Evaluation of Root and Root Canal Morphology of Mandibular and Maxillary Canine Teeth in Turkish Subpopulation by Cone Beam Computed Tomography with Using Two Classification Systems 

Evaluation of Root and Root Canal Morphology of Mandibular and Maxillary Canine Teeth in Turkish Subpopulation by Cone Beam Computed Tomography with Using Two Classification Systems | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Root and Root Canal Morphology of Mandibular and Maxillary Canine Teeth in Turkish Subpopulation by Cone Beam Computed Tomography with Using Two Classification Systems Guldane MAGAT, Sultan UZUN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4650402/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2024 Read the published version in BMC Oral Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background Knowledge of root and canal morphology is a prerequisite for effective nonsurgical and surgical endodontic treatments. The aim of this cone beam computed tomography (CBCT) study was to evaluate the root canal morphology of permanent canines in a Turkish subpopulation using two classification systems. Methods A total of 2,000 canine teeth were examined. The number of roots was identified, and root canal configurations were classified according to Vertucci's classification and a new system for classifying root and canal morphology. Fisher's exact test was used for statistical analysis, and the level of significance was set at 0.05 (p = 0.05). Results The canal configuration type I was the most common in all canines, while type III was the second most common. According to the new system, the code 1 C 1−1 was the most common, whilst 1 C 1 (A1) codes were the second most common for all canines. In this study, more than 10% morphology that did not fit the Vertucci classification was detected. In the categorization of accessory canals based on the new classification, the most common type in all canines was 1 C 1,1 (A1) . Age had an effect only on the morphology of the left maxillary canine (p < 0.05). Conclusion Canines in the Turkish subpopulation showed a relatively high degree of variation in root and canal anatomical variations. Clinicians should be aware of where canals converge or diverge to avoid missing canals. The new system for classifying canal morphology describes root and canal configurations more accurately and practically compared to the Vertucci classification. canine root canal configuration Vertucci classification Ahmed et al. classification Figures Figure 1 BACKGROUND Canines are widely regarded as the "cornerstone" of the dental arches. Canine prominence on the labial region of the teeth is a cosmetic feature of both maxillary and mandibular canines. They aid in regular facial emotions at the "corners" of the mouth. The shape and position of the canines play an important influence in intercuspal placement via "canine guidance". 1 Owing to the importance of cosmetic and occlusal guidance of canines,’ proper endodontic and restorative treatment is needed. Endodontics' primary goals include biomechanical cleaning of the pulp cavity and root canal, as well as preparation of this space for receiving filling material and full hermetic closure of the apical and coronal regions. 2 Proper understanding of dental morphology, as well as the ability to accurately interpret it and have enough access to its sources, are essential for an effective treatment of root canals and for determining the treatment outcome. 3,4 There are several ways for classifying root canal and accessory canal morphology. 5,6 In the literature, these systems are classified as Weine et al. 7 (classify root canal configurations into four various types with using cross-sectional and radiographic techniques), Vertucci et al. 8 (utilized the cleaning procedure to figure out internal root canal structure and developed a more complicated classification with eight configurations), and Versiani et al. 5 (reported 37 different root canal configurations throughout a single root utilizing micro-CT technology). Ahmed et al. 9 developed a more complete approach for the classification of root, root canal, and accessory canal patterns due to the increasing variety of anatomical variances and obvious inadequacies of existing methods. Further, the system not only has wider applicability but also exceeds in accuracy. 10 A detailed understanding of root canal morphology and its variations is an absolute requirement for treatment success. Many roots have many canals and different canal configurations. Occasionally, a rupture in Hertwig's epithelial root sheath occurs during root development, resulting in a small gap. This causes "accessory canals" to grow anywhere in the root, resulting in periodontal-endodontic communication. 2 Studies on root canal morphology and its variations have been widely recorded throughout history. 3,4,11 As a result, the final results of root canal treatments are dictated by a thorough understanding of root canal morphology and its aberrations. 8 The morphological study of root canals can be performed in a variety of ways, including staining and tooth clearing, tooth sectioning, conventional radiography, digital radiography, and conventional computed tomography (CT). 12,13 The ideal technique is one that is accurate, simple, non-invasive, and capable of in vivo application. 12 Cone-beam computed tomography (CBCT) has proven to be an effective method for investigating root canal anatomy. 14,15 According to Neelakantan et al. 16 , CBCT is as precise as modified canal staining and clearing and is the gold standard in determining root canal anatomy. The key advantages of this technology are the ability to produce three-dimensional images versus conventional radiography, the fact that it is non-invasive, the reduction of superimpositions in intraoral and extraoral anatomies and the adjacent structures, and the use of lower radiation doses and costs in comparison to conventional CT. 17–19 Clinicians must have a thorough awareness of various root and root canal formations. It is critical to recognize and manage these variances effectively during root canal procedures in order to improve treatment outcomes. The present research used CBCT scans to analyze the root morphology and canal configurations of maxillary and mandibular canines in order to assess the trustworthiness and preciseness of various methods for instructional and clinical purposes. Furthermore, the study aimed to figure out whether these patterns differed by age or gender. MATERIAL AND METHODS Data collection In the present cross-sectional retrospective study, the root and root canal configurations of permanent maxillary and mandibular canines were evaluated using CBCT images from 250 females and 250 men collected between January 2022 and August 2023 for various diagnostic reasons. Two thousand canines were assessed with 500 CBCT images in each group (right-left, maxillary-mandibular) considering the inclusion and exclusion criteria ( Table 1) . The sample size was determined using the G-power 3.1.9.4 software tool to be at least 188 individuals at a 95% confidence level, =0.05, power (1-)=0.95 based on the differences between two independent proportions. 