Clinical Research
3-Rooted Maxillary First Premolars: An Ex Vivo
Study of External and Internal Morphologies
Panagiotis Beltes, DDS, PhD,* Maria-Elpida Kalaitzoglou, DDS,† Eleni Kantilieraki, DDS,*
Charalampos Beltes, DDS, MSc, MClinDent, PhD,* and Christos Angelopoulos, DDS, MSc, PhD‡
Abstract
Introduction: This study aimed to analyze the external
and internal morphologies of 3-rooted maxillary first
premolars using cone-beam computed tomographic
(CBCT) imaging. Methods: Fifty-six three-rooted maxil-
lary first premolars were imaged by CBCT imaging and
classified into 4 groups on the basis of external root
morphology. Internal morphologic features, including
the shapes of the buccal and palatal orifices and
distances of bifurcation of the buccal-palatal and
mesiobuccal-distobuccal root canals from the cementoe-
namel junction (CEJ), were measured. Results: The
teeth were classified into 4 groups on the basis of
external morphology: group A, separation of the buccal
and palatal roots with bifurcation of the former into the
mesiobuccal and distobuccal roots (n = 22); group B,
fusion of 2 buccal roots with the palatal root being sepa-
rate (n = 19); group C, complete or partial fusion of the
distobuccal and palatal roots (n = 9); and group D,
fusion of all 3 roots (n = 6). The buccal orifice was
mainly triangular/heart shaped. The distance of bifurca-
tion of the buccal-palatal root canals from the CEJ in
group A differed significantly from those in groups B
and C (P < .05). There were significant differences in
the distance of bifurcation of the mesiobuccal-
distobuccal root canals from the CEJ among groups A,
B, and C (P < .05). Four teeth exhibited C-shaped root
canal systems of different configurations. Conclusions:
The external and internal morphologies of 3-rooted
maxillary first premolars vary considerably. (J Endod
2017;43:1267–1272)
Key Words
3-rooted maxillary first premolar, cone-beam computed
tomography, external-internal morphology
From the Departments of *Endodontology and ‡Dento-alveolar Surgery, Implantology and Radiology, School of Dentistry, Aristotle University of Thessaloniki, The-
ssaloniki, Greece; and †Private Practice, Thessaloniki, Greece.
Address requests for reprints to Prof Panagiotis Beltes, Department of Endodontology, School of Dentistry, Aristotle University of Thessaloniki, Agiou Dimitriou Str,
54124 Thessaloniki, Greece. E-mail address: beltes@otenet.gr
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.03.045
JOE — Volume 43, Number 8, August 2017
T he success of endodon-
tic therapy depends on
a good understanding of
Significance
Little information is available in the literature
regarding canal configurations or relationships
root canal morphology.
among roots in 3-rooted maxillary premolars. The
The awareness of probable
present study provides an evaluation of external
variations in root and root
and internal morphologies in a fairly large sample
canal anatomy for all types
size using CBCT imaging.
of teeth reduces the possi-
bility of root canals being
overlooked during treatment (1). Although all types of teeth might possess extra roots
and/or canals, the likelihood of finding aberrant canal configurations is higher among pre-
molars and molars (2).
Although maxillary first premolars usually have 1 or 2 roots, the presence of
3-rooted teeth is considered the most common anatomic variation, with an overall inci-
dence of 1.7% (range, 0.4%–9.2%) (3–5). Because of the low frequency of 3-rooted
maxillary first premolars in previous morphologic studies, little information is available
regarding canal configurations or relationships among roots in these teeth. On the other
hand, clinical interest in this rare variation is underlined by the availability of several
case reports, which have, however, been unable to reach any certain conclusions on
the morphologic features of 3-rooted maxillary first premolars.
To the best of our knowledge, only a few studies to date have investigated the internal
and external morphologies of 3-rooted maxillary premolars. Bellizzi and Hartwell (6) pro-
posed the categorization of external morphologies of 3-rooted maxillary premolars for the
first time and also suggested possible therapeutic approaches. Pinheiro et al (7) investi-
gated the external and internal anatomic features of a large number of first and second
3-rooted maxillary premolars using the clearing technique and proposed a different cate-
gorization system for external anatomy. Recently, a research group (8–10) evaluated a set
of tooth samples, with a maximum sample of 16 three-rooted maxillary premolars, using
different approaches in 3 separate studies. Although 2 of the studies involved anatomic eval-
uation, the third involved a comparative evaluation of the sample using cone-beam
computed tomographic (CBCT) and micro–computed tomographic (mCT) imaging.
This study aimed to evaluate the external and internal morphologies of a relatively large
sample of 3-rooted maxillary first premolars with fully formed apices using CBCT imaging.
Materials and Methods
This study was approved by the research committee of the Aristotle University of
