Current Endodontic Treatment

Current Endodontic Treatment
Contents
Learning Objectives
1Current Endodontic Treatment
Introduction
Use of Tapered, Rotary Instruments - Initiation of Changes in File Design
Need for Early Enlargement of the Orifce Area
The "Zip" and the "Elbow" and Their Signifcance in Curved Canal Preparation
Introduction of Nickel-Titanium Instruments
Other Excellent Files for Use in Curved Canals
No-No's When Using NiTi Files
Step-By-Step Use of .04 Files in Curved Canals
Conclusion
2Recent Studies of Canal Confguration
Introduction
Terminology for Canal Confguration Studies
Early Studies on the MBR of Maxillary Molars
Further Studies of the MBR
Retreatment of Failing MBRs
Names of the Canals in Maxillary Molars
Studies of the Maxillary Second Molar
Studies of the Mandibular Bicuspids
Studies of the Mandibular First Molar
Studies of the Mandibular Second Molar -A Tooth With Multiple Variations
Studies of the Maxillary Bicuspids
Studies of the Mandibular Incisors
Studies of Teeth With Five or More Canals
Role of Ethnicity in Confguration Studies
Efect of Preparation Methods on Confguration Studies
Future for Canal Confguration Studies
3Endodontics of the Future
Newer Types of Canal Filling Materials
Use of Single-Appointment Treatment
Conclusions
References
Legends
Post Test
1. Current Endodontic Treatment
Introduction
Current treatment procedures in endodontic therapy have undergone almost a complete changeover in
the last ten years. Teeth that were formerly considered to be hopeless now may be saved on a very high
percentage basis using procedures and instruments recently introduced. The net result is that teeth that
were extracted not long ago now have an outstanding chance for being retained. The following pages
will deal with many of these innovations and illustrate how they may be used for best results. Even so,
the author wishes to inform the reader that some of the views listed here are not universally accepted by
endodontic experts and there are many outstanding textbooks and publications which can be consulted
for excellent discussions of alternative methods of therapy. The areas of discussion will be accompanied
by appropriate case radiographs, some with extensive follow-up views (Figs. 1 and 2), to illustrate the
methods of treatment and healing.
Figure 1
Figure 2 - 27 Years Post- Op
The subjects to be discussed will be the following: (1) use of tapered, rotary instruments, (2) recent
studies of canal confguration, and (3) areas of future interest.
Use of Tapered, Rotary Instruments - Initiation of Changes in
File Design
Prior to 1958, there were many varying types of intracanal instruments for use in endodontics. Although
all were designed with the intent to clean and widen the canal, diferences in instrument length, width,
degree of taper, and rake angle were constant. Then, John Ingle decided to introduce a standardized
system for the use of canal preparation, with a clear demarcation in the relationship of the instruments
(1)
.
Ingle then was Departmental Chairman at Washington University Dental School and later became Dean
at University of Southern California School of Dentistry. His contributions vaulted endodontics into a new
era where canal preparation became easier to perform and results were more predictable.
There were many difering fle shapes available at that time. Long-handled instruments, useful only on
maxillary anterior teeth (where much of the endodontic treatment of that time was performed), were
grasped by the entire hand and conducive for use with reaming action. There were numerous fle
systems available with short handles, for use with the fngers, but there were variations in length, width,
taper, and length of futes among them. The instruments were designated #1 through #12, but, for
instance, a #3 Union Broach might be totally diferent than a #3 Kerr fle in fute length, width, and/or
taper. Even fles by the same manufacturer could be diferent from year to year. Ingles system changed
this. He standardized the fles to have similar total lengths, length of futes, degree of taper, and widths,
and also assigned a lettering/numbering system to use for identifcation of these sites on the new
instruments. The International Standardization Organization (ISO) had control over fle dimensions, but
immediately recognized the improvement ofered and accepted Ingles principles.
Ingle standardized the total length of the fles to 21 mm, 25 mm, or 31 mm in length, eliminating the
long-handled instruments. Of these lengths, 16 mm of the apical portion was futed to provide for dentin
removal. The tip area of the fle where the frst rake-angle was formed was called diameter 1, or D
1
and
the futes end site (16 mm up the shaft) was called diameter 2, or D
2
. At that time, fute length
commonly ranged from 15 mm to 25 mm. He fxed the width of the fles to widen from the frst rake-
angle (at D
1
) to the rake-angle at D2 at a rate of approximately 1 mm of length to enlarge the fle width
by .02 mm.
Several alterations were made within the next few years. Some manufacturers had their fute level
ground between a length of as little as 15 mm to as long as 19 mm. The D
1
and D
2
indicators were
changed, D
1
(the frst rake-angle) to D
0
. The D
2
subscript was changed to indicate the exact length of the
futes, which usually was 16 mm, but could be anywhere from 15 mm (referred to as D
15
) to 19 mm
(referred to as D
19
) up the shaft (Fig.3). In all cases, the fute width still increased by .02 mm of width per
one mm of lengthstill a .02 taper.
Figure 3
These changes were welcomed by virtually all dentists involved in endodontic therapy, even those who
treated a minimal number of teeth. This innovation was especially valuable when reordering fles
because fles purchased at varying times would still ft into the standardized system. Previously, older
fles, that were still usable, had to be discarded to maintain tip and taper degree relationships.
Need for Early Enlargement of the Orifce Area
The standardized use of .02 for taper degree opened up an entirely new horizon for endodontic
instruments. It had been assumed for many years that most teeth treated endodontically were widest at
the orifce and then tapered down to a much narrower width near the apex. This might be true in teeth
that required treatment due to trauma or from incorrect dentin removal during restorative procedures.
However, Leeb
(2)
wrote an eye-opening paper indicating the error of such views (Fig. 4). He showed that
teeth that were heavily restored or had extensive decay (which included most teeth requiring treatment)
had very narrow orifces that widened to a larger diameter in midroot and then narrowed again toward
the apex.
Figure 4. Schematic representation of Leebs study. Dentists have an erroneous idea of the shape of
canals in heavily restored teeth (center, mesial canal enlarged at right). It has been assumed that the
canal is widest near the orifce and then tapers down to the apex. In truth (left), the canal is narrow at the
orifce due to the deposition of reparative dentin in response to the restoration. Away from the orifce, the
canal widens in midroot and then tapers down to the apex. (From: Weine FS: Endodontic Therapy, 6th
ed. Elsevier Publishing, with permission)
Since all endodontic fles had some degree of taper, this fnding meant that in many teeth the small
orifce area could cause premature binding of the instruments and result in much less apical
enlargement than was anticipated. Whereas many clinicians believed that the narrowness of the canal
preventing the penetration of the entire canal was from the apical area, it was obvious that the coronal
site was largely responsible. This transferred the need for early enlargement of the canal in the orifce
area in order to gain more efective cleaning towards the apex.
With this in mind, changes in the fles had to be made so that the orifce area could be widened quickly
and safely without any damage to the apical portion. This was accomplished by the introduction of rotary
engine driven fles of tapers greater than the standard .02 taper developed by Ingle. The areas at the
upper portion of futes were made to be wider so that the orifce could be enlarged early in the
preparation. At this time, the apical portion (minimally enlarged) merely provided a pathway for directing
the instrument but did little, if any, enlargement.
The Zip and the Elbow and Their Signifcance in Curved
Canal Preparation
For many years, it was assumed that canal preparation in anterior teeth and posterior teeth were very
similar. Of course, posterior teeth almost always had more canals, many of which were quite curved as
compared to the straighter anterior teeth, but no severe alteration was drawn in the facets of treatment.
Then, in a landmark study by Weine, Kelly and Lio in 1975
(3)
, the difculties encountered in treating teeth
of greater curvature were elucidated and new words were added to the endodontic glossary of terms.
In their analysis, Weine, et al. determined that in curved canals the fles did not cut dentin equally in all
directions, but instead took more of from the inside portion of the curve than the outer side except
nearer to the apex where the opposite occurred. This meant that the desirable canal long-section view of
a gradual taper from the orifce to the apex was not obtainable in curved canals by using the techniques
then in vogue. Because of the fles working to the inner portion from the orifce and then to the outer
portion near the apex, the tapered funnel really was never present when a sharply curved canal was
prepared, but the shape in long-section was really more of an hourglass. From the orifce it was wide
and tapered to the center of the curve, but then widened again (Fig. 5).
Figure 5
The authors of the study attached names to the two most signifcant changes in canal shape. The
narrowest area was called the elbow, which is a plumbing term at the turning site of plumbing
equipment which may fll with debris and cause blockage in the system. The area at the very apex of the
preparation was called the zip, because this site was wider than expected and ragged. The elbow
generally occurred in the middle of the curve in a canal with an apical curvature of 30 degrees or greater
and usually is noted from 2 to 5 mm from the tip of the preparation. Zipping occurs from that point to
the apex (Fig.5). The article went on to suggest that modifcation of the futes should be performed and
use of fles of greater fexibility be used to lessen the zipping problem.
Many endodontists refused to accept these fndings and believed that their preparation methods were
useable in any canal confguration. However, within a few years most endodontists were compelled to
agree with the study and began to make changes in their preparation techniques, which also included
their choice of fles. Newer fles were evaluated which were more fexible than those in common use and
several styles were found to be useable and able to minimize the elbow and zipping. However, most
dentists felt that fute removal was a tedious and, perhaps, unnecessary procedure. But, the best was
yet to come!
Introduction of Nickel-Titanium Instruments
Another important innovation pertained to the metal used in the instruments. Originally made from
carbon steel blanks, at this time most endodontic fles were being made from stainless-steel blanks and
thus were less susceptible to corrosion. Stainless-steel was at least mildly resistant to breakage and
could be cleaned and resterilized after use. Then, a newer metal was introduced into endodontic
treatment after previous use in other areas of grinding. This metal was Nickel-Titanium, which had been
used in industry since 1960 and was at frst referred to as Nitinolni for nickel, ti for titanium and ol
for the Naval Ordinance Laboratory in Maryland, where it was frst used. The initial dental use was
orthodontic wiring and shortened to be called NiTi. Endodontic fles of this material have increased
fexibility due to a low modulus of elasticity and therefore retain its general shape even when strained
within the canal. Too much strain can still be responsible for breakage, but requires a much higher level
of stress than does carbon or stainless-steel. While the Ni-Ti instruments are more expensive than
stainless-steel, they retain their shape much longer, a phenomenon known as pseudoelasticity
(4)
. The
metal has diferent properties when stressed, but returns to the original shape when the stress is
relieved. There is a limit to the amount of stress that NiTi fles can resist and this is an important
consideration when the fle is used in conjunction with mechanical handpieces, as compared to use by
hand
(5)
.
