Evaluation of Mandibular and Maxillary Second Molar Root Canal Anatomy in a Turkish Subpopulation Using CBCT: Comparison of Briseno-Marroquin and Vertucci Classifications

Evaluation of Mandibular and Maxillary Second Molar Root Canal Anatomy in a Turkish Subpopulation Using CBCT: Comparison of Briseno-Marroquin and Vertucci Classifications | 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 Mandibular and Maxillary Second Molar Root Canal Anatomy in a Turkish Subpopulation Using CBCT: Comparison of Briseno-Marroquin and Vertucci Classifications Hüseyin Gürkan GÜNEÇ, İpek ÖREROĞLU, Kemal ÇAĞLAR, Kader CESUR AYDIN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5285143/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jan, 2025 Read the published version in BMC Medical Imaging → Version 1 posted 4 You are reading this latest preprint version Abstract Background This retrospective study aims to characterise the root canal morphology of maxillary and mandibular molars using cone-beam computed tomography (CBCT). The number of roots and canal configurations were evaluated using both the Vertucci and Benjamı´n Brisen˜ o Marroquı´n classification systems. Methods Total of 1084 second molar images (523 upper; 266 right and 257 left sides & 561 lower; 285 right and 276 left sides) were obtained from 320 CBCT scans that were analysed. CBCT imaging provided superior visualisation of root canal anatomy compared to periapical radiography. The findings revealed diverse root canal configurations, with variations observed even within the same population. Statistical analyses, including the chi-squared test, were used to assess correlations between root number and demographic variables such as age and sex. Results According to Benjamı´n Brisen˜ o Marroquı´n classification system, the most common configuration for upper right three-rooted teeth mesial root was 3 17 2−1 (n:66, 35.7%), for distal root was 3 17 1 (n:169, 91.4%), and for palatal root was 3 17 1 (n:165, 89.2%). Additionally, the most common configuration for upper left three-rooted teeth mesial root was 3 27 1 (n:50, 28.4%), for distal root was 3 27 1 (n:160, 90.9%), and for palatal root was 3 27 1 (n:158, 89.8%). In lower left molars, the most common configuration in the two-rooted teeth mesial root was 2 37 2 (n:114, 49.4%), and for the distal root was 2 37 1 (n:170, 73.6%). For lower right the most common configuration for two-rooted teeth mesial root was 2 47 2 (n:125, 52.5%), and for distal root was 2 47 1 (n:173, 72.7%)( p < 0.05). Conclusion Due to highly variable morphological features observed in the upper- and lower-second molars of the Turkish subpopulation, CBCT is strongly recommended on a case-by-case basis. The results revealed extensive variations in root canal morphology. CBCT Root canal morphology Vertucci classification Benjamı´n Brisen˜ o Marroquı´n classification Second molars Figures Figure 1 Figure 2 Figure 3 Introduction The success of endodontic treatments relies heavily on several critical factors, including the intricate anatomy and morphology of the root canal system, thorough disinfection of the root canal, and effective sealing [ 1 – 6 ]. A deep understanding of root canal anatomy and morphology is crucial for the success of endodontic treatments [ 7 – 10 ]. Among many factors, the root canal system stands out as paramount due to the complexity of its anatomy and morphology. However, the root canal system may be complex and/or colonised by a variety of microorganisms. Thus, detailed knowledge of tooth anatomy is vital to pursuing endodontic treatment because the inability to detect and treat all identified canals may result in treatment failure [ 4 , 11 , 12 ]. Knowledge of root canal morphology is important for clinicians to master therapeutic techniques and clinical outcomes are improved. Understanding the root canal system involves identifying the number of roots and canals, the canal configurations, and their cross-sectional shapes [ 6 , 13 , 14 ]. Weine et al. were the first to classify root canal morphology [ 7 ] within a single root, also they added an additional type in 1982 [ 7 ]. They focused on single-rooted teeth in their classification, creating four main categories. This classification is based on whether the canal is single, there are two canals from beginning to end, or the root is divided into two at the middle or apex. In 1974, Vertucci et al. recognized [ 7 , 10 , 16 ] further complex root canal systems and reported eight types of configurations according to the pattern of division in the main root canal from the pulp chamber to the apex of the root. However, Vertucci’s classification may not allow for unambiguous description given their classification variability according to the Vertucci system. Sert and Bayirli [ 10 ] added fourteen supplemental types to Vertucci's classification system. A new classification was introduced n Brisen˜ o Marroquı´n et al in the year 2015, which is simple, easy to understand, and more accurate at classifying root canal configurations compared to earlier systems [ 7 , 17 ]. This system uses the three-dimensional diagnostic imaging advantages. The