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Evaluation of periapical radiographs in the recognition of C-shaped mandibular second molars

T. Lambrianidis1, K. Lyroudia1, O. Pandelidou1 & A. Nicolaou2


1 Department of Endodontology, Dental School, Aristotelian University; and 2Department of Business Administration, University of Macedonia, Thessaloniki, Greece

Abstract
Lambrianidis T, Lyroudia K, Pandelidou O, Nicolaou A.
Evaluation of periapical radiographs in the recognition of C-shaped mandibular second molars. International Endodontic Journal, 34, 458462, 2001.

Aim The purpose of this study was to evaluate in a blind trial the efcacy of radiographs to recognize C-shaped mandibular second molars and to determine the incidence of this entity amongst second mandibular molars treated in the Department of Endodontology at the School of Dentistry of the University of Thessaloniki during a seven-year period (1989 95). Methodology A total of 480 clinical records of root treated mandibular second molars were reviewed. The preoperative, working length, and nal radiograph of each tooth alone and in combination were examined in groups as follows: group 1 (preoperative radiographs only), group 2 (working length radiographs), group 3 (nal radiographs), group 4 (preoperative and working length radiographs), group 5 (preoperative and nal radiographs) and group 6 (all three radiographs). The

efcacy of each combination to identify the C-shaped cases was evaluated based on the interpretation of three experienced dentists looking simultaneously at each case. Films were examined on a viewer using a magnifying glass and allowing a two-week interval between groups. Results were compared with the clinical diagnoses stated on the patients records (group 7). Results The review of clinical records revealed that 4.58% of second molars had C-shaped canals. Radiographic interpretation was overall more effective when based on lm combinations (groups 4, 5, and 6) than on single radiographs. Amongst the latter, working length radiographs were more helpful than the preoperative and nal ones. Preoperative radiographs were the least effective in diagnosing C-shaped cases. Conclusions Simultaneous interpretation of preoperative, working length and post-treatment radiographs is important when attempting to diagnose a C-shaped conguration. Keywords: C-shaped mandibular molars, diagnosis, radiographs.
Received 6 April 2000; accepted 11 October 2000

Introduction
Mandibular second molars usually have two roots, one mesial and one distal, with three root canals. However, two canals in the distal root and other variations in canal morphology have been described (Pineda & Kuttler 1972, Vertucci 1984, Quackenbush 1986, Jacobsen et al. 1994). One of the variations is the C-shaped mandibular second molar (Cooke & Cox 1979). The reported incidence of this conguration ranges from 2.7% (Weine et al. 1988) to 8% (Cooke & Cox 1979). In another study on

Correspondence: Lambrianidis Theodoros, 17, Ag. Soas Str, 54623 Thessaloniki, Greece (fax: +031 275071; e-mail: lyroudia@zeus.csd.auth.gr).

the prevalence of C-shaped roots, root canal orices and root canals in mandibular second molars of a Chinese population, it was reported that approximately onethird had C-shaped roots. Less than half of these had true C-shaped canals, and only one-fth of the teeth studied (581 extracted mandibular second molars) had Cshaped canal orices (Yang et al. 1988). The root conguration of molars having this canal shape may be represented by fusion of either the facial or lingual aspects of the mesial and distal roots. Radiographic detection of root fusion is difcult since the criteria for its recognition are ambiguous. Thus, recognition of C-shaped canals is improbable until access to the pulp chamber has been achieved. Early detection, however, is imperative since successful debridement, instrumentation,

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obturation, and even prosthetic restoration depend on a thorough knowledge of the root canal morphology. Radiographic recognition may be of particular importance for prosthodontists, especially in cases where a cast post involving the root canal is planned. The purpose of this study was two-fold: 1 To evaluate in a blind trial the efcacy of preoperative radiographs, working length radiographs (taken with small instruments within the canals), and nal radiographs, alone or in combinations, to recognize C-shaped canals in mandibular molars. 2 To determine the incidence of clinically recognized C-shaped canal systems amongst mandibular second molars treated in the undergraduate clinic of the Department of Endodontology at the School of Dentistry, University of Thessaloniki during the period 1989 95.