20 Cone-beam computed tomography (CBCT) CBCT data were gathered using a CBCT machine (J Morita MFG. Corp., 3D Accuitomo 170, Kyoto, Japan) with exposure parameters of 90 kVp and 5 mA for a scanning period of 17.5 seconds, a voxel resolution of 0.250 mm, and a field of view of 10x10 cm. The tests were conducted on a 27-inch color Ultra Sharp LED TFT display (Dell, Dell Inc. Round Rock, TX, USA) with a resolution of 2560 x 1440 and 3.7 MP using the i-Dixel One Data Viewer imaging program (J Morita MFG Corp., Kyoto, Japan). Techniques of image processing were used to modify the contrast and brightness of the images in order to get proper visualization. The root number and morphological features of maxillary and mandibular canines were determined utilizing several planes (coronal, axial, and sagittal). Calibration An oral and maxillofacial radiologist with six years of experience (SU) classified canines' root canal configurations. The expert received instructions to examine 100 CBCT radiographic images from the axial, sagittal, and coronal views. The anatomy of the root canals was described using the classifications defined by Vertucci et al. 21 ( Table 2 ) and Ahmed et al. 9 ( Table 2-3 ). To assess reproducibility, repeat measurements of the canine root and canal designs were performed twice, two weeks apart. The reference observer was assigned as the other observer (GM) with 14 years of experience and inter-observer reliability was assessed. Intra- and inter-observer reliability were assessed for 100 random images. Cronbach's alpha analysis revealed high intra- and inter-observer agreement (0.891-0.948). Root canal analysis The images were categorized based on the patient's age (20-30, 31-40, 41-50, and over 51 years) and sexes (female and male). The morphology of the root canals of the permanent maxillary and mandibular canines was assessed individually using the classification techniques developed by Vertucci et al. 8 ( Table 2 ) and Ahmed et al. 9 ( Table 2-3 ). Statistical analysis For data entry and statistical analysis, SPSS version 26 (IBM Corp., Armonk, NY, USA) software was used. Frequency, mean, and standard deviation were determined as descriptive statistics. The chi-square test was used to analyze the data, with the significance threshold set at 0.05 (p<0.05). RESULTS The distribution of all evaluated CBCT images according to age groups and gender is shown in Figure 1 . A total of 2000 permanent maxillary and mandibular canines were examined in 500 CBCT images. The mean age of the participants was 36.95 ± 15.02 years. The predominant age group among the female participants was 21-30 years (n=75), whereas for male participants, it was those aged 51 years and older (n=68). There was no statistically significant difference in the gender distribution among the age groups (p=0.284). Table 4 shows the distribution of the number of roots of permanent canines according to age and gender. Most of the canines had one root. The presence of two-rooted canine teeth was more common in the mandible (2.2% on the right and 2.8% on the left) ( Table 4 ). There was no statistically significant difference in the number of roots based on gender and age groups (p>0.05) ( Table 4 ). The majority of canines had Type I morphology according to the Vertucci et al. 6 classification (right maxilla: 96.4%; left maxilla: 95.6%; right mandibula: 93.2%; left mandibula: 91.0%) ( Table 5 ), and according to the new root canal morphology classification system 9 , the most common code detected was 404 1 C 1 in the right maxilla (80.8%), 394 1 C 1 in the left maxilla (78.8%), 410 1 C 1 in the right mandibula (82.0%), and 407 1 C 1 in the left mandibula (81.6%) ( Table 6 ). Subsequently, Type III (right maxilla: 1.6%; left maxilla: 2.0%; right mandibula: 3.2%; left mandibula: 4.6%) and Type V (right maxilla: 1.4%; left maxilla: 1.6%; right mandibula: 3.0%; left mandibula: 3.6%) were the next most frequently identified morphologies according to the Vertucci et al. 6 classification ( Table 5 ), whereas according to Ahmed et al. 9 classification 8 1 C 1,2,1 in the right maxilla (1.6%), 9 1 C 1-2-1 in the left maxilla (1.8%), 13 1 C 1-2-1 in the right mandibula (2.6%), and 23 1 C 1-2-1 in the left mandibula (4.6%) were the most common ( Table 6 ). According to both Vertucci et al. 6 and Ahmed et al. 9 classifications, there was no statistically significant difference in root morphologies based on gender and age (p>0.05) ( Table 5-6 ), except left maxillary canines (p<0.05) ( Table 6 ). The rate of "other" type morphology was statistically higher in individuals aged 21-30 years (24.8%) than in individuals aged 31-40 years (8.1%) ( Table 6 ). The teeth were encountered that were not specified in the Vertucci et al. 6 classification and were coded as "other". In the categorization of accessory canals based on the classification of Ahmed et al. 9 the most common type in all canines was 1 C 1-1 (A1) (9.8% for right maxilla; 11.6% for left maxilla; 8.3% for right mandibula; 6.3% for left mandibula) ( Table 7 ). The least common morphologies (0.2%) were 1 13 1-1 (M1-0) , 1 13 1-1 (A1-0) , 1 13 1-1 (M2, A1) , 1 13 1-1-2 (M2) DA 1-1 (A1) , 1 13 1-1 (M 1-2, A2) , 1 23 1-1 (M1-0, A1) , 1 23 1-2-1 (M1) , 1 23 1-1 (M1, A1-2) , 1 43 1-1 (O1-0) , 1 43 1-2-1 (A1) , 2 43La 1(M1) Li 1 , 1 33 1-1 (M 1-2-0, A1) , 1 33 1-1 (M 1-2, A2) , 1 33 1-1 (M1 1-2-0, M2 2-1, A1) , and 1 33 1-1 (M 1-2-0) ( Table 7 ). DISCUSSION Understanding any variations in the shape of canals is essential for endodontic treatment. 22 It helps us foresee potential complications and enables us to successfully remove necrotic material and pulp tissue without endangering the tooth's or root's structural integrity. 23 The current study focuses on the root canal morphology of permanent maxillary and mandibular canines to overcome potential problems related to root canal treatment and enhance the clarity of canal morphology classification. In all, there were not any statistically significant differences between males and females regarding the number of roots in maxillary and mandibular canine teeth, respectively, and combined (p > 0.05). Mashyakhy et al. 24 reported similar findings for both the maxillary and mandibular teeth as a whole. Both studies found that canine teeth often have a single root. A higher prevalence of two-rooted canines was noted in the mandible. We found that two-rooted canines were present in 0.3% of the upper jaw and 2.5% of the lower jaw in our research. Supporting these data, Mashyakhy et al. 24 found two-rooted canines in 2.2% of the maxilla and 5.2% of the mandible. In a study conducted in 2022 in the Saudi population 25 , the rate of detection of two roots in mandibular canines was found to be 5%. When examining studies in the literature, it has been observed that the rates of two-rooted canine teeth vary between 0% and 15.1% across different ethnic groups. 25–30 In this study, according to the Vertucci classification, the most common root canal patterns in maxillary canine teeth are Type I (right maxilla: 96.4%; left maxilla: 95.6%), Type III (right maxilla: 1.6%; left maxilla: 2.0%), and Type V (right maxilla: 1.4%; left maxilla: 1.6%), respectively. Mashyakhy et al. (81.6%) 31 , Vertucci (100%) 21 , Pineda and Kuttler (100%) 32 , Calışkan et al. (93.48%) 33 , and Sert and Bayırlı (91% male and 96% female) 3 reported similar findings in the literature, which identified Type I as the most prevalent root canal pattern in maxillary canine teeth. However, while the third most common canal morphology in our study was Type V, Type V canal configuration was not reported in the study by Pineda and Kuttler 32 , Sert and Bayırlı 3 , and Vertucci 21 . Mashyakhy et al. 31 showed the presence of a Type V canal configuration in the fourth place with a rate of 2%. If we classify these data according to the Ahmed et al. 9 classification, the most frequently observed canal configuration is 1 C 1 (right maxilla: 80.8%, left maxilla: 41.2%). This is followed by the configuration 1 C 1–2−1 (right maxilla: 1.6%, left maxilla: 1.8%). The effect of age on dental anatomy has not been extensively studied. One study found that individuals over 65 years of age exhibited a higher proportion of more complex root canal structures compared to younger groups. 27 Similar findings were reported by Karataslioglu and Kalabalik 34 in a Turkish cohort and by Martins et al. 35 who studied age-related changes in root canal configurations using CBCT. However, previous studies in Turkish and Chongqing populations found that younger individuals more commonly had multiple canals compared to older individuals. 