree of root canal outline consistency between
maxillary and mandibular primary molars. The significance
level was set to 0.05.
Results
Figs. 1 and 2 show examples of tooth photographs (A), ra-
diographs (B), and reconstructed 3D images of the tooth
structures and root canals (C, D, E) of a maxillary second
primary molar (Fig. 1) and a mandibular second primary
molar (Fig. 2). Images in A, B, and C of the figures show
buccolingual projections of the tooth, dental radiograph,
and 3D image (C) of the tooth and root canals displayed in
the same orientation as clinically obtained periapical ra-
diographs. Images D and E are mesiodistal and distomesial
views, respectively, of the tooth structures and root canal
systems of the tooth. Images a, b, and c represent cross-
sectional mCT images corresponding to horizontal lines at
the apical (a), middle (b), and cervical (c) levels of the
roots as shown in photograph A of the figure.
Fig. 1 shows a maxillary second primary molar in which
inter-radicular communication was exhibited between the
mesiobuccal and distobuccal roots, and apical ramifications
at the distobuccal root were also visible on the 3D images.
Numbers of roots and root canals, and shapes of the roots
and canal systems are shown on the 3D images in different
directions (Fig. 1C, D, E) and different root levels (a, b, c)
as well. Fig. 2 shows a mandibular second primary molar
with two canals in the mesial root, and single root canals in
the distobuccal and distolingual roots.
Table 1 shows the numbers of roots and root canals of
each primary molar. Equal numbers of maxillary first pri-
mary molars presented two and three roots. Regardless of
the number of roots of a tooth, all maxillary first primary
molar in this study had three canals. Most of the maxillary
second primary molars (9 of 10) were three-rooted, in
which numbers of teeth with three or four canals were
approximately identical. Our mandibular first molar sam-
ples displayed only two roots, in which the mesial root had
two canals and the distal root had either one or two canals.
Among nine mandibular second primary molars, four were
two-rooted and the other five were three-rooted. The
majority of mandibular second primary molars presented
one more root canal than the number of roots.
Among eight maxillary first primary molars, most
mesiobuccal roots were one-canalled roots (Table 2). All
distobuccal and palatal roots of maxillary molars were
single-canalled roots. When a distobuccal root was fused to
a palatal root, it exhibited two distinct root canals for the
root. Numbers of root canals in respective roots of maxil-
lary second primary molars were similar to those in
324 Y.-L. Wang et al

Figure 2 Images of the crown, roots, and root canals system of a mandibular second primary molar. Numbers of roots and root
canals are visible at different orientations of the 3D images. The cross-sectional microcomputed tomographic images of roots and
root canals at different root levels are shown. B Z buccal; D Z distal; DB Z distobuccal; DL Z distolingual; L Z lingual;
M Z mesial; MB Z mesiobuccal.

maxillary first primary molars. Mesial roots of both the apical level. However, more ribbon-shaped root canal
mandibular first and second primary molars showed two outlines were shown coronally above the middle level. All
canals, while distal roots had either one or two canals. palatal roots of maxillary first primary molars showed
However, if the distal root was divided into distobuccal and
distolingual roots, there was only one canal for each root.
Table 2 Distribution of the number of root canal in indi-
Table 3 shows tomographic images of roots and root
vidual root of each primary molar.
canals at various root levels, i.e., apical (a), middle (b),
and cervical (c) levels of the roots. Approximately 80% (47/ Tooth Root Number of root
59) of maxillary primary molars presented an ovoid- canals
outlined root canal at the apical level. However, mandib- 1-canal 2-canal
ular primary molars presented approximately equal
Max m1 (n Z 8) MB 7 1
numbers (20 vs. 19) of ovoid- and ribbon-shaped outlines at
DB 4 0
P 4 0
DB þ P 0 4
Table 1 Number of roots and root canals in primary Max m2 (n Z 10) MB 6 4
molars. DB 9 0
Number of Tooth P 9 0
roots & canals DB þ P 0 1
Max m1 Max m2 Mand m1 Mand m2
Mand m1 (n Z 2) M 0 2
(n Z 8) (n Z 10) (n Z 2) (n Z 9)
D 1 1
Two-root 4 1 2 4 Mand m2 (n Z 9) M 0 9
3-canal 4 1 1 3 D 4 1
4-canal 0 0 1 1 DB 4 0
Three-root 4 9 0 5 DL 4 0
3-canal 4 4 0 1
þ Z fused; B Z buccal; D Z distal; L Z lingual; M Z mesial;
4-canal 0 5 0 4
m1 Z primary first molar; m2 Z primary second molar;
m1 Z primary first molar; m2 Z primary second molar; Mand Z mandibular; Max Z Maxillary; n Z number of teeth;
Mand Z mandibular; Max Z maxillary; n Z number of teeth. P Z palatal.