benefit of Benjamı´n Brisen˜ o Marroquı´n classification is its user-friendly coding system, which is accessible to both students and dentists [ 17 ]. The coding system assigns individual codes for the tooth number, the number of roots, and the configuration of the canals. Vertucci classified root canal morphology into eight types. This classification is more detailed than Weine’s classification. The first 3 types have single apical foramen and contain separation inside them, except type I. From type IV to type VII, teeth have two apical foramina. Type VIII differs from the others by having three apical foramens (Fig. 1 ). Sert and Bayirli added supplementary configurations to Vertucci’s Classification due to the systems’ limitations. The authors evaluated the root canal configuration in maxillary and mandibular permanent teeth amongst the Turkish population using a clearing technique. They added fourteen types to Vertucci’s classification, numbering them from Type IX to Type XXIII [ 4 , 10 ]. These added classes were developed to better describe intra-canal branching accounting for situations with more than two canal openings and more than three apical foramina. The Vertucci classification does not consider the number of roots in the anterior and posterior teeth which is a major shortcoming, this insufficiency in explaining the root canal anatomy creates a necessity for a new classification [ 4 , 7 , 10 ]. The new four-digit coding system describes the anatomical features of roots in a consistent manner regardless of the tooth type and whether a tooth is single or multi rooted [ 18 ]. This new system for classifying root and canal morphology has defined any ‘division’ of a root, whether in the coronal, middle or apical third, is coded as two or more roots. To enable researchers to interpret the configuration of the root canal consistently, the components of the pulp cavity, including the pulp chamber and root canal, should be defined accurately. For correct use of this classification correctly, it is essential to utilise three-dimensional imaging systems such as CBCT or Micro-CT [ 3 , 19 , 20 ]. Due to its high radiation exposure, micro-CT is not safe enough to use on patients. Conversely, CBCT has a lower radiation level, is more cost-effective, and provides sufficient information about the root canal system [ 11 ]. Several studies have found root canal configurations to be highly complex and found Non classifiable canal configurations during evaluation of internal and external anatomical canal variation using 3D imaging techniques [ 4 , 11 , 22 , 23 ]. The new system for root and canal morphology defines the root canal configuration with a start (root canal orifice) passing through the canal and ends at the apical foramen. The root canal orifice is located at the level of the cervicomental junction (CEJ) in single-rooted teeth, and at the level of root bi/trifurcation (floor of the pulp chamber) in double and multi-rooted teeth [ 2 , 7 , 17 , 18 ] (Table 1 ). A single-rooted tooth is defined as any tooth that clearly displayed no bifurcation, or roots with a bifurcation in the apical-most portion of the root. This distinction is important to understand the root canal anatomy clearly. Multiple-rooted teeth, whether two-or three-rooted, include teeth that demonstrate clearly bifurcated roots, whether partial or complete. The proposed morphological description of the root canal configuration starts with two root canals at the pulp chamber floor level. The digits describe the canal number at the coronal level of the respective third limit. The number of foramina is separated using a slash to facilitate understanding of the meaning of the digits. For Double-rooted teeth , If a researcher considers root fusion as a separate entity and would like to follow a defined classification to describe the type of root fusion, then the abbreviation for root fusion and its type can be added on the left of the tooth number, just as with other dental anomalies. Regarding Three-rooted teeth , Root fusion in three-rooted teeth can have several presentations, as described by Zhang et al.[ 25 ], which can be used in the new coding system. When it is difficult to differentiate between a single root with deep developmental grooves, and roots that have complete fusion along the root length, categorization can be based on the common number of roots for that particular tooth. As an example, a double-rooted maxillary premolar tooth may exhibit deep buccal and palatal grooves in the buccal root. On some occasions, research studies related to anatomy or mechanical instrumentation may focus on specific roots, such as the mesiobuccal or mesial root in maxillary or mandibular molars, respectively. The two-dimensional nature of periapical radiographs may result in missed roots and canals [ 21 , 26 ]. Changing the horizontal tube angulation may improve visualisation of the tooth anatomy, however this technique's applicability may be limited in patients who have a smaller mouth space [ 27 ]. With the improving technologies, three-dimensional diagnostic imaging modalities such as CBCT allow greater detection of root and canal