Original Article A cone‑beam computed tomography study of the root canal morphology of anterior teeth in a Turkish population Mustafa Altunsoy1, Evren Ok2, Bilge Gulsum Nur1, Osman Sami Aglarci3, Enes Gungor4, Mehmet Colak4 1Department of Pediatric Dentistry, Faculty of Dentistry, Sifa University, Izmir, Turkiye, 2Department of Endodontics, Faculty of Dentistry, Sifa University, Izmir, Turkiye, 3Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Sifa University, Izmir, Turkiye, 4Department of Oral and Maxillofacial Radiology, Correspondence: Dr. Mustafa Altunsoy Faculty of Dentistry, Dicle University, Diyarbakir, Email: [email protected] Turkiye ABSTRACT Objective: The aim of this study was to determine the root and canal morphology of the maxillary and mandibular anterior teeth in a Turkish population by analyzing cone-beam computed tomography (CBCT) images. Materials and Methods: CBCT images of 417 females and 410 males with a mean age of ranging from 14 to 70 years were examined in this study. A total of 1453 maxillary central incisors, 1504 maxillary lateral incisors, 1523 maxillary canines, 1582 mandibular central incisors, 1603 mandibular lateral incisors, and 1604 mandibular canines were analyzed. The number of root canals and the canal configurations were investigated and then were classified according to Vertucci’s classification. The data were analyzed with the Pearson Chi‑square test. Results: The Type 1 canal configuration was most prevalent in the maxillary anterior teeth (96.8‑99.7%). The Types 2, 3, 4, and 5 canal configurations were observed within the range of 0‑1.3%, 0‑0.8%, 0‑0.7%, and 0‑1.8%, respectively. In the mandibular anterior teeth, the Type 1 canal configuration was most prevalent (77‑95%). The Types 2, 3, 4, and 5 canal configurations were observed within a range of 0.2‑2.7%, 0.2‑1.6%, 0.9‑5.9%, and 1.8‑14.4%, respectively. The prevalence of two canals was higher in males than in females both in the maxillary and mandibular anterior teeth (P < 0.05). Conclusions: Type 1 was the most prevalent canal configuration of maxillary and mandibular anterior teeth in the Turkish population. Type 5 was the most frequently observed canal configuration of the two canalled teeth. The incidence of root canal numbers and configurations differed with sex. Key words: Anterior teeth, cone-beam computed tomography, endodontics, root canal morphology INTRODUCTION various methods. The methods used in analyzing root canal morphology are sectioning,[4] canal Identification of root canal morphology and staining and tooth clearing techniques,[5] conventional configuration plays an important role in successful radiography techniques,[6] contrast medium‑enhanced endodontic diagnosis and treatment. There are radiography,[7] modified canal staining and clearing,[1] differences in the root canal morphologies of and computed tomography (CT) scanning.[8] different populations; thus, identifying the root canal anatomy of different ethnic populations is required Cone‑beam CT (CBCT) scanning has been used in for successful endodontic treatment.[1‑3] Many studies the field of endodontics since 1990.[9] CBCT uses a have examined root and canal morphologies using cone‑shaped beam of radiation to acquire data in How to cite this article: Altunsoy M, Ok E, Nur BG, Aglarci OS, Gungor E, Colak M. A cone-beam computed tomography study of the root canal morphology of anterior teeth in a Turkish population. Eur J Dent 2014;8:302-6. Copyright © 2014 Dental Investigations Society. DOI: 10.4103/1305-7456.137630 302 European Journal of Dentistry, Vol 8 / Issue 3 / Jul-Sep 2014 Altunsoy, et al.: Evaluation of root canal morphology with CBCT a single 360° rotation, which reveals the internal International, Hatfield, USA, 2008) at 120 kVp, structure of an object. When CBCT is compared with 18.54 mA with an exposure time of 9 s. The voxel size conventional CT, it provides improved accuracy, of the images was 0.3 mm. An experienced radiologist higher resolution, lower scan time, and radiation acquired the images according to the manufacturer’s doses.