doi:10.1111/iej.

13199

REVIEW
Application of a new system for classifying tooth,
root and canal morphology in the primary
dentition

H. M. A. Ahmed1 , P. K. Musale2 , O. I. El Shahawy3 & P. M. H. Dummer4

1
Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; 2“Little Ones Big
Smiles” Laser and Microscope Integrated Paediatric Dentistry, Pune, India; 3Department of Paediatric Dentistry, Faculty of
Dentistry, Cairo University, Cairo, Egypt; and 4School of Dentistry, College of Biomedical and Life Sciences, Cardiff University,
Cardiff, UK

Abstract classifying the roots and main canals (https://doi.org/

Ahmed HMA, Musale PK, El Shahawy OI, Dummer
PMH. Application of a new system for classifying tooth, root
and canal morphology in the primary dentition. International
Endodontic Journal, 53, 27–35, 2020.
Knowledge of root and canal morphology is essential
for the effective practice of root canal treatment. Pae-
diatric endodontics aims to preserve fully functional
primary teeth in the dental arch; however, pulpec-
tomy procedures in bizarre and tortuous canals
encased in roots programmed for physiologic resorp-
tion are unique challenges. A new coding system for
10.1111/iej.12685), accessory canals (https://doi.
org/10.1111/iej.12800) and developmental anoma-
lies (https://doi.org/10.1111/iej.12867) has been
introduced recently. This paper discusses challenges
for describing root and canal morphology in primary
teeth and describes the potential application of the
new classification system for root canals in the pri-
mary dentition.
Keywords: canal morphology, deciduous teeth,
new classification, primary teeth.
Received 29 May 2019; accepted 5 August 2019

the successor tooth or their long-term survival when

Introduction
The morphology of roots and canal systems is variable
and complex. During root canal treatment, a lack of
knowledge on root and canal morphology is often asso-
ciated with a failure to locate, instrument, irrigate and
fill canals adequately (Vertucci 2005, Cantatore et al.
2006). Therefore, an understanding of root and canal
morphology of the human dentition is essential for effec-
tive root canal treatment procedures (Vertucci 2005).
Pulpectomy procedures in primary teeth aim to
ensure normal physiologic exfoliation and eruption of
Correspondence: Hany Mohamed Aly Ahmed, Department of
Restorative Dentistry, Faculty of Dentistry, University of
Malaya, 50603, Kuala Lumpur, Malaysia (e-mail: hany_en-
dodontist@hotmail.com).
their retention is required. Root and canal morphology
in the primary dentition has a wide range of anatomi-
cal variations and is unpredictable (Ahmed 2013,
Ozcan et al. 2016a, Reddy et al. 2018, Neboda et al.
2018, El Hachem et al. 2019). As a consequence, the
bizarre and tortuous canals encased in roots pro-
grammed for physiologic resorption are a unique chal-
lenge for dentists (Dummett & Kopel 2002,
Waterhouse et al. 2011, Ahmed 2013, 2014).
With an increasing range of anatomical complexi-
ties being reported and the deficiencies of the existing
systems for categorizing canal systems becoming more
apparent, a new system for classifying root and canal
morphology has been proposed, which provides
detailed information on tooth notation, number of
roots and root canal configuration in addition to
accessory canals and tooth anomalies (Ahmed et al.