The metal may go through any of three transformations, to detwinned martensite, to austenite, or to
twinned martinsite via heating and cooling
(6)
. It appears that the phase of transformation between
austenite and martinsite is where the greatest elasticity occurs and thus is the best time to work under
some stress.
To obtain even more advantage to these newer fle systems, they were modifed to be used in
conjunction with mechanical handpieces. Mechanical handpieces had been introduced in endodontic
treatment many years earlier for use with carbon steel as well as stainless-steel. When used in straight
canals, which were by far the minority found in the teeth being treated, they seemed to work quite well.
However, in the more curved canals many fles fractured within the tooth and posed many difculties in
attempts to retrieve them. When used in conjunction with the NiTi instruments, this was much less of a
problem. Thus a very useful series of instruments that could complete routine canal preparation in much
less time than hand fling and allow for considerable increase in orifce size to promote more efective
canal cleaning and flling were then available.
Immediately after their introduction, the NiTi systems became quite popular. In fact, they probably were
used more quickly than any of the endodontic systems for the past 50 years. For many manufacers
introduced varying systems, combining the use of NiTi instruments and .04 tapers. Some of the systems
still have wide usage (Fig. 6a and b) whereas others came into the market and in a short period of time
were withdrawn (Fig. 6c).
Figure 6A

Figure 6B
Figure 6C
The combination of NiTi fles with mechanical handpieces as rotary instruments delivering an
extraordinary type of fexibility alone was greatly responsible for diminishing zipping. However, fle
separation did occur if these new instruments were stressed to a great level and this caused a serious
problem. Cantatore, an excellent endodontist practicing in Rome, with great skill in the removal of
separated instruments in the apical third of the canal (where a huge majority of separations will occur),
has stated that even with much time, efort, experience and auxiliary instruments, only approximately
one-third of the fles separated at this level could be retrieved
(7)
.
With more dependable instruments and the knowledge that the mechanical handpieces could give a
better shape to the canal preparation, another innovation was introduced. This was the making of some
of the fles to double the width that Ingle had promoted and with even greater than doubleto triple or
quadruple them (Fig. 7). This meant that the orifce area could be widened more quickly and the areas
toward the apex also could be made wider. Personally, I am not an advocate of those fles which are
much wider, such as the .08 tapers or larger, and I rarely even use the .06 instrument. I fear that these
wider fles have a greater chance of getting stressed in narrow, curved canals and thus lead to possible
separation. I much prefer using only the .04 tapered instruments, even though they may require some
additional time for completion of the preparation, but this is more than balanced by the greater safety
aforded to the narrower fles. In fact, my preference is to use only the .04 tapered instruments, and then
never even use them past the elbow, which virtually assures very low chance for separation, and
completing the apical portion (past the elbow) with hand fles, usually the most fexible obtainable. This
aspect of treatment has been followed by me in virtually every complex case that I have had in the last
10 years without any separation whatsoever.
Figure 7
Other Excellent Files for Use in Curved Canals
Several fles were developed in order to gain safely the wideness of the canal orifce, as per Leebs
instructions. The fle that I fnd to be most advantageous for this important step is the SX fle (Fig. 8).
Instead of the fle having a taper of .04 or larger it has a taper that is quite wide at D
16
, but then
decreases much more than the routine fles to the apex and is a shorter fle19 mm in length. When
placed into the canal orifce, only the set of futes highest on the shaft will cut, with the tip portion of the
fle merely indicating the direction of the canal. To be extra-sure that the fle will not separate nor cut into
the sides of the canal, I often cut the apical 2 mm of the fle prior to use. The resultant instrument is
shorter and, thus, easier to insert and the safety is increased.
Figure 8
The importance of the use of SX fles, particularly in molar teeth, is demonstrated in Figure 9. It shows
how the instrument may be used to place pressure on the outer surfaces of the molar canals to allow the
exterior triangles to be reduced and result in decreasing the angle of entrya very desirable condition.
There are other mechanical handpieces that are used in endodontic treatmentthe Gates-Glidden drills
and the Peeso reamer. However, they are centering fles and when pressed against the outside of
curved canals may result in instrument breakage. The manufacturers of these instruments acknowledge
this but state that the broken portions of the instrument are not difcult to remove. This may be true, but
it never is fun to have to remove a separated instrument.
Figure 9
The most difcult canal in the dental arch to prepare is the mesio-buccal of the maxillary 2
nd
molar. This
tooth has a distal inclination and the fles must be inserted from the disto-lingual direction. This is an
extremely difcult fle placement. As will be discussed later in this report, there is a high incidence of two
canals in this root. By early use of the SX fle and pressure on the mesial aspect of the orifce with the
SX, a much straighter access is obtained to the root. Pressure to the mesio-lingual wall will allow for
examination for the mesio-lingual canal.
No-Nos When Using NiTi Files
As excellent as the NiTi fles are, the instruction booklet that may come with them may be incomplete or
inaccurate. Also, some of the speakers who discuss them at dental meetings may give erroneous
information. I have used these instruments for over ten years with outstanding results, but I have
modifed and added information to make their use better and safer. My advice for safety follows.
When using the NiTi fles, the operator must distribute the rotation of the stress throughout the canal
and, therefore, must NOT stop preparation in this area. To accomplish this best, the fle rotation must be
started prior to the insertion into the canal and use of light pressures to obtain deeper insertion. If the fle
starts to rotate more slowly as it goes down the canal, it is best to withdraw the fle, still rotating, and go
back to smaller sizes nearer the orifce.
The handpieces that are typically used with the NiTi fles are made with controls that are diferent
than those used for routine preparation for operative dentistry, that is cavity, crown, or onlay preparation.
The best handpieces for use with these fles are those with torque control electric engines that allow for
300 to 450 rotation per minute. The readout for the machines are indicated on the control box and the
operator is free to utilize the desired speed. I prefer something in the neighborhood of 350 to 400
revolutions per minute (Fig. 10).
Figure 10
As stated earlier, the best safety for rotary instruments involves using them ONLY to the center of the
apical curvature and using hand instruments for the remaining distance. Therefore, place the marker on
the NiTi fle to indicate no more deeply than the center of the curve and do NOT allow for the marker to
go past this length. In most mandibular molars, this calculation is easily made by placing the fle along
the long axis of the tooth on the radiograph. In maxillary molars and bicuspids with unusually placed
curvatures, a working-length fle of small diameter (no wider than a #15 fle) may be placed and
measured to indicate the position of safety.
When starting out to use the NiTi instruments, the operator should select easier caseseven anterior
teeth that do not ordinarily require complex methods of therapy, merely to adjust to the feel of the fles
within the canal. Once these are mastered, it is best to use extracted teeth or plastic blocks (available
from companies selling these NiTi products) and examine the result to be certain that mastery has been
obtained.
Step-By-Step Use of .04 Files in Curved Canals
In order to allow the reader to follow the step-by-step use of the instruments described, I am utilizing
three cases of expanded complexity that will serve to demonstrate the techniques.
CASE ONE: Mandibular second molar with recurrent decay, acting as posterior abutment of 5-unit fxed
bridge, with adjacent tooth replaced by an implant in place for over one year. The involved tooth had a
periapical lesion at the apex that was draining along the distal portion of the distal root, a condition
thought never to be treatable some 25 years earlier. The preparation of the mesiolingual canal is given,
and the radiographs and fle use are presented in Figs. 11 and 12.
The curvature of the mesiolingual canal (Fig. 11, b) is approximately 50 degrees. A size #10 fle of a
fexible fle system is passed to the working length and the tooth is radiographed to verify length, which
was calculated to be 19 mm. If an apex locator is being used along with the radiographs to calculate
working length, it too may be used at this time. The distance to the center of the curve is approximately 4
to 5 mm from the apex.
Use the *SX fle in the mechanical handpiece to widen the orifce area to allow for ease of placement of
the fles which will be inserted to the apex.
Figure 11A Figure 11B
1. Place the #10 fle to 19 mm and using rasping action by hand widen the apical portion of the
canal until the fle is loose.
2. Clip 1 mm from the size #10 fle (making it a size #12) and widen the apical portion of the
canal.
3. Set the stop on the smallest rotary fle at 14 to 15 mm (distance to the center of the curve) and
widen the canal. Do not worry if the fle does not go to the stop, but BE CERTAIN that it does
not go BEYOND the stop.
4. Use the #12 fle to the full working length.
5. Set the stop on the second smallest rotary fle at 14 to 15 mm and widen the canal.
6. Repeat step 5.
7. Set the stop on the third smallest rotary fle at 14 to 15 mm and widen the canal.
8. Repeat step 5.
9. At this point, if you took a radiograph with the size #12 fle a fle in the ML canal, the angle of
the canal is now 30 degrees, a much easier preparation than a curvature of 50 degrees (Fig.
11, c).
The two mesial canals merge and the ML is made the master canal with the mesiobuccal merging
several mm from the apex and the preparations of the three canals are completed. Be certain to keep
the canals heavily irrigated with sodium hypochlorite or similar irrigant during the completion of the
preparation.
The distal canal is very straight and may be prepared easily after the mesials. In the 30-month post-
operative flm, complete healing of the lesion is seen. (Fig 11G)
Figure 11C Figure 11D
Figure 11E Figure 11F

Figure 11G
* In the case shown, I was only rarely using the SX fles and was not sufciently understanding their
excellent use. Now I would use them more aggressively, after each fle to the full working length. The .04
tapered fles were used as indicated. No tapered, rotary instrument was used past the site of the elbow
only hand instrumentation.
Figure 12
CASE TWO: Mandibular frst molar with periapical and lateral lesion associated with the mesial root and
drainage into the furcation. Preparation of the mesial and distal canals is provided. I was using the SX
fles actively at this time.
The working length of the mesial canals was calculated to be 21 mm and the distal was 20.5. The apex
locator may be used at this time to verify the length. The curvatures on the mesial canals were
approximately 35 degrees, close to the root tips. The curvature of the distal, which was wide bucco-
lingually, was approximately 45 degrees, also close to the root tip. The preparation of the three canals is
presented in Figs. 13 and 14.
Use the SX fle frst in the mechanical handpiece to widen the orifce area to allow for ease of placement
of fles which will be inserted to the apex.
Mesial canals:
1. Insert the size #10 fle to 21 mm and using rasping action by hand widen the apical portion of
the each canal until the fle is loose.
2. Clip 1 mm from the size #10 fle (making it a size #12) and widen the apical portion of the
canal.
3. Use the SX fle in the mechanical handpiece after cutting of 1 mm at the tip and widen the
orifce portion of the canal, slightly deeper than it had been in the frst use. The clipped portion
of the tip keeps the fle at 18 mm or less, not long enough to do any preparation at the tip.
4. Set the stop on the smallest rotary fle at 19 mm (distance to the center of the curve) and widen
the canal. Do not worry if the fle does not go to the stop, but BE CERTAIN that it does not go
BEYOND the stop.