morphology prior to endodontic treatment. Micro-CT has become the “gold-standard” for evaluating bone morphology and microstructure in the ex vivo models [ 4 , 14 , 28 ]. On the other hand, clinical CBCT has been widely applied in dentistry for over two decades, offering high image quality with low radiation dose at a low cost. Compared to micro CBCT, CBCT is less invasive but still an accurate method that can be used in clinical works. Moreover, CBCT is superior to periapical radiography in successfully detecting root canal anatomy. The root can be easily examined in more detail with different sections [ 4 , 10 , 18 ]. Difficulty working in molar teeth and the complex anatomy of root canals may cause treatment failure. Two-Dimensional images taken from periapical radiographs may not always provide accurate results due to superpositions. At this point, treatment success increases when the relevant tooth is examined with 3D imaging methods such as CBCT and the canal anatomy is understood correctly [ 11 , 30 , 31 ]. This study aims to investigate the differences among Vertucci and the Benjamı´n Brisen˜ o Marroquı´n classifications using CBCT evaluations of mandibular and maxillary second molars in a Turkish subpopulation. Materials and Methods Sample selection Ethical approval for this study was obtained from the Non- Interventional Ethics Committee of the xxxx University (protocol no. 309/2024). Statistical analyses were performed using the G Power version 3.1 software program (Heinrich University, Dusseldorf, Germany). The Chi square test was used for analysing contingency tables, 764 samples of each subgroup, consisting of four sections. This was determined with an (error margin) = 0.05, 0.15 effect (w), 0.95 power (1-) level, yielding a minimum sample size of 382. Subjects This cross-sectional retrospective study evaluated 1084 second molar images (523 upper; 266 right and 257 left sides and 561 lower; 285 right and 276 left sides second molars, respectively) obtained from 320 CBCT scans. CBCT exams showing mandibular and maxillary second molars with complete root formation and integrity were included and subjects aged between 18 and 76 years. The images were used to determine the root number and canal configurations of maxillary and mandibular molars. Both left and right second molars were included. Scans from both male (n = 503) and female (n = 581) subjects were evaluated. Participant age at the time of the scan was recorded, but no information on race or ethnicity was collected. The existing CBCT database was used, and no new scans were acquired for this study. Scans were assessed chronologically back from the most recently acquired one until the necessary sample size was achieved. The study time period ranged from 2021 to 2024. Inclusion criteria Scans containing fully formed maxillary and mandibular molars were included in this research. The scans were needed to exhibit adequate quality for visualising individual roots and canals. CBCT images that met the following criteria were included: Scans that included the entire pulp chamber and root canal system were considered (496 upper and 545 lower second molars). Presence of a fully mature and erupted maxillary and mandibular second molar. Participants must be over 18 years old Participants must be Turkish citizens. Exclusion criteria Teeth were excluded for the following reasons: molars with open apex, incompletely visualised teeth, evidence of previous endodontic treatment the presence of posts and crowns, surgical or pathological alterations made to tooth anatomy, or the existence of artefacts that impede proper visualisation of tooth anatomy. Regarding these criteria, 27 maxillary and 16 mandibular second molars were excluded. Evaluation of Radiological images All scans were acquired by using an I-CAT Next Generation CBCT (Hatfield, USA) unit in the Department of Dentomaxillofacial Radiology at Istanbul Medipol University. The principle of “as low as reasonably achievable,” (ALARA) concerning the exposure of patients to ionising radiation, was strictly adhered to at the time of image acquisition. The images were viewed using the i-CAT Next Generation Vision software (Imaging Sciences International, Hatfield, USA). The scans were originally taken for several reasons including the diagnosis of maxillofacial trauma, implant planning, and decision making for endodontic and orthodontic treatment cases. All scans were retrospectively analysed, and no new scans were acquired for the purpose of this study. (Fig. 2 ) The CBCT unit resolution ranged from 100 to 600 µm, with 300 to 750 basic frames. The anode current was 1 to 14 mA and the anode voltage was 54 to 90 kV. The focal spot was 0.6 × 0.6 mm (about 0.02 in) in diameter. The unit was capable of producing scans with a voxel size ranging from 100 to 600 µm, with fields of view ranging between 5.0 × 5.7 cm and 23.0 × 27.5 cm in size. During evaluation of the images, sagittal, axial, coronal slices with a thickness of 0.1 mm were evaluated. Also the ‘line’ property of the software was used to reform additional planes through the coronal, sagittal and axial planes. Evaluation of