|Year : 2015 | Volume
| Issue : 2 | Page : 99-106
Root and root canal morphology of Saudi Arabian permanent dentition
Ibrahim Ali Ahmad
Department of Restorative Dentistry, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia
|Date of Web Publication||20-Apr-2015|
Ibrahim Ali Ahmad
Department of Restorative Dentistry, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, P.O Box 84891, Riyadh 11681
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
The aims of this paper were to review the studies that investigated the root and root canal morphology of permanent dentition in the Saudi Arabian population and to compare their results with the findings of international morphological studies conducted on other populations. An electronic search using the PubMed and Scopus databases was conducted using combination of the following keywords: "root canal morphology", "root morphology", "dental anomalies", and "Saudi Arabian population". In addition, all issues of the Saudi Dental Journal (since 1989) and Saudi Endodontic Journal (since 2011) were manually searched for relevant articles. Then, the reference lists of the articles were screened to identify further eligible publications. A total of 23 studies met the inclusion criteria and were subjected to data extraction and analysis. Variations from the normal root and canal morphology may occur in all populations including the Saudi Arabian population. Therefore, the clinicians must always take these variations in consideration during root canal treatment to ensure a successful treatment outcome.
Keywords: Canal configuration, morphology, permanent dentition, root canal system, Saudi Arabia
|How to cite this article:|
Ahmad IA. Root and root canal morphology of Saudi Arabian permanent dentition. Saudi Endod J 2015;5:99-106
| Introduction|| |
The major objectives of root canal therapy are to perform adequate biomechanical preparation and to fill the entire root canal system three-dimensionally. Inability to locate, prepare, or ﬁll all root canals may lead to posttreatment disease of treated teeth. [1,2] Therefore, clinicians should have a thorough knowledge of the common root and root canal morphology and its possible variations to improve the predictability of root canal therapy.
Since the beginning of the 20 th century, the external and internal anatomy of different teeth groups has been investigated using a number of in vivo and in vitro techniques. The in vivo techniques include clinical evaluation during root canal treatment, retrospective evaluation of patients' records, radiographic examination using conventional, and advanced radiographic techniques such as cone beam computed tomography (CBCT). The in vitro techniques include root sectioning, canal staining and tooth clearing, microscopic examination, and radiographic examination using conventional radiographs and three-dimensional techniques such as micro-computed tomography (m-CT). [3,4]
The findings of morphological studies may vary according to study methodology, study population, and age and gender of the study sample.  The majority of morphological studies on permanent dentition were conducted in Western countries and East Asia and their results may not be applicable to Saudi Arabian population. Therefore, the aims of the present paper were to review the studies that investigated the root and root canal morphology of permanent dentition in Saudi Arabian population and compare their results with the findings of international morphological studies conducted on other populations.
| Literature Review|| |
The PubMed (http://www.ncbi.nlm.nih.gov/pubmed) and Scopus (http://www.scopus.com) databases (last accessed August 11 th , 2014) were searched for relevant articles using combination of the following search terms: "root canal morphology", "root morphology", "dental anomalies", and "Saudi Arabian population". After removal of duplicate articles, the title/abstract of the remaining articles were screened for their relevance and potential articles were retrieved in full-text. In addition, all issues of the Saudi Dental Journal (since 1989) and Saudi Endodontic Journal (since 2011) were manually searched for relevant articles. Finally, the references list of each article was checked for further eligible articles.
Studies that reported root and/or root canal morphology of permanent teeth in Saudi Arabian population and published in peer-reviewed journals were included in the current review.