26,36 In the present study, root canal morphologies were not found to vary according to the system of Vertucci et al. 8 and Ahmed et al. 9 Although there are various differences between the studies on mandibular canine teeth based on the Vertucci classification, the most common canal morphology was observed as Type I, similar to our study. 21,31,37 The second most common canal morphology in our study was Type III. Despite Mashyakhy et al. 31 and Çalışkan et al. 33 having similar results, Vertucci 21 reported the second most common canal type as Type II. While it was not reported by Mashyakhy et al. 31 , Type IV canal morphology was observed at 2% in the current study. Further, Pecora et al. 37 reported Tip IV canal morphology as 1.2% in their study. When assessed by the Ahmed et al. classification, the most common canal morphology is 1 C 1 (right mandibula: 82.0%, left mandibula: 81.6%), followed by 1 C 1–2−1 (right mandibula: 2.6%, left mandibula: 4.6%), respectively. For all canines, more than 10% morphology that did not fit the classification of Vertucci et al. 21 was detected in this study. The effect of gender on root number and morphology, this study also found that the number of roots did not differ according to gender, similar to some studies in the literature. 25,30,31,38 However, there are also studies in the literature indicating that canine teeth with two roots are more dominant in males. 39,40 In two study conducted in the same population as this study 3,41,42 , it was stated that the root morphology of mandibular canine teeth did not vary according to gender. However, Taha et al. 43 claimed that males have more complex root canal systems than females. Variations in the outcomes of studies may be due to factors like the size of the sample, the methods used, or the genetic characteristics of the participants in the study. There are publications in the literature that age significantly affects the morphology of permanent teeth. 43 However, in this study, age was found to have no effect on the morphology of canine teeth evaluated with the two systems, except for the left maxillary canines. Complex root morphology was statistically more common in the 21–30 age group than in the 31–40 age group in the left maxillary canines (p < 0.05). These results in consistent with the studies conducted in Chinese, Turkish and Malaysian populations in terms of complexity. 26,30,36,44 Consistent with this study, Almohaimede et al. 27 found also that the number of roots did not vary according to age groups. The Vertucci classification is a long-standing and user-friendly approach that we utilized in this study to evaluate categorization systems. 21 Nevertheless, the Vertucci categorization has drawbacks. These failures involve not reporting intricate root-canal structures such root number, auxiliary canals, root fusion, and dental anomalies. 9,45 We found that the Vertucci categorization is insufficient for categorizing root-canal configurations within the "other" category. The term "other" in this study refers to accessory canals and complex morphology. The Ahmed et al. et al. 46 classification contributes to the reporting of the localization and number of accessory canals observed under the heading "other" to give knowledge before treatment. With the only coding system used by Ahmed et al. et al.'s classification, it can identify root and canal structures, dental anomalies, and anatomical variations. 9,46 Although this classification system is quite explicit and accurate in defining complex morphologies, it has the limitation of creating a greater number of unique codes and categories compared to previous classifications, which makes it complex. 45,47 Since this work is managed from a single center, it would be more appropriate to conduct a multi-centric and broadened sample size to provide comprehensive information about the root-canal morphologies of the Turkish community. CBCT has lower spatial resolution than micro-CT and nano-CT when assessing intricate structures like root-canal morphology. This could have influenced the study's outcomes. The new classification method by Ahmed et al. 46 is crucial for gaining a comprehensive understanding of root-canal morphology. The inclusion of this novel system in undergraduate and graduate dental education could enhance comprehension of intricate subjects like root and canal morphology and decrease post-operative complications in clinical settings. CONCLUSION The results of this study revealed that the rate of complicated crown morphologies in canine teeth was relatively high. This rate was especially higher in the 21–30 age group. Due to the position of the canine teeth on the dental arch, successful root canal treatments are important in terms of occlusal guidance and aesthetics. Therefore, it is important to know the complex root canal structures in detail and clearly before treatment. For clinicians who want to know more clearly about conditions such as the presence of accessory canals, dental anomalies, complex canal structures, and the number of roots, the new system developed by Ahmed et al. is superior to the Vertucci classification. Due to the position of the canine teeth on the dental arch, successful root canal treatments are important in terms of occlusal guidance and aesthetics. Therefore, it is important to know the complex root canal structures in detail and clearly before treatment. For clinicians who want to know more clearly about conditions such as the presence of accessory canals, dental anomalies, complex canal structures, and the number of roots, the new system developed by Ahmed et al. is superior to the Vertucci classification. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Necmettin Erbakan Faculty of Dentistry Ethics Committee for Non-Drug and Medical Device Research with the number 2023/298. All changes were made following the principles of the Helsinki Declaration. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding None declared. Authors' contributions SU analyzed and interpreted the data in CBCT images in all planes (axial, sagittal and coronal). GM designed the study and contributed greatly to writing the manuscript. All authors read and approved the final manuscript. Acknowledgements None declared. References Ash MM, Nelson SJ. The permanent canines: maxillary and mandibular. Wheeler’s dental anatomy, physiology, and occlusion. 2007;191-214. Luukko K, Kettunen P, Fristad I, Berggreen E. Structure and functions of the dentin-pulp complex. Cohen's Pathways of the Pulp: Mosby. 2011;452-503. Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. 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Endodontology. 2016;28(2):148-53. Pan JYY, Parolia A, Chuah SR, Bhatia S, Mutalik S, Pau A. Root canal morphology of permanent teeth in a Malaysian subpopulation using cone-beam computed tomography. BMC Oral Health. 2019;19:1-15. doi:10.1186/s12903-019-0710-z. Mashyakhy M, Gambarini G. Root and Root Canal Morphology Differences Between Genders: A Comprehensive in-vivo CBCT Study in a Saudi Population. Acta Stomatol Croat, 2019;53(3):213-46. doi:10.15644/asc53/3/5. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol. 1972;33(1):101-10. doi:10.1016/0030-4220(72)90214-9. Çalişkan MK, Pehlivan Y, Sepetçioğlu F, Türkün M, Tuncer SŞ. Root canal morphology of human permanent teeth in a Turkish population. J Endod.1995;21(4):200-4. doi:10.1016/S0099-2399(06)80566-2. Karataslioglu E, Kalabalik E. Morphological evaluation of maxillary and mandibular canines using cone-beam computed tomography in Turkish population. 