Endodontic scans Images were evaluated simultaneously by two calibrated examiners with 10 years of experience in endodontics through the planes as mentioned above, and a joint decision was made. In case of uncertainty, a dentomaxillofacial radiologist was consulted for a final opinion. A maximum allowed voxel size of 200 µm was selected. Scans exceeding these thresholds are deemed insufficient quality for evaluation. A single-rooted tooth was defined as follows: any that clearly displayed no bifurcation or roots with a bifurcation in the apical-most portion of the root. Multiple-rooted teeth, whether two or three-rooted, included teeth that demonstrated clearly bifurcated roots, whether partial or complete. In three rooted teeth, if fusion was present along the entire root length or partial fusion with common canals, the tooth was classified according to the criteria set out by Zhang et al. [ 25 ], including the modifications suggested by Ahmed and Dummer [ 18 ] (Fig. 3 ). Statistical analysis Interobserver reliability was calculated using percentage agreements. Statistical analyses were performed using the SPSS version 26.0 software program (IBM Corp., Armonk, NY, USA). Within the scope of the study, measurement data for basic descriptive statistics were categorical and expressed as frequency and percentage. Chi-square analysis was used to compare the data from the study. Statistical significance level was accepted as p < 0.05. RESULTS The outcomes of the study suggest that there is a statistically significant relationship between the number of roots in the upper molars and the age of the patients (x 2 = 48.528, p < 0.05). Four-rooted tooth samples were not observed in patients over the age of 50 years. On the other hand, the lowest rate of three-rooted teeth was observed in the 18–20 age group, and the highest rate in the 41–50 age group. Similarly, a statistically significant correlation was found between the number of roots in the lower molars and the age of the patients (x 2 = 57.455, p < 0.05). In patients over 60 years of age, no tooth samples with 3 roots were found. Meanwhile, the lowest rate was observed in the 18–20 age group and the highest rate was observed in the 41–50 age group (Table 2). Root morphology and number of roots The data demonstrated a significant correlation between the number of roots in the upper molars and the gender of the patients (x 2 = 12.784, p < 0.05). The ratio of teeth with three roots was found to be higher in male patients. A substantial correlation was found between the number of roots in the lower molars and the gender of the patients (x 2 = 12.970, p < 0.05). The ratio of teeth with two roots was found to be higher in male patients. In the upper molar single-rooted teeth analysed, the proportion of female patients was 58.3% and the proportion of male patients was 41.7%. In two-rooted teeth, the proportion of female patients was 57.9% and the proportion of male patients was 42.1%. In three-rooted teeth, the proportion of female and male patients was 47.1% and 52.9%. In four-rooted teeth, the ratio of female and male patients was 50% each. Moreover, there is a statistically significant difference in the gender distribution of patients based on the number of roots in the upper molars (x 2 = 11.060, p < 0.05). While the proportion of female patients was higher in single-rooted and two-rooted samples, the proportion of male patients was higher in three-rooted teeth. In the analysed lower molar single-rooted teeth, the proportion of female patients was 75.4% and the proportion of male patients was 24.6%. In two-rooted teeth, the proportion of female patients was 53.9% and the proportion of male patients was 46.1%. In teeth with three roots, the ratio of female patients was 66.7% and the ratio of male patients was 33.3%. There is a notable statistical difference between the gender distributions of the patients according to the number of roots in the lower molar teeth (x 2 = 13.332, p < 0.05). The proportion of female patients was found to be significantly higher than male patients (Table 3). Root canals configuration of second upper molars according to Vertucci’s classification As seen in Table 4 , the most prevalent vertucci classification among the single-rooted upper teeth examined in the upper right region was XV (n:4, 28.6%). For the analysed two-rooted upper molars, the most common classification for the buccal root was IV (n:17, 37.8%). while type I (n:43, 95.5%) was the most frequently observed classification for the palatal root. Among the three-rooted upper molars analysed, the highest vertucci classification for specimens located in the mesiobuccal root was type II (n:67, 36.8%). In the distobuccal root, type I (n:169, 91.4%) was the most common classification, and similarly, type I (n:165, 89.2%) was the most frequently observed for the palatal root. Among the four rooted upper molars analysed, the highest vertucci classification was type I (n:2, 50.0%) for the specimens located in the mesiobuccal root. The Vertucci classification for all specimens in the distobuccal root was type I (n:1, 100%), and type I (n:1, 100%) was also the highest