5. Use the #12 fle to the full working length.
6. Set the stop on the second smallest rotary fle at 19 mm and widen the canal.
7. Repeat step 5.
8. Set the stop on the third smallest rotary fle at 19 mm and widen the canal.
9. Repeat step 5.
10.At this point, the size #20 should go the full working length without any problem. The canal
curvatures should now be approximately 25 degrees, much easier than 35 degrees. The canals
should be widened to size #30 easily.
Figure 14
Distal canal: This canal is wide bucco-lingually, so the SX fle used should make an oval shape in the
orifce instead of round as was done on the mesials. Use the SX in this manner now to start the
preparation.
1. Place the initial size (size #10 or #15) into the disto-buccal and disto-lingual portions of the
canal using rasping action and widen the apical portion of the canal. Set the stop at 20.5 and
use rasping action at that length.
2. The SX fle length is normally 19 mm, just about the length to the middle of the curve, so it is
safe to place it into the canal and allow it to go to the full length and no damage to the apex will
occur.
3. Set the stop on the second or third smallest rotary fle at 18 mm and widen apical portion of the
canal. Do not worry if the fle does not go to the stop, but BE CERTAIN that it does not go
BEYOND the stop.
4. Use the SX fle to widen the occlusal portion of the canal.
5. Use the next size hand fle and widen the canal at 20.5 mm.
6. Repeat step 4.
7. Go up one more size with the next larger rotary instrument and fle no farther than 18 mm.
8. Repeat step 4 then step 7.
9. Go up one more size with the next larger rotary instrument and fle no farther than 18 mm.
10.At this point, the canal curvature should be approximately 30 degrees, much easier than 45
degrees. Little more preparation is required at the apex and some further use of the SX may be
employed.
As before, use the irrigant and lubricant constantly and ensure that the path to the apex remains clear by
using a smaller-sized fle (size #12) at any time.
CASE THREE: Maxillary second bicuspid with double curves of almost 90 degrees each. Large
periapical lesion, slightly behind the implant, often making the apical area difcult to see. The working
length of the tooth (with the crown removed) was 17 mm. NOTE: This case is presented to illustrate the
excellent possibilities aforded by the .04 tapered and SX instruments. This case is VERY difcult and I
tried treating similar teeth without these burs with limited success. The fnal results here were very
gratifying but not always predictable. They should ONLY be attempted after a considerable number of
teeth has been successfully treated.
The SX fle was used short of the frst curve to widen the orifce. Second bicuspids are wide
buccolingually, but much narrower mesio-distally, a condition not often realized. Therefore, the SX fle is
used to the buccal and lingual initially to give more access to the canal portion in the curved area. The
size #8 fle was used to the apex, with minimal clips made and heavy use of irrigant and lubricant. Then
the size #10 was used to the apex (Fig. 15, a). The SX fle was placed more deeply into the canal, but
kept short of the initial curve. A small amount of the tip of the size #10 was removed, making it a size
#11 and passed to the apex. Much irrigant and lubricant are used. Continue gradually working the hand
fles and SX fles toward the apex, using minimal clip on the hand fles and the SX fles short of the frst
curve. When the apical portion has reached size #25, it is safe to attempt to fll the canal (Fig. 15, b).
The four-year postoperative flm indicates excellent healing (Fig. 15, e).

Figure 15E
Conclusion
The use of tapered, rotary instrument of sizes .04 taper plus fles to open the canal orifces quickly and
safely is a huge step for endodontic treatment even on very complicated cases. It is anticipated that
more fle systems will be introduced in the future and it is up to the individual dentist to assess these
newer products and determine their usefulness. Just because something is new does not mean that it is
better. Use extracted teeth and plastic blocks to verify the abilities of the newer products before initiating
treatment based on advertisements or poorly designed studies.
2. Recent Studies of Canal Confguration
Introduction
In 1925, Hess, a German dentist, wrote a book on the internal anatomy of human permanent teeth, by
taking vulcanite impressions of the cleared canals and decalcifying the surrounding dentin. One of his
most interesting fndings was the presence of two canals in some mesiobuccal roots (MBRs) of the
maxillary frst and second molars. He also demonstrated that some of the canals in that root displayed
anastomoses that made several curves before joining another canal near the apex. Hess made
observations on other teeth as well, including the possibility of complex canal anatomy in the roots of
teeth that were wider bucco-lingually than mesio-distally
(8)
. Although it was hardly appreciated at the
time, his work was truly an immense achievement which is verifed by the fact that no one had ever
attempted a similar compilation on the subject of tooth internal anatomy. When one realizes that from the
1970s to the present, hundreds of papers have been published that use aspects of his work, enabling
clinicians to better treat endodontically involved teeth. The result of Hess eforts is that many millions of
teeth have been saved, starting with his text.
As interesting as these conclusions were, very little attention was directed to them. At that time,
endodontic treatment was frmly positioned on the lowest rung of the dental ladder. There were three
reasons for this: 1) problems with the focal infection theory were centered around pulpless teeth, 2) teeth
that were treated before the development of proper radiological principles but then were judged some
years later radiographically to have latent infections, 3) there was a pervasive attitude by both physicians
and dentists against saving teeth.
On the rare occasion when endodontic therapy was performed, it was usually for anterior teeth and
some bicuspids with teeth, but curved canals and molars were almost never treated. Endodontics as a
specialty was still 40 years away. Some of the pioneers of endodonticsGrossman, Rhine, Hine,
Healey, Sommer, and others attempted to convince their contemporaries of the value of retaining
involved teeth, but it was a difcult task. Molar teeth with necrotic pulps required four to eight, often
difcult, appointments and there were frequent failures.
Terminology for Canal Confguration Studies
To understand the potentially diferent anatomy of the canals of the various teeth, some general
terminology is necessary. According to Weine, there are four frequent confgurations or pathways that
canals may take as they traverse from the crown through the root to the apex (Fig 16). They are:
(1) type Ia single canal from the crown to the apical site of exiting
(2) type IItwo canals in the crown which merge short of the apex to form a single exit site
(3) type IIItwo canals which remain separate and distinct to their sites of exiting
(4) type IVa single canal in the crown that divides well short of the apex into two separate canals at
the apex
(9)
.
Figure 16A
Types I, II, and III are found in many teeth and have been referred to in many articles. Type IV, however,
was frst discussed when studies on the mandibular frst bicuspid were undertaken. This pathway has
also been reported in maxillary second bicuspids, and MBRs of maxillary molars.
There are at least three other systems that have been proposed to classify canal confguration, but this
is the most simple to understand and covers over 99.5% of human teeth. The remaining 0.5% usually
will ft into this system, although not perfectly. For instance, a single canal that divides in midroot into two
canals that merge short of the apex into a single canal again is very rare, perhaps 0.5%, but does exist.
It would be classifed as a Type I canal in this system. It is important to understand that this
classifcation, as well as the others, takes into account only the main canals within the tooth. Auxiliary
and lateral canals and small branches are not considered. Also, the comparatively few confguration
studies in this review using other systems have been converted and listed according to the method
stated above.
Figure 16B Figure 16C Figure 16D
Early Studies on the MBR of Maxillary Molars
For over 40 years following the Hess study, few articles on canal confguration were published, generally
in minor journals and with minimal attention. Then, in 1965, Rankine-Wilson and Henry of the Perth
Endodontic Study Club, a group of sophisticated restorative dentists who were forced to perform
endodontics on their own patients in the absence of specialists in southwestern Australia, published a
study on mandibular anterior teeth in the JADA, indicating that incisors bifurcated in 40.5% of the teeth in
the study and remained separate to the apex in 7.5%
(10)
. With the interest in endodontic therapy now on
the rise, the report did generate interest, but mandibular incisors did not require treatment very
frequently so it had little efect on clinical procedures.
Figure 16E
Weine and Rankine-Wilson met shortly thereafter when both were on the faculty of Northwestern
University Dental School and discussed possible future studies in confguration. Although neither had
ever read Hess work, both agreed that the MBR had more failures than any other roots treated
endodontically. At that time, sophomore students radiographed, accessed, fled, and flled extracted
teeth while mounted in a block, practicing for treating patients in the clinic. The Class of 1970, 52
students,each drilled down the mesial portion of the MBR on four teeth until the canal system was totally
exposed. Obviously, in some cases the inexperienced sophomores drilled past the canals and not far
enough in others. However, compilation of the data revealed that two canals were present in 51.5%
(Type II and Type III) of the total of 204 teeth, an astonishing and unexpected total! Also noted was that
14% of the MBR had two canals that were separate and distinct to the apex (Type III), an even more
signifcant fnding
(11)
.
The study was published in Oral Surg, Oral Med, Oral Pathol in 1969 and created immediate reactions
among educators as well as clinicians, many of them quite negative. Ingle had published the frst edition
of his textbook, Endodontics, in 1975
(12)
, with triple the number of pages than in the older endodontic
textbooks and many large, appealing drawings. However, the maxillary frst molar was listed and drawn
as having three roots and three canals. The books on root anatomy written by Wheeler, probably the
most widely used texts in dental education, including the edition printed in 1976
(13)
, listed the MBR as
having a single canal, even though the drawing of the root from the proximal was over 50% wider than
that of the distobuccal root (Table 1).
Further Studies of the MBR
Many subsequent studies
(14-35)
have been undertaken on the maxillary frst and second molars and they
have had more articles in the dental literature than any other teeth. If anything, the results seem to
indicate that the number of two canals in the Weine et al. study was too low. This is especially true of the
more recent reports which incorporated magnifying equipment for identifcation.
Figure 16F Figure 16G Figure 16H
Two other studies, both from Europe, deserve additional discussion, those by Evenot from France, and
by Zill from Germany. Both were the basis of theses for Ph.D. degrees and have many more pages and
much more information than the other studies. Evenot reported on a great number of teeth (378) in his
study and his use of the microscope in addition to radiographs had not been used in other studies until
recently. He also reported the lowest number of a single canal in the MBRs studied up to that time and,
hence, the highest number of teeth with two canals in the MBR
(18)
. Zill used a diferent type of
classifcation system than used by most of the studies referred to in this review and thus his statistics are
a bit difcult to state. He did fnd two interesting statistics not proposed up to that time. They were that
male patients had more teeth with two separate and distinct canals than did females (41.5% vs. 25.0%)
and that the percentage of MBRs with two canals increased with the age of the patient
(24)
.
Table 1. Confguration of MBR of Maxillary Molars, (1925-2002)
Author(s)(Year) Number
of Teeth
Method of study %Type I Type II Type III Type IV
Hess
8
(1925) 513 Vulcanite
Impressions
47.0 <-------------- 53.0
------------>
0
Weine et
al.11(1969)
208 Vertical sectioning 48.5 37.5 14.0 0
Pineda
14
(1973) 262 Proximal
radiographs
39.3 12.2 35.7 12.8
Green
15
(1973)** 100 Vertical sectioning 64.0 22.0 14.0
Seidberg et al.