2019. Martins JN, Ordinola‐Zapata R, Marques D, Francisco H, Caramês J. Differences in root canal system configuration in human permanent teeth within different age groups. Int Endod J. 2018;51(8):931-41. doi:10.1111/iej.12896. Zhengyan Y, Keke L, Fei W, Yueheng L, Zhi Z. Cone-beam computed tomography study of the root and canal morphology of mandibular permanent anterior teeth in a Chongqing population. Ther Clin Risk Manag. 2015;19-25. doi:10.2147/TCRM.S95657. Pécora JD, Neto S, Saquy PC. Internal anatomy, direction and number of roots and size of human mandibular canines. Braz Dent J. 1993;4(1):53-7. Al-Dahman Y, Alqedairi A, Alfawaz H, Alnassar F, Al-Jebaly A. Cone-beam computed tomographic evaluation of root canal morphology of mandibular canines in a Saudi subpopulation. Saudi Endodontic Journal. 2019;9(2):113-8. Shrestha K, Shubham S, Ahmed S, Gautam V. Variations in the Root Form and Root Canal Morphology of Permanent Mandibular canine. J Nepal Health Res Counc. 2024;21(3):463-6. doi:10.33314/jnhrc.v21i3.4707. Soleymani A, Namaryan N, Moudi E, Gholinia A. Root canal morphology of mandibular canine in an Iranian population: A CBCT assessment. Iran Endod J. 2017;12(1):78. doi:10.22037/iej.2017.16. Geduk G, Deniz Y, Zengin AZ, Eroglu E. Cone-beam computed tomography study of root canal morphology of permanent mandibular incisors in a Turkish sub-population. Journal of Oral and Maxillofacial Radiology. 2015;3(1):7-10. 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(3):302-6. doi:10.4103/1305-7456.137630. Karobari MI, Noorani TY, Halim MS, Ahmed HM. A.Root and canal morphology of the anterior permanent dentition in Malaysian population using two classification systems: A CBCT clinical study. Aust Endod J. 2021;47(2):202-16. doi:10.1111/aej.12454. Mağat G, Uzun S, Buchanan GD. Evaluation of Maxillary First Molar Teeth's Mesiobuccal Root and Root Canal Morphology using two classification systems amongst a Turkish population: A Cone-beam Computed Tomography study: Root Canal Morphology of Maxillary First Molar. Journal of Endodontics and Restorative Dentistry. 2023;1(1):8-14. Ahmed H, Neelakantan P, Dummer PMH. A new system for classifying accessory canal morphology. Int Endod J. 2018;51(2):164-76. doi:10.1111/iej.12800. Buchanan GD, Gamieldien MY, Fabris‐Rotelli I, Van Schoor A, Uys A.Root and canal morphology of maxillary second molars in a Black South African subpopulation using cone‐beam computed tomography and two classifications. Aust Endod J. 2023;49:217-27. doi:10.1111/aej.12720. Tables Tables 1 to 7 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2024 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 09 Oct, 2024 Reviews received at journal 31 Jul, 2024 Reviewers agreed at journal 30 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 26 Jul, 2024 Reviews received at journal 22 Jul, 2024 Reviewers agreed at journal 22 Jul, 2024 Reviewers invited by journal 22 Jul, 2024 Editor invited by journal 05 Jul, 2024 Editor assigned by journal 01 Jul, 2024 Submission checks completed at journal 01 Jul, 2024 First submitted to journal 27 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4650402","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":330400608,"identity":"3c073670-f921-4d3a-8beb-09ac376e183a","order_by":0,"name":"Guldane MAGAT","email":"","orcid":"","institution":"Necmettin Erbakan University","correspondingAuthor":false,"prefix":"","firstName":"Guldane","middleName":"","lastName":"MAGAT","suffix":""},{"id":330400609,"identity":"17997d06-866b-495b-81e3-98f31c8cca49","order_by":1,"name":"Sultan UZUN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDCCA0D8AMb5AMRs7IS0HAPihAQIm3EGSAszKVqYecAkAR1899ufSST+sMszOH/G7LHNr23yfMwMjB8+5uDWInmMx0wiISG52ODAGXPj3L7bhm3MDMySM7fh1mJwjIcNqIU5ccPBHjPp3J7bjEAtbMy8eLWwPwNqqU/ccJjHTNqy57Y9EVoYQA47nLgB6EJphh+3EwlqkTyWY2yRkHY8ceYZtjLJ3obbyW3MjM14/cJ3+PjDGx9sqhP7zh/eJvHjz23b+e3NBz98xKMFFTC2gckGYtWDwB9SFI+CUTAKRsFIAQBM1lCo8K0I/AAAAABJRU5ErkJggg==","orcid":"","institution":"Necmettin Erbakan University","correspondingAuthor":true,"prefix":"","firstName":"Sultan","middleName":"","lastName":"UZUN","suffix":""}],"badges":[],"createdAt":"2024-06-27 17:36:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4650402/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4650402/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-024-05252-z","type":"published","date":"2024-12-18T15:58:35+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60945087,"identity":"fc294de4-55b7-4778-805b-9e96f5c683e5","added_by":"auto","created_at":"2024-07-23 22:19:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24617,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of all evaluated CBCT images according to age groups and gender\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4650402/v1/fcab30be57fe4d69ed1e71af.jpg"},{"id":72202023,"identity":"a8482acd-c387-4134-b224-6d9040cc2f31","added_by":"auto","created_at":"2024-12-23 16:13:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":483652,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4650402/v1/e7e8cf72-2d52-4e60-958b-4feda05bc872.pdf"},{"id":60945088,"identity":"e62a4efd-7f6e-462d-bd47-e017a65d30c1","added_by":"auto","created_at":"2024-07-23 22:19:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2166305,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4650402/v1/811e97207aa90eb41f40deb2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Root and Root Canal Morphology of Mandibular and Maxillary Canine Teeth in Turkish Subpopulation by Cone Beam Computed Tomography with Using Two Classification Systems ","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eCanines are widely regarded as the \"cornerstone\" of the dental arches. Canine prominence on the labial region of the teeth is a cosmetic feature of both maxillary and mandibular canines. They aid in regular facial emotions at the \"corners\" of the mouth. The shape and position of the canines play an important influence in intercuspal placement via \"canine guidance\". \u003csup\u003e1\u003c/sup\u003e Owing to the importance of cosmetic and occlusal guidance of canines,\u0026rsquo; proper endodontic and restorative treatment is needed.\u003c/p\u003e \u003cp\u003eEndodontics' primary goals include biomechanical cleaning of the pulp cavity and root canal, as well as preparation of this space for receiving filling material and full hermetic closure of the apical and coronal regions.\u003csup\u003e2\u003c/sup\u003e Proper understanding of dental morphology, as well as the ability to accurately interpret it and have enough access to its sources, are essential for an effective treatment of root canals and for determining the treatment outcome.\u003csup\u003e3,4\u003c/sup\u003e There are several ways for classifying root canal and accessory canal morphology.\u003csup\u003e5,6\u003c/sup\u003e In the literature, these systems are classified as Weine et al.\u003csup\u003e7\u003c/sup\u003e (classify root canal configurations into four various types with using cross-sectional and radiographic techniques), Vertucci et al.\u003csup\u003e8\u003c/sup\u003e (utilized the cleaning procedure to figure out internal root canal structure and developed a more complicated classification with eight configurations), and Versiani et al.\u003csup\u003e5\u003c/sup\u003e (reported 37 different root canal configurations throughout a single root utilizing micro-CT technology). Ahmed et al.\u003csup\u003e9\u003c/sup\u003e developed a more complete approach for the classification of root, root canal, and accessory canal patterns due to the increasing variety of anatomical variances and obvious inadequacies of existing methods. Further, the system not only has wider applicability but also exceeds in accuracy.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA detailed understanding of root canal morphology and its variations is an absolute requirement for treatment success. Many roots have many canals and different canal configurations. Occasionally, a rupture in Hertwig's epithelial root sheath occurs during root development, resulting in a small gap. This causes \"accessory canals\" to grow anywhere in the root, resulting in periodontal-endodontic communication.