[10] CBCT can be used for diagnosis in instructions. Tomography sections of 0.3 mm axial endodontic applications due to its nondestructive planes were created. Serial axial CBCT images were in vivo application. examined by carefully rolling the toolbar from the pulp chamber to the apex [Figure 1]. Many studies have performed to assess the anatomic characteristics and types of root canal morphology Two examiners assessed all the images separately, by conventional techniques[1,4,5,7] and only two and any disagreement between them was discussed studies performed by CBCT.[11,12] To the best of our until a consensus was reached. To test the knowledge, few studies have evaluated the root and reproducibility, the two observers reexamined 60 canal morphology in the Turkish population.[13‑15] randomly selected radiographs 6 weeks after the However, no data are available on the determination first evaluation. Examination of results using the of root and canal morphology of the anterior teeth Wilcoxon matched paired signed‑rank test showed with CBCT in a Turkish population. Therefore, the no statistically significant difference between the aim of this study was to investigate and determine two observers. The number of root canals and the the root and canal morphology of the maxillary and canal configurations were classified according to mandibular anterior teeth in a Turkish population by Vertucci’s classification[5] [Figure 2]. The data were analyzing CBCT images. analyzed with Chi‑square test. All statistical analyses were performed using SPSS (Version 17.0; SPSS Inc., MATERIALS AND METHODS Chicago, IL, USA) software. Cone‑beam computed tomography images were RESULTS obtained in the Dicle University, Department of Oral and Maxillofacial Radiology between May 2009 The prevalence of the root canal numbers of the and April 2012. This study was approved by the maxillary and mandibular anterior teeth are shown in Institutional Review Board of Sifa University, Izmir, Table 1. The most prevalent root canal numbers in the Turkey (B.30.2.ŞFÜ.00.50.500/52). Subjects with maxillary anterior teeth was one canal (approximately fully erupted permanent maxillary and mandibular 96.8‑99.7%), followed by two canals (approximately anterior teeth (centrals, laterals, and canines) were 0.3‑3.2%). The prevalence of two canals was higher selected. CBCT images of 417 women and 410 men in males than in females in the maxillary anterior with a mean age of ranging from 14 to 70 years were teeth. The most prevalent root canal numbers in the examined. A total of 1453 maxillary central incisors, mandibular anterior teeth was one canal with a range 1504 maxillary lateral incisors, 1523 maxillary canines, of 77‑95%, followed by two canals with a range of 1582 mandibular central incisors, 1603 mandibular 5.3‑18.9%. The prevalence of two canals was higher in lateral incisors, and 1604 mandibular canines were males than in females in the mandibular anterior teeth. analyzed in the database. Table 2 shows the prevalence of the different canal The CBCT images were obtained using a CBCT configurations in the maxillary anterior teeth. The imaging system (I‑CAT Vision TM Imaging Science Type 1 canal configuration was most prevalent in the Table 1: Root canal number of the maxillary and mandibular anterior teeth n (%) Maxillary teeth Centrals Laterals Canines Male Female Male Female Male Female Number of canals 1 772 (99.6) 766 (99.7) 735 (96.8) 732 (98.3) 748 (96.8) 740 (98.7) 2 3 (0.4) 2 (0.3) 24 (3.2) 13 (1.7) 25 (3.2) 10 (1.3) Total 1543 1504 1523 Mandibular teeth 1 636 (81.1) 704 (88.2) 617 (77.2) 678 (84.3) 741 (92) 757 (94.7) 2 148 (18.9) 94 (11.8) 182 (22.8) 126 (15.7) 64 (8) 42 (5.3) Total 1582 1603 1604 European Journal of Dentistry, Vol 8 / Issue 3 / Jul-Sep 2014 303 Altunsoy, et al.: Evaluation of root canal morphology with CBCT Table 2: Root canal configurations of the maxillary and mandibular anterior