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 53, 27–35, 2020 27

Classification of canal anatomy in primary teeth Ahmed et al.
2017, 2018, Ahmed & Dummer 2018a,b). The pre-
sent article discusses the various challenges when
describing root and canal morphology in primary
teeth and the application of the new system to classify
root and canal morphology in the primary dentition.
Review
Challenges for describing root canal morphology in
the primary dentition
Anatomical variations
Root canal configurations. There are wide range of
anatomical variations in the primary dentition, espe-
cially molars. Root canal configurations change
dynamically with increasing age, especially in
mandibular molars, because of the deposition of den-
tine islands that influence the number, size and shape
of canals within primary roots (Camp 2008). In addi-
tion, physiologic root resorption changes the morphol-
ogy of the root apex leading to difficulty in working
length determination (Camp 2008).
Incisors and canines—Primary anteriors are usually
single-rooted with a single root canal (Cleghorn et al.
2010, Waterhouse et al. 2011). However, several
reports have documented the occurrence of accessory
roots and root canals in primary anterior teeth (Bar-
ker et al. 1975, Cleghorn et al. 2010, Musale & Hegde
2010, Ahmed 2013, Ahmed & Hashem 2016), espe-
cially double-rooted primary maxillary canines
(Mochizuki et al. 2001). Musale & Hegde (2010) doc-
umented the successful endodontic management of a
unilateral three-rooted primary maxillary canine.
Figure 1 Different tooth numbering systems using the new
classification system for root and canal morphology (Upper –
FDI, Middle – Palmer, Lower – Universal).
28 International Endodontic Journal, 53, 27–35, 2020
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Maxillary molars—Primary maxillary molars may
have two to four roots, with the three-rooted variant
being the most common (Cleghorn et al. 2010,
Ahmed 2013). The double-rooted variant, in which
the distobuccal root is fused with the palatal root, is
also common (Cleghorn et al. 2010, Ahmed 2013).
The prevalence of a second mesiobuccal root canal
can be as high as 95% (Sarkar & Rao 2002, Water-
house et al. 2011). Three mesiobuccal canals have
been documented (Ahmed et al. 2016), and other
complex root canal configurations have been reported
in the distobuccal and palatal roots (Cleghorn et al.
2010, Ahmed 2013).
Mandibular molars—Primary mandibular molars can
have one to four roots; the double-rooted variant is
the most common (Cleghorn et al. 2010, Ahmed
2013, Yang et al. 2013, Fumes et al. 2014). Acces-
sory roots in primary mandibular molars, especially
in second molars, have been reported in a number of
population groups (Song et al. 2009, Liu et al. 2010,
Tu et al. 2010, Yang et al. 2013). The mesial roots of
primary mandibular molars usually have two root
canals (Bagherian et al. 2010) but three canals have
also been reported (Sarkar & Rao 2002). The distal
root in mandibular primary molars usually has one
or two canals (Ahmed 2013), but three separate
canals in the distal root have been reported in
extracted mandibular primary second molars when
evaluated using CBCT (Demiriz et al. 2018).
Accessory canals. Accessory canals are common in the
primary dentition, especially in the furcation area
(Wrbas et al. 1997, Dammaschke et al. 2004,
Figure 2 Degree/stage of root resorption is not considered in
the new system. Notably, palatal root resorption (the hidden
third bucco-palatal dimension) usually is at a more advanced
stage compared to apical since the eruption of the perma-
nent successors of primary incisors is from a palatal direc-
tion.
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
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Ahmed et al. Classification of canal anatomy in primary teeth

Figure 3 Drawings showing that physiologic root resorption

may change the root canal configuration of a given root, Figure 6 Drawings showing different canal configurations in
which could be evident during the physiologic root resorp- maxillary primary molars.
tion of a root canal filled primary molar.

(a) (b) (c)

(d)

Figure 4 Drawings showing different canal configurations in

mandibular primary incisors.

Figure 7 Clinical cases of primary anterior teeth using the new

classification system. (a,b), Maxillary anteriors (Courtesy Dr.
Mohamed Salah Shalaby), (c) Mandibular primary incisor
(Courtesy Dr. Abhishek Soni), (d) Three-rooted maxillary canine
(Reproduced with permission from Quintessence - Musale &
Hegde 2010).

Berscheid 2015, Sharma et al. 2016). One micro-CT

study reported that approx. 83% of extracted primary
molars had a least one accessory canal in the furca-
tion area (chamber/furcation canals) (Berscheid
2015), whilst another reported that all mesial and
distal roots of primary second mandibular molars had
lateral canals (El Hachem et al. 2019). It is worth
noting that only a small number of those canals are
patent, and the majority usually terminate within the
root dentine (Berscheid 2015, Sharma et al. 2016).

Figure 5 Drawings showing different canal configurations in Tooth anomalies. The occurrence of root and canal
mandibular primary molars. anomalies in the primary dentition has been