A total of 23 studies were identified: 10 clinical studies, [5, 6, 7, 8, 9, 10, 11, 12, 13, 14] 3 laboratory studies, [15, 16, 17] 1 clinical/laboratory study,  and 9 case reports. [19, 20, 21, 22, 23, 24, 25, 26, 27] From each of the clinical and laboratory studies [Table 1], the following information was extracted: (i) the author(s); (ii) the study sample (tooth type and number); (iii) the method used to study tooth morphology; and (iv) key anatomical features (number of roots, number of root canals, and their configurations). For each clinical case report [Table 2], the following information was recorded: (i) the author(s); (ii) the age and gender of the patient; (iii) the treated tooth; and (iv) the important anatomical features of the treated tooth.
|Table 1: Summary of clinical and laboratory morphological studies of number of roots, root canals, and canals' configuration conducted on Saudi Arabian population |
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|Table 2: Summary of case reports showing morphological variations in permanent teeth of Saudi Arabian population |
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Next, the morphological features reported in the clinical and laboratory studies were compared with their counterparts in international studies [Table 3] and [Table 4]. For this purpose, all studies that reported a certain morphological feature (i.e., maxillary premolars with three roots) in Saudi Arabian population were grouped together. Then, the weighted average of the given feature was calculated by dividing the number of samples that had that feature in the identified studies by the total number of samples in these studies. The weighted averages of the corresponding morphological features in the international studies were calculated in a same manner from the data presented in a number of classical morphological studies. [28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49] For some morphological features, comprehensive literature reviews were identified [3, 50, 51] and the weighted averages were calculated from the studies cited in these articles.
|Table 3: Comparison of selected anatomical features of permanent anterior teeth and premolars in Saudi and non-Saudi populations |
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|Table 4: Comparison of selected anatomical features of permanent molars in Saudi and non-Saudi populations |
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Root and canal morphology of anterior teeth
The morphology of anterior teeth was evaluated by one laboratory study  and three case reports. [20, 21, 24] In 2012, Al-Fouzan et al.,  investigated the internal morphology of 80 mandibular incisors using canal staining and clearing technique and found that the majority (70%) had one canal while 30% had two canals. All of the two canalled-teeth had type III (1-2-1) canal configuration. Al-Nazhan (1991)  reported a maxillary central incisor with two canals, while two clinical cases reported two-rooted mandibular canine. [21,24]
Root and canal morphology of premolars
The root morphology of maxillary premolars was assessed by three studies. [13, 15, 16] Atieh (2008)  found that the majority (80.9%) of maxillary first premolars had two roots, while one and three roots were found in 17.9% and 1.2%, respectively. He also found that 37.4% of multirooted first premolars had root fusion. Recently, Elkady and Allouba (2013)  studied the root morphology of maxillary premolars using CBCT. They found that 28.3% of maxillary first premolars had one root and 71.7% had two roots, while 76.4% of maxillary second premolars showed one root and 23.6% showed two roots. An important anatomical variation in maxillary premolars is the presence of three roots. This feature was reported in 0-11.7% of first premolars [13, 15, 16] and in 0-5% of second premolars [13,16] in Saudi Arabian population. Furthermore, two clinical cases of maxillary second premolars with this anatomical variation were reported. [19,25]
The internal morphology of maxillary premolars was investigated by three studies. [12, 13, 15] The majority of first (89.9-95%) and second (59.4-63.7%) premolars had two root canals. One canal was detected in 3.7-8.9% of first premolars and 36.3-39.7% of second premolars, while three canals were evident in 0-2.4% and 0.9% of first and second premolars, respectively. Al-Abdulwahhab et al., (2010)  described the clinical retreatment of a three-canalled maxillary first premolar with two buccal canals that joined in the apical third and one palatal canal.
The mandibular premolars may show variations in the number of roots and/or root canals. Although no clinical or laboratory study on mandibular premolars was identified in the Saudi Arabian population, two clinical cases of two-rooted mandibular second premolars with three  and four  root canals were reported.
