Clinical Research

Cone-Beam Computed Tomography Study of Root and Canal

Morphology of Maxillary First and Second Molars in an Indian
Population
Prasanna Neelakantan, MDS,* Chandana Subbarao, BDS,* Roshni Ahuja, MDS,*
Chandragiri Venkata Subbarao, MDS,* and James L. Gutmann, DDS, PhD†

Abstract
Introduction: The aim of this study was to investigate
the root and canal morphology of maxillary first and
second molars in an Indian population by using cone-
beam computed tomography (CBCT). Methods: Maxil-
lary first (n = 220) and second (n = 205) molars were
collected from an indigenous Indian population and
scanned by using a CBCT scanner at a constant slice
thickness of 125 mm/slice. Volume rendering and multi-
planar volume reconstruction were performed. The
number of root canals was examined, and root canal
system configurations were classified by using historical
and contemporary classifications. Results: Single-
rooted first and second molars commonly showed
types I, IV (0.5%) and type III (1%) canal systems,
respectively. Buccal roots of two-rooted first molars
showed 2 canal systems, type I and type IV, whereas
second molars with 2 roots showed wide variations in
canal anatomy. The most common canal morphology
in the mesiobuccal roots of three-rooted first and second
molars was type I (51.8% and 62%, respectively), fol-
lowed by type IV (38.6% and 50%, respectively). The
distobuccal and palatal roots of first and second molars
showed predominantly type I canal morphology. Addi-
tional canal types were identified in 2.2% and 9.3% of
the first and second molars, respectively. Conclusions:
The root number, morphology, and canal morphology of
Indian maxillary molars showed features that were
different from both Caucasian and Mongoloid traits.
CBCT is an exciting and clinically useful tool in studying
root canal morphology. (J Endod 2010;36:1622–1627)
Key Words
Canal configuration, cone-beam computed tomography,
Indian, maxillary molar, root canal anatomy
R ecognition of variations in root canal anatomy is an essential prerequisite for
successful endodontic diagnosis and treatment. The complexities of internal
anatomy are often masked by the external surfaces, which have a relatively simple
and uniform anatomy (1). Internal complexities of the root canal are genetically deter-
mined and have definitive importance in anthropology (2), thereby necessitating the
identification of root canal morphologies of different ethnic populations.
The methods used in analyzing root canal morphology are canal staining and tooth
clearing (1, 3–5), conventional radiographs (6–8), digital radiographic techniques
(9–11), radiographic assessment enhanced with contrast media (12, 13), and more
recently, computed tomography (CT) techniques (14, 15) and modified canal
staining and clearing (16). An ideal technique would be one that is accurate, simple,
nondestructive, and most importantly, feasible in the in vivo scenario.
The applications of CT in endodontics were first reported by Tachibana and Mat-
sumoto (17) in 1990. CT uses a fan-shaped beam and multiple exposures around an
object to reveal the internal architecture of this object, thereby helping the clinician to
view morphologic features as well as pathology from different three-dimensional (3D)
perspectives. The distinct advantage of CT is that it allows for 3D reconstruction of root
canal systems. CT has been suggested as the preferential imaging modality in difficult
situations demanding localization and description of root canal systems because of
its ability to render 3D information (18–20). Cone-beam computed tomography
(CBCT) or digital volume tomography (DVT) uses an extraoral imaging scanner to
produce 3D scans of the maxillofacial skeleton at a considerably lower radiation
dose than conventional CT. CBCT has been shown to be more accurate than digital
radiographs in determining root canal systems. CBCT has also been used in vivo in
diagnosis and preoperative assessment (19–23).
The Indian population is generally considered to be a hybrid of several ethnic
groups with characteristics of Caucasian, Mongoloid, and Negroid races, which is
generally referred to as the Dravidian group (24). There are reports on the root canal
morphology of Indian mandibular molars and premolars (25, 26). There are no
reports, however, on the root and canal morphology of Indian maxillary molars by
using CT. The aim of this report was to study the root and canal morphology of
maxillary first and second molars in an Indian population by using CBCT.
Materials and Methods
Four hundred twenty-five maxillary molars were collected from dental practitioners
across the Indian subcontinent. The teeth belonged to indigenous Indians, and no teeth
from other minority ethnicities were included. The teeth were washed under tap water