teeth n (%) Maxillary teeth Centrals Laterals Canines Male Female Male Female Male Female Canal configurations 1 771 (99.5) 766 (99.7) 734 (96.7) 732 (98.3) 748 (96.8) 740 (98.7) 2 0 0 10 (1.3) 5 (0.7) 5 (0.6) 1 (0.1) 3 3 (0.4) 0 5 (0.7) 0 6 (0.8) 1 (0.1) 4 0 2 (0.3) 0 4 (0.5) 0 5 (0.7) 5 1 (0.1) 0 10 (1.3) 4 (0.5) 14 (1.8) 3 (0.4) 6 0 0 0 0 0 0 7 0 0 0 0 0 0 8 0 0 0 0 0 0 Mandibular teeth 1 633 (80.7) 704 (88.2) 613 (76.7) 673 (83.7) 737 (91.6) 751 (94) 2 5 (0.6) 2 (0.3) 13 (1.6) 8 (1) 21 (2.6) 13 (1.6) 3 10 (1.3) 2 (0.3) 11 (1.4) 5 (0.6) 12 (1.5) 7 (0.9) 4 33 (4.2) 34 (4.3) 47 (5.9) 39 (4.9) 7 (0.9) 14 (1.8) 5 103 (13.1) 56 (7) 115 (14.4) 79 (9.8) 28 (3.5) 14 (1.8) 6 0 0 0 0 0 0 7 0 0 0 0 0 0 8 0 0 0 0 0 0 a b c d Figure 1: Images of teeth with root and canal configurations in axial Figure 2: The Vertucci classification of root canal configurations section. (a) Coronal part of the root in maxillary teeth (b) apical part of the root in maxillary teeth (c) coronal part of the root in mandibular 0.2‑1.6%. The Type 4 canal configuration was observed teeth (d) apical part of the root in mandibular teeth. (Same color arrows show the same color teeth) within the range of 0.9‑5.9%, and the Type 5 canal configuration was observed within the range of 1.8‑ maxillary anterior teeth (96.8‑99.7%). The Type 2 canal 14.4%. configuration was observed within the range of 0‑1.3%. The Type 3 canal configuration was observed within DISCUSSION the range of 0‑0.8%. The Type 4 canal configuration was observed within the range of 0‑0.7%, and the Technological innovations have led to the improvement Type 5 canal configuration was observed within of new diagnostic and imaging techniques in dentistry. the range of 0‑1.8%. The distribution frequency for CBCT scanning provides an excellent imaging method different canal configurations in the mandibular to detect differences in external and internal dental anterior teeth is shown in Table 2. The Type 1 canal anatomy. CBCT images offer high‑resolution and configuration was the most prevalent in mandibular are well‑suited for endodontic applications.[8,16] With anterior teeth (77‑95%). The Type 2 canal configuration the methods used in this study, the root and canal was observed within the range of 0.2‑2.7%. The Type 3 morphology of the teeth can be visualized in the three canal configuration was observed within the range of main plans. 304 European Journal of Dentistry, Vol 8 / Issue 3 / Jul-Sep 2014 Altunsoy, et al.: Evaluation of root canal morphology with CBCT Maxillary central incisor teeth have been reported the mandibular central, lateral incisors, and canines to have one canal in 100% of American and Turkish were 72.7%, 70.6%, and 71.8%, respectively in Iranian populations.[5,13] Sert and Bayirli[15] have reported that population. In this study, the Type 1 canal configuration maxillary central incisors have one canal in 98% of of the mandibular centrals in males was 80.7% and males and 99% of females in the Turkish population. 88.2% for females, mandibular laterals in males was Our study found that 99.6% and 99.7% of maxillary 76.7% and 83.7% for females, and mandibular canines central incisors in males and females, respectively, had in males was 91.6% and 94% for females. one canal. The canal configurations for teeth with two canals were Type 3 (0.4%) in males and Type 4 (0.3%) Sert and Bayirli[15] reported that gender was an in females. important factor to be considered in the preoperative evaluation of canal morphology for root canal A study by Caliskan et al.[13] have reported that treatment.[8] In our study, the prevalence of two canals 78.05% of maxillary laterals and 93.48% of maxillary in the maxillary and mandibular anterior teeth was canines had Type 1 canal configuration in a Turkish higher in males than in females, which is in agreement population. Sert and Bayirli[15] reported that the root with the findings of Sert and Bayirli.