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Review Article

Radix entomolaris and paramolaris in children:

A review of the literature
Nagaveni NB, Umashankara KV1

Abstract
Pediatric dentistry in the current scenario is not just about
teeth and gums that are easily visible in childrens mouth
anymore. It is all about those structures that are hidden,
difficult to identify, and often remain undiagnosed. Dentist
can come across various anomalies pertaining to the crown
structure during the clinical practice. Although supernumerary
tooth is the most commonly seen anomaly, the presence of
extra roots in molars is an interesting example of anatomic
root variation. It is well known that both primary and
permanent mandibular first molars usually have roots, one
mesial, and the other distal root. Very rarely an additional
third root (supernumerary root) is seen and when it is located
distolingually to the main distal root is called radix entomolaris
(RE) and when it is placed mesiobuccaly to the mesial root
is called radix paramolaris (RP). The purpose of this article
is to discuss the prevalence, morphology, classification,
clinical diagnosis, and significance of supernumerary roots
in contemporary clinical pediatric dentistry.

Key words
Distolingual root, endodontic treatment, extra third root,
periapical radiographs, radix entomolaris, radix paramolaris

Department of Pediatric and Preventive Dentistry, College of

Dental Sciences, 1Department of Oral and Maxillofacial Surgery,
Bapuji Dental College and Hospital, Davangere, Karnataka,
India.
Correspondence:
Dr. N. B. Nagaveni, Department of Pediatric and Preventive
Dentistry, College of Dental Sciences, Davangere, Karnataka,
India. E-mail: nagavenianurag@gmail.com

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DOI:
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overall benefit to a child patient because when they are

present are highly challenging to diagnosis as well as
to endodontic treatment. The purpose of this article
is to discuss the prevalence, morphology, classification,
clinical diagnosis, and significance of supernumerary
roots in contemporary clinical pediatric dentistry.

Introduction

Review of the Literature

Molars are frequently affected by caries at an early

age and may require successful endodontic treatment
for their long-term retention in the oral cavity. The
objective of pediatric endodontic therapy is thorough
removal of the pulp tissue from all the roots and canals
followed by chemo-mechanical cleaning and filling
with a suitable material. Failure to diagnose and treat
the extra roots in molars may lead to the endodontic
treatment failure and even tooth loss at an early age
resulting patient to suffer functionally, esthetically, and
psychologically. Therefore, pediatric dentist must be
aware of these unusual root structures to provide the

Synonyms

94

Radix entomolaris (RE) an additional third root was

first mentioned in the literature by Carabelli[1] in 1844
and is described by various terms, such as extra third
root or distolingual root or extra distolingual root.[2]
Radix paramolaris (RP) is known as the mesiobuccal
root[3] was first described by Bolk[4] in 1915.

Prevalence of RE and RP
Various prevalence studies have been done using
periapical radiographs,[5-9] extracted teeth[10-14] recently
by microcomputed tomography (micro-CT),[15-17] and

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Nagaveni, et al.: Supernumerary roots in mandibular molars

cone-beam computed tomographic images (CBCT)

[Table 1]. [18-21] Therefore, interstudy variations
can be seen among different surveys. In periapical
radiographic method it is not easy to identify the extra
root, as superimposition of two roots occur resulting
inaccurate diagnosis. In the case of extracted teeth,
teeth might fracture during the extraction procedure as
they are more slender and curved. From studies based
on extracted teeth,[10-14] it was impossible to compare
precisely the prevalence related to gender and bilateral
occurrence of three-rooted permanent first molars. It
has been speculated that recent studies using advanced
techniques showed higher prevalence compared to
previous 2D image studies;[15-20] the reason could be
attributed to the use of 3D image analysis, which
provides more accurate determination.