From the *Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, Tamil Nadu, India; and
†
Baylor College of Dentistry, Texas A&M Health Science Center, Dallas, Texas.
Address requests for reprints to Dr Prasanna Neelakantan, Senior Lecturer, Department of Conservative Dentistry and Endodontics, Saveetha University, Plot 1500,
16th Main Rd, Anna Nagar West, Chennai, Tamil Nadu, India. E-mail address: prasanna@totaldentalcare.org.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.07.006

1622 Neelakantan et al. JOE — Volume 36, Number 10, October 2010

Figure 1. Classification of canal configurations according to Vertucci (3).
immediately after extraction and stored in distilled water with thymol
iodide crystals until the collection was complete. The process of collec-
tion was performed by a team of practitioners who understood the aims
of the study, and collection of every tooth was accompanied by a case
record stating and confirming the ethnicity of the patients. On the basis
of the morphology of the crown and the case records given by the prac-
titioners, the teeth were grouped into maxillary first molars (n = 220)
and maxillary second molars (n = 205). After this, the samples were
washed thoroughly under tap water and immersed in 2.5% sodium hypo-
chlorite for 5 minutes to remove adherent soft tissue.
CT Scans
All the teeth were scanned by a CBCT scanner (3DAccuitomo; J.
Morita Corporation, Osaka, Japan), with constant thicknesses of 125
mm/slice. The teeth were viewed both cross-sectionally and longitudi-
nally. Volume rendering and multiplanar volume reconstruction were
performed by using the Advantage Windows workstation (GE Systems,
Milwaukee, WI).
The following features were analyzed by 2 examiners (one
endodontist and one maxillofacial radiologist): number and
morphology of roots, number of root canals per root, root canal config-
uration (Vertucci classification; Fig. 1) (3), and additional classes
based on number of orifices, canals, and apical foramina (Gulabivala
classification; Fig. 2) (4). Inter-rater agreement was measured between
the endodontist evaluator and radiologist. Intra-rater agreement was
measured by having the endodontist and radiologist evaluate one half
of the CBCT images at each of 2 separate sessions.
Results
Number and Morphology of Roots
The most common morphology was that of 3 separate roots in
both the first (96.8%) and second molars (93.1%) (Table 1).
Single-rooted first and second molars were identified in 0.9% of the
teeth studied. Four separate roots were found in 0.9% of the first
molars, whereas no second molar had 4 roots.
Number of Root Canals and Canal Configurations
Both the examiners were consistent in reporting their findings
(100% intra-rater and inter-rater agreement).
Figure 2. Additional classes of canal configurations according to Gulabivala
(4).
JOE — Volume 36, Number 10, October 2010 Root and Canal Morphology of Maxillary First and Second Molars in an Indian Population
Clinical Research
In molars with 3 roots, the mesiobuccal (MB) roots showed
different canal configurations (Tables 2 and 3). The most common
was type I (51.8%), followed by type IV (38.6%). Four additional canal