16
(1973)
100 Horizontal
sectioning
38.0 37.0 25.0
100 Clinical cases 66.7 <-------------- 33.3
------------>

Pomerantz and
Fishelberg
17
(1974)
71 Decalcifed and
dyed
71.8 16.9 11.3 0
100 Clinical cases 69.0 16.0 15.0 0
Evenot
18
(1980) 178,
208
Radiographs,
several microscopic
28.8 23.5 38.8 8.8
Hartwell and Bellizzi
(l982)
19
538 Clinical cases 81.4 <-------------- 18.6
------------>
0
Vertucci
20
(1984) 100 Decalcifed and
dyed
45.0 37.0 18.0
Bjorndal and
Skidmore
21
(1987)
85 Acrylic casts 41.1 40.0 18.9
Weller and
Hartwell
22
(1989)
835 Clinical cases 61.0 <-------------- 39.0
------------>

Fogel et al.
23
(1994) 208 Clinical cases 28.9 39.4 31.7 0
Zill
24
(1997) 105 Radiographs and
some sections
1.0 41.0 39.0 19.0***
Weine et al.
25
(1999)
300 Radiographs, fles
in teeth
42.0 24.2 30.4 3.4
Stropko
26
(1999)* 1732 Clinical cases with
operating
microscope
16.5 31.9 44.3
Wolcott et al.
27
(2002)**
1193 Clinical cases, initial <-------------- 58.8
------------>

Clinical cases,
retreatment
<-------------- 67.4
------------>

*MBR studied in frst, second, and third molars, only 72/92 4-canaled teeth could be fled
**MBR studied in frst and second molars
***German, sonstige, means otherwise
While the frst fnding does not ofer a clear rationality, the second may be explained by the canal in the
MBR after eruption having a single, fgure-eight shaped canal. With age, there is increased dentin
deposition and the center point of the fgure-eight eventually squeezes of the single canal into two in the
MBRs.
After the frst few studies were published on the MBR of the maxillary frst molar, many more were
undertaken using diferent methods of investigation and reporting diferent results. It is possible that
some of these investigations were undertaken to disprove the frequency of two canals in the MBR, since
it had been noted in precious few studies in the preceding years. However, the fnding of over 50% of the
teeth examined having two canals was a constant of in vitro reports. The early in vivo reports indicated
fewer bicanaled MBRs. However, several of the very recent studies, including that by Stropko using an
operating microscope and a large number of cases, have indicated that two canals may occur as often
as in 80% or more of the teeth (Table 1)
(26)
.
Retreatment of Failing MBRs
The frst determination to make when treating a failure of endodontic therapy on a maxillary frst molar is
the root(s) involved. By far, the MBR is the most frequent, perhaps by a ratio of 5 to 1, or more. The
distobuccal, smallest of the three roots, usually has a gentle curve that is prepared and flled rather
easily. The palatal is more curved than the distobuccal but not as much as the MBR, generally to the
buccal direction. However, the canal is much wider than the buccals and, therefore, easier to prepare
and fll than the MBR. But the keys to determination in evaluation of the MBR root are the preoperative
radiographs. In addition to the normal straight-on view, another view must be taken from the distal so
that the distal and palatal roots overlap or the distal is mesial to the palatal. This puts the MBR into a
mild profle, and, if present, will show the canal flling not centered in the root, but to the mesial. Post-
flling flms must include an angle from the distal (Fig. 17, a).
Although not as reliable an indicator as the flm from the distal, another hint that two canals are present
in the MBR and should be located is that the tooth is shorter than average from occlusal to apex, that is
less than 19 millimeters. Such teeth have a tendency to be wider bucco-lingually than teeth that are
longer, thus permitting essentially similar periodontal ligament attachment regardless of length (Fig. 17,
b). It is usually best to attempt location and position of the mesiolingual canal before making a decision
on the retreatment of the mesiobuccal canal. If the latter is obviously inadequate, both canals in that root
should be treated. If the mesiolingual canal merges with the mesiobuccal canal, some advise that the
latter may be left alone. Weine advises retreatment of the mesiobuccal and treatment of the mesiolingual
whenever retreating a failure of the MBR and has demonstrated cases where a type II canal system was
shown to be present, but a sinus tract did not clear up until both canals were prepared
(9)
.
Names of the Canals in Maxillary Molars
Some authors and/or clinicians have referred to the second canal in the MBR as the MB2. This is
neither an accurate nor a correct name and has no basis as compared to the references to any of the
other canals in the dental arch. The teeth with multiple canals have always had an important basis in
commonthe direction for entering the root is the opposite to the name of the canal. In bicanaled
bicuspids, the buccal canal is entered from the lingual and the lingual canal from the buccal. In the three-
canaled mandibular molars, the distal canal is entered from the mesial, the mesiobuccal from the
distolingual, and the mesiolingual from the distobuccal.
In the maxillary molars, the palatal canal is entered from the buccal, the distobuccal from the
mesiolingual, and the mesiobuccal from the distolingual. Examination of the typical mesial roots from the
1969 report
(11)
indicated that the correct path towards entering the second canal in the mesial root is
from the distobuccal, hence it should be referred to as the mesiolingual. As was mentioned and will be
discussed in the next section, the maxillary second molars very rarely may have two palatal canals.
These would never be called P1 and P2, but, more properly, the mesiolingual and the distolingual. The
same conditions apply to the mesiobuccal root.
In the frst English edition of his text, Castellucci states that rather than using MB2 as the name of this
canal, it is more appropriately named the mesiolingual canal
(28)
. Failure to gain entrance to this canal
often occurs because the operator fails to consider this initial curve to the distobuccal and the small fle
continuously bends when pressure is exerted as the instrument tip bypasses the angle of the orifce.
Weller and Hartwell
(22)
and Fogel
(23)
et al. also refer to the second canal in the mesial root as the
mesiolingual.
Studies of the Maxillary Second Molar
With so many multicanaled MBRs found in maxillary frst molars, it was not too long before this root in
second molars started to receive attention. Several of the earlier reports on the frst molar had
concomitant results listed for the second molar, too (Table 2). Subsequent studies on the second molar
only are listed in Table 2
(17,30-33,36)
. Many endodontists started fnding a second mesiobuccal canal in the
frst molar, but had great difculty in locating an additional canal in the second molar, probably due to the
position as most posterior tooth and inclination to the distal. However, the statistics are probably correct.
Still, the in-vitro investigations depict a much higher percentage of average number of canals than do the
in-vivo reports. At this time, when many maxillary frst molars have four canals flled frequently, the
percentage of treating four canals in the second molar still lags far behind.
The maxillary second molar has many more canal confgurations than does the frst molar. One, two,
three, or four roots may be present with two, three, or four canals, whereas the frst molar has three or
four roots in virtually every instance, always with three or four canals. The spread of the roots in the frst
molar is much greater than in the second molar and the position of the canal orifces also may difer,
particularly the distobuccal in the second molar being more to the mesiolingual in some teeth.
Table 2. Confguration of the MBR of Maxillary Second Molar, (1972-2002)
of Teeth
Pineda and Kuttler
29
(1972)
294 Proximal
radiographs
64.6 8.2 12.8 14.4
Nosonwitz and
Brenner
30
(1973)
161 Clinical cases 68.9 25.5 5.6 0
Pomeranz and
Fishelberg
17
(1974)
29 Clinical cases 62.1 13.8 24.1 0
Vertucci
20
dyed
71.0 17.0 12.0 0
Kulild and Peters
31
(1990)
32 Access and bur
penetration
21.8 <-------------- 78.2
------------>
0
32 Sectioning and
microscope
6.3 <-------------- 93.7
------------>
0
Eskoz and Weine
32
(1995)
in place
59.7 20.9 16.4 3.0
Wolcott et al.
27
(2002)
689 Clinical cases, initial <-------------- 35.3
------------>

Clinical cases,
retreatment
<-------------- 43.6
------------>

The maxillary second molars also may have two palatal roots, in one of two distinctly difering
formations, a condition almost never seen in the frst molar. In one of the types, the palatal roots are
rather far from each other and the tooth resembles an upside down card-table, easily discernible on the
radiograph (Fig. 18, a). In the other condition, the palatal roots are much closer together, difcult to see
on the radiograph, and often are noticed only when examining the foor of the chamber of the tooth (Fig.
18, b).
Table 3. Confguration of the Mandibular First Bicuspid (1972-1992)
of Teeth
Pineda and Kuttler
29
(1972)
202 Proximal
radiographs
69.3 1.5 1.5 0.9
Green
15
(1973)** 50 Vertical sectioning 86.0 <-------------- 10.0
------------>
Zillich and Dowson
33
1393 Radiographs 69.3 <-------------- 2.7 ------------>
(1973)***
Vertucci
20
dyed
70.0 4.0 1.5 0.5
Baisden et al.
34
(1992)
106 Transverse
sectioning
76.4 0 0 23.6
*reported 0.9% had 3 separate canals
**did not report on 3 canaled teeth
***reported on frst and second bicuspid; 0.4% of the teeth had 3 canals
Studies of the Mandibular Bicuspids
Next to the MBR of maxillary molars, the confguration studies on the mandibular frst bicuspid have
been the most illuminating and useful. (Table 3)
(15,20,29,33,34)
. For many years it was thought that the
mandibular frst bicuspid had only a single canal, although there were a few examples of those teeth
being bicanaled in rare instances. Of all the teeth studied for additional canals, this tooth seems the
most mystifying for failure to diagnose that more than a single canal is present immediately upon
examining properly angled radiographs. The key sign is that the occlusal portion of the canal seems
large and well developed, but suddenly disappears in midroot (Fig. 19, a). That site is obviously the point
of separation of the canals into two, and, sometimes, even three canals to their apices.
Figure 19A
The older studies on this tooth listed Type I systems on 69%-86% of the teeth examined and some
percentage of Types II, III, and IV. A recent study, by Baisden et al.(34), reported that the tooth only had
either a single canal or a bifurcated canal system. The net result of these studies indicates that more
and more mandibular frst bicuspids being treated are found to have more than a single canal, but rather
a Type IV system, the most complicated of the systems to treat. This fnding occurs in a much higher
number than had been assumedperhaps as high as 30%and the Baisden study certainly should
result in fewer failures in the future. In 1973, Zillich and Dowson reported on this tooth, studying 1393
teetha huge numberand reported that 69.3% had a type I system. Of the remaining bicuspids,
22.7% had 2 canals and 0.4 had three canals
(33)
. Both mandibular bicuspids may have two or three
canals, but this fnding occurs much less frequently in the second bicuspid than it does in the frst.