Ethnic differences in permanent molars

The existence of RE/RP in permanent mandibular first
molar is associated with certain ethnic and racial groups.
The dentist therefore must be aware of racial anatomic
variations when diagnosing and managing endodontic
patients because he/she may see patients of diverse
ethnicities daily. Tu et al.[5] found a prevalence of 21.1%
using periapical radiographs and 33.33% using the conebeam computed tomography in Taiwanese subjects.[18]
Compared with the prevalence of the permanent threerooted mandibular molars in Taiwanese individuals,
33.33% data of the prevalence in the Tu et al.[18] study
are higher than those 2D image study by Tu et al.[5] By
using extracted teeth, Walker and Quackenbush[22] found
a prevalence of 14.6% in Hong Kong Chinese and Loh[10]
found a prevalence of 7.9% in Singapore Chinese subjects.
A maximum frequency of 3% is documented in the African
population[23] while in Eurosian and Indian populations
the frequency is less than 5%.[14] In Mangoloid traits
such as Eskimo, Chinese, and American Indians, it has
been reported that RE seen with a frequency ranging
from 530%.[14,22-27] Because of its high prevalence in
these populations, the RE is considered to be a normal
morphological variant (Eumorphic root morphology).
In Caucasians low frequency of 3.44.2% has been
found and considered to be unusual or dysmorphic root
morphology[9,28] [Table 1].

Prevalence of three roots in primary molars

Most previous surveys into the occurrence of an
extra root investigated extracted teeth, and hence
considered mainly permanent molars and virtually no
primary molars.[10-14] Analyzing the root configuration
in primary molars can be difficult because of the
presence of physiologic or pathologic root resorption,

and extracting primary molars with sound roots is

difficult because of root divergence. Therefore, fewer
studies have investigated the incidence of third roots
in the primary molars.
The prevalence of root variations is lower in the
primary dentition than in the permanent dentition.
There are several case reports[29,30] on the existence of
three-rooted primary mandibular molars but studies
of the prevalence of extra roots are few in number.
Tratman[14] reported that three-rooted mandibular first
molars are rare with a frequency of <1% in the primary
dentition and common in the permanent dentition.
Curzon and Curzon[31] suggested that the incidence of
primary anomalies is higher in Native American than
white populations. 21.1% of Taiwanese (Chinese) have
permanent three-rooted mandibular molars, but there is
little information on primary three-rooted mandibular
molars in those of Mongolian descent.[5] Jorgensen[32]
reported seven cases (0.67%) of an additional root in 1041
second primary molars extracted from Danish subjects.
Tratman[14] found no extra root in samples collected
from Europe and India, but found an additional root in
3 of 42 second primary molars (7.1%) from Japanese
subjects. A Japanese radiographic study revealed that
5.6% of 1408 samples of mandibular primary first
molars had an additional distolingual root.[33] In a study
by Tu et al.[34] the prevalence of supernumerary root
in primary first molars of Taiwanese children was 5%.
Recently Song et al.[35] found a maximum prevalence
of 27.8% and 9.7% of second primary and first primary
molars respectively in Korean children and Liu et al.[36]
reported 18 (9%) cases of three-rooted primary second
molars in Chinese subjects [Table 1].
Although extra root can be found in both first and
second molars of the primary dentition, there is
no definitive proven study showing whether the
presence of RE in primary molars, indicates extra
root in permanent molars, although the commonly
hypothesized field of development influence suggests
that this is the case. A long-term prospective study
involving the primary and permanent molars certainly
would add to the present knowledge. However,
recently Song et al.[35] assessed the incidence and
relationship of an additional root in the mandibular
first permanent molar and primary molars in 4050
children examined. They found additional roots in
33.1%, 27.8%, and 9.7% of the first permanent, second
primary, and first primary molars, respectively, and
concluded that when an additional root was present
in a primary molar, the probability of the posterior

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Nagaveni, et al.: Supernumerary roots in mandibular molars

Table 1: Survey of available studies showing prevalence of

3-rooted mandibular first molar

Table 1: cond...
Author/Year

Population group

Author/Year

Population group Incidence (%)

Taylor (1899)[54]
Bolk (1915)[4]
Campbell (1925)[55]