Root and canal morphology of molars
The internal morphology of the mesiobuccal root (MBR) in maxillary first molars was evaluated by two studies. [11,14] Al-Nazhan (2005)  found that the majority (76.7%) of the MBRs had one canal, while 23.3% had two canals. On the other hand, Al-Fouzan et al., (2013)  found one and two canals in 48.7% and 51.3% of their sample, respectively. In both studies, the most common canal configurations in two-canalled MBRs were Vertucci's types II (2-1) and IV (2-2). Al-Fouzan et al., (2013)  evaluated the internal morphology of MBR in maxillary second molars and found that 80.2% had one canal and 19.8% had two canals. About two-thirds (13.6%) of the two-canalled root canal systems ended in a common apical foramen and the rest (6.2%) had two separate foramina. The maxillary second molars may also show variations in the number of their roots. Recently, Alenazy and Ahmad (2015)  reported a clinical case of four-rooted second molar with four root canals.
The root and canal morphology of the mandibular first molars was evaluated by one clinical study that included 251 teeth.  The results showed that 94% had two roots and 6% had three roots. About 42% of the study sample had three canals and 58% had four canals. The additional fourth canal was always present in the distal root (s). Younes et al., (1990)  compared the incidence of three-rooted mandibular first molars in the Saudi Arabian and Egyptian populations. The authors examined teeth extracted from Saudi Arabian and Egyptian patients and found an incidence of 2.5% and 0.8%, respectively. The authors also evaluated radiographs of randomly selected patients and found that 2.1% of Saudi Arabian and 1.0% of Egyptian patients had three roots.
Al-Fouzan (2002)  investigated the incidence of C-shaped canals in 251 root canal-treated mandibular second molars. C-shaped canals were evident in 10.6% of these molars and the majority (50%) of these canals were classified as type III (C-shaped orifice that divided into two or more canals), while 31.3% had type I (continuous C-shaped throughout the canal) and 18.7% had type II (semicolon-shaped orifice with a main C-shaped canal separated by dentine from a mesial distinct canal). [Figure 1] illustrates some of the anatomical variations that were reported in the Saudi Arabian population.
|Figure 1: Examples of anatomical variations reported in the Saudi Arabian population (a) Maxillary right central incisor with two canals (Reproduced with permission from Al-Nazhan S. Two root canals in a maxillary central incisor with enamel hypoplasia. J Endod 1991;17:469-71). (b) Mandibular central incisor with two canals (Reproduced with permission from Al-Fouzan KS, AlManee A, Jan J, Al-Rejaie M. Incidence of two canals in extracted mandibular incisors teeth of Saudi Arabian samples. Saudi Endod J 2012;2:65-9). (c) Mandibular right canine with two roots (Reproduced with permission from Rahmatulla M, Wyne AH. Bifid roots in a mandibular canine: report of an unusual case. Saudi Dent J 1993;5:77-8). (d) and (e) Mandibular left second premolar with two roots and four canals (Reproduced with permission from Al-Fouzan KS. The microscopic diagnosis and treatment of a mandibular second premolar with four canals. Int Endod J 2001;34:406-10). (f) C-shaped mandibular left second molar (Reproduced with permission from Al-Fouzan KS. C-shaped root canals in mandibular second molars in a Saudi Arabian population. Int Endod J 2002;35:499-504). (g) Maxillary left second molar with four roots (Reproduced with permission from Alenazy MS, Ahmad IA. Double palatal roots in maxillary second molars: A case report and literature review. Saudi Endod J 2015;5:56-60).|
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The permanent dentition may be affected by a number of development anomalies including dens invaginatus, dens evaginatus, developmental grooves, and taurodontism. Teeth with these anomalies usually have abnormal root and/or canal morphology and require careful diagnosis and treatment planning. Three studies [5, 7, 8] investigated the incidence of taurodontism in the Saudi Arabian population clinically and radiographically. The incidence ranged from 8.5% to 11.2% and it was not affected by patient's gender. In addition, maxillary molars were more commonly affected than mandibular molars. Saini et al.,(1990)  studied periapical radiographs of 3,960 maxillary incisors in 990 Saudi Arabian patients and found that 29 (0.7%) of them had dens invaginatus. The lateral incisors were more commonly affected than the central incisors (75.9% and 24.1%, respectively).