All of the studies indicating two canals in this tooth stress the need for a wide preparation buccolingually.
The buccal canal is penetrated from the lingual whereas the lingual canal is found from the buccal. The
height of the division from one canal to two usually will determine the outlook for the treatment. When
the division is towards the occlusal, the treatment is not complicated. However, in cases where the site
of division approaches the apex, treatment is very difcult.
In general the mandibular second bicuspid is one of the easiest teeth to treat endodontically, with a
single canal well centered in the crown and extending to the apex. Even in single-canaled mandibular
frst bicuspids the access is more difcult because it is the only tooth in which the long axes of the crown
and the root meet at an angle (Fig. 19, b).
Figure 19B Figure 19C Figure 19D
Studies of the Mandibular First Molar
Shortly after the frst study of the MBR of the maxillary frst molar, Skidmore and Bjorndal reported on
the canal confgurations in the mandibular frst molar
(35)
. Bjorndal had investigated many of the human
teeth and, with aid from his graduate students, reported not only the confguration but also the lengths
and widths of the permanent teeth in a booklet, Anatomy and Morphology of Human Teeth, second
edition
(35)
. Many hours were invested in this complex undertaking. Bjorndal and Hess probably should be
given co-credit as the fathers of modern canal confguration reporting (Tables 4-7 and 9).
Table 4. Confguration of the Mesial Root of the Mandibular First Molar (1971-1988)
of Teeth
Skidmore and
Bjorndal
35
(1971)
45 Acrylic casts 6.7 55.6 37.7 0
Pineda and Kuttler
29
(1972)
300 Proximal
radiographs
12.8 30.2 50.4 6.6
Green
15
(1973)* 100 Vertical sectioning 12.8 48.5 37.7 1.0
Vertucci
20
dyed
27.0 38.0 26.0 9.0
*sections of both mandibular frst and second molars
Table 5. Confguration of the Distal Root of the Mandibular First Molar (1971-1973)
of Teeth
Skidmore and
Bjorndal
35
(1971)
45 Acrylic casts 71.1 17.7 11.1 0
Pineda and Kuttler
29
(1972)
300 Proximal
radiographs
73.0 12.7 5.7 8.6
Vertucci
20
dyed
89.3 4.9 2.9 2.9
Table 6. Confguration of the Mesial Root of the Mandibular Second Molar (1972-1988)
of Teeth
Pineda and Kuttler
29
(1972)
300 Proximal
radiographs
58.0 20.6 13.8 7.6
Vertucci
20
dyed
27.0 38.0 26.0 9.0
Bjorndal and
Skidmore
21
(1987)
60 Acrylic casts 25.0 43.0 32.0 0
Weine et al.
36
(1988)*
in place
4.0 52.0 40.0 0
*4.0% C-shaped teeth were found
Table 7. Confguration of the C-shaped Mandibular Second Molar (1972-1998)
Author(s)(Year) Number of
Teeth
Method of study % of Second Molars
that were C-shaped
Pineda and Kuttler
29
(1972) 300 Proximal radiographs none noted
Cooke and Cox
37
(1979) * Clinical cases 8%
Tamse and Kafe
38
(1981) 508 Radiographic 10.9
Bjorndal and Skidmore
21
(1987)
60 Acrylic casts 13
Melton et al.
39
(1991) 15 known
to be C-
8polyester resin casts 7
cross sectioned, 3 levels
100
shaped
Weine et al.
40
(1998) 399 Retrospectiveclinical cases 6.2
412 Prospectiveclinical cases 8.9
*no number reported
In their evaluation, Skidmore and Bjorndal stated that four canals were present in the mandibular frst
molar in 28% of the cases, separate and distinct in 11% and merging short of the apex in 17.5%. They
listed three roots to be present in 2.2% of the teeth studies and recommended a larger, more rectangular
access preparation than had been shown in Ingles frst edition
(12)
, which was largely adopted by the
endodontic community soon thereafter. This change from a smallish triangular form allowed for the
added room to locate the fourth canal, if present (Fig. 20).
Figure 20
The mandibular frst molar, being the frst permanent tooth to erupt, probably is the most common tooth
to have pulpal damage but early in the 20
th
century it was usually extracted when involved. For the past
40 years, it has been treated more and more as endodontic techniques have become more predictable.
For this reason, it is important for any dentist treating this tooth to be well informed as to the
confguration possibilities and some excellent studies have been reported
(20,29)
.
According to the studies on human teeth, the mandibular frst molar is one of the few teeth where the
normal confgurations difer between the European/American and the Asian population. Most of the
studies reported in this review are from the former group. A further discussion of some of the types
prevalent in the Asian population will be presented later in this report.
Studies of the Mandibular Second MolarA Tooth With
Multiple Variations
The mandibular second molar has the greatest variation of confgurations among the molar teeth. One of
the most egregious errors is the often-felt opinion that the mesial root has a fairly high percentage of
only one canal (Table 6)
(20,35,36)
. In the study of Weine et al.
(36)
this was clearly stated as a source of
failure on this root and, furthermore, when only one canal is located, radiographs of several angles with
fles in place, mesial and distal, should be taken to verify that only one centered canal is present. In
addition, the distal root may have several variations and, in some more rare cases, a completely diferent
variant is present, the so-called C-shape. This will be discussed in further detail in the next section.
One of the major reasons why researchers were content to believe that only one canal in the mesial root
is a dominant feature of the mandibular second molar is that there is a high percentage of two canals
which merge short of the apex in that root (Type II system). In that case, if only one of the two canals is
found, generally the mesiolingual, but it is prepared and flled adequately, that root will have a decent
chance for success. But in case the two canals are separate to the apex (Type III), then the chances of
success are severely decreased.
The mandibular second molar has a few very unusual confgurations, including a second canal in the
distal root and, very rarely, a second distal root (Fig. 21). Viewing the preoperative radiographs of this
tooth with magnifcation is mandatory because of the many variants that are possible.
Figure 21
The C-shaped confguration of the mandibular second molar (CMnd2M) was frst reported by Cooke and
Cox
(37)
in 1979, who stated that of the second molars treated in the late 1970 at the Dental School of
Washington University (St. Louis), 8% were CMnd2Ms. This was quite a surprise because of 300
mandibular second molars investigated by Pineda and Kuttler in 1972
(29)
, no CMnd2Ms were reported
and no single-rooted teeth were seen. Similar results were reported by Vertucci
(20)
. In succeeding years,
other studies were reported noting the CMnd2Ms, with similar frequencies to the original Cooke-Cox
report
(38-41)
. There have been a few papers indicating the fnding of a C-shape on other teeth beside the
second molar
(43,44)
.
The tooth is referred to as C-shaped because the canals present (usually three, but may be two or four,
on occasion) have a continuous septum at the orifce area that may or may not extend to the apex. If cut
in cross section, the septum is that of the letter C. Generally the closed area of the C is to the lingual,
but it may be to the buccal. The canals are usually far from each other at the orifce, but merge near the
site of exiting. In some cases only two of the three canals merge (Fig. 22).
Figure 22A Figure 22B Figure 22C
In 1981, Tamse and Kafe reported on conical mandibular second molars in 10.9% of 508 teeth
surveyed, demonstrating radiographs that did indicate some, but perhaps not all, as being CMnd2Ms
(38)
.
Melton et al.
(39)
studied only 15 mandibular second molars, but all were known to be C-shaped and made
a number of interesting fndings. In general, C-shaped teeth have one of two root confgurations, a single
root or two roots with an attached segment to allow for the septum to traverse from the mesial to the
distal. They also found that not all of the C sections were continuous, but that some had interruptions.
Also, not all of the canals merged at the apical portion, but instead one canal was separated from the
others at the site of exiting.
The study involving the most teeth was reported by Weine and Members of the Arizona Endodontic
Association
(40)
. Three hundred ninety-nine second molars were evaluated retrospectively by radiographs
and 412 were examined while they were being treated, including radiographs with fles in place and
postoperatively. It is of interest to note that fewer CMnd2Ms were recorded retrospectively (25/399,
6.2%) than prospectively (37/412, 8.9%). This probably occurred because the operators were looking for
the specifc variant in the prospective portion of the study.
It is obvious that this variantthe C-shapehas multiple shapes and confgurations, easily the most
complicated of any single tooth. For this reason, Weine et al.
(40)
suggested that larger sample sizes
should be obtained and studied to clarify some of the situations noted and examine for more
possibilities. They recommended that endodontic study clubs or other smaller organizations pool their
cases to gain larger number of teeth for study, just as the mandibular incisors were investigated by a
small group.
The confguration ofers some difculty in flling because of the slit-like canal present, as opposed to the
normally occurring oval or roundish canal. Several of the reports warned that the condition should be
considered early in treatment, lest irreparable damage occurs in the narrow slits present
(43,44)
. Manning
wrote two papers on the variants in the C-shape and gave two interesting conclusions. He said that the
slit portion of the C-shape should be fled and flled with great care to avoid perforation through the
narrow walls. He further stated that studies of the Chinese and the Hong Kong Chinese had greater
number of C-shaped roots than did Caucasians.
Studies of the Maxillary Bicuspids
The maxillary bicuspids have a number of potential confgurations, but somehow do not present as much
of a problem during treatment as do the MBRs, C-shaped molars, or bicanaled mandibular incisors.
Perhaps it is because the teeth are easier to radiograph or that the patients are able to open widely
enough to allow for better examination than with the maxillary molars. The frst bicuspid often has only a
single root, usually with Type II or III confgurations, but rarely just a single canal. It may have two roots,
each with a single canal. It also may have three separate and distinct roots, although rarely, which may
be difcult to recognize and thus cause difculties early in the treatment (Fig. 23). The three-rooted tooth
resembles the common maxillary second molar which has three separate canals. Two types of this
condition are seen, one where the buccal canals separate near the end of the crown with the other, more
difcult type, having canals separating further toward the apex, similar to a Type IV system, making
preparation and flling more complicated.
Figure 23
The maxillary second bicuspids also may have one or two roots, but with this tooth the two canaled
combination may be slightly more common than in the frst bicuspid. Type I, II, and III canal systems may
be present in the tooth with a single root. However, this tooth may have two complex confgurationsa
Type IV canal system that has the position of division fairly deeply in the root (Fig. 24) and three
separate and distinct canals. The latter is even more rare than in the frst bicuspid (Table 8).
Table 8. Confguration of the Maxillary Second Bicuspids (1972-1976)
of Teeth
Pineda and Kuttler
29
250 Proximal
radiographs
98.9 0 1.2 0
Vertucci et al
45
(1974)*
100 Decalcifed and
dyed
48.0 27.0 17.0 6.0
*2 teeth had 3 canals
Figure 24A Figure 24B Figure 24C Figure 24D
Vertucci
(20,45-47)
has been the most prolifc investigator of confguration in these teeth. He has also
described combinations of canal systems that are more complex than the Type I, II ,III, IV description
used in this review. Vertucci obtained his specimens from exodontists in the southeastern portion of the
US and many were extracted to allow for replacement with dentures, rather than with restorative and/or
pulpal problems. Even so, the specimens are quite beautiful and have interesting curvatures and
anastomoses.