United Kingdom
Netherlands
Australian
Aborigine
South African
Bushman
African Bantu
Chinese
Malay
Javanese
Indians
Eurasians
Japanese
Malay
Greenland Eskimo
Danish
Canadian Indians
European
Japanese
Caucasian
Aleut Eskimo
American Indian
Keewatin Eskimo
United Kingdom
Baffin Eskimo
Guam
Japanese
Chinese
Malaysian
Thai
Hong Kong Chinese
Hong Kong Chinese
Japanese
Chinese
(Singapore)
Saudi
Egyptian
Japanese
Negroid
Caucasian
Chinese
Senegalese
Hispanic children
Burmese
Thai
Taiwanese
Korean
Primary molars
(first and second)
Permanent first
molars
Germanese
Taiwanese

Liu et al. (2010)[36]

Garg et al. (2010)[51]
Song et al. (2010)[21]
Yang et al. (2010)[62]
Peiris et al. (2007)[63]
Huang et al. (2010)[64]

Chinese
Indian
Korean
Shanghai Chinese
Sri Lankan
Taiwanese

Drennan (1929)[56]
Shaw (1931)[57]
Tratman (1938)[14]

Laband (1941)[13]
Pedersen (1949)[24]
Jorgensen (1956)[32]
Somogyi-Csizmazia and Simons (1971)[38]
de Souza-Freitas et al. (1971)[37]
Skidmore and Bjorndahl (1971)[58]
Turner (1971)[25]
Curzon and Curzon (1971)[26]
Curzon (1973)[28]
Curzon (1974)[42]
Hochtstetter (1975)[12]
Sugiyama et al. (1976)[33]
Jones (1980)[11]
Reichart and Metah (1981)[27]
Walker and Quackenbush (1985)[22]
Walker (1988)[59]
Harada et al. (1989)[52]
Loh (1990)[10]
Younes et al. (1990)[60]
Ferraz and Pecora (1992)[9]

Yew and Chan (1993)[8]

Sperber and Moreau (1998)[23]
Steelman (1998)[39]
Gulabivala et al. (2001)[7]
Gulabivala et al. (2002)[6]
Tu et al. (2007)[5]
Song et al. (2009)[35]

Schafer et al. (2009)[61]

Tu et al. (2010)[34]

3.4
1
0
0
0
5.8
8.6
10.9
0.2
4.2
1.2
8.2
12.5
0.67
16
3.2
17.8
2.2
32
5.8
27
3.4
21.7
13
5.6
13.4
16
19
14.6
15
18.8
7.9
2.92
0.01
11.4
2.8
4.2
21.5
3
3.2
10.1
13
21.09
9.7, 27.8

9
5.97
24.5
32.35
3
22

adjacent molar also having an additional root was

greater than 94.3%.

Gender differences
Gender predilection for an additional root in the
first permanent molar has been reported by several
investigators. Some claimed it to be a sex-linked,
dominant character and others reported that it has
no sex predilection. Most studies have found male
predominance.[36-39] However, others reported that the
prevalence of extra root was similar in both sexes[10,34,36]
or rather more in females.[5] Tratman[14] mentioned
that it is more common on the right for the male and
bilateral for the female. Loh[10] did not show statistically
significant difference in predilection of RE for either
sex. Based on these reports, it is not common for RE
to occur symmetrically.

Topological predilection
The incidence of supernumerary roots in the first
permanent molar on the left and right side are variable
as seen from the reported studies.[14] Many studies
have found right-side predominance not only for the
permanent molar, but also for the primary molars.[5,14,39]
In contrast, some investigators reported a predilection
for the left side.[10]
Unilateral or bilateral occurrence of an additional
root is also a controversial issue. Some studies
reported bilateral occurrence of the RE ranging from
5067%.[5,10,36,39] According to Quackenbusch[40] and
other reports, this extra root occurred unilaterally in
approximately 40% of all cases and predominantly on
the right side. This is noticed in other reports also.[5,14,39]
This finding highly emphasized the fact that in treating
most right mandibular molars clinician always look for
additional distal root to prevent root canal treatment
failure.

33.1
1.35
5

Table 1: cond...

96

Incidence (%)

Prevalence of RE/RP in other Teeth

RE has been reported occurring in the first (7.4%),
second (0%), and third mandibular permanent molars

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Nagaveni, et al.: Supernumerary roots in mandibular molars

(3.7%) occurring with a least frequency or none on the

second molar.[41]
The existence of RP root variant is very rare and occurs
less frequently than the RE. It seems to be rare in Europian
and Mongolian populations.[41] Visser[41] found 0%
(0/1954) for the mandibular first molar, 0.5% (11/2086)
for the second and 2% (28/1405) for the third molar.