Materials and methods


Clinical records of all mandibular second molars treated in the undergraduate clinic of the Department of Endodontology at the School of Dentistry, University of Thessaloniki, during the period 1989 95 were reviewed. Each record, in addition to data regarding medical and dental history, and the treatment protocol, contained a preoperative radiograph, a working length radiograph with small instruments within the canal, and a nal postoperative radiograph. After discarding incomplete records or records with unreadable radiographs, 480 records of mandibular second molars, numbered arbitrarily from 1 to 480, were reviewed. The same numbers were given to the three radiographs of each tooth, i.e. the preoperative, the working length, and the nal. All of them had been taken with the bisecting angle technique. Evaluation in a blind trial of the usefulness of the radiographs, alone or in combinations, to recognize C-shaped canal conguration followed. Table 1 summarizes the study groups as dened by the diagnostic method. Interpretation of all the lms was made simultaneously by three experienced endodontists (faculty members of the department). All radiographs were examined on a

viewer with a magnifying glass. A two-week period was allowed between the evaluation of each group. The molars were classied as C-shaped or non-C-shaped by consent, based on the following criteria: Conical shape of the roots with poorly distinguished root canals Poorly distinguished pulp chamber oor Exiting of instruments/ lling materials in the furcation area or crossing of the furcation from the mesial /distal direction to the opposite side. Following review of the radiographs, the results were compared with clinical diagnoses stated in the patient records (group 7). The study design was a repeated measurements experiment (Melton et al. 1991). Each tooth was classied in terms of a dichotomous response variable as C-shaped or non-C-shaped (values 1 or 0, respectively) under seven different observational conditions. The statistical analysis aimed at comparing the effectiveness of each radiographic method against that of the clinical method. The rationale of the analysis was that if any two methods were equally effective then the discordant pairs (i.e. teeth that were characterized as C-shaped by one method and non-C-shaped by the clinical diagnosis or vice versa) were expected to occur with equal frequency. Since two groups were compared at a time, the McNemars statistic for dependent proportions was used to test for statistical signicance (Koch et al. 1977).

Results
The review of the patient records revealed 22 clinically diagnosed C-shaped mandibular second molars treated during the seven-year period (4.58%). Table 2 summarizes the number of C-shaped cases identied by each diagnostic method. Tables 3 8 illustrate the classication results of each radiographic method in relation to the clinical diagnosis. Based on the P-value calculated for each table, there is evidence that the proportions of C-shaped teeth detected by radiographic methods 1 and 2 were signicantly lower than the proportion of

Table 1 Experimental groups

Group 1 2 3 4 5 6 7

Diagnostic method Preoperative radiographs only Working length radiographs only Final radiographs only Preoperative and working length radiographs Preoperative and nal radiographs Preoperative, working length, and nal radiographs Clinical evaluation (combination of three radiographs and clinical features)

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Group 1 No10 No21 No34 No84 No155 No163 No202 No289 No350 No400

Group 2

Group 3 No10 No21 No34 No84 No163 No202 No289 No350 No400 No90 No182 No201 No321 No335 No441 No480 No370 No197

Group 4 No10 No21 No34 No84 No163 No202 No350 No400 No182 No201 No208 No335 No441 No480 No160 No370 No180 No60

Group 5

Group 6

Group 7 clinical

Table 2 C-shaped molars diagnosed in

each group by specimen number

No21 No34 No84 No155 No163

No21 No34 No84 No163 No202 No350 No90 No182 No201 No321 No335 No441 No160 No370 No197 No180 No174 No239 No284

No21 No34 No155 No202 No350 No400 No90 No182 No201 No208 No321 No335 No441 No480 No370 No197 No180 No60 No174 No284 20

No21 No34 No84 No155 No163 No202 No350 No400 No90 No182 No201 No208 No321 No335 No441 No480 No160 No370 No180 No174 No284 No432 22

No350 No400 No90 No182 No201 No208 No321 No335 No441 No480 No160

10

16

18

18

19

Table 3 Results of groups 1 and 7 (P = 0.0006)


Clinical diagnosis (group 7) non-C-shaped Group 1 non-C-shaped C-shaped 456 2 C-shaped 14 8

Table 6 Results of groups 4 and 7 (P = 0.28)


Clinical diagnosis (group 7) non-C-shaped Group 4 non-C-shaped C-shaped 456 2 C-shaped 6 16

Table 4 Results of groups 2 and 7 (P = 0.04)


Clinical diagnosis (group 7) non-C-shaped Group 2 non-C-shaped C-shaped 458 0 C-shaped 6 16

Table 7 Results of groups 5 and 7 (P = 0.57)


Clinical diagnosis (group 7) non-C-shaped Group 5 non-C-shaped C-shaped 456 2 C-shaped 5 17

Table 5 Results of groups 3 and 7 (P = 0.34)


Clinical diagnosis (group 7) non-C-shaped Group 3 non-C-shaped C-shaped 455 3 C-shaped 7 15