types were identified in the first and second molars: 2-1-2-1, 2-3, 3-2,
and 3-1. In first molars with a single root, the incidence of type I and
type V configurations was equal (0.5%), whereas all single-rooted
second molars showed a type III canal system. Two-rooted first molars
showed 2 canal systems, type I (1%) and type IV (0.5%), whereas
second molars with 2 roots showed wide variations in canal anatomy;
the variation was commonly in the buccal (B) roots. Canal types I, II,
III, V and type 3-1 were identified in buccal roots of two-rooted maxil-
lary second molars. The palatal roots of first and second molars
commonly showed a type I canal system (88.1% and 87.8%, respec-
tively). The mesiopalatal (MP) and distobuccal (DB) roots of the
four-rooted first molars showed only type I canal system, whereas
0.5% of the MB and distopalatal (DP) roots showed type I canal config-
urations.
Discussion
This study provides a detailed report on the root canal morphology
of molars in an Indian population by using CBCT. CT is currently widely
used in implantology, maxillofacial reconstruction, and in endodontic
diagnosis before surgical endodontics as well as for assessment of canal
preparation, obturation, and removal of root fillings. A recent report
concluded that CBCT was as accurate as the modified canal staining
and clearing technique in identifying root canal morphology (25).
The main advantages of CT are that it is nondestructive and allows 3D
reconstruction and visualization of the external and internal anatomy
of the teeth (18–23). The slice thickness in CBCT ranges from
80–200 mm. The slice thickness used in our study was 125 mm. The
primary advantages of CBCT are significantly lower effective radiation
dose, short exposure time (2–5 seconds), less expensive than
conventional CT, and highly accurate. Furthermore, CBCT
measurements are geometrically accurate, owing to the fact that the
CBCT voxels (3D pixels containing data) are isotropic (18, 22).
TABLE 1. Number of Roots and Root Morphology in Maxillary First and
Second Molars
Maxillary Maxillary
No. and nature of roots first molar second molar
Single root 2 (0.9) 2 (0.9)
Two separate roots 3 (1.3) 12 (5.8)
Two fused roots 0 0
Three separate roots 213 (96.8) 191 (93.1)
Three fused roots 0 0
Four separate roots 2 (0.9) 0
Four roots where 2 or 3 0 0
roots are fused
Total 220 205
Values indicate number of teeth in which each of the features was identified.
Values within parentheses are percentages (% of total number of teeth examined).
1623
Clinical Research
TABLE 2. Configuration of Root Canal Systems in Maxillary First Molars (n = 220)
Additional
Specimen Root Type I Type II Type III Type IV Type V Type VI Type VII Type VIII canal types
Single root 1 (0.5) — — — 1 (0.5) — — — —
(n = 2)
Two separate B 2 (1) — — 1 (0.5) — — — — —
roots (n = 3)
P 3 (1.4) — — — — — — — —
Three separate MB 114 (51.8) 12 (5.5) — 85 (38.6) — — — — 2 (1)*
roots
(n = 213)
DB 199 (90.4) 6 (2.7) 4 (1.8) 4 (1.8) — — — — —
P 194 (88.1) 4 (1.8) — 9 (4.0) 3 (1.4) — — — 1 (0.5)†;2 (1)‡
Four separate MB 1 (0.5) — — 1 (0.5) — — — — —
roots
(n = 2)
DB 2 (1) — — — — — — — —
MP 2 (1) — — — — — — — —
DP 1 (0.5) — 1 (0.5) — — — — — —