classification for teeth in the palatal root (Table 4 ). The most common vertucci classification in the single-rooted upper teeth examined in the upper left region was XVIII (n:5, 33.3%). For the analysed two-rooted upper molars, the most prevalent classification in the buccal root was type IV (n:17, 33.4%). While type I (n:43, 84.3%) was the most frequently observed classification for the palatal root. Among the three rooted upper molars examined, the highest vertucci classification was type II for specimens located in the mesiobuccal root (n:53, 30.5%). The highest vertucci classification for the specimens located in the distobuccal root was type I (n:160, 90.9%) and the highest vertucci classification for the teeth located in the palatal root was type I (n:158, 89.8%). Among the four rooted upper molars examined, type I (n:2, 50.0%) was the highest classification for specimens in the mesiobuccal root. All specimens in the distobuccal root were classified as type I (n:4, 100%) likewise the highest vertucci classification for teeth in the palatal root was type I (n:4, 100%). There was a statistically significant difference between the Vertucci classifications according to the distribution of the teeth analysed (x 2 = 117.111, p < 0.05) (Table 4 ). Root canals configuration of second lower molars according to Vertucci’s classification The most common Vertucci classification for the examined lower left single-rooted teeth was type II (n:4, 20%). Among the two-rooted lower molars analysed, type IV (n:114, 50.4%) was the most frequently observed classification in the mesial root. In contrast, type I (n:170, 70.4%) was predominant in the distal root. For the three-rooted lower molars, type I was again the most common classification, found in the mesiobuccal root (n:7, 70.0%), the distal root (n:5, 50%), and the mesiolingual root (n:5, 50%). Turning to the lower right single-rooted teeth, type II was also the most common classification (n:8, 26.7%). In the analysed two-rooted lower molars, the mesial root again shows type IV as the most prevalent classification (n:125, 53.0%), while the distal root predominantly features type I (n:173, 73.0%). Among the three-rooted lower molars on the right side, type I was the highest classification observed in the mesiobuccal root (n = 3, 60.0%), distal root (n:4, 80.0%), and mesiolingual root (n:4, 80.0%). Overall, there is a statistically significant difference between the Vertucci classifications based on the distribution of the examined teeth (x² = 256.074, p < 0.05) (Table 4 ). Root canals configuration of second upper and lower molars according to Benjamı´n Brisen˜ o Marroquı´n classification For the proposed Benjamı´n Brisen˜ o Marroquı´n classification, the most common configuration for upper right single-rooted teeth was 1 17 3−2 (n:4, 20%). The most common configuration for two-rooted teeth; buccal root was 2 17 2 (n:17, 37.8%) and palatal root was 2 17 1 (n:43, 95. 5%). The most common configuration for upper right three-rooted teeth; mesial root was 3 17 2−1 (n:66, 35.7%), in distal root was 3 17 1 (n:169, 91.4%), and in palatal root was 3 17 1 (n:165, 89.2%). Only 4 17 1 configuration was observed in all roots of upper right second molars with four roots. For the Benjamín Briseño Marroquín classification, the most common configuration in the upper left single-rooted teeth was 1 27 3−1 (n:5, 31.3%). In the two-rooted teeth, the most prevalent configuration in buccal root was 2 27 2 (n:17, 33.4%), while in the palatal root was 2 27 1 (n:43, 84.3%). For the Benjamı´n Brisen˜ o Marroquı´n classification, the most common configuration for upper left three-rooted teeth; mesial root was 3 27 2−1 (n:52, 29.5%), in contrast the most prevalent configuration for distal root was 3 27 1 (n:160, 90.9%), and the most common configuration for palatal root was 3 27 1 (n:158, 89.8%). Notably, only 4 27 1 configuration was observed in all roots of upper right second molars with four roots (Table 5 ). According to the Benjamı´n Brisen˜ o Marroquı´n classification, the most frequent configuration in the lower left single-rooted teeth was 37 2−1 (n:4, 14.8%), In the case of two-rooted teeth; the most common configuration in the mesial root was 2 37 2 (n:114, 49.4%), while the distal root exhibited the configuration 2 37 1 (n:170, 73.6%). For lower left three-rooted teeth, the configuration 3 37 1 was the most frequent for the mesiobuccal root (n:7, 70%), and this same configuration also appeared most often in both the distal root 3 37 1 (n:5, 50%), and the mesiolingual root 3 37 1 (n:5, 50.0%). In the lower right single-rooted teeth, the predominant configuration was 1 47 2−1 (n:8, 23.5%), For two-rooted teeth, 2 47 2 was the most common configuration in the mesial root (n:125, 52.5%) and the distal root showed 2 47 1 (n:173, 72.7%). When examining lower right three-rooted teeth, the most common configuration for the mesial root was 3 47 1 (n:3, 60%), which was also the case for both the distal root 3 47 1 (n:4, 80%), and the mesiolingual root 3 47 1 (n:4, 80.0%). There is a statistically significant difference exists among the new configuration according to the