Etiology
The exact etiology behind the development of RE/
RP is still unknown. The literature suggests that,
in dysmorphic, extra roots, its formation could be
related to external factors during odontogenesis,
or to penetrance of an atavistic gene or polygenetic
system whereas in eumorphic roots, racial genetic
factors cause more profound expression of a particular
gene that results in the more pronounced phenotypic
manifestation.[27] The high degree of RE in Mongoloid
populations has provoked more specific analyses of
the heritable basis of this supernumerary radicular
structure by various authors.[14,36,37] More specifically,
only Curzon[42] suggested that certain traits such as
the three-rooted molar had a high degree of genetic
penetrance as its dominance was reflected in the fact
that pure Eskimo and Eskimo/Caucasian mixes had
similar prevalence of the trait.

Morphology of RE and RP
The identification and external morphology of RE
and RP root complexes are described by Carlsen and
Alexandersen.[3,43] RE is found distolingually with its
coronal third completely or partially fixed to the distal
root. It usually appears smaller and more curved than
the distobuccal or mesial root and is located in the same
transverse plane as the two other roots.[Figure 1] This

Figure 1: Morphology of RE from different aspects (arrows)

suggests that dentists must pay special attention when

considering root canal treatment and/or extraction
for a molar with RE. The dimension of RE can vary
from a short conical extension to a mature root with
normal length and root canal [Figure 2].[2,43] It is crosssectionally more circular than the distal root, projected
lingually about 45 to the long axis of the tooth, and
has the type I canal system.[2,43] In most cases, the pulpal
extension is radiographically visible. In the apical two
thirds of the RE, a moderate to severe mesially or
distally oriented inclination can be seen in addition to
this inclination the root can be found straight or curved
to the lingual. Tratman[14] stated that RE is not simply
a division of the distal root but rather is a true extra
root with a separate orifice and apex.
RP is seen buccally to the mesial root and may be found
separate or fused with the mesial root.[Figure 3] The
dimensions of the RP can vary from a mature root
with a root canal, to a short conical extension.[3] This
additional root exists in two forms as separate and
nonseparate.[3]

Classification of RE and RP
RE a distolingual root exhibit diverse morphologic
features varying from severe curvature [2] to an
underdeveloped conical form.[21] De Moore et al.[2]
classified RE based on the curvature of the root or
root canal in bucco-lingual orientation (separate RE)
evaluated from 18 extracted human teeth into three
types [Table 2]. In 1991, Carlson and Alexandersen[43]
classified four types of RE (A, B, C, and AC), based on
the location of the cervical portion of the root and this
helps in identification of separate and non separate RE
[Table 3]. Recently in 2010 Song et al.[21] have suggested
a new classification based on morphologic characteristics

Figure 2: Radix entomolaris in permanent right first molar (arrow)

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Nagaveni, et al.: Supernumerary roots in mandibular molars

Figure 3: Radix paramolaris in permanent right first molar (arrow)

Table 2: Classification of RE, based on its curvature[2]

Types Description
I
II
III

A straight root and canal

Initial entrance is curved but the root is straight
The coronal third of the root canal is curved; in addition, there is a
second, buccally oriented curve from the middle to the apical third.

Table 3: Classification of RE, based on the location of its

cervical portion[43]
Types Description
A
B
C
AC

Located distally, with two normal distal root components

Located distally, with one normal distal root component
A mesially located cervical part
A central location, between the distal and mesial root components

Table 4: New classification of RE[21]

Types

Features

Type I
Type II

No curvature
Curvature in the coronal third and straight continuation to the
apex
Type III
Curvature in the coronal third and additional buccal curvature
from the middle third to the apical third of the root.
Small type Root length less than half that of the distobuccal root.
Conical type Cone-shaped extension with no root canal

Table 5: Classification of RP[3]

Types Features
A

Refers to an RP in which the cervical part is located on the mesial root

complex
Refers to an RP in which the cervical part is located centrally, between
the mesial and distal root complexes.