\u003csup\u003e2\u003c/sup\u003e Studies on root canal morphology and its variations have been widely recorded throughout history.\u003csup\u003e3,4,11\u003c/sup\u003e As a result, the final results of root canal treatments are dictated by a thorough understanding of root canal morphology and its aberrations.\u003csup\u003e8\u003c/sup\u003e The morphological study of root canals can be performed in a variety of ways, including staining and tooth clearing, tooth sectioning, conventional radiography, digital radiography, and conventional computed tomography (CT).\u003csup\u003e12,13\u003c/sup\u003e The ideal technique is one that is accurate, simple, non-invasive, and capable of in vivo application.\u003csup\u003e12\u003c/sup\u003e Cone-beam computed tomography (CBCT) has proven to be an effective method for investigating root canal anatomy.\u003csup\u003e14,15\u003c/sup\u003e According to Neelakantan et al.\u003csup\u003e16\u003c/sup\u003e, CBCT is as precise as modified canal staining and clearing and is the gold standard in determining root canal anatomy. The key advantages of this technology are the ability to produce three-dimensional images versus conventional radiography, the fact that it is non-invasive, the reduction of superimpositions in intraoral and extraoral anatomies and the adjacent structures, and the use of lower radiation doses and costs in comparison to conventional CT.\u003csup\u003e17\u0026ndash;19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinicians must have a thorough awareness of various root and root canal formations. It is critical to recognize and manage these variances effectively during root canal procedures in order to improve treatment outcomes. The present research used CBCT scans to analyze the root morphology and canal configurations of maxillary and mandibular canines in order to assess the trustworthiness and preciseness of various methods for instructional and clinical purposes. Furthermore, the study aimed to figure out whether these patterns differed by age or gender.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the present cross-sectional retrospective study, the root and root canal configurations\u0026nbsp;of permanent maxillary and mandibular canines were evaluated using CBCT images from 250 females and 250 men collected between January 2022 and August 2023 for various diagnostic reasons. Two thousand canines were assessed with 500 CBCT images in each group (right-left, maxillary-mandibular) considering the inclusion and exclusion criteria (\u003cstrong\u003e\u003cem\u003eTable 1)\u003c/em\u003e\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size was determined using the G-power 3.1.9.4 software tool to be at least 188 individuals at a 95% confidence level, =0.05, power (1-)=0.95 based on the differences between two independent proportions.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCone-beam computed tomography (CBCT)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBCT data were gathered using a CBCT machine (J Morita MFG. Corp., 3D Accuitomo 170, Kyoto, Japan) with exposure parameters of 90 kVp and 5 mA for a scanning period of 17.5 seconds, a voxel resolution of 0.250 mm, and a field of view of 10x10 cm. The tests were conducted on a 27-inch color Ultra Sharp LED TFT display (Dell, Dell Inc. Round Rock, TX, USA) with a resolution of 2560 x 1440 and 3.7 MP using the i-Dixel One Data Viewer imaging program (J Morita MFG Corp., Kyoto, Japan). Techniques of image processing were used to modify the contrast and brightness of the images in order to get proper visualization. The root number and morphological features of maxillary and mandibular canines were determined utilizing several planes (coronal, axial, and sagittal).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCalibration\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn oral and maxillofacial radiologist with six years of experience (SU) classified canines' root canal configurations. The expert received instructions to examine 100 CBCT radiographic images from the axial, sagittal, and coronal views. The anatomy of the root canals was described using the classifications defined by Vertucci et al.\u003csup\u003e21\u003c/sup\u003e (\u003cstrong\u003eTable 2\u003c/strong\u003e) and Ahmed et al.\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e (\u003cstrong\u003eTable 2-3\u003c/strong\u003e). To assess reproducibility, repeat measurements of the canine root and canal designs were performed twice, two weeks apart. The reference observer was assigned as the other observer (GM) with 14 years of experience and inter-observer reliability was assessed. Intra- and inter-observer reliability were assessed for 100 random images. Cronbach's alpha analysis revealed high intra- and inter-observer agreement (0.891-0.948).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRoot canal analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe images were categorized based on the patient's age (20-30, 31-40, 41-50, and over 51 years) and sexes (female and male). The morphology of the root canals of the permanent maxillary and mandibular canines was assessed individually using the classification techniques developed by Vertucci et al.\u0026nbsp;\u003csup\u003e8\u003c/sup\u003e (\u003cstrong\u003eTable 2\u003c/strong\u003e) and Ahmed et al.\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e (\u003cstrong\u003eTable 2-3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor data entry and statistical analysis, SPSS version 26 (IBM Corp., Armonk, NY, USA) software was used. Frequency, mean, and standard deviation were determined as descriptive statistics. The chi-square test was used to analyze the data, with the significance threshold set at 0.05 (p\u0026lt;0.05).\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe distribution of all evaluated CBCT images according to age groups and gender is shown in \u003cstrong\u003eFigure 1\u003c/strong\u003e. A total of 2000 permanent maxillary and mandibular canines were examined in 500 CBCT images. The mean age of the participants was 36.95 ± 15.02 years. The predominant age group among the female participants was 21-30 years (n=75), whereas for male participants, it was those aged 51 years and older (n=68). There was no statistically significant difference in the gender distribution among the age groups (p=0.284).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 4\u003c/em\u003e\u003c/strong\u003e shows the distribution of the number of roots of permanent canines according to age and gender. Most of the canines had one root. The presence of two-rooted canine teeth was more common in the mandible (2.2% on the right and 2.8% on the left) (\u003cstrong\u003e\u003cem\u003eTable 4\u003c/em\u003e\u003c/strong\u003e). There was no statistically significant difference in the number of roots based on gender and age groups (p\u0026gt;0.05) (\u003cstrong\u003e\u003cem\u003eTable 4\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of canines had Type I morphology according to the Vertucci et al.