Root canal morphology of primary molars 325

Table 3 Cross-sectional outlines of different root canals Table 4 Number and percentage of consistency of root
at different root levels. canal outlines in primary molars.
Tooth Name of Root canal outlines at Tooth Root Consistent* Inconsistent
root different root levels* Upper m1 (n Z 8) MB 7 2
Cervix Middle Apex DB 3 1
(c) (b) (a) P 4 0
O R O R O R DB þ P 5 3
Upper m2 (n Z 10) MB 8 6
Max m1 (n Z 8) MB 4 5 4 5 7 2 DB 7 2
DB 1 3 1 3 1 2 P 9 0
P 4 0 4 0 4 0 DB þ P 2 0
DB þ P 2 6 2 6 5 3 Total 45 (76.3%) 14 (23.7%)
Max m2 (n Z 10) MB 7 7 9 5 13 1 Lower m1 (n Z 2) M 4 0
DB 4 5 7 2 7 2 D 2 1
P 7 2 7 2 7 2 Lower m2 (n Z 9) M 13 5
DB þ P 1 1 1 1 2 0 D 5 1
Total 30 29 35 24 47 12 DB 3 1
Mand m1 (n Z 2) M 2 2 2 2 2 2 DL 3 1
D 0 3 0 3 1 2 Total 30 (76.9%) 9 (23.1%)
Mand m2 (n Z 9) M 5 13 7 11 10 8
D 2 4 2 4 3 3 *No significant difference of the degree of consistency of root
DB 1 3 2 2 2 2 canal shapes at different root levels between maxillary and
mandibular primary molars (P Z 0.57).
DL root 1 3 2 2 2 2
þ Z fused; B Z buccal; D Z distal; L Z lingual; M Z mesial;
Total 11 28 15 24 20 19
m1 Z primary first molar; m2 Z primary second molar;
*Significant difference existed in the prevalence of root canal n Z number of teeth; P Z palatal.
shapes between maxillary and mandibular primary molars at
different root levels (P < 0.05).
þ Z fused; B Z buccal; D Z distal; L Z lingual; M Z mesial;
m1 Z primary first molar; m2 Z primary second molar; Discussion
Mand Z mandibular; Max Z Maxillary; n Z number of teeth;
P Z palatal.
The mCT technique used in this study made it possible to
obtain 3D images of the external and internal morphology
of roots and root canals without destroying the specimens.
In addition to the main root canals, intercanalicular com-
ovoid-shaped canals for the entire length of the roots. In
munications and apical ramifications were visible on our 3D
palatal roots of maxillary second molars, fewer ribbon-
images. In general, cross-sectional pixels of 19e63 mm and
shaped outlines were seen. Regardless of the shape of the
longitudinal slice distances of 13e200 mm were selected for
root canals at the cervical and/or middle levels, most root
sample scanning.23e25 However, because we used a larger
canal outlines tended to be ovoid at the apices. The mesial
voxel size of 100 mm
100 mm
100 mm for tooth scanning,
root of the mandibular first primary molar shared ovoid-
some fine details of the root canal morphology might have
and ribbon-shaped outlines throughout the entire root
been sacrificed, although Nielsen et al demonstrated that
length. In general, the lower primary molars exhibited
when using mCT with a pixel size of 127 mm, it is possible to
more ribbon-shaped root canals at the cervical and middle
reproduce root canal spaces and the tooth anatomy.26
levels; however, equal numbers of ovoid- and ribbon-
The present study showed four maxillary first primary
shaped canal outlines were found at the apical level. Dif-
molars and one maxillary second primary molar had only two
ferences in the prevalences of cross-sectional root canal
roots, and other maxillary primary molars had three roots.
outlines between maxillary and mandibular primary molars
Previous studies did not show two-rooted maxillary molars in
at various levels of the root were statistically significant
any of their samples.27,28 This discrepancy is likely to reflect
(P < 0.05).
differences in identifying the root number of fused dis-
Table 4 shows the consistency of the root canal
tobuccalepalatal roots. Although the fusion separated at
morphology throughout the entire root length. Seventy-six
the apical third of the root, we treated each fused root as a
percent of the primary molar roots showed consistent
single root. All of our fused distobuccalepalatal roots dis-
root canal outlines for the entire root length. All palatal
played two root canals for the root.
roots of maxillary primary molars showed a consistent root
Regardless of the number of roots, two or three, of the
canal morphology from cervices to the apices. For
maxillary first molars, three canals were the only number of
mandibular primary molars, the percentage with a consis-
root canals for this tooth. This result agreed with a report
tent root canal morphology was similar to that of the
by Zoremchhingi et al27 and a study examining a method of
maxillary primary molars. However, no difference in the
root canal accessibility.29 Most maxillary primary molars
degree of consistency of the cross-sectional root canal
had one canal for each root with two canals in dis-
shape existed between maxillary and mandibular primary
tobuccallyepalatally fused roots. This result was also
molars (P Z 0.57).