assessed from cross-sectional computed tomography

technique [Table 4].
Carlsen and Alexandersen[3] classified RP into two
types by examining 203 permanent mandibular molars
with root complexes containing RP [Table 5].
98

Figure 4: Evidence of RE (c) and RP (d) in radiographs taken with

angulation. They are not evident on conventional radiographs
(a and b)

RE in Association with Other Anomalies

Some reports[23,44] showed that RE in the first molars
occurred in association with additional cusp usually
on the buccal side (protostylid). Therefore, it has been
suggested that extra root is nearly always associated
with an increased number of cusps and with an
increased number of root canals.[44] However, an
increased number of cusps are not necessarily related
to increased number of roots. George etal.[45] reported
simultaneous occurrence of shovel-shaped incisors,
three-rooted primary and permanent molars, talon
cusp and supernumerary tooth in a 7-year-old Hispanic
male patient. Whereas, Winkler and Ahmad[46] reported
multiroot anomalies including bifurcated maxillary
primary canine, primary three-rooted first molar and
bilateral primary three-rooted first and second primary
molars in Native Americans.

Examination of RE/RP
Clinical diagnosis
The crown and the two normal roots of a molar with a
distolingual/mesiobuccal root are very similar to those
found in a normal molar.[44] Hence, identification of RE/
RP is not really possible from only a clinical examination
of the crown. The literature has reported that clinical
observation and analysis of the cervical morphology
of the roots by means of periodontal probing facilitate
identification of RE. It has also been reported that the
presence of an extra cusp (tuberculum paramolare) or
more prominent occlusal distal or distolingual lobe, in

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Nagaveni, et al.: Supernumerary roots in mandibular molars

combination with a cervical prominence or convexity,

can indicate the presence of an additional root.[44] If
an RE or RP is diagnosed before endodontic treatment,
one knows what to expect or where to look once the
pulp chamber has been opened.

periodontal implications of extra roots in permanent

mandibular first molars.[44-46,48,49] The same caution
should be followed in the treatment of primary
mandibular molars with accessory roots as permanent
mandibular molars.

There are various methods to locate the orifice of

the extra roots. They can be listed as knowledge of
law of symmetry and law of orifice location, tactile
sensation with hand instruments, using various
instruments like endodontic explorer, path finder,
DG 16 probe and microopener, use of fiber-optic
illumination dental endoscopy, intraoral camera,
using surgical loupes, using operating microscope,
microcomputed tomography, and magnetic resonance
microscopy.[44]

Endodontic implications

Radiographic diagnosis
Anatomical variations of roots in the mandibular first
molar may be identified by reading radiographs carefully.
An accurate diagnosis of RE/RP is very important to
avoid complications or missing of canal during RCT. As
the RE/RP is mostly located in the same bucco-lingual
plane as the other two roots, a superimposition of both
roots can appear on the preoperative radiograph and
remain undiagnosed.[2,3,44] A thorough examination
of the preoperative radiograph and interpretation of
particular marks or characteristics, such as an unclear
view or outline of the distal/mesial root contour
or the root canal, can suggests the presence of a
hidden RE/RP.[44] Ingle et al.[47] has recommended
a thorough radiographic study of the involved tooth,
using exposure from the standard buccal-to-lingual
projection, one taken 20 from the mesial, and the third
taken 20 from the distal to obtain basic information
regarding the anatomy of the tooth. [Figure 4] Loh[10]
has claimed that the RE/RP does not normally appear in
periapical radiographs that are taken in the traditional
manner. Adjusting the exposure time and dose of
the x-ray and angulating the main beam (to avoid
superimposing the larger distobuccal/mesial root) can
to help make RE/RP more evident although accurate
interpretation of radiographs depends on the trained
eye.[10] A 1985 study by Walker and Quackenbush[22]
claimed that panoramic radiographs resulted in an
accuracy rate of approximately 90%.