distribution of the teeth analysed (x 2 = 343.068, p < 0.05) (Table 5 ). DISCUSSION The outcome of root canal treatment can be influenced by several factors. The presence of bacteria is the main cause of most non-healed root canal treatments. Additionally, use of improper radiographic projections, including different mesiodistal angulations to identify various root canal system aberrations, such as extra canals often result in failure, even with a correct diagnosis [ 32 ]. Other morphologic factors include lateral and accessory canals, canal curvatures, canal wall irregularities, fins, and isthmuses [ 32 ]. A thorough understanding and accurate characterization of root and canal anatomy are crucial prerequisites for successful root canal treatment. Three-dimensional diagnostic imaging modalities such as CBCT, allow for greater detection of root and canal morphology prior to endodontic treatment [ 33 ]. Over the decades, various methodologies have been developed to study the morphology of root canal systems [ 3 ]. One of the Technologies that has advanced this process is the CBCT which non-invasive technology that allows 1:1 accurate three-dimensional evaluation of tooth dimensions and root and canal morphology [ 31 ] CBCT has been utilised to examine various tooth types both experimentally and clinically [ 34 ]. CBCT has been formerly presented as a viable three-dimensional option for in vivo studies, with low radiation doses when compared with spiral CT [ 35 ]. To address deficiencies in existing systems, a new coding system for classifying root and canal morphology, accessory canals and anomalies has been introduced. In recent years, micro-computed tomography (micro-CT) [ 14 , 15 , 17 , 26 , 28 ] and cone beam computed tomography (CBCT) have been extensively used to study the details of root and canal anatomy in extracted teeth and within clinical settings [ 5 , 8 , 9 , 13 , 22 – 27 , 35 – 40 ]. Considering these findings, CBCT has been employed to evaluate the root morphologies in the present study. The number of root teeth were classified according to Vertucci’s classification, whereas canal configurations and numbers were classified by using Benjamı´n Brisen˜ o Marroquı´n [ 17 ] and Ahmad et al’s [ 26 ] system. Voxel size was determined as 200µm, similar to other studies [ 9 , 24 , 37 ]. Some of the previous studies focused on the comparison of C-shaped configurations in mandibular second molars between different populations in the world. In the present study, only the Turkish subpopulations root canal numbers and configurations were evaluated. Additionally, gender and age were considered as other criterias during classification in this study, similar to other previous studies [ 5 , 9 , 13 – 15 , 22 , 23 , 27 , 30 , 35 , 38 , 39 ]. In this study, the most common Vertucci classification in buccal roots of two rooted upper molars was type IV, on the other hand Type I was most prevalent in palatinal roots. For three rooted upper molars, the highest Vertucci Classifications for Mesiobuccal, Distobuccal and Palatinal roots were; Type II, Type I and Type I respectively. Four rooted upper molars each root classified in Type I. No difference found between the right and left region of upper second molars. The results which are belong to two rooted upper molars are consistent with the findings of Buchanan et al’s [ 9 ] who studied the maxillary second premolars, as well as Mheiri et al. [ 39 ], who examined the morphology of maxillary first molars, palatal and distal roots. Similarly, in the lower molars, type I was the most common Vertucci classification, followed by type IV. These results align with the findings reported by Kim et al. [ 30 ]. In this study, the most common type of Vertucci classification in lower molar single rooted teeth was Type II. In two rooted teeth, the most common Vertucci classification in the Mesial root was type IV, while Type I was the most common in Distal root. These findings are agreement with Saber et al’s findings [ 2 ]. Among the examined lower molar three rooted teeth, the highest Vertucci classification was Type I for Mesibuccal, mesiolingual and distal canals. The findings found similar for both left and right regions. These findings indicate that both round-shape canals and single-canal anatomy are usually classified in Vertucci’s classification Type I. Mesial roots which contain 2 canals, may be classified as Type IV or Type II. These results compatible with the other studies [ 9 , 15 , 22 , 39 ]; however, those studies evaluated the teeth by using micro-CT and four-digit classifying system [ 17 , 28 ]. The roots which have round shape, generally classified in Type I. Senan et al. [ 15 ], in agreement with our findings on a large scale. Type II was found in higher rate in mesial root of mandibular second molars whereas our findings mainly referred Type IV. In the present study, when the teeth root configurations based on the region of the localisation according to Benjamin Brisen Marroquin’s classification, it was found that the results were mostly similar for both right and left regions in the upper second molars, also it’s similar for lower second