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 53, 27–35, 2020 29

Classification of canal anatomy in primary teeth Ahmed et al.
(a) (b)
(c) (d)
Figure 8 Clinical cases of primary mandibular molar teeth
using the new classification system.
documented with Radix Entomolaris, taurodontism,
root fusion, dens evaginatus, dens invaginatus,
enamel pearls being reported (Kupietzky & Rozenfarb
1993, Eden et al. 2002, Levitan & Himel 2006, Jafar-
zadeh et al. 2008, Song et al. 2009, Cleghorn et al.
2010, King et al. 2010, Venugopal et al. 2010, Naga-
veni & Umashankara 2012, Ahmed 2013) and C-
shaped canals in mandibular molars (Ballal et al.
2006, Ozcan et al. 2016b). Fusion between primary
molars and supernumerary primary teeth has also
been documented (Caceda et al. 1994, Wang et al.
2013, Mukhopadhyay & Mitra 2014).
Physiologic root resorption
Physiologic root resorption, which starts soon after
the complete formation of the root and the
(a)
Figure 9 Clinical cases of primary maxillary molar teeth using the new classification system.
30 International Endodontic Journal, 53, 27–35, 2020
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continuous formation of secondary dentine, modifies
the root canal system over time (Rimondini & Baroni
1995, Waterhouse et al. 2011). In addition, pulp
and/or periodontal inflammation may cause patholog-
ical changes in the resorption process and further
complicate root and canal morphology (Rimondini &
Baroni 1995). As a consequence, root and canal
anatomy in resorbed roots is unpredictable since the
resorptive process along the root surface is uneven
and is subject to continuous morphological changes
(Rimondini & Baroni 1995, Waterhouse et al. 2011).
Moreover, the roots are also subject to internal
resorption that can further modify the root canals
(Rimondini & Baroni 1995, Waterhouse et al. 2011,
Ahmed 2014).
Application of the new root and canal
classification system in the primary dentition
Root and canal morphology
The classification system of Ahmed et al. (2017)
includes codes for three separate components: the
tooth number, the number of roots and the root canal
configuration within each root. The tooth number
(TN) can be written using any numbering system (e.g.
universal numbering system, Palmer Notation Num-
bering System or the FDI World Dental Federation Sys-
tem; Fig. 1) or with a suitable abbreviation if the tooth
number cannot be identified (e.g. extracted teeth). The
number of roots is added as a superscript before the
tooth number (TN), and the root canal configuration is
added as a superscript on the right after the tooth
number (Ahmed et al. 2017) (Fig. 1). For simplicity,
the presence/extent of physiologic root resorption is
not considered in the new system (Fig. 2). However, if
the root canal configuration has been altered as a con-
sequence of physiologic root resorption of a root canal
filled tooth, then the code for root canal configuration
has to be changed accordingly (Fig. 3).
(b) (c)
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

(a)
(c) (d)
Figure 10 CBCT images showing the anatomy of the tooth, root and canals and its description using the new system. (a)
Sagittal section, (b) Coronal section, (c) Axial section (coronal), (d) Axial section (middle), (e) Axial section (apical).
Figure 11 Drawings showing the application of the new sys-
tem for classifying accessory canals in the primary dentition
(A: Apical third, C: Coronal third, D: Delta).
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Ahmed et al. Classification of canal anatomy in primary teeth
(b)
(e)
B
C
D
Figure 12 Details of the code describing the root and canal
morphology in a primary molar. A: Tooth number and num-
ber of roots. B: Accessory (furcation) canal(s). C: Description
of the mesial root and canal configuration. D: Details of the
distal root and canal configuration.
It is clear that root and canal morphology in the
primary dentition is variable and complex. The new
classification system is more accurate and simpler
compared with the Vertucci system (and its supple-
mentary configurations) that was developed to cate-
gorize canal systems in permanent teeth. The
Vertucci system uses Roman numerals for each ‘type’
International Endodontic Journal, 53, 27–35, 2020 31

Classification of canal anatomy in primary teeth Ahmed et al.
Figure 13 Despite potential confusion between accessory
canals and resorption defects, the close approximation of the
permanent successor and loss of integrity of the root outline
indicate the presence of resorption defects.
Figure 14 A three-rooted mandibular tooth 74 (M, D, DL) –
Radix Entomolaris type 2 (type II: curvature in the coronal
third and straight continuation to the apex).
of root canal configuration (Vertucci et al. 1974,
Gulabivala et al. 2001, 2002, Ng et al. 2001, Sert &
Bayirli 2004). However, it does not take into consid-
eration the number of roots in several tooth types
(such as anterior teeth). In addition, it was not
intended for the primary dentition (Vertucci 1984).
The description of tooth anatomy in the primary
dentition using the Ahmed et al. (2017) system fol-
lows the same format as for permanent teeth. Fig-
ure 1 shows a single-rooted maxillary right primary
central incisor coded as 1511 with a single canal. Fig-
ure 4a shows a single-rooted mandibular left primary
lateral incisor with two canals leaving the pulp
32 International Endodontic Journal, 53, 27–35, 2020
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chamber that merge apically – coded as 1722-1. Fig-
ure 5a shows a double-rooted mandibular right pri-
mary molar coded as 284 M2 D1; the mesial (M) and
distal (D) roots have 2 and 1 canal(s), respectively.
Figure 6a shows a three-rooted maxillary left primary
second molar coded as 365 MB1 DB1 P1 having three
roots in which each of the mesiobuccal (MB), disto-
buccal (DB) and palatal (P) roots have one canal.
Other examples are shown in Figs 4–6 in addition to
clinical cases in Figs 7–10.
Accessory canals
Accessory canals in primary molars can be classified
using an existing system (Ahmed et al. 2018). The
length of the root is divided into thirds: 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 canal ter-
minus (Fig. 11). Each third is identified as a super-
script within parenthesis after the tooth number. For
accessory canals leaving the floor of the pulp cham-
ber, the superscript is written before the root nota-
tion. The configuration of these accessory canals can
be described as for the main root canal configuration.
An apical delta is identified by the letter ‘D’ (Fig. 11).
In some instances, the accessory/chamber canal may
not end in a foramen or be looped (Fig. 11). 1511(A1)
describes a single-rooted maxillary right primary cen-
tral incisor having a single root canal, and a single
accessory canal located in the apical third of the root
(Fig. 11a). 1511(D) describes a single-rooted maxillary
right primary central incisor having a single root
canal and an apical delta (Fig. 11c). 274 M1(A1) D1
describes a double-rooted tooth 74 in which the
mesial root has a single root canal and single acces-
sory canal in the apical third of the root; the distal
root has one single canal (Fig. 11d). 274 (1)M1 D1
describes a double-rooted tooth 74 with the same
canal morphology but with a single furcation canal
(Fig. 11e). 274 (1-0)M1 D1 describes the same tooth
with a furcation canal configuration 1-0 (nonpatent)
(Fig. 11f). Figure 12 shows a detailed description of a
mandibular molar with two furcation canals.
The description of accessory canals using the new
system in the permanent dentition is clear and can be
applied in clinical and experimental settings. How-
ever, in the primary dentition, especially when clini-
cally the permanent successor is close to the roots of
primary teeth, the differentiation of accessory canals
(small canals leaving the root canal that (usually)
communicate with the external surface of the root or
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