Significance of RE/RP in clinical pediatric

dentistry
Apart from its role as a genetic marker, RE/RP has
significance in clinical pediatric dentistry. Many
studies have discussed the endodontic, exodontic, and

Root canal treatment should result in the thorough

mechanical and chemical debridement of the entire pulp
cavity, followed by complete obturation with a hermetic
seal. As a result, RE/RP pose a great endodontic
challenge, as incomplete pulp extirpation due to missed
canal can result in treatment failure. Dentists should be
familiar with multiple root anatomy to avoid missing
canals.
With RE, the conventional triangular access cavity
opening must be modified to take the form of a trapezoid
or rectangular form to better locate and access the
distolingual orifice of the additional root.[2,44] A severe
root inclination or canal curvature, particularly in the
apical third of the root (in type III RE), can cause shaping
aberrations such as straightening of the root canal or a
ledge that displays a loss of working length in the ledge
canal. Calberson et al.[44] recommend using flexible nickel
titanium rotary files to increase the chance of centering
the canal third and orifice relocation. Nevertheless,
unexpected complications (such as instrument separation)
occur and are more likely to happen in the RE due to the
severe curvature or narrow root canals. Therefore, after
relocation and enlargement of the orifice of the RE,
Calberson et al.[44] suggested initial root canal exploration
with small files (size 10 or less), determining the working
length of the curved root, and creating a glide path before
preparation to avoid procedural errors.
It also has been reported that regardless of the type
of root canal, the orifice of the RE can be located
distolingually from the root canals in the main distal root.
In 2009, Tu et al.[18] did a prevalence study in Taiwanese
subjects using cone-beam computed tomography and
estimated the interorifice distance of all canals in
mandibulat first molar with RE. The mean interorifice
distances from the distolingual canal to the distobuccal
(DB), mesiobuccal (MB), and mesiolingual (ML) canals
of the permanent three-rooted molars were 2.7, 4.4, and
3.5 mm, respectively. These values might help dentists
to locate orifices and to achieve successful endodontic
treatments of permanent molars with distolingual root.
In the case of RP, the access cavity must be extended in
mesiobuccal direction that involves modification in access

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Nagaveni, et al.: Supernumerary roots in mandibular molars

cavity from triangular to rectangular or trapezoidal form

in order to better locate and access the canal of this root.
[3,44]
The same precautions and procedure should be
followed as in RE during endodontic procedure.

Exodontic procedure
During extraction of primary molars with three roots,
the clinician should make sure that the crown of the
premolar is not trapped in the inter-radicular area
of the primary molar as this could cause accidental
removal of the developing permanent tooth bud.[46]
After the extraction, dentist should examine the
extracted anomalous primary molar to confirm that
all roots have been retrieved.
Extraction of permanent first molar with RE is difficult
compared to the molar without RE. If rotational
movements are used, root fractures could occur. It is
expected that an extra distolingual root would fracture
during extraction due to its divergent and curved form.[2]
The low incidence of distolingual roots documented
previously is probably because the roots curvature was
in the line of extraction movements and withdrawal.[10]
A 2004 study[50] suggested that molars are extracted
more frequently than anteriors and premolars among
some races because those groups have a higher prevalence
of three-rooted mandibular first molars, combined with
the possibility of misinterpretation of extra distolingual
root aberrations during root canal treatment.

Orthodontic implications
Other clinical difficulties resulting from distolingual
root would relate to orthodontic procedures, where the
extra root would render movement difficult.[10,49] It is
also hypothesized that the presence of extra root (RE)
adds to the stability of molars by providing an increased
surface area of attachment to the alveolus.[10,49]
Since it is not known whether abnormal root
configurations like three-rooted molar affect, the normal
exfoliation of the primary teeth, it is unclear whether
these anomalous teeth present orthodontic problems.

RE as a contributing factor to localized

periodontitis
According to Huang et al.[48] RE may be a contributory
factor in localized periodontal destruction. In their
study, patients with a distolingual root demonstrated
significantly greater probing depth and attachment
loss at distolingual sites than at distobuccal sites.
Molars with RE demonstrated greater loss around the
100

distolingual root compared with molars that had only

one distal root.