molars. The most common configuration for upper right two-rooted teeth buccal root is 2 17 2 and but then for upper left two rooted teeth buccal root is 2 27 2 . For the palatinal canals, the findings were similar both left ( 2 27 1 ) and right ( 2 17 1 ) regions. For the Benjamin Brisen Marroquin’s classification, the most common configuration for upper right three-rooted mesial root is 3 17 2−1 , whereas for upper left three rooted mesial root is 3 27 2−1 , the most common configuration for distal root is 3 17 1 in upper right molars; 3 27 1 is the most prevalent type in upper left second molars. For palatinal root configuration is commonly 3 17 1 in upper right second molars; 3 27 1 in upper left second molars. These findings are correlated with the Wolf et al’s study which evaluated the teeth by using microct [ 14 ]. They suggested that the root canal configuration of maxillary 2. Molar is heterogeneous [ 14 ]. However, comparison of the single rooted teeth results were quite different according to the region. The configuration canal results were for upper right second molar and upper left second molars; 1 17 3−2 , 1 27 3−1 respectively. In upper second molars with three roots, it was found that mesial roots have 2 canals which are fusing near the apex. Distal and palatinal roots have 1 canal for each. These findings are expected by the examiners in this study. The evaluation of lower second molars root configuration according to Benjamin Brisen Marroquin’s classification revealed to comment about the symmetrical structure of the teeth. The findings indicated that the root canal configurations were so similar in lower second molars. The most frequent type for lower left single rooted was 1 37 2−1 , while it was 1 47 2−1 for lower right single rooted second molars for both left and right regions. In two rooted teeth’s mesial canal configuration for lower left second molars and lower right second molars was 2 37 2 and 2 47 2 respectively. Distal roots findings were similar again both right ( 2 47 1 ) and left lower ( 2 37 1 ) second molars. The distribution of root canal configurations in lower left three rooted teeth was for all root canal types; MB: 3 37 1 , D: 3 37 1 and P: 3 37 1 , on the other hand the results were so similar in lower right second three rooted molars. The most configuration in left second molars for mesiobuccal root, distal root and mesiolingual root was 3 37 1 . In the right region of mandibula, the findings were the similar. For MB: 3 47 1 , D: 3 47 1 also ML: 3 47 1 , Abarca et al. evaluated the mandibular 1. and 2. molar root canals morphology using by CBCT, and classified the canals according to Ahmad et al’s classification. They found the similar results with our findings [ 16 ]. These results obviously revealed that symmetrical structure of root canals commonly in Turkish subpopulation. In Contrary, Alfawaz et al found the unilateral presence of C shaped root canal system more common [ 12 ]. The other studies suggested the symmetrically configuration of root canals [ 8 , 15 ] In the present study; canal orifices generally begin with two canals and than canals are getting fused in the single rooted lower second molars. The root canal may have only a foramen near the apex. In two rooted lower second molar teeth, number of mesial canals were 2, while distal canals were 1. It was a predicted result for this study. When the three roots examined in lower second molars, it was seen that all the roots have 1 canal for each. If we adapt the Benjamin Brisen Marroquin’s classification to Vertucci‘s Classification system, all results of this study are coherent. The previous CBCT studies [ 1 , 2 , 7 , 8 , 10 , 15 , 18 ] mainly based on Vertucci’s classification, whereas Buchanan et al.[ 1 ], Abarca et al. [ 16 ] classified the root canals in order to adapt the system that Ahmad et al’s classification [ 13 ]. The results of studies that examined the micro-CT [ 3 , 4 , 6 , 14 ] evaluated according to the 4 digit system. So, the comparison of the results between our study and the previous studies can achieve the explanation of the other classifications. The four digit system could be described; dividing the roots into thirds. Each of part includes coronal, middle and apical thirds, respectively. The fourth digit indicates the number of foramina [ 6 ]. If the litreature is searched, it can clearly seen that number of studies that had classified the roots according to the new classifications are so restricted. Because of these limitations, we compared our findings associated with the CBCT in addition to this microct studies. A statistically significant relationship was found between the number of roots in the upper molars and the gender of the patient with a higher ratio of three-rooted teeth observed in male patients. Similarly, a significant relationship was identified between the number of roots in lower molars and patient gender. In single rooted and two rooted upper molars the ratio of female patients higher than male patients. In contrast, in three rooted teeth, the proportion of male was higher than female. Despite the numerous studies about the analysis of gender