Table 9. Confguration of Mandibular Incisors (1965-1997)
of Teeth
Rankine-Wilson and
Henry
10
(1965)
in place
59.5 35.1 5.4
Pineda and Kuttler
29
(1972)
356 Radiographs,
proximal view
98.3 0.5 1.2 0
Vertucci
47
(1974) 100
centrals
Decalcifed and
dyed
92.0 5.0 3.0 0
100
laterals
93.0 5.0 2.0 0
Bjorndal and
Skidmore
21
(1987)
277 Acrylic casts 63.9 25.9 2.2 7.9
Miyashita et al.
48
(1997)
1085 Decalcifed and
dyed
87.6 9.3 1.4 1.7

Studies of the Mandibular Incisors
Most dentists, and even many endodontists, do not realize that it was on these teeth that the frst
defnitive study of canal confguration was performed. Many general dentists, similarly, do not appreciate
the difculty that these teeth ofer during endodontic treatment, thinking that they are merely small
maxillary centrals. Nothing could be further from the truth and can only lead to disaster. As stated earlier
in this review, because these teeth are not treated endodontically very often, the complexities of the bi-
canal possibilities coupled with the narrowness and depressions on the proximal surfaces are not
considered during therapy (Table 9). Miyashita et al.
(48)
, reported on the types of canal systems in these
teeth as an introduction to their article on general aspects of mandibular incisors shape, canals, external
appearance, and accessory canals, which is of considerable interest to anyone treating these complex
teeth. Furthermore, the difculty in taking useful angled radiographs to indicate the possibility of more
than a Type I systems is very difcult to obtain because of the mesio-distal narrowness of the teeth and
the ease with which they appear overlapped in angled views. The study by Rankine-Wilson and Henry
emphasized the need for placing the access in the incisal edge to give best approach to the two canaled
teeth (Fig. 25)
(10)
. The mandibular incisors should always be treated with great care.
Figure 25
Studies of Teeth With Five or More Canals
Periodically, reports crop up in the endodontic literature demonstrating teeth with fve, and sometimes
even more, flled canals. Because these cases are in-vivo and the teeth were treated in the hope that
they may remain in the mouth, no sectioning to verify individual canals is ever made. Demonstration of
fve and more canals in-vitro with fle placement has been reported only very rarely.
In 1982, Weine published an article in which three canals were flled in the mesial root of a mandibular
frst molar
(49)
. He stated that although it would appear that the mesial root had three defnite canals, such
was not the case. The tooth had been treated originally when the patient was only 10 years old and the
canals obviously quite large. The preoperative radiographs appeared to show two (poorly) flled canals
that had merged short of at the apex. After opening the tooth, he found that the two canals that had
been flled were both in the mesiobuccal segment of the tooth. Opening the chamber foor further, a
defnite path to the mesiolingual was opened and enlarged. Both of the previously flled canals were
prepared, as was the last-found mesiolingual and all three separate canals flled into a common site of
exiting near the apex. He postulated that this did not constitute three separate canals in the mesial root,
but rather a single, very wide canal that permitted preparation and flling in more than two sites. In 1997,
DeGrood and Cunningham published a case report that demonstrated three canals flled in the mesial
root that was identical
(50)
. This was a Type II canal in the system used for this review. In 1989, Fabra-
Campos also published a similar paper, except that one mesial canal had a separate exit but the other
two had a common exit
(51)
. This was a Type III canal. In 2004, Baugh and Wallace described the
treatment of a mandibular frst molar with two separate and distinct canals in the distal root and two
separate mesial roots, one of which showed two canal fllings, merging short of the apex
(52)
. Pomeranz et
al. were early investigators on wide canals in the mesial roots of mandibular molars which were able to
be flled as three canals
(53)
. In a recent case report, Ferguson et al. described the flling of three canals in
the MBR of a maxillary frst molar for the frst time(54). The postoperative angled radiograph shows only
two sites of exit, one to the buccal and one to the lingual, clearly a Type III system. The patient was
youngonly 18 years oldand a photo of the access to the canals indicated the two orifces to the
lingual much closer than the middle orifce to the buccal.
Most of the radiographs demonstrating fve or more flled canals show four or less sites of exiting at the
apex. This can be explained as a canal being quite wide or the pulp becoming necrotic when the patient
was quite young and allowing for multiple sites of flling. These reports are interesting to read and we all
should endeavor to treat any canal that can be located. However, these fndings of an unusual number of
canals (fve or more), as compared with the total number of teeth treated, still remain an extremely small
group.
Role of Ethnicity in Confguration Studies
Most of the studies listed in Table 1 through 9 have statistics derived from teeth accumulated from two
ethnic groups. They are from the Europeans, largely Caucasians, and the African-Americans. Both of
these groups have large populations in Europe, the Americas, and Australia, and, in the case of the
African-Americans, Africa as well. However, this leaves out a very huge percentage of the world
population, particularly the Asians. In these days of multi-national companies and super-sonic travel,
dentists and especially endodontists should be aware of the deviations from Tables 1 through 9 that
might occur when a patient of an alternative ethnic group seeks treatment.
Walker
(55-57)
, who was on the Dental Faculty in Hong Kong, and, therefore, had access to the Chinese
population from the southern portion of China, wrote several illuminating articles, listing some of the
diferences that this group had as compared to other groups. In general these studies were on
mandibular molars and bicuspids. Other studies of Asians were also reported
(58,59)
. Weine et al.
(25)
investigated the MBR of maxillary frst molars of an exclusively Japanese sub-population and reported
few diferences from those with the European/African background.
It still would seem that studies of Asians, including Asian Indians, the people of the eastern former
Russian republics, and Oceania, would be interesting and useful to anyone whose patients from those
areas require endodontic treatment. Perhaps these groups will be studied in the future.
Efect of Preparation Methods on Confguration Studies
Tables 1 through 9 not only supply statistics on the numbers and confguration of the canals indicated,
but they state the methods used in the investigations. The easiest, useful technique is the sectioning
method. A high number of teeth may be investigated and evaluated relatively quickly. The technique may
be by vertical or horizontal cutting and it may be used to grind away tooth structure
(11)
or cut through it
horizontally
(16)
. In the latter case with various levels of cutting, for example every 1 millimeter, there is the
allowance for repositioning the segments to demonstrate the variance at any level. The disadvantage for
the grinding method, as stated earlier, is that it is possible to grind through too far, removing the most, or
even the entire canal, or grind too little. In either error, the critical midcanal area is lost for demonstration.
Another popular method has a clinical orientation, using radiographs with fles in place to demonstrate
the relationship of the fles in any canal, in vitro. The extracted tooth may be rotated in several planes to
disclose positions not always available in vivo. This method was used in the Rankine-Wilson and Henry
study
(10)
and works well when study clubs combine results for large numbers of teeth. The possible
disadvantage is that the fles have stifness and, if traversing a very curved canal, will tend to take a
central path rather than detail the true curvatures. The injection methods demonstrate this condition very
well. Another radiographic technique combines the use of x-rays and sectioning of roots to allow for
views from the proximal without the placement of fles. Other than the palatal root of the maxillary frst
molar, all of the other roots in the mouth are either wider bucco-lingually or roundish. By taking
radiographs of sectioned roots from the proximal, the wider dimension, the more signifcant view is
obtained and there is no overlap of adjacent roots. This method was used by Pineda and Kuttler
(29)
to
survey a very large number7,275of teeth. Many teeth may be examined in a relatively short period
of time, but the assessment of the interior of the teethwhere the canals aremay not be accurate.
A very frequent, but time-consuming technique, is the decalcifying and dyeing method, which probably
gives the best results for student use and for long-range retention of the specimens. The contrasts seen
in the preserved roots show examples of the unusual relationship of the curving canals, not seen in
either the grinding or fles-in-place methods. Vertucci
(20, 45-47)
, who studied most of the teeth in the arches,
including anteriors, used this method and because of the many anastomoses picked up by the dyes,
applied a diferent and more complicated confguration coding. Hess studies used a vulcanite
impression technique, which difers from the decalcifying-dyeing method, but his results look very
similar
(8)
to Vertuccis.
The major problem for the articles by Vertucci is that because many of the patients supplying the teeth
were young and had extractions for prosthetic rather than pulpal/periapical disease, the canals were
relatively wide. This is not typical of the types of cases seen in most endodontic practices because of the
absence of reparative dentin that occurs in response to decay and/or restorations. The canals in his
specimens show many exotic curvatures. Several other reports using the dyeing mechanism also are
replete with multiple lateral canals and curvatures. These are rarely demonstrated following treatment of
patients, especially of middle-aged or older, using any of the popular canal flling techniques.
In vivo clinical cases may be correlated, although they may yield fewer complicated canal arrangements
due to the difculty in locating all of the canals. Recent use of the surgical operating microscope
(26)
has
improved the results for this method and probably will be the basis for studies of the future.
Future for Canal Confguration Studies
In the 1970s, when canal confguration studies reached their zenith, every tooth in the dental arches was
investigated. Except for the maxillary incisors and cuspid, unexpected and unusual results were obtained
in every instance. Anyone attempting a study of depth really hopes to uncover new material or refutation
of a previously accepted condition. However, after the publication of the fndings in the MBRs of the
maxillary molars, the mandibular molars, and the bicuspids, repeated studies have been uneventful.
It is possible that future studies, particularly those performed in vivo with the aid of magnifcation, may
produce results that increase the frequency of the variants from the most typical Type I confguration.
Studies of other population groups and use of other fxatives may be fruitful. However, the vast
diferences from the expected types probably will not occur as they did in the 1970s, truly the hey-day for
canal confguration studies.
3. Endodontics of the Future
Newer Types of Canal Filling Materials
The most challenging aspect of endodontics for the immediate future is the canal flling material to be
utilized. This subject has taken up a huge amount of space in the endodontic journals of the past few
years and shows no signs of subsiding.
Gutta-percha, the trans isomer of polyisoprene, has dominated the canal flling scene for well over 100
years and the results obtained, in combination with exacting canal preparation eforts, have been quite
positive. Gutta-percha itself has been around for a long time. It was used in the 18
th
century as a
component of golf balls and was used for many years in the manufacture of chewing gum. The cis
isomer has been used in many rubber products, such as tires, rubber gloves, and other similar products.