\u003csup\u003e6\u003c/sup\u003e classification \u0026nbsp;(right maxilla: 96.4%; left maxilla: 95.6%; right mandibula: 93.2%; left mandibula: 91.0%) (\u003cstrong\u003e\u003cem\u003eTable 5\u003c/em\u003e\u003c/strong\u003e), and according to the new root canal morphology classification system\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e, the most common code detected was 404 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026nbsp;\u003c/sup\u003ein the right maxilla (80.8%), 394 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026nbsp;\u003c/sup\u003e in the left maxilla (78.8%), 410 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026nbsp;\u003c/sup\u003ein the right mandibula (82.0%), and 407 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026nbsp;\u003c/sup\u003e in the left mandibula (81.6%) (\u003cstrong\u003e\u003cem\u003eTable 6\u003c/em\u003e\u003c/strong\u003e). Subsequently, Type III (right maxilla: 1.6%; left maxilla: 2.0%; right mandibula: 3.2%; left mandibula: 4.6%) and Type V (right maxilla: 1.4%; left maxilla: 1.6%; right mandibula: 3.0%; left mandibula: 3.6%) were the next most frequently identified morphologies according to the Vertucci et al.\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e classification (\u003cstrong\u003e\u003cem\u003eTable 5\u003c/em\u003e\u003c/strong\u003e), whereas according to Ahmed et al.\u003csup\u003e9\u003c/sup\u003e classification 8 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1,2,1\u0026nbsp;\u003c/sup\u003ein the right maxilla (1.6%), 9 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1-2-1\u0026nbsp;\u003c/sup\u003e in the left maxilla (1.8%), 13 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1-2-1\u0026nbsp;\u003c/sup\u003ein the right mandibula (2.6%), and 23 \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1-2-1\u0026nbsp;\u003c/sup\u003e in the left mandibula (4.6%) were the most common (\u003cstrong\u003e\u003cem\u003eTable 6\u003c/em\u003e\u003c/strong\u003e). According to both Vertucci et al.\u003csup\u003e6\u003c/sup\u003e and Ahmed et al.\u003csup\u003e9\u003c/sup\u003e classifications, there was no statistically significant difference in root morphologies based on gender and age (p\u0026gt;0.05) (\u003cstrong\u003e\u003cem\u003eTable 5-6\u003c/em\u003e\u003c/strong\u003e), except left maxillary canines (p\u0026lt;0.05) (\u003cstrong\u003e\u003cem\u003eTable 6\u003c/em\u003e\u003c/strong\u003e). The rate of \"other\" type morphology was statistically higher in individuals aged 21-30 years (24.8%) than in individuals aged 31-40 years (8.1%) (\u003cstrong\u003e\u003cem\u003eTable 6\u003c/em\u003e\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe teeth were encountered that were not specified in the Vertucci et al.\u003csup\u003e6\u003c/sup\u003e classification and were coded as \"other\". \u0026nbsp;In the categorization of accessory canals based on the classification of Ahmed et al.\u003csup\u003e9\u003c/sup\u003e the most common type in all canines was \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1-1 (A1)\u003c/sup\u003e (9.8% for right maxilla; 11.6% for left maxilla; 8.3% for right mandibula; 6.3% for left mandibula) (\u003cstrong\u003e\u003cem\u003eTable 7\u003c/em\u003e\u003c/strong\u003e). The least common morphologies (0.2%) were \u003csup\u003e1\u003c/sup\u003e13\u003csup\u003e1-1 (M1-0)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e13\u003csup\u003e1-1 (A1-0)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e13\u003csup\u003e1-1 (M2, A1)\u003c/sup\u003e,\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e13\u003csup\u003e1-1-2 (M2)\u003c/sup\u003e DA\u003csup\u003e\u0026nbsp;1-1 (A1)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e13\u003csup\u003e1-1 (M 1-2, A2)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e23\u003csup\u003e1-1 (M1-0, A1)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e23\u003csup\u003e1-2-1 (M1)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e23\u003csup\u003e1-1 (M1, A1-2)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e43\u003csup\u003e1-1 (O1-0)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e43\u003csup\u003e1-2-1 (A1)\u003c/sup\u003e, \u003csup\u003e2\u003c/sup\u003e43La\u003csup\u003e1(M1)\u003c/sup\u003e Li\u003csup\u003e1\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e33\u003csup\u003e1-1 (M 1-2-0, A1)\u003c/sup\u003e,\u003csup\u003e\u0026nbsp;1\u003c/sup\u003e33\u003csup\u003e1-1 (M 1-2, A2)\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e33\u003csup\u003e1-1 (M1 1-2-0, M2 2-1, A1)\u003c/sup\u003e, and \u003csup\u003e1\u003c/sup\u003e33\u003csup\u003e1-1 (M 1-2-0)\u003c/sup\u003e (\u003cstrong\u003e\u003cem\u003eTable 7\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eUnderstanding any variations in the shape of canals is essential for endodontic treatment.\u003csup\u003e22\u003c/sup\u003e It helps us foresee potential complications and enables us to successfully remove necrotic material and pulp tissue without endangering the tooth's or root's structural integrity.\u003csup\u003e23\u003c/sup\u003e The current study focuses on the root canal morphology of permanent maxillary and mandibular canines to overcome potential problems related to root canal treatment and enhance the clarity of canal morphology classification.\u003c/p\u003e \u003cp\u003eIn all, there were not any statistically significant differences between males and females regarding the number of roots in maxillary and mandibular canine teeth, respectively, and combined (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Mashyakhy et al.\u003csup\u003e24\u003c/sup\u003e reported similar findings for both the maxillary and mandibular teeth as a whole. Both studies found that canine teeth often have a single root. A higher prevalence of two-rooted canines was noted in the mandible. We found that two-rooted canines were present in 0.3% of the upper jaw and 2.5% of the lower jaw in our research. Supporting these data, Mashyakhy et al.\u003csup\u003e24\u003c/sup\u003e found two-rooted canines in 2.2% of the maxilla and 5.2% of the mandible. In a study conducted in 2022 in the Saudi population\u003csup\u003e25\u003c/sup\u003e, the rate of detection of two roots in mandibular canines was found to be 5%. When examining studies in the literature, it has been observed that the rates of two-rooted canine teeth vary between 0% and 15.1% across different ethnic groups.\u003csup\u003e25\u0026ndash;30\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, according to the Vertucci classification, the most common root canal patterns in maxillary canine teeth are Type I (right maxilla: 96.4%; left maxilla: 95.6%), Type III (right maxilla: 1.6%; left maxilla: 2.0%), and Type V (right maxilla: 1.4%; left maxilla: 1.6%), respectively. Mashyakhy et al. (81.6%)\u003csup\u003e31\u003c/sup\u003e, Vertucci (100%)\u003csup\u003e21\u003c/sup\u003e, Pineda and Kuttler (100%)\u003csup\u003e32\u003c/sup\u003e, Calışkan et al. (93.48%)\u003csup\u003e33\u003c/sup\u003e, and Sert and Bayırlı (91% male and 96% female)\u003csup\u003e3\u003c/sup\u003e reported similar findings in the literature, which identified Type I as the most prevalent root canal pattern in maxillary canine teeth. However, while the third most common canal morphology in our study was Type V, Type V canal configuration was not reported in the study by Pineda and Kuttler \u003csup\u003e32\u003c/sup\u003e, Sert and Bayırlı\u003csup\u003e3\u003c/sup\u003e, and Vertucci\u003csup\u003e21\u003c/sup\u003e. Mashyakhy et al.\u003csup\u003e31\u003c/sup\u003e showed the presence of a Type V canal configuration in the fourth place with a rate of 2%. If we classify these data according to the Ahmed et al.\u003csup\u003e9\u003c/sup\u003e classification, the most frequently observed canal configuration is \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u003c/sup\u003e (right maxilla: 80.8%, left maxilla: 41.2%). This is followed by the configuration \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026ndash;2\u0026minus;1\u003c/sup\u003e (right maxilla: 1.6%, left maxilla: 1.8%). The effect of age on dental anatomy has not been extensively studied. One study found that individuals over 65 years of age exhibited a higher proportion of more complex root canal structures compared to younger groups.\u003csup\u003e27\u003c/sup\u003e Similar findings were reported by Karataslioglu and Kalabalik \u003csup\u003e34\u003c/sup\u003e in a Turkish cohort and by Martins et al.