(a) (b) (c)
(e)
(g) (h)
Figure 15 Application of the new system to classify primary teeth with fused roots – a sample using micro-CT imaging – Root
fusion types 3 – DB fused to P (Reproduced with permission from Wiley - Ahmed et al. 2016).
furcation) from early physiologic resorption defects is
challenging given that both may overlap and appear
with similar patterns on 2D radiographic images after
root canal filling with a resorbable paste (Fig. 13).
Therefore, the classification of accessory canals in a
clinical setting is advisable only when the primary
tooth is not about to exfoliate or if there are no signs
of extensive root resorption. The application of the
system in experimental settings will be more accurate
since the investigator can differentiate accessory
canals from resorption areas if present.
Tooth anomalies
Similar to the permanent dentition, the abbreviation
of an anomaly (A) is added between brackets before
the tooth number (TN) that is (A)TN (Ahmed & Dum-
mer 2018a,b). For instance, (DE)1 511 describes a
dens evaginatus (DE) in a single-rooted maxillary
right primary central incisor tooth with a single
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
13652591, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13199 by INASP/HINARI - GUATEMALA, Wiley Online Library on [12/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Ahmed et al. Classification of canal anatomy in primary teeth
(d)
(f)
(i)
canal. (DIIII)1511 describes a single-rooted tooth 51
with a Dens Invaginatus type III and single canal.
(RE1)374 M1 D1 DL1 describes a three-rooted tooth
74 [mesial (M), distal (D) and distolingual (DL) –
Radix Entomolaris type 1 (RE)]; each root has a single
root canal (Fig. 14).1 ST1/1511 describes a single-
rooted tooth 51 fused to a single-rooted Supernumer-
ary Tooth (ST) – both with single canals.
If the anomaly is related to one or more roots in
double- or multirooted teeth, respectively, then the
anomaly should be written after the abbreviation of
the affected root. Thus, 275 M1 D1(EP) describes a
double-rooted tooth 75 having an enamel pearl (EP)
related to the D root – both mesial and distal roots
having a single canal. Root fusion (RF) in three-
rooted teeth is an exception in which all types should
be written before the tooth number (TN).
(RF3)365 MB3 DB2-1-2 P2-1 describes a three-rooted
tooth 65 having fused DB (canal configuration 2-1-2)
International Endodontic Journal, 53, 27–35, 2020 33

Classification of canal anatomy in primary teeth Ahmed et al.
[Root fusion (RF) type 3 (Ahmed & Dummer 2018a,
b)] and P (canal configuration 2-1) roots whilst the
MB (canal configuration 3) is not fused (Ahmed &
Dummer 2018a,b) (Fig. 15).
Conclusions
• The morphology of root canals, accessory canals
and tooth anomalies in the primary dentition can
be classified using the system of Ahmed et al.
(2017), 2018 and Ahmed & Dummer 2018b, in a
similar way to the permanent dentition.
• For simplicity, the stage of physiologic root resorp-
tion is not considered when classifying primary
teeth using the new system.
• Physiologic root resorption and the presence of a
permanent successor close to the roots of primary
teeth are challenges for accurate interpretation of
accessory canals and several anomalies especially
in clinical settings.
Conflict of Interest
The authors have stated explicitly that there are no
conflicts of interest in connection with this article.
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