B, buccal; DB, distobuccal; DP, distopalatal; MB, mesiobuccal; MP, mesiopalatal; P, palatal.
Values indicate number of teeth in which each of the features was identified. Values within parentheses are percentages (% of total number of teeth examined).
*Type 2-3 canal system.
†
2-1-2-1 canal system.
‡
3-2 canal system.

The number and morphology of roots of Indians were different several aberrations in accordance with Poorni et al (30), who reported
from those of Caucasians (13, 17, 22) in that 3.1% and 6.7% of the type II canal systems in the palatal roots of first molars, and Gopikrishna
Indian maxillary first and second molars, respectively, showed et al (31), who reported a case of 2 palatal roots and fused buccal roots.
morphology different from the classic three-rooted morphology The maximum variations in our study were found in the MB roots
(Table 4). The root and canal morphology of Indian molars also of both first and second molars, which is in agreement with Singh et al
differed from the Thai population in that 0.9% of the first molars (32), who reported wide variations in MB roots of Indian maxillary
showed 4 roots (4). Although this contributes to only a small second molars. The MB roots of both first and second molars exhibited
percentage of the number of teeth studied, it is important to consider a wide variation of canal anatomy. Such variation has been reported by
this variation in the clinical scenario. None of the molars studied Alavi et al (4) in Thai molars. In MB roots with 2 canals, the predom-
showed fused roots or C-shaped canals, in contrast to reports on the inant canal systems were type IV, followed by type II. This has been
teeth of Caucasians (13, 22, 23). shown to be prevalent in the Thai and Japanese populations (4, 7),
The method of analysis appears to have an influence on the iden- whereas in the Caucasian population most second MB canals joined
tification of different canal systems, as evidenced from other works the main canal. Thomas et al (13) reported that MB canals of maxillary
(Tables 5, 6). Two percent of both first and second molars showed molars have wide variations in canal systems, owing to continuous
a single root, with type I, III, or V canal system. To our knowledge, deposition of dentin in mesiodistal and buccolingual directions. This
there is only one report of a case of maxillary first molar with single was also confirmed by Neaverth et al (33). The most commonly missed
root and single canal diagnosed by using spiral CT (28). In our inves- canals are the second canals in the MB root (34). Nevertheless, canal
tigation, 2% of the first molars showed 4 roots, most of which had a type systems like types II and III facilitate chemical debridement during
I configuration of canals in the 4 roots, except for the MB and DP roots, canal instrumentation (17). The number of apical foramina and inter-
which showed variations. Reports of maxillary molars with 4 roots are canal communications hold importance in surgical endodontics during
scanty (29). Palatal roots of both first and second molars presented the process of root-end resection and root-end cavity preparation.
TABLE 3. Configuration of Root Canal Systems in Maxillary Second Molars (n = 205)
Additional
Specimen Root Type I Type II Type III Type IV Type V Type VI Type VII Type VIII canal types
Single root — — 2 (0.9) — — — — — —
(n = 2)
Two separate B 4 (1.9) 1 (0.5) 3 (1.5) — 2 (0.9) — — — 2 (0.9)*
roots
(n = 12)
P 10 (4.9) — — — 2 (0.9) — — — —
Three separate MB 127 (62) 13 (6.3) — 50 (24.4) — — — — 1(0.5) †
roots
(n = 191)
DB 174 (84.9) 3 (1.5) 5 (2.4) 9 (4.4) — — — — —
P 180 (87.8) — — 7 (3.4) 2 (0.9) — — 1 (0.5) 1 (0.5)‡
B, buccal; DB, distobuccal; MB, mesiobuccal; P, palatal.
Values indicate number of teeth in which each of the features was identified. Values within parentheses are percentages (% of total number of teeth examined).
*Type 3-1 canal system.
†
Type 2-1-2-1 canal system.
‡
Type 3-1 canal system.

1624 Neelakantan et al. JOE — Volume 36, Number 10, October 2010
JOE — Volume 36, Number 10, October 2010

TABLE 4. Number of Roots Found in Maxillary First and Second Molars in Various Studies
Reference No. of teeth Teeth studied Nature of study 1 root (%) 2 roots (%) 3 roots (%) 4 roots (%) 5 roots (%)
Barrett (1925) (35) 32 First molar Sectioning — 6.30 90.6 —
Gray (1983) (36) 85 First molar Staining and clearing — — 100 —
Thomas et al (1993) (13) 216 First molar Radiographic analysis with — 5.6% 94.4% —
infusion of radiopaque gel
Al Shalabi et al (2000) (37) 83 First molar Staining and clearing — 2.4 97.6 —
Ng et al (2001) (1) 90 First molar Staining and clearing — — 100 —
Alavi et al (2002) (4) 52 First molar Staining and clearing — — 100 —
Gopikrishna et al (2006) (28) 1 First molar Clinical case – Spiral CT 100 — — —
Adanir (2007) (29) 1 First molar Clinical case – radiograph — — — 100
Ng et al (2001) (1) 77 Second molar Sectioning and clearing — — 100 —
Alavi et al (2001) (4) 65 Second molar Sectioning and clearing — — 100 —
Fahid et al (1988) (38) 1 Second molar Clinical case – radiograph — — — 100 —
Zmener et al (1998) (39) 1 Second molar Clinical case – radiograph — — — 100 —
Jafarzadeh et al (2006) (40) 1 Second molar Clinical case – radiograph — — — 100 —
Kottoor et al (2010) (41) 1 Second molar Clinical case – CBCT — — — — 100
Present study 220 First molar CBCT 0.9 1.3 96.8 0.9 —
Present study 205 Second molar CBCT 0.9 5.8 93.1 — —
Root and Canal Morphology of Maxillary First and Second Molars in an Indian Population