\u003csup\u003e35\u003c/sup\u003e who studied age-related changes in root canal configurations using CBCT. However, previous studies in Turkish and Chongqing populations found that younger individuals more commonly had multiple canals compared to older individuals.\u003csup\u003e26,36\u003c/sup\u003e In the present study, root canal morphologies were not found to vary according to the system of Vertucci et al.\u003csup\u003e8\u003c/sup\u003e and Ahmed et al.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough there are various differences between the studies on mandibular canine teeth based on the Vertucci classification, the most common canal morphology was observed as Type I, similar to our study.\u003csup\u003e21,31,37\u003c/sup\u003e The second most common canal morphology in our study was Type III. Despite Mashyakhy et al. \u003csup\u003e31\u003c/sup\u003e and \u0026Ccedil;alışkan et al. \u003csup\u003e33\u003c/sup\u003e having similar results, Vertucci \u003csup\u003e21\u003c/sup\u003e reported the second most common canal type as Type II. While it was not reported by Mashyakhy et al.\u003csup\u003e31\u003c/sup\u003e, Type IV canal morphology was observed at 2% in the current study. Further, Pecora et al.\u003csup\u003e37\u003c/sup\u003e reported Tip IV canal morphology as 1.2% in their study. When assessed by the Ahmed et al. classification, the most common canal morphology is \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u003c/sup\u003e (right mandibula: 82.0%, left mandibula: 81.6%), followed by \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026ndash;2\u0026minus;1\u003c/sup\u003e (right mandibula: 2.6%, left mandibula: 4.6%), respectively. For all canines, more than 10% morphology that did not fit the classification of Vertucci et al.\u003csup\u003e21\u003c/sup\u003e was detected in this study.\u003c/p\u003e \u003cp\u003eThe effect of gender on root number and morphology, this study also found that the number of roots did not differ according to gender, similar to some studies in the literature.\u003csup\u003e25,30,31,38\u003c/sup\u003e However, there are also studies in the literature indicating that canine teeth with two roots are more dominant in males.\u003csup\u003e39,40\u003c/sup\u003e In two study conducted in the same population as this study \u003csup\u003e3,41,42\u003c/sup\u003e, it was stated that the root morphology of mandibular canine teeth did not vary according to gender. However, Taha et al.\u003csup\u003e43\u003c/sup\u003e claimed that males have more complex root canal systems than females. Variations in the outcomes of studies may be due to factors like the size of the sample, the methods used, or the genetic characteristics of the participants in the study.\u003c/p\u003e \u003cp\u003eThere are publications in the literature that age significantly affects the morphology of permanent teeth.\u003csup\u003e43\u003c/sup\u003e However, in this study, age was found to have no effect on the morphology of canine teeth evaluated with the two systems, except for the left maxillary canines. Complex root morphology was statistically more common in the 21\u0026ndash;30 age group than in the 31\u0026ndash;40 age group in the left maxillary canines (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These results in consistent with the studies conducted in Chinese, Turkish and Malaysian populations in terms of complexity.\u003csup\u003e26,30,36,44\u003c/sup\u003e Consistent with this study, Almohaimede et al.\u003csup\u003e27\u003c/sup\u003e found also that the number of roots did not vary according to age groups.\u003c/p\u003e \u003cp\u003eThe Vertucci classification is a long-standing and user-friendly approach that we utilized in this study to evaluate categorization systems.\u003csup\u003e21\u003c/sup\u003e Nevertheless, the Vertucci categorization has drawbacks. These failures involve not reporting intricate root-canal structures such root number, auxiliary canals, root fusion, and dental anomalies.\u003csup\u003e9,45\u003c/sup\u003e We found that the Vertucci categorization is insufficient for categorizing root-canal configurations within the \"other\" category. The term \"other\" in this study refers to accessory canals and complex morphology. The Ahmed et al. et al.\u003csup\u003e46\u003c/sup\u003e classification contributes to the reporting of the localization and number of accessory canals observed under the heading \"other\" to give knowledge before treatment. With the only coding system used by Ahmed et al. et al.'s classification, it can identify root and canal structures, dental anomalies, and anatomical variations.\u003csup\u003e9,46\u003c/sup\u003e Although this classification system is quite explicit and accurate in defining complex morphologies, it has the limitation of creating a greater number of unique codes and categories compared to previous classifications, which makes it complex.\u003csup\u003e45,47\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSince this work is managed from a single center, it would be more appropriate to conduct a multi-centric and broadened sample size to provide comprehensive information about the root-canal morphologies of the Turkish community. CBCT has lower spatial resolution than micro-CT and nano-CT when assessing intricate structures like root-canal morphology. This could have influenced the study's outcomes. The new classification method by Ahmed et al. \u003csup\u003e46\u003c/sup\u003e is crucial for gaining a comprehensive understanding of root-canal morphology. The inclusion of this novel system in undergraduate and graduate dental education could enhance comprehension of intricate subjects like root and canal morphology and decrease post-operative complications in clinical settings.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe results of this study revealed that the rate of complicated crown morphologies in canine teeth was relatively high. This rate was especially higher in the 21\u0026ndash;30 age group. Due to the position of the canine teeth on the dental arch, successful root canal treatments are important in terms of occlusal guidance and aesthetics. Therefore, it is important to know the complex root canal structures in detail and clearly before treatment. For clinicians who want to know more clearly about conditions such as the presence of accessory canals, dental anomalies, complex canal structures, and the number of roots, the new system developed by Ahmed et al. is superior to the Vertucci classification. Due to the position of the canine teeth on the dental arch, successful root canal treatments are important in terms of occlusal guidance and aesthetics. Therefore, it is important to know the complex root canal structures in detail and clearly before treatment. For clinicians who want to know more clearly about conditions such as the presence of accessory canals, dental anomalies, complex canal structures, and the number of roots, the new system developed by Ahmed et al. is superior to the Vertucci classification.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Necmettin Erbakan Faculty of Dentistry Ethics Committee for Non-Drug and Medical Device Research with the number 2023/298. All changes were made following the principles of the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSU analyzed and interpreted the data in CBCT images in all planes (axial, sagittal and coronal). GM designed the study and contributed greatly to writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAsh MM, Nelson SJ. The permanent canines: maxillary and mandibular. Wheeler\u0026rsquo;s dental anatomy, physiology, and occlusion. 2007;191-214.\u003c/li\u003e\n\u003cli\u003eLuukko K, Kettunen P, Fristad I, Berggreen E. Structure and functions of the dentin-pulp complex. Cohen\u0026apos;s Pathways of the Pulp: Mosby. 