Table 8 Results of groups 6 and 7 (P = 0.16)


Clinical diagnosis (group 7) non-C-shaped Group 6 non-C-shaped C-shaped 456 2 C-shaped 4 18

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Table 9 Summary of false diagnoses


False positive* False negative**

Group 1 2 14

Group 2 0 6

Group 3 3 7

Group 4 2 6

Group 5 2 5

Group 6 1 3

*False positive denotes any case radiographically diagnosed as a C-shaped molar, which was not conrmed by the clinical diagnosis. **False negative denotes any clinically diagnosed C-shaped case, which has not been recognized using the radiographic method.

clinically diagnosed cases (P < 0.05). There was no signicant difference between the other groups. From Tables 3 8 it is evident that all radiographic combinations failed to recognize some C-shaped cases, whilst they occasionally resulted in the diagnosis of a C-shaped conguration despite a negative clinical diagnosis. Table 9 summarizes the cases of false negative and false positive responses of each radiographic method.

Discussion
Studies on the morphology of the root canal system have demonstrated the complexity in number and distribution of canals in mandibular molars. Differences may be due to dissimilarities of examination methods, classication systems, sample size and ethnic background of tooth sources. For example, in studies where a single radiograph was used it may be possible that extremely calcied canals or superimposed canals were not detected. According to our clinical records of the 480 second mandibular molars treated in the undergraduate clinic of our department, 22 were C-shaped, a percentage of approximately 5%. This is approximately half of that indicated by the clinical records of mandibular second molars treated at Washington University School of Dental Medicine; where 8%, had C, conguration (Cooke & Cox 1979). The percentage found in the present study is also approximately double the 2.7% found in vitro (Weine et al. 1988). The dependence of tooth morphology on ethnic background is probably the explanation of the discrepancy between the ndings of this study and those of Yang et al. (1988), who found an incidence of 13.9% cases amongst Chinese subjects. Clinical recognition of C-shaped canals was based on denite and observable criteria, i.e. the anatomy of the oor of the pulp chamber and the persistence of haemorrhage or pain when separate canal orices were found. Cooke & Cox (1979) asserted that it was impossible to diagnose C-shaped canals on preoperative radiographs. This was partly the case in the present study as group 1 (i.e. interpretation of preoperative radiographs) identied fewer cases than any other method. Indeed, the contribu-

tion of the preoperative and working length radiographs in the diagnosis of C-shaped cases was limited. This, however, does not imply that early radiographic information is of no value. It is interesting to note that all radiographic methods missed a number of C-shaped cases (false negative responses varied from 3 to 14). They were less misleading, however, when they identied a C-shaped molar (false positive responses ranged from 0 to 3). It is well established that great variation exists amongst dentists interpreting radiographs of endodontically treated teeth ( Brynolf 1970, Molven 1974, Nielsen 1979, Smith et al. 1981, Goldman et al. 1972, Reit & Hollender 1983, Lambrianidis 1985, Gelfand et al. 1983). In addition to interobserver variations, an individual examiner can contradict his own ndings at re-examination ( Brynolf 1970, Reit & Hollender 1983). To minimize the effect of subjectivity, the opinion of many observers (Goldman et al. 1972) and the employment of several radiographs of the same tooth have been proposed (Brynolf 1967). In a previous study, nine individual observers interpreting radiographs of 90 endodontically treated teeth had complete agreement in 38% cases for the periapical condition and in 41% for the quality of the seal (Lambrianidis 1985). When the same radiographs were examined by two observers simultaneously, the corresponding gures rose to 65% and 57%. Thus, in this study, lm interpretations were made by the three dentists viewing each case simultaneously. The criteria used for the radiographic recognition of C-shaped mandibular second molars, although based on their morphology, may be misleading as the anatomic complexities of all teeth is well established in the literature and roots can have great variations in size, shape, and orientation. Presence of instruments or lling materials in the furcation area may also be seen in cases of furcation perforation. However, this nding, in combination with the poorly distinguished oor of the pulp chamber, can lead to radiographic recognition of a C-shaped conguration. Differential diagnosis of C-shaped molars from furcation perforation, on the basis of the radiographs of the present study, can only be aided in cases of interpretation of more than one radiographs, as in groups 4, 5, and 6.

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Conclusion
Only a small percentage of C-shaped mandibular second molars were recognized on the preoperative radiograph. Clinical diagnosis can only be established following access to the chamber. Simultaneous interpretation of the preoperative, tooth length, and post-treatment X-rays will help diagnosis.

References
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