Thessaloniki, Thessaloniki, Greece (protocol no. 26/03-02-2016). The sample was
composed of 56 three-rooted maxillary first premolars derived from the personal
collection of the first author. Data regarding the origin of individual teeth or donor
3-Rooted Maxillary First Premolars 1267
Clinical Research
age, sex, or race were not available. Teeth without fully formed apices as
well as those with root cracks or resorption, endodontic treatment, or
crown loss were excluded.
The teeth were stored in 0.1% thymol, rinsed with normal saline, and
dried. They were placed on low-density bases (sponges) in groups of 4 and
scanned using a high-resolution imaging protocol (voxel size = 0.1 mm)
with a CBCT scanner (NewTom VGi EVO; QR Verona, Verona, Italy; 110
kVp; 3.00 mA; exposure time = 4.3 seconds). Image acquisition was per-
formed in accordance with standardized procedures by a trained radiology
technician. The acquired volumetric data were analyzed in the axial, cor-
onal, and sagittal planes using the proprietary software of the CBCT scanner
in order to determine specific morphologic features of the included teeth.
External Morphology
On the basis of axial imaging findings, the teeth were classified into
4 groups based on root separation (Fig. 1A–D).
1. Group A: Teeth with 3 distinct roots, the mesiobuccal (MB), distobuc-
cal (DB), and palatal roots. In these teeth, the buccal (B) and palatal
(P) roots are separated, below which point, the buccal root is divided
into the MB and DB roots. Teeth in this group were subdivided into 3
categories:
a. Group A1: The MB root bifurcated from the DB root at the cer-
vical third of the root
b. Group A2: The MB root bifurcated from the DB root at the
midthird of the root
c. Group A3: The MB root bifurcated from the DB root at the apical
third of the root
2. Group B: Teeth with fused MB and DB roots and a completely or
partially separate palatal root. This group included teeth in which
the MB and DB roots bifurcated at a distance of 1.0 mm or less
from the apex.
3. Group C: Teeth with completely or partially fused DB and palatal
roots.
4. Group D: Teeth with 3 fused roots. These teeth exhibited visible
grooves showing the fusion of roots. This group included teeth in
which any of the 3 roots bifurcated at a distance of 1.0 mm or
less from the apex.
Internal Morphology
The following parameters were evaluated by analysis of axial
images of the teeth.
1. Shapes of orifices at the point of bifurcation of the B and P root
canals
Figure 1. Classification of external morphology of 3-rooted maxillary premolars. Representative teeth from groups (A) A, (B) B, (C) C, and (D) D.
1268 Beltes et al.
2. The distance from the point of bifurcation of the B and P root canals
to the most apical part of the cementoenamel junction (CEJ) (B-P
bifurcation)
3. The distance from the point of bifurcation of the MB and DB root
canals to the most apical part of the CEJ (MB-DB bifurcation)
4. The distance between the B-P and MB-DB bifurcations determined
by the difference of the 2 previous measurements for each tooth
5. Canal configurations of C-shaped teeth, which were excluded from
the previously mentioned measurements and analyzed separately.
The C-shaped parts of the canals were categorized in accordance
with the classification proposed by Fan et al (11).
The distances from the B-P and MB-DB bifurcations to the CEJ
were measured as follows. Each scan comprised 501 axial sections
numbered on the upper left corner. Individual images were acquired
at 0.1-mm intervals (voxel resolution = 0.1 mm). The root bifurca-
tion–CEJ distances for each tooth were calculated by subtracting the
number of axial images of the B-P/MB-DB bifurcation and the CEJ
and multiplying the result by 0.1 mm.
Differences in root bifurcation–CEJ distance between the B-P and
MB-DB bifurcations and the distance between the 2 bifurcations were
statistically analyzed using the nonparametric Kruskal-Wallis H test
for 3 independent groups (A, B, and C) followed by the Mann–Whitney
U test for pair-wise comparison among these groups at a 5% signifi-
cance level (SPSS 22.0; SPSS, Chicago, IL).
Results
External Morphology
1. Group A was composed of 22 (39.3%) teeth; group A1, 9; group A2,
11; and group A3, 2 (Fig. 1A)
2. Group B was composed of 19 (33.9%) teeth (Fig. 1B)
3. Group C was composed of 9 (16.1%) teeth (Fig. 1C)
4. Group D was composed of 6 (10.7%) teeth (Fig. 1D)
Internal Morphology
Groups A, B, and C comprised teeth exhibiting similar patterns of
internal morphology in which the B root canal, after bifurcation from
the P, was divided into MB and DB root canals (Fig. 2A–C). One tooth
from group B exhibited 2 fused buccal roots with C-shaped root canals.
Group D was excluded from analysis of the distance of bifurcation
because it comprised 6 teeth exhibiting unique internal morphologic
features, whereas 1 tooth exhibited a similar internal morphology as
the teeth in the other groups (Fig. 2D) and 2 teeth possessed 2 root ca-
nals (1 B and 1 P canal) that were fused apically, ending in a single main
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 Clinical Research