Factors affecting root and canal morphology
None of the clinical and laboratory studies evaluated the effect of age on tooth anatomy, while three studies [9, 11, 12] evaluated the effect of gender on the number of root canals. Two studies [9,11] reported that gender did not affect the number of canals. Al-Nazhan et al.,(2012)  studied the effect of gender on the number of canals in maxillary premolars and found that while males had significantly more canals in second premolars, no gender differences were reported for first premolars. Elkady and Allouba (2013)  studied the effect of tooth location on the morphology of maxillary premolars by comparing the bilateral symmetry of the number of roots and types of canal configurations. They found that among patients with bilateral first premolars, 88.5% had similar number of roots and 77% had similar types of canal configurations. For patients with bilateral second premolars, 84% and 76% had the same roots number and canal configurations, respectively. In clinical case reports, the anatomical variations were reported in patients with different ages without apparent gender predilection [Table 2]. Further studies using larger samples are needed to explore the effect of age, gender, and tooth position on the internal and external morphology of different teeth groups.
Comparison with international studies
Tables 3 and 4 show comparison of some anatomical features reported in the Saudi Arabian population with previously published international studies. Although the findings of the studies in the Saudi Arabian population were generally comparable with their international counterparts, some differences were evident. These differences may be attributed to variations in the number of study sample, used methodology (clinical versus laboratory), or may reflect real differences between the studied populations. For example, the Saudi Arabian population had a low (2.1%) incidence of three-rooted mandibular first molars. [9,18] According to de Pablo et al., (2010)  this anatomic feature is directly related to ethnicity of the studied population and is more commonly found in the Mongoloid, Native American, Eskimo, and Chinese populations. Another example is the presence of C-shaped canals in mandibular second molars which is known to be more common in Asians as compared to other populations including the Saudi Arabian population. 
| Discussion|| |
The aims of this paper were to review the available literature on the internal and external anatomy of permanent teeth in Saudi Arabian population and to compare it with international studies that investigated other populations. This will help to draw a "road map" of the common morphology of different teeth groups in Saudi Arabian population to guide the dental practitioners while performing root canal treatment. Nevertheless, the clinicians should always remember that variations in tooth morphology may occur making the root canal treatment more challenging. In such cases, clinicians should utilize his/her knowledge and the available tools to locate and treat the whole root canal system to improve treatment outcome. There are several clinical guidelines and tools that may be used before or during root canal treatment to locate and negotiate root canals including: [1, 2, 52]
There are some limitations in the studies that were included in the current review: small sample size and collection of the sample from one area. Increasing the study sample and collecting it from different areas and types of practice can result in more consistent and reliable data, leading to a clear conclusion about the common morphological features as well as their variations. Furthermore, the use of recent technological advances in the field such as CBCT and m-CT will help in exploring the root and canal morphology of the various teeth in this population.
- Careful interpretation of conventional radiographs taken at different horizontal angulations. Advanced radiographic techniques such as CBCT can be also used to evaluate cases with complex root canal system
- Proper design of access cavity to visualize the entire pulp chamber floor
- Use of magnifying tools such as eye loupes and dental operating microscope to enhance the vision in the operating field
- Careful inspection of the pulpal floor to locate canal orifices. This may include exploring the floor with an endodontic explorer and troughing it with burs or ultrasonic tips. Other useful aids in locating canal orifices are staining the pulpal floor with a dye, performing the champagne test with sodium hypochlorite, the red line test (visualizing bleeding points), the white line test (detection of debris in orifices or developmental grooves between them), and applying the laws of canals' symmetry
- Allocation of sufficient treatment time for each case and referral of complicated cases for more experienced operators.
| Conclusions|| |
The root and root canal morphology of Saudi Arabian population was, in general, comparable to that of other populations. The dental practitioners should have a sound knowledge of common anatomy of permanent teeth and its possible variations and use the available tools to locate and treat the whole root canal system to ensure a successful treatment outcome.
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[Table 1], [Table 2], [Table 3], [Table 4]
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