Forensic odontology
The presence of a third root, whether primary or
permanent may have forensic value for identifying
people of the Mongoloid origin.[5,49]

Discussion
The present article reports 15 extra roots in mandibular
molars of Indian children that were diagnosed using both
periapical radiographs (12 cases) and extracted teeth
(three cases). There have been several reports of the
occurrence of supernumerary roots in both permanent
and primary mandibular molars of different populations.
But studies of the prevalence of extra root variants in
Indian population are few in number.[14] Garg et al.[51]
have found 5% prevalence of three-rooted permanent
mandibular first molars in Indian adult patients.
In the present report, the number of three-rooted
mandibular molars including both primary and permanent
did not show difference with gender, which is consistent
with findings of other reports of permanent first molars
done in Hong Kong Chinese,[22] Taiwanese,[5] and
Singapore Chinese[10] and Japanese patients.[9,52] However,
some studies found male predominance.[36-39] Only four
cases of three-rooted primary molars were diagnosed
with remaining 11 cases of extra roots in permanent
first molars. This finding is in accordance with the results
suggesting that three-rooted mandibular first molars are
rarer in primary than permanent dentition.[14,35]
Most of the three-rooted mandibular fist molars in
Asians show a bilateral occurrence.[5,10,36,39] Only one
patient of our report showed bilateral occurrence of
extra root in primary mandibular first molar. The
incidences of bilateral occurrence were 67.8%, 64.0%,
and 39.3% for the first permanent, second primary,
and first primary molars, respectively as shown in one
study.[35] Sabala et al.[53] reported that aberrant root
morphology in a given tooth is observed with varying
frequency in the corresponding contra lateral tooth, but
it is not found in mandibular primary first molars with
three roots. Tu et al.[34] found bilateral occurrence of
primary first molars (17.67%) less than the report by
Song et al.[35] Both Taiwanese and Korean populations
appeared much more unilateral occurrence of threerooted primary mandibular first molars than permanent
mandibular first molars do.[34,35]

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Nagaveni, et al.: Supernumerary roots in mandibular molars

The first morphologic classification of distolingual root

(RE) was established by De Moore et al.[2] who examined
extracted first molar and divided morphologic features
of third root into three types according to the pattern
of their curvature. They found two cases of type I, five
cases of type II, and 11 cases of type III. In contrast
to this, our study found 12 cases of type I, 1 case of
typeII, and 2 cases of type III. In case of mesiobuccal
root (RP), Carlsen and Alexandersen[3] found five cases
of type A and none of type B in the total 203 permanent
molars examined. Our study found only two cases of
type A mesiobuccal root.
Association of extra roots with adjacent molars was
not seen in none of the reported cases. One study done
by Song et al.[35] showed the relationship of extra roots
with adjacent molars and have suggested that when
an additional root was present in a primary molar, the
probability of the posterior adjacent molar also having an
additional root was greater than 94.3% that help to predict
the presence of an extra root in molars posterior to it.
For successful root canal treatment it is necessary to
locate all roots and canals as unfilled canals remain a nidus
for infection and can compromise treatment outcome.[31]
This was evident in three of our cases due to undiagnosed
and untreated third root [Figure 1]. Therefore, to make
RE/RP evident and for accurate diagnosis, a second
radiograph should be taken from a more mesial or distal
angle and clinician should be aware of the existence of
additional roots in molars of both dentition.
The limitation of the present report is that it provides
information about only 15 cases of extra roots in
mandibular molars. From this it is difficult to state
precisely the prevalence of extra roots in mandibular
molars of Indian children. Therefore, further studies
involving large samples are highly essential to assess
the prevalence of additional roots in group of children
from Indian origin which will add more knowledge to
the existing literature.

Conclusion
Dentists should take into account the prevalence of
extra root variants in both primary and permanent
mandibular first molars among children during their
routine endodontic and exodontic procedures. Before
initiating root canal treatment or extraction, clinician
should utilize two periapical radiographs (taken at
different angles) to confirm the presence of an extra
root in order to achieve the successful treatment.

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How to cite this article: Nagaven NB, Umashankara KV. Radix
entomolaris and paramolaris in children: A review of the literature.
J Indian Soc Pedod Prev Dent 2012;30:94-102.
Source of Support: Nil, Conflict of Interest: None declared.

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