Figure 2. Cross-sectional CBCT images from the cervical to apical levels of representative teeth from groups (A) A, (B) B, (C) C, and (D) D.

apical foramen; in the remaining 3 teeth, the 3 fused roots exhibited C-
shaped root canals. These 3 teeth, along with the C-shaped tooth from
group B, were analyzed separately.
The B and P orifices of teeth in groups A, B, C, and D (recorded
at the level of B-P bifurcation) were classified into 3 groups on the
basis of configuration: triangular/heart shaped, tear shaped, and
oval (Fig. 3A–D). As shown in Table 1, in groups A, B, and C, which
exhibited the same pattern of internal tooth morphology, the buccal
orifices were mainly triangular/heart shaped, whereas the palatal or-
ifices were mainly tear shaped.
Table 2 presents the minimum, maximum, and mean values of dis-
tance between the CEJ and B-P/MB-DB bifurcation for each group. The

Figure 3. Cross-sectional CBCT images showing B and P orifice configurations. (A) B triangular and P tear-shaped, (B) B heart-shaped and P tear-shaped, (C) B
and P tear-shaped, and (D) B and P oval-shaped configurations.

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Clinical Research
TABLE 1. Configurations of Buccal and Palatal Orifices in Each Group
Group Triangular/heart Tear
(No. of teeth) Orifice shaped shaped
A (22) Buccal 17 4 1
Palatal — 18
B (18)* Buccal 14 4 —
Palatal — 18
C (9) Buccal 6 2
Palatal — 7
D (3)* Buccal 1 2
Palatal — 3
*One sample from group B and 3 from group D with C-shaped root canals were excluded from
analysis.
Kruskal-Wallis H test for 3 independent groups (A, B, and C) indicated
statistically significant differences in the B-P and MB-DB bifurcations
and the distance between the 2 bifurcations. The Mann-Whitney U
test showed significant differences between groups A-B and A-C in the
B-P bifurcation, all pairs of groups in MB-DB bifurcation, and groups
A-B and B-C in the distance between the 2 bifurcations (P < .05).
Four teeth (1 from group B and 3 from group D) exhibited
C-shaped canal configurations recorded at a distance of approximately
2.0 mm from the CEJ. Table 3 presents the different canal configurations
along the length of their roots (Fig. 4A–D).
Discussion
The purpose of this study was not to investigate the frequency of
3-rooted maxillary first premolars but rather to analyze the anatomic
features of these teeth, with a special focus on evaluating a fairly large
sample size. This study used CBCT imaging, a noninvasive diagnostic im-
aging modality considered important for comprehensive endodontic
evaluation in clinical practice (12). This technique provides extensive
3-dimensional anatomic information regarding teeth in the axial,
sagittal, and coronal views and offers the main advantages of reduced
distortion and superimposition of anatomic structures and relatively
low patient radiation exposure. However, CBCT imaging does not offer
adequate resolution for gaining accurate information on morphologic
details such as lateral root canals of minor diameters, isthmi, intracanal
ramifications, apical deltas, and accessory apical foramina—aspects
not included in the present analysis. In comparison, mCT imaging pro-
vides better image quality and resolution for such morphologic details
because of its smaller slice thickness (13, 14). However, the high-
resolution CBCT protocol used provided satisfying results regarding
the main purpose of the present study—the investigation of the number
and course of the root canals of 3-rooted maxillary first premolars.
Marca et al (10) analyzed the anatomic features of 16 three-rooted
maxillary premolars using CBCT and mCT imaging and reported that,
despite its diagnostic strength, CBCT imaging exhibits inferior image
quality in comparison with mCT imaging because of scattering and a