It has many desirable qualities as a canal flling material, including nonsupport of bacteria and substrate,
compactibility into the canal, and has been used in several diferent forms in endodontics. These include
packing of room-temperature gutta-percha, insertion of warmed injection-molded gutta-percha, and
flling in conjunction with such solvents as chloroform, eucalyptol, and xylene. Its few disadvantages are
its lack of rigidity to be placed deeply into curved canals and lack of length control
(60)
.
Another mild problem is that gutta-percha for use in endodontics is naturally occurring, coming from the
sap of the Indian rubber tree and, for many years, was taken from trees in the Malaysian peninsula.
Because the use of rubber products has been more signifcant than the uses of gutta-percha, the
preponderance of the yields has been away from the dental use. For the last 10 years, or so, the product
has been taken from trees in the western region of Brazil where the temperatures and humidity are
similar to those in Malaysia.
Despite the excellent results that it has delivered for many years in many, many cases, periodically there
have been eforts to replace it with other materials. In l941 Jasper introduced silver wires or points
(61)
.
This material could be placed into canals with curvatures and had good length control, the two
defciencies associated with gutta-percha. However, there were also some problems. If the point was
overextended and entered the periapical tissue, the extended portion could become corroded because
of the silver content. Perhaps even more importantly, the ease of insertion led many dentists to minimize
the critical factor in gaining endodontic success by failing to clean the canal properly, leaving behind
bacteria and substrates. Also, the silver wires were strongly radiopaque and would give the illusion on
the post-operative radiograph of a density that was deceivingly good. After a brief period of expanded
use, silver points gradually went out of favor and gutta-percha was back in vogue.
Now eforts to replace gutta-percha are gaining advocates and a new product has reached the market
recently as a replacement. Called Resilon, it is a synthetic, semi-crystalline aliphatic polyester named
polycaprolactone which has been approved by the FDA for use in several areas of medicine and
dentistry. Because it is synthetic, the material may be produced in the laboratory in accordance with the
determined volume needed rather than in far away areas which require specialized delivery systems to
the manufacturer.
The initial studies were published by Trope and his colleagues at the University of North Carolina
(62,63)
.
These studies usually included a specifc sealer, Epiphany Primer (Pentron Clinical Technologies) and
the combination of the two were reportedly responsible for a stronger root structure after canal flling. In
an in vitro study, Torabinejad, et al.
(64)
reported 50 percent penetration along the entire canal 30 days
after flling using gutta-percha and a sealer other than Epiphany. In their articles, Shipper and Trope
(64,65)
seem to suggest that following canal flling with presently accepted procedures, bacteria are able to
infltrate the root and potentially may be responsible for treatment failure. Ray and Trope
(66)
have
suggested that the quality of the restoration following endodontic treatment may have more to do with
treatment success than the canal flling procedure. They further recommended that resins be used for
better sealing of the canal.
These statements have been accepted by a signifcant number of endodontists. I have particular
problems with much of the data. First of all, Trope has a fnancial interest in Resilon and although he has
been a highly recognized researcher for many years, his results are subject to question. A spate of
papers and programs endorsed the Resilon material, several suggesting the use of other resin products,
including resin posts for the restoration. Then Tay, originally from the University of Hong Kong, and his
cohorts, at the Medical College of Georgia and the group that he developed there, undertook a number
of studies
( 67-70)
that cast considerable doubt about the efcacy of the materials. The group in Georgia
included David Pashley, who has authored or co-authored a slew of excellent papers investigating
endodontic interests, including initial studies on the smear layer and the efectiveness of apical seal. For
the most part, these articles did not agree with the Trope studies. The assertion concerning the claim of
increased root strength has been essentially discarded.
Obviously the jury is still out on the subject of whether or not Resilon/Epiphany will replace gutta-percha
as the dominant flling material used. However, it appears that the ice-jam of reliance on the old favorite
probably has been broken and other synthetic materials will be investigated very soon. In my opinion,
these newer and, perhaps, better substitutes will require intensive investigation before gutta-percha use
is discontinued. Furthermore, it is hoped that the newer materials, yet unknown, will be reported upon by
investigators without fnancial interest to eliminate any chance of personal bias.
Use of Single-Appointment Treatment
Another subject that should be investigated is the proper place of one-sitting treatment. Such therapy is
far from recent, with an article on the subject by Kells published in Dental Cosmos in 1887
(71)
. Certainly
the practice is very frequent among a number of dentists and it is my contention that it occurs very close
to 50 per cent of the time, thus with virtually an even distribution as compared to multiple-appointment
therapy. There can be no question that there are times when any practitioner leans heavily toward
single-visit treatment, as when a patient sufers a clean horizontal break of a maxillary anterior tooth with
minimal exposure of the pulp and no history of pain prior to the incident. By the same token, treating a
tooth endodontically in a single visit when the tooth has been left open for a long period without having
more than minimal canal preparation would seem to be asking for a serious exacerbation, if attempted.
Even prescribing strong antibiotics probably would not ofer sufcient coverage to prevent an undesirable
response. The greater problem here is that endodontists have found that limiting cases to one
appointment can be very remunerative, even if they decrease the total fee for the service, which few
have done. Because the tooth need not be opened and then subsequently reopened to complete, the
total ofce time is signifcantly decreased
(72)
.
What is needed is a wide-ranging study of a large number of patients with eforts made to clarify the
problems of single-visit treatment. Also, a clear defnition of single-visit treatment must be made. Some
dentists have patients in for a preliminary visit but, except for those in pain, only radiographs and an
evaluation of the patients problem take place. The patient then is rescheduled for a future time when the
tooth can be completely treated. Thus, it may take two scheduled appointments to treat a single tooth.
I know that in my own experience it is rare that I can locate and prepare the fourth canal in a maxillary
molar, if present, in a reasonable appointment time (1 hour or less). Merely attempting to locate it,
even with magnifcation, may take 30 minutes or more. Mandibular frst bicuspids with two canals may
also be time consuming. It is my opinion that extending the appointment time (to 3 hours, for example) is
counterproductive as patients do not like the very long time of keeping their mouths open with the rubber
dam in place.
Even though I rarely fnish a tooth in one appointment, I readily agree that there are some cases,
perhaps many, when the tooth may be treated safely in a single visit. Most older studies on the subject
have endorsed single-visit treatment
(73-75)
, but most of them were reported by dentists who prefer that
method of treatment. Many older articles discussing the subject from both sides of the controversy have
been poorly designed and only were listing of cases that enforced the authors position. A more recent
report by Holland et al.
(76)
was carefully planned, but healing in dogs teeth is much superior to that in
humans.
Recently, there have been several interesting reports dealing with this situation. Many have implicated
failure to successfully remove microorganisms as more responsible for healing failure than the number
of appointments utilized. Trope et al. (77) studied the results of 556 cases that exhibited periapical
lesions prior to treatment. The teeth were divided into 3 groups, one group treated in a single visit, a
second treated in two visits, and the third treated in two appointments with calcium hydroxide placed in
the canal for at least one week. After one year, evaluated by culture samples, the calcium hydroxide-
treated cases were judged to be successful in 74 per cent of those teeth whereas the one-visit cases
were successful in 64 per cent. The group treated in two appointments without calcium hydroxide had
the poorest results. However, the authors stated that due to the difering teeth treated, no statistical
analysis could be ofered. However, the total percentages of success were much lower than reported in
many other reports.
Saleh et al.
(78)
prepared canals, verifed sterility, and then placed a suspension of Entoerococcus
faecalis prior to canal flling at that appointment. Those teeth using sealers with strong antibacterial
properties gave the best results. However, the authors warned that sealers high in antibacterial contents
may be cytogenic or even mutagenic. AH Plus and Grossmans sealer were considered the most reliable
for antibacterial action with safety. Insertion of calcium hydroxide decreased the number of bacteria in
the canals, but did not kill all the bacteria in the tubules.
Nair et al.
(79)
, in an impressive study with beautiful color sections, evaluated treatment of 16 MBRs of
maxillary frst molars (a low number) with two canals and periapical disease in vivo. Immediately
following the single-appointment therapy, the treated roots were surgically removed and evaluated
microscopically. Multiple areas of canals revealed complex confgurations with sites uninstrumented and
many microbes. The authors speculated that treatment of this type of root in a single appointment with
impressive decrease of bacteria is highly questionable. They quoted a study by Bystom and Sundqvist in
1981 that reported considerable debris, and microbes were noted in treated MBRs after fve
appointments. The conclusion by Nair was that the development of a bacteria-free MBR with presently
used techniques is doubtful, particularly if using a single-treatment technique.
Waltimo et al.
(80)
reported in 2005 on an extension of the Saleh study
(78)
with several coauthors of the
previous work. The study divided 50 teeth with chronic apical periodontitis into 3 groups. One group had
one-visit treatment, the second had calcium hydroxide used as a medication for one week and the tooth
treated in two appointments, and the third leaving the canal empty but sealed for one week. Only minor
diferences were found in the groups after one year, but the teeth where sodium hypochlorite was used
as irrigant rather than calcium hydroxide being placed showed much better results. Calcium hydroxide
has been recommended as intracanal medicament for the last 10 years, but this study had a diferent
fnding.
A widely informative study, with clear delineations and a proper cross section with ample post-operative
follow-up evaluations, could be extremely valuable to every dentist who performs endodontic treatment
and will allow the decision-making to be based on suitable criteria
(81)
.
Conclusions
Endodontic therapy has reached a very high level of knowledge and usage in the past 10 years, even
though the number of teeth requiring the treatment has probably decreased. The new instruments make
treatment easier and the increased knowledge concerning the number and direction of the canals in
each tooth is more apparent by recent studies and better radiology. It is very likely that newer
replacements for gutta-percha involving synthetic materials is just over the horizon. Very few areas of
dental treatment have had as much progress in evaluation and treatment in the last few years than has
endodontics. I hope that this will continue for the near future, as well.
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Legends
Figure 1. a, Mandibular second molar, immediate post-flling view, canals flled with laterally condensed
gutta-percha and Wachs Paste. Note periapical radiolucency present. Although I did not know it at that
time, this tooth probably was a C-shaped second molar, a difcult tooth to treat, especially when I didnt
realize what I was dealing with. Note that the mandibular frst molar has furcation involvement. b,
Twenty-two years later, periapical lesion is perfectly healed, and treated tooth supports a fxed bridge.
The frst molar had been extracted for periodontal reasons and if the second molar was not treated
properly, the patient certainly would have masticatory difculties.
Figure 2. a, Preoperative radiograph of mandibular second bicuspid, indicating poor canal flling
performed 5 years early and periapical involvement. b, Tooth was treated and canal flled with gutta-
percha and Wachs Paste. c, Radiograph taken 27 years later, indicating perfect healing. d, Radiograph
taken 34 years after treatment, still excellent healing.
Figure 3. Present landmarks for standardized endodontic fles as determined by Ingle and International
Standardization Organization after many years with total lack of conformity among the manufacturers.