[15] canal configurations for maxillary lateral incisors in males were 91% Type 1, 2% Type 2, 4% Type 3, Our findings concerning the canal configurations and 5% Type 4. The root canal configuration of of the maxillary and mandibular teeth are also lateral incisors were 90% Type 1, 1.5% Type 2, and different from the results of previous studies 5% Type 3 in females. In the same study, the root carried out in the Turkish population.[13‑15] These canal configurations for maxillary canines were differences may be explained by certain factors. 91% Type 1, 3% Type 2, 4% Type 3, and 2% Type 4 Regional differences in the country may have an in males. The root canal configurations for female influence on the outcome of morphological studies. patients were 96% Type 1 and 4% Type 4. Weng et al.[1] It has been reported that differences between the have reported that 95.8% of the maxillary central results of morphological studies may be due to incisors, 97.1% of the maxillary lateral incisors, and variations of examination methods, classification 76.9% of the maxillary canines were Type 1 canal systems, sample sizes and ethnic backgrounds of configuration in Han Nationality in China. In these tooth sources.[14,18] To the best of our knowledge, studies, staining and clearing method were used. In there were only three studies in the literature the present investigation, Type 1 canal configuration concerned with canal numbers and configurations was detected in 96.7% of maxillary laterals for males of maxillary and mandibular anterior permanent and 98.3% of maxillary laterals for females. Type 1 teeth in a Turkish population.[13‑15] These studies root canal configuration in maxillary canines was were performed with canal staining and tooth found in 96.8% of males and 98.7% of females. In our clearing techniques and used only 100 and 200 study, the prevalence of Type 1 canal configuration tooth samples for each type of tooth. In this study, of the maxillary laterals and canines was higher than the root canal numbers and configurations were the results of these investigators mentioned above. determined with CBCT images. For each tooth, However, our findings were close to the results we evaluated approximately 1453‑1604 images. reported by Sert and Bayirli.[15] Staining and clearing technique could give the most detailed information about the root canal Caliskan et al.[13] have reported that 68.63% of the anatomy in in vitro conditions.[5,19] However, in mandibular central and lateral incisors and 80.39% clinical conditions this technique cannot be used of the mandibular canines were found to have a and CBCT is a good option for identifying root Type 1 canal configuration in Turkish population. canals, anatomical variations and root fractures and Al‑Qudah and Awawdeh[17] reported that 73.8% of the resorptions.[20] Other factors affecting differences mandibular incisors had Type 1 canal configuration in between the findings of current and previous a Jordanian population. In those studies, staining and studies may be differences in the region where clearing methods were used. In the studies performed studies were carried out. Previous studies were by CBCT, Liu et al.[12] have reported that the Type 1 carried out in the Northwestern and Western canal configuration of the mandibular central and regions of Turkey; however, in this study, we lateral incisors were 91.1% and 82.5%, respectively obtained CBCT images from patients who lived in a Chinese population and Aminsobhani et al.[11] in the Southeastern of Turkey. These regions have have reported that the Type 1 canal configuration of profound environmental and climatic differences. European Journal of Dentistry, Vol 8 / Issue 3 / Jul-Sep 2014 305 Altunsoy, et al.: Evaluation of root canal morphology with CBCT CONCLUSION permanent molar root and canal morphology in a Chinese population. J Endod 2010;36:1480-4. 9. Tachibana H, Matsumoto K. Applicability of X-ray computerized It can be concluded that a higher prevalence of tomography in endodontics. 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