Oval lack of sharpness. However, the CBCT scanner used in the previous
study acquired images at a voxel size of 200  200  200 mm, thus
producing fewer images than the CBCT scanner used in the present
4
study, which acquired images at a voxel size of
— 100  100  100 mm and exhibited relatively high image quality.
1 With regard to external morphology, all samples in the present
2 study exhibited 1 P and 2 B (MB and DB) roots although the existence
—
—
of 3-rooted maxillary first premolars with 1 B and 2 P roots has been
previously reported (15). Moreover, the present findings revealed
that 3-rooted maxillary first premolars most frequently present with 3
distinct roots or 2 fused B roots and a separate P root; in the former
case, B-P bifurcation was observed mainly at the midthird of the root.
In contrast, Pinheiro et al (7) reported a majority of teeth as exhibiting
bifurcation at the cervical third of the root.
The classification presented in this study differs from that pro-
posed by Bellizzi and Hartwell (6); it is, however, more in accordance
with that proposed by Pinheiro et al (7) because we agree that teeth with
3 fused roots and those with fused MB and DB roots are 2 distinct
groups with different internal morphologies as revealed by the present
findings. However, teeth in which the DB root is completely or partially
fused with the P root, included in the present study as group C, were not
included in the previous 2 classifications.
With respect to internal morphology, all teeth in the present study
(apart from the C-shaped teeth) initially presented with 2 orifices, a B
and a smaller P orifice. None of the specimens, not even the 4 teeth in
group A that exhibited trifurcation of roots in the same section, ex-
hibited 3 orifices (an MB, a DB, and a P orifice). Misinterpretation
of the metaphor that 3-rooted maxillary premolars are small molars
(16) could mislead clinicians into searching the pulp chamber floor
for 3 orifices.
The majority of B orifices in the present study were triangular or
heart shaped, with the B side of the orifices being greater in dimension
than the P side. In contrast, P orifices were tear shaped, with the base of
the tear located palatally. These orifice configurations are key indicators
of the possibility of 3 canals. It is well-known that single- or 2-rooted
maxillary first premolars with 2 canals usually possess 2 centrally posi-
tioned, similar-sized, round or oval-shaped orifices—a B and a P orifice.
With regard to the course of root canals, we initially observed 2
canals, a B and a P, with the B then bifurcating to form the mesial
and distal canals at different heights of the root. These findings suggest
that this internal morphologic pattern is demonstrated by almost all
teeth regardless of the relationship among the roots.
In the present study, the CEJ was chosen as a fixed reference point
for the measurement of distances from the B-P and MB-DB bifurcations.
Alternatively, these measurements could have been acquired with the

TABLE 2. Distance between Bifurcation of Root Canals from the Cementoenamel Junction in Each Group
Distance between bifurcations
B-P bifurcation (mm) MB-DB bifurcation (mm) (mm)
Group (No. of teeth) Min Max Mean SD Min Max Mean SD Min Max Mean SD
A (22) 0.4 3.1 1.7 0.8 0.7 5.2 3.5 1.2 0.3 3.8 1.8 0.8
A1 (9) 0.1 3.3 2.6 0.5 2.9 5.0 3.9 0.8 0.3 2.2 1.3 0.7
A2 (11) 1.7 4.1 2.7 0.8 3.2 6.2 4.8 1.0 1.2 3.8 2.1 0.7
A3 (2) 2.9 4.3 3.6 –† 5.3 5.6 5.5 –† 1.3 2.4 1.9 –†
B (19)* 0.7 3.5 2.3 0.8 3.4 10.1 6.8 2.3 2.1 7.5 4.5 1.8
C (9) 1.8 3.3 2.6 0.5 2.7 6.6 4.7 1.1 0.6 4.4 2.1 1.0

B-P, buccal-palatal; MB-DB, mesiobuccal-distobuccal; Min, minimum; Max, maximum; SD, standard deviation.
*One tooth with C-shaped root canals was excluded from analysis.
†
Because of the small sample size, SD was not calculated for group A3.