The tip of the fle at the frst rake angle is referred to as D0 (had been called D1 initially by Ingle) and 16
mm up the shaft from that site is referred to as D16 (was referred to as D2), where futes are often halted.
Depending on how far up the futes cease, that number is combined with Dsub whatever the distance
to the rake angle. The width of the futes between D0 and D16 expands by .02 mm per mm of length.
Therefore, every mm of length equals .02 mm of width, meaning that the fle had a .02 taper of futes.
Other lengths still used the .02 taper, but might have a diferent subscript determined by the length of
futes on the given fle.
Figure 4. Leeb2 stated that the conception that canals are wide at the orifce and then become more
narrow towards the apex is erroneous. He determined that often the width at the canal orifce was
responsible for the difculty of small fles reaching the apex rather than the width at the apex. This was
due to narrowing of the orifce due to deposition of reparative dentin in heavily restored teeth. Apical to
this site, the canal gradually widens and then narrows closer to the tip. He advised that the orifce area
be widened early in the canal preparation phase to give more coronal room for the fles to penetrate.
Figure 5. Weine, et al., introduced zip and elbow as new endodontic terms in their paper in 19753.
The study showed that canal preparation in relatively straight canals and those with canal curvatures of
30 degrees or more was totally diferent. In the canal with greater degrees of curvature, when the
preparation was completed, the narrowest level was not at the apex, but in the middle of the curve
usually 2 to 5 mm from the apexwhich they called the elbow. The canal then widened towards the
apex and the end of the preparation was called the zip because of the irregularity that developed. The
fles removed more tooth structure on the inside of the curve above the elbow, but attempted to
straighten there and thus took of more tooth structure on the outside of the curved between the zip and
the elbow.
Figure 6. a, Difering types of NiTi fles: Style manufactured by Denstply/Tulsa, using a slight change in
colors of the shaft as compared to colors used in regulation-type instruments and a diferent tapering
system. b, Style manufactured by Dentsply/Maillefer with a striped color as used with regulation fles and
a tapering systems with smaller total increments. c, Mc-Xim fles as made by New Technology. The frst
2 sets of instruments are still made and popularly used. The Mc-Xim system had fles with difering
degrees of taper and a large number of basic fles. However, it did not receive good acceptance by
clinicians and has undergone several changes in design and shape.
Figure 7. Other types of NiTi instruments. After the popularity of the .04 tapered instruments was
established, many new designs were introduced. One system had tapers greater than .04, (top to
bottom) .10 taper, .08 taper, .06 taper, and comparison to the .04 taper. Note that the wider tapers have
a shorter length of futes than the .04 taper to concentrate cutting in the orifce area. The wider tapers
should be used with great care, because they work quickly and make a larger hole.
Figure 8. The SX fle (bottom) as compared to fnishing fles (two top fles). The fnishing fles have 21
mm fute lengths, whereas the SX has a 19 mm fute length. Instead of a uniform taper, these
instruments have a wider taper at the top of the futes and the degree of taper decreases toward the tip.
In very curved canals, I prefer to clip an additional 2 mm of the tip of the SX to lessen any chance of
breakage in the elbow area.
Figure 9. Clinical action of SX fles in the decreasing of canal curvatures. a, Maxillary frst molar with
initial fles (#10s in the buccal canals) placed to the apex. The curvatures are approximately 45 degrees
in the MB and 35 degrees in the DB. Note that the fles cross within the access opening. b, After only
minimal use in the buccal canals with the SX fle, against the mesial wall of the MB and the distal wall of
the DB, note that the same fles have decreased curvatures. Now the fles in the canals cross outside of
the access cavity.
Figure 10. Torque control electric engine for use with tapered, rotary fles. The rpm readout is on the
control box and should indicate a speed of 300 to 450 rpm.
Figure 11. Treatment of mandibular second molar with NiTi instruments. a, Mandibular second molar
with pocket to the apex on distal surface of distal root with moderate mobility. b, Initial fles in place, #15
in distal root and #10 in mesiolingual root. Note that the curvature of fle in mesial root is approximately
45 degrees. c, Mesiolingual canal was enlarged as indicated in Fig. 12 and fle in place now has a
curvature of approximately 30 degrees or less, much easier to treatment than 45 degree curvature. d,
Files in place in all 3 canals. e, Canals flled with gutta-percha, post room prepared in distal canal. f, The
referring dentist was unsure of the outcome for the tooth due to the distal pocket (I was not worried), so
a temporary bridge was made. This radiograph, taken 6 months after treatment, indicated excellent
healing of the tooth, now very tight. g, The radiograph taken 30 months after treatment indicates perfect
healing.
Figure 12. Files used between Fig. 11 b and c. From top, size #10 fle, clipped #10 now #12, #2 NiTi
tapered, rotary fle to middle of curve, back with #12 to apex, #3 rotary fle, back with #12 to apex, #4
rotary fle, back with #12 to apex. Rotary fles were manufactured by Dentsply/Tulsa. Exact use of fles
listed as Case One.
Figure 13. Treatment of frst molar with NiTi instruments. a, Maxillary frst molar with pocket to the apex
of mesial root. Distal canal has curvature of approximately 45 degrees, mesial canals have lesser
curvatures. Tooth treated according to text, Case Two, with ample use of SX fle. b, Angle view of canal
flling, post room in distal root. c, Radiograph taken 6 months after completion of treatment, lesions
healing very well. d, Radiograph taken 4 years after treatment, excellent healing, no lesion associated
with mesial root and no probing possible.
Figure 14. Files used in initial treatment of case shown in Fig. 13. From top, size #10 fle, clipped #10
now #12, SX fle clipped 2mm, #15 rotary fle to center of curve, SX fle, back with #12 to apex, #20
rotary fle, SX fle, back with #12 to apex, #25 rotary fle, SX fle, back with #12 to apex, regular #20 fle
drops in easily. Exact use of fles listed as Case Two.
Figure 15. Treatment of double curvature. Extremely difcult case, requiring exhaustive use of SX fling
to widen access in a buccal-lingual direction, heavy use of irrigation and lubricants, and clipping to make
intermediate fles.
Figure 16. a, Diagrammatic representation of 4 types of canal confgurations that depict 99.5% of the
conditions found in human teeth, views from the proximal (views rarely seen in most clinical cases). The
major canals only are shown, not auxiliary or lateral canals, or apical delta. From left to right, Type I
canal system, single canal from orifce to apex. Type II canal system, 2 canals at orifce merging to form
a single canal short of the apex. Please note that left canal appears to be straighter and will be the
master canal, with the right canal flled into it. Type III canal system, 2 separate and distinct canals from
orifce to apex. Type IV canal system, single crown from orifce, dividing into 2 separate canals short of
the apex. b, Vertical ground section of maxillary 1st molar with a single canal (Type I). c, Vertical ground
section of maxillary 1st molar with 2 canals at orifce merging into a single canal at the apex (Type II). d,
Vertical ground section of maxillary 1st molar with 2 canals at orifce, separate and distinct to apex (type
III). (No type IV canals were found in 1969 study.) e, Radiograph of Type I canal in maxillary 1st molar. f,
Radiograph of Type II canal in maxillary 1st molar. g, Radiograph of Type III canal in maxillary 1st molar.
h, Radiograph of Type IV canal in maxillary 1st molar. Figs. e through h had roots other than MB root
removed for clarity. (Obviously fle placement in Fig. h could not occur in a clinical case, but merely
shows that a Type IV in this tooth is possible.)
Figure 17. a, Key radiograph of maxillary frst molar to know if two canals in the mesiobuccal root is from
the distal. Post-flling radiograph clearly demonstrates two canals flled in MB root. Note that the
distobuccal canal is mesial to the palatal canal. b, Working lengths on the frst molar canals were 18 to
19mm. One-year post-operative flm taken from the distal clearly shows 2 canals in MB root and
periapical lesion, present before treatment, almost completely healed. Note that DB canal is also mesial
to palatal canal.
Figure 18. Maxillary second molars with 2 palatal roots. a, Sixteen-year postoperative flm of maxillary
posterior area. Second molar has 4 flled canals, one to the left is the mesiobuccal, one to the right is
distobuccal, and two palatal canals between them. Both the second molar and second bicuspid (to left)
had large lesions before treatment. b, Four canals in maxillary second molar. From right to left (viewed
slightly from distal), mesiobuccal, mesiolingual, distobuccal, and distolingual.
Figure 19. Mandibular frst bicuspid with 2 canals. a, Preoperative straight-on radiograph indicates a
large canal in crown of the tooth, but it almost disappears in the root. This site of disappearance is where
the canal divides into a Type IV system. b, Lateral view of an extracted maxillary frst bicuspid of a
similar tooth, indicating a dividing canal system. c, One-year postoperative flm of tooth shown in a. d,
Ten-year postoperative flm.
Figure 20. Most endodontic textbooks through the 1960s advised that the access cavity for entry into
the maxillary frst molar be triangular in shape. Such an access makes location and preparation of the
distal portion of the tooth, which contains one wide, kidney-bean shaped canal or two canals, quite
difcult. The correct access is a trapezoid with rounded corners for better access to the distal root or
roots.
Figure 21. Mandibular second molar with 4 distinct canals. Note the second separate and distinct canal
to the distal with a sharp curve that would be difcult to locate and very difcult to prepare and fll.
(Endodontic treatment by Dr. Brad Gettleman, Glendale, AZ.)
Figure 22. C-shaped mandibular second molars, frst reported by Cooke and Cox
37
. a, Two canals, one
to the mesial and one to the distal. b, Three canals merging at the apex. c, Three canals, two distals
merging and mesial canal separate and distinct.
Figure 23. Maxillary frst bicuspid with three canals. Most often when this condition occurs, the three
canal orifces can be found on the foor of the chamber and the confguration is similar to a small
maxillary second molar. The confguration in this tooth, however, is much more difcult because only two
orifces can be found on the foor of the chamber and the canals divide in midroot, similar to a Type IV
system.
Figure 24. Treatment of maxillary second bicuspid with Type IV canal system. a, Preoperative flm of
posterior maxillary teeth with periapical areas on second bicuspid and second molar. Please note that
the canal in bicuspid seems to disappear toward the apex, typical of Type IV canal system. b, Initial fles
placed seemed to indicate a Type II canal system because the fle in palatal canal seemed to engage
the fle in buccal canal near the apex or vice versa. However, further manipulation proved that the wide
canal split into 2 canals near the apex. c, Immediate postoperative flm, slight angle from the distal,
shows 2 canals flled near the apex, a Type IV system. d, Six years after treatment of both teeth,
excellent healing of both.
Figure 25. Angled radiograph of mandibular incisors treated after locating two separate and distinct
canals. A straight-on preoperative radiograph would never pick this up and the lingual canal probably
would be missed. Note the access to the roots with this confguration goes through the incisal edge.

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