2011;452-503.\u003c/li\u003e\n\u003cli\u003eSert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. 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Oral Surg Oral Med Oral Pathol. 1972;33(1):101-10. doi:10.1016/0030-4220(72)90214-9.\u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;alişkan MK, Pehlivan Y, Sepet\u0026ccedil;ioğlu F, T\u0026uuml;rk\u0026uuml;n M, Tuncer SŞ. Root canal morphology of human permanent teeth in a Turkish population. J Endod.1995;21(4):200-4. doi:10.1016/S0099-2399(06)80566-2.\u003c/li\u003e\n\u003cli\u003eKarataslioglu E, Kalabalik E. Morphological evaluation of maxillary and mandibular canines using cone-beam computed tomography in Turkish population. 2019.\u003c/li\u003e\n\u003cli\u003eMartins JN, Ordinola‐Zapata R, Marques D, Francisco H, Caram\u0026ecirc;s J. Differences in root canal system configuration in human permanent teeth within different age groups. Int Endod J. 2018;51(8):931-41. doi:10.1111/iej.12896.\u003c/li\u003e\n\u003cli\u003eZhengyan Y, Keke L, Fei W, Yueheng L, Zhi Z. Cone-beam computed tomography study of the root and canal morphology of mandibular permanent anterior teeth in a Chongqing population. Ther Clin Risk Manag. 2015;19-25. doi:10.2147/TCRM.S95657.\u003c/li\u003e\n\u003cli\u003eP\u0026eacute;cora JD, Neto S, Saquy PC. Internal anatomy, direction and number of roots and size of human mandibular canines. Braz Dent J. 1993;4(1):53-7.\u003c/li\u003e\n\u003cli\u003eAl-Dahman Y, Alqedairi A, Alfawaz H, Alnassar F, Al-Jebaly A. Cone-beam computed tomographic evaluation of root canal morphology of mandibular canines in a Saudi subpopulation. Saudi Endodontic Journal. 2019;9(2):113-8.\u003c/li\u003e\n\u003cli\u003eShrestha K, Shubham S, Ahmed S, Gautam V. Variations in the Root Form and Root Canal Morphology of Permanent Mandibular canine. J Nepal Health Res Counc. 2024;21(3):463-6. doi:10.33314/jnhrc.v21i3.4707.\u003c/li\u003e\n\u003cli\u003eSoleymani A, Namaryan N, Moudi E, Gholinia A. Root canal morphology of mandibular canine in an Iranian population: A CBCT assessment. Iran Endod J. 2017;12(1):78. doi:10.22037/iej.2017.16.\u003c/li\u003e\n\u003cli\u003eGeduk G, Deniz Y, Zengin AZ, Eroglu E. Cone-beam computed tomography study of root canal morphology of permanent mandibular incisors in a Turkish sub-population. Journal of Oral and Maxillofacial Radiology. 2015;3(1):7-10.\u003c/li\u003e\n\u003cli\u003eAltunsoy 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(3):302-6. doi:10.4103/1305-7456.137630.\u003c/li\u003e\n\u003cli\u003eKarobari MI, Noorani TY, Halim MS, Ahmed HM. A.Root and canal morphology of the anterior permanent dentition in Malaysian population using two classification systems: A CBCT clinical study. Aust Endod J. 2021;47(2):202-16. doi:10.1111/aej.12454.\u003c/li\u003e\n\u003cli\u003eMağat G, Uzun S, Buchanan GD. Evaluation of Maxillary First Molar Teeth\u0026apos;s Mesiobuccal Root and Root Canal Morphology using two classification systems amongst a Turkish population: A Cone-beam Computed Tomography study: Root Canal Morphology of Maxillary First Molar. Journal of Endodontics and Restorative Dentistry. 2023;1(1):8-14.\u003c/li\u003e\n\u003cli\u003eAhmed H, Neelakantan P, Dummer PMH. A new system for classifying accessory canal morphology. Int Endod J. 2018;51(2):164-76. doi:10.1111/iej.12800.\u003c/li\u003e\n\u003cli\u003eBuchanan GD, Gamieldien MY, Fabris‐Rotelli I, Van Schoor A, Uys A.Root and canal morphology of maxillary second molars in a Black South African subpopulation using cone‐beam computed tomography and two classifications. Aust Endod J. 2023;49:217-27. doi:10.1111/aej.12720.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"canine, root canal configuration, Vertucci classification, Ahmed et al. classification","lastPublishedDoi":"10.21203/rs.3.rs-4650402/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4650402/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eKnowledge of root and canal morphology is a prerequisite for effective nonsurgical and surgical endodontic treatments. The aim of this cone beam computed tomography (CBCT) study was to evaluate the root canal morphology of permanent canines in a Turkish subpopulation using two classification systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 2,000 canine teeth were examined. The number of roots was identified, and root canal configurations were classified according to Vertucci's classification and a new system for classifying root and canal morphology. Fisher's exact test was used for statistical analysis, and the level of significance was set at 0.05 (p\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe canal configuration type I was the most common in all canines, while type III was the second most common. According to the new system, the code \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1\u0026minus;1\u003c/sup\u003e was the most common, whilst \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1 (A1)\u003c/sup\u003e codes were the second most common for all canines. In this study, more than 10% morphology that did not fit the Vertucci classification was detected. In the categorization of accessory canals based on the new classification, the most common type in all canines was \u003csup\u003e1\u003c/sup\u003eC\u003csup\u003e1,1 (A1)\u003c/sup\u003e. Age had an effect only on the morphology of the left maxillary canine (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCanines in the Turkish subpopulation showed a relatively high degree of variation in root and canal anatomical variations. Clinicians should be aware of where canals converge or diverge to avoid missing canals. The new system for classifying canal morphology describes root and canal configurations more accurately and practically compared to the Vertucci classification.\u003c/p\u003e","manuscriptTitle":"Evaluation of Root and Root Canal Morphology of Mandibular and Maxillary Canine Teeth in Turkish Subpopulation by Cone Beam Computed Tomography with Using Two Classification Systems ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 22:19:06","doi":"10.21203/rs.3.rs-4650402/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-09T12:44:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-31T08:36:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81101228669488066043106299557751871243","date":"2024-07-30T18:30:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51956209895165639557610322475455664973","date":"2024-07-28T15:58:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163163926966398370269747335532670657113","date":"2024-07-26T18:47:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-22T21:42:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21559140642262828759545951978932140215","date":"2024-07-22T16:31:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-22T13:59:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-05T06:34:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-01T11:10:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-01T11:08:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-06-27T17:32:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eec582a2-f602-470a-b345-92a86d953b25","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:06:11+00:00","versionOfRecord":{"articleIdentity":"rs-4650402","link":"https://doi.org/10.1186/s12903-024-05252-z","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2024-12-18 15:58:35","publishedOnDateReadable":"December 18th, 2024"},"versionCreatedAt":"2024-07-23 22:19:06","video":"","vorDoi":"10.1186/s12903-024-05252-z","vorDoiUrl":"https://doi.org/10.1186/s12903-024-05252-z","workflowStages":[]},"version":"v1","identity":"rs-4650402","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4650402","identity":"rs-4650402","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}