1270 Beltes et al. JOE — Volume 43, Number 8, August 2017

 Clinical Research
TABLE 3. Canal Configurations of C-shaped 3-Rooted Maxillary First A was smaller than those in groups B and C. With regard to the distance
Premolars at Different Root Thirds from the MB-DB bifurcation to the CEJ, there were significant differ-
Samples Coronal Middle Apical ences among all groups. The mean MB-DB bifurcation–CEJ distance
in group B was the highest followed by that in group C, with group A
1st — C1 C3 exhibiting the lowest value. The distance between the CEJ and the ori-
2nd — C1/C2 C3/C4
3rd C3 C3 C3/C4 fices of the 2 buccal root canals ranged from 0.7 mm (group A) to
4th — C3/C2 C1/C4 10.1 mm (group B). The clinical implication of these findings is that
the division of buccal root canals can occur at any point along the
root. Teeth with adequately short root canal–CEJ distances exhibit
roof of the pulp chamber as a direct internal reference point, thus greater ease of detection and access of both B root canals than teeth
gaining a better understanding of the pulp cavity size in these teeth with greater corresponding distances.
(7). However, we preferred CEJ as a reference point because age- With regard to the distance between the 2 bifurcations, there were
related reduction of pulp chamber volume caused by reparative dentin significant differences between groups A and B and groups B and C.
formation (17) would have produced inaccurate results. Although this distance is a derivative of the root canal–CEJ measure-
The present findings revealed significant differences in the dis- ments, it is of major clinical interest. In the present study, the mean
tance from the B-P bifurcation to the CEJ between groups A and B distance between the MB-DB and B-P bifurcations in group B was
and groups A and C. The mean B-P bifurcation–CEJ distance in group greater than those in groups A and C.

Figure 4. Cross-sectional CBCT images showing first maxillary premolars with C-shaped configurations. Sample 1: 2 fused buccal roots with C-shaped canal sys-
tems. Cross sections at the (A1) most apical part of the CEJ and at distances of (A2) 2.0, (A3) 4.7, (A4) 7.1, (A5) 9.7, and (A6) 10.5 mm from the CEJ. Sample 2: 3
fused roots with C-shaped canal systems. Cross sections at the (B1) most apical part of the CEJ and at distances of (B2) 3.9, (B3) 6.7, (B4) 7.4, (B5) 8.7, and (B6)
12.3 mm from the CEJ. Sample 3: 3 fused roots with C-shaped canal systems. Cross sections at the (C1) most apical part of the CEJ and at distances of (C2) 4.1, (C3)
4.4, (C4) 5.0, (C5) 9.1, and (C6) 10.4 mm from the CEJ. Sample 4: 3 fused roots with C-shaped canal systems. Cross sections at the (D1) most apical part of the CEJ
and at distances of (D2) 3.2, (D3) 7.1, (D4) 7.8, (D5) 8.7, and (D6) 12.0 mm from the CEJ. The arrows indicate different C-shaped canal configurations according
to Fan’s classification.

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Clinical Research
The particularly impressive findings of the present study were the 4
three-rooted maxillary first premolars with C-shaped root canal systems
(1 sample from group B with 2 fused B roots and 3 samples from group
D with 3 fused roots). The fact that 3 of the 6 samples in group D ex-
hibited C-shaped canal systems might be an indication that 3-rooted
maxillary first premolars with 3 fused roots are possibly C shaped.
To our knowledge, there is no report in the extant literature of maxillary
premolars with C-shaped root canal systems.
All 4 C-shaped teeth exhibited an elliptical pulp chamber with the
buccopalatal dimension being the greatest (the typical configuration of
the pulp chamber in maxillary premolars). The orifices differed in
configuration in each case, and none conformed to an uninterrupted
C shape. Thus, it can be said that the internal morphology of teeth at
the pulp chamber and at the coronal third of the roots does not indicate
predisposition to a C-shaped canal configuration, which is in
accordance with the internal morphology of C-shaped mandibular
premolars (18, 19).
Conclusions
Three-rooted maxillary premolars exhibit heterogeneous separa-
tion of roots, with 4 possible morphologies. None of the samples
exhibited 3 separate orifices at the beginning. On the contrary, all teeth
exhibited 2 orifices, a triangular/heart-shaped B orifice and a tear-
shaped P orifice. Below the point of separation of the B and P roots,
the B root canal bifurcated into the MB and DB canals at different
heights of the root, irrespective of the type of external tooth morphology.
Three-rooted maxillary premolars with C-shaped root canal systems are
a novel finding of the present study.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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