TABLE 5. Percentages of Root Canal Systems Found in MB, DB and P Roots of Maxillary First Molars in Various Studies
Number Additional
Reference of teeth Root Nature of study Type I Type II Type III Type IV Type V canal types
Pineda and Kuttler (1972) (6) 262 MB Radiographic analysis 39.3 12.2 0 23.7 12.8 —
Pecora et al (1992) (42) 120 MB Staining and clearing 75 17.5 0 7.5 0 —
Weine et al (1999) (7) 293 MB Radiographic analysis 42 24.2 0 30.4 3.4 —
Ng et al (2001) (1) 90 MB Staining and clearing 30 25.6 1.1 33.3 6.7 3.3
Alavi et al (2002) (4) 52 MB Staining and clearing 32.7 17.3 1.9 44.2 1.9 1.9
Weng et al (2009) (16) 45 MB Modified canal staining and clearing 66.7 8.9 8.9 8.9 6.6 —
Ng et al (2001) (1) 90 DB Staining and clearing 94.5 2.2 1.1 1.1 0 1.1
Alavi et al (2002) (4) 52 DB Staining and clearing 98.1 1.9 0 0 0 0
Weng et al (2009) (16) 45 DB Modified canal staining and clearing 88.9 6.7 0 0 4.4 —
Ng et al (2001) (1) 90 P Staining and clearing 100 0 0 0 0 0
Alavi et al (2002) (4) 52 P Staining and clearing 100 0 0 0 0 0

Clinical Research
Weng et al (2009) (16) 45 P Modified canal staining and clearing 97.8 0 2.2 0 0 —
Present study 213 MB CBCT 51.8 5.5 0 38.6 0 1
Present study 213 DB CBCT 90.4 2.7 1.8 1.8 0 0
Present study 213 P CBCT 88.1 1.8 0 4 1.4 1.5
1625
Clinical Research
Canal systems of types IV, V, and 3-2 showed 2 separate apical foramina,
canal types
Additional whereas type 2-3 canal systems showed 3 apical foramina.
The palatal roots of three-rooted first and second molars showed

2.6
1.5

0.5

0.5
—

—
—

0
0
0

0
0
0

0
type I canal systems in 88.1% and 87.8%, respectively, which is much
lower than those (100%) of previous reports with traditional tech-
niques of canal staining (4, 17). However, the findings of our
Type VIII

investigation are in agreement with those of Weng et al (16), who

1.5

0.5
used a modified canal clearing and staining approach to study the canal
0

0
0
0

0
0
0

0
0
0

0
0
morphology of the Chinese population.
Type VII

Conclusions
1.3
3.1
0
0
0

0
0
0

0
0
0

0
0
0
The root number, morphology, and canal morphology of Indian
maxillary molars showed features that were different from both Cauca-
sian and Mongoloid traits. The prevalence of 2 canals in the MB roots of
Type VI

first molars was higher than second molars, in contrast to Mongoloid

7.7
0
0
0
0

0
0
0

0
0
0

0
0
0
populations. Type IV canal anatomy was the most prevalent in two-
canal roots, which is a Mongoloid trait. CBCT is an efficient method
of studying root canal systems.
Type V
14.4

9.1
7.7

1.3

0.9
0
0

0
6

0
0
0

0
0

Acknowledgments
Type IV

The authors thank the Department of Oral and Maxillofacial

15.6
26.2

24.4
9.5

4.4
3.4
4
12

0
0
0

0
0
0

Surgery, Saveetha University and the private practitioners across

the country for the collection of teeth for this study.
The authors disclose no conflicts of interest.
Type III

3.9
3.1

1.3

2.4
TABLE 6. Percentages of Root Canal Systems Found in MB, DB and P Roots of Maxillary Second Molars in Various Studies

0
0

0
0

0
0
6

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JOE — Volume 36, Number 10, October 2010 Root and Canal Morphology of Maxillary First and Second Molars in an Indian Population
Clinical Research
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