326
comparable to the report by Zoremchhingi et al.27 In the
present study, three of 18 (17%) maxillary primary molars
demonstrated communication between the mesiobuccal
and distobuccal root canals. Mesbahi et al.12 reported that
37.5% of maxillary first primary molar had similar root canal
communication.
The prevalence of fused distobuccal and palatal roots in
maxillary primary molars varied among studies. In the
present study, five of 18 (27.7%) maxillary primary molars
showed fusion between the distobuccal and palatal roots,
especially in the maxillary first primary molars. Fusion of
the distobuccal and palatal roots in maxillary primary mo-
lars is common, with a greater prevalence in maxillary first
primary molars.12,27,28 Fusion between palatal and dis-
tobuccal roots of maxillary primary molars may increase the
possibility of superimposition on diagnostic radiographs.28
Therefore, multiple exposures at different angles may be
necessary for better detection of root canals.
In this study, only two-rooted mandibular first molars
were found; however, the number of this tooth examined was
too small to validate our findings. Despite the small number
for this tooth in this study, similar results were reported in
previous studies, which also found that the majority of
mandibular second primary molars were two-rooted.27,28 Our
samples displayed approximately equal numbers of two- and
three-rooted mandibular second molars. By examining bite-
wing radiographs, studies on the prevalence of three-
rooted mandibular primary molars in Taiwanese children
showed that 5.0% and 10% of mandibular first and second
primary molars, respectively, were three-rooted.6,7 More
teeth need to be examined in future studies.
The present study showed that all mesial roots of
mandibular primary molars had two root canals. There were
no one-canalled mesial roots in mandibular primary molars in
this study. This result is comparable to previous studies by
Zoremchhingi et al27 and Aminabadi et al.29 However, Zor-
emchhingi et al27 reported only one case of a one-canal mesial
root among 15 mandibular first primary molar samples.
The cross-sections of the root canal outlines were
divided into ovoid and ribbon shapes. This study showed
that ovoid root canal outlines were the only root canal
shape for palatal roots of maxillary first primary molars. In
palatal roots of maxillary second primary molars, ribbon-
shaped root canals were observed, but there were only a
few. It was noted that numbers of ovoid- and ribbon-shaped
root canals equally occurred at the cervical level in
maxillary primary molars. In mandibular primary molars,
however, the ribbon shape occurred more frequently than
the ovoid shape at the cervical level. As we examined the
shapes of root canals from the cervical to the apical level,
the number of ovoid root canal outlines increased. Similar
findings were reported in previous studies on permanent
incisors and premolars indicating that canals were more
rounded or oval closer to the apex, and tended to a ribbon
shape more coronally.30,31
In this study, the cross-sectional root canal outlines of
palatal roots of maxillary primary molars and mesial roots
of mandibular first primary molar remained constant from
the cervical to apical level. Our results indicate that 76% of
primary molars had a consistent cross-sectional root canal
outline from the cervical to the apical level in both maxil-
lary and mandibular molars. This result differed from a
Y.-L. Wang et al
study on the root canal morphology of mandibular perma-
nent incisors, which indicated that the root canal outline of
75% of teeth did not remain constant from one level to the
next.31
Since radiographs are superimpositions of overlying
structures, which may obscure the structure of interest and
might not represent the actual morphology, it is unlikely
that radiographs show complexities of the root canal
morphology, and they cannot be used to detect multiple
canals or lateral canals.32 Therefore, there are limitations
in the value of radiographs alone in describing certain
aspect of root canal morphology.33 In contrast with con-
ventional dental radiographs, 3D images of primary molars
may provide better clues and knowledge of variations in the
root canal morphology, which would improve dentists’
interpretative capability for correct diagnoses.
Acknowledgments
We acknowledge the Department of Oral and Maxillofacial
Radiology, Kanagawa Dental College, Yokosuka City, Japan
for the help in acquiring mCT scanning data at their
facilities.
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