and root anatomy, it was seen that the findings were not compatible in the studies. Previous studies [ 9 , 14 , 15 , 22 , 23 , 27 , 35 , 38 , 39 ] investigated the connection between root numbers and canal configurations associated with gender, revealing similarities to Kim et al.’s study [ 30 ] as well as studies focusing on premolar root anatomy [ 9 ]. Some of the studies suggested that there is no correlation between the gender and the root canal anatomy [ 23 , 36 , 39 ]. However, Varrela suggested that there is some correlation between root development and. The X chromosome [ 41 ] Abarca et al found that the anatomical variation was more in women than men, and difference was statistically significant [ 16 ], Nejaim claimed the similar results in correlation between C canal variations and female rates [ 20 ]. Alfawaz, claimed that female patients had a higher C canal variations than male patients [ 12 ]. Conversely, different studies found no correlation between the gender and the roots [ 2 , 8 , 10 , 15 ]. The outcomes of the study suggest that there is a statistically significant correlation between the number of roots in the both upper and lower molars and the age of the patients. Four-rooted tooth samples were not observed in patients over the age of 50 years. On the other hand, the lowest rate of three-rooted teeth was observed in the 18–20 age group, and the highest rate in the 41–50 age group. In patients over 60 years of age, no tooth samples with 3 roots were found. Meanwhile, the lowest rate was observed in the 18–20 age group and the highest rate was observed in the 41–50 age group. Razumova et al. [ 17 ] examined the crosssectional root canal shape using CBCT in different age groups. They found that cross sectional shape of root canal becomes round in apical third with age. In addition to this, they described that the root canal shape changed in the young and middle age group. For the elderly group, the stable shape of the canals in the M and D roots was most characteristic. In upper molars, the round or oval shape existed in both palatinal and distal root canals. Whereas MB canals showed variable structure oval to ribbon, from the coronal 1/3 to apical 1/3. Despite the differences between the methods of studies, these findings are considered in agreement with our results. This study revealed that mesial canal of molar teeth may classified commonly in Vertucci Type IV,VI and other complicated structures [ 17 ]. In contrary, Kaplan et al didn’t find any correlation between the ages and the root canal configurations [ 9 ]. In Brief, the configuration of root canal morphologies classified according to Vertucci and Benjamin Brisen Marroquin’s systems. Most of the findings exhibited that the anatomical structure is symmetrical for both sides in Turkish Subpopulation. Mesial canals configuratios can be variable when the compared with other roots. Palatinal roots and distal root canals indicated Type I (single structure) commonly. Mesial root canals both in maxillary and mandibulary teeth, exhibited Type IV and rarely Type II. The correlation between the gender and the root number was assesed. In terms of anatomic variation of root canals, the increased rate was found in female than male patients. CONCLUSION Overall, this study emphasises the importance of employing comprehensive classification systems to accurately characterise root canal morphology and highlights the significance of adequate sample size determination for robust statistical analysis. The insights gained from this study contribute to enhancing the understanding of root canal anatomy, ultimately improving the success rates of endodontic treatments in clinical practice. Abbreviations CBCT Cone beam computed tomography Micro CT Micro-computed tomography Declarations Acknowledgments None. Author contributions H.G.G: Writing – Original draft, Conceptualisation, Methodology, Validation, Investigation, Project administration; İ.Ö: Writing – review and editing, Supervision, Visualisation, Resources, Formal analysis; K.Ç: Data curation, Funding acquisition, Investigation; K.C.A: Data curation, Investigation, Software, Formal analysis. All authors reviewed the manuscript. Funding The authors declare no financial support or sponsorship. Data availability Data supporting the findings of this study are available from the corresponding author upon reasonable request. Declarations Ethics approval and consent to participate Non-Interventional Clinical Research Ethics Committee of Istanbul Medipol University approved the study and informed consent to participate was waived (E-10840098-202.3.02-2246). Clinical trial number Not applicable. Consent for publication The authors of this study provide complete consent for publication of this article in BMC Medical Imaging after approval from the review process. Competing interests The authors declare no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References Briseñ Marroquín B, El-Sayed A, M. A., Willershausen-Zö nnchen B. (2004). Morphology of the Physiological Foramen: I. Maxillary and Mandibular Molars (Vol. 30, Issue 5). https://doi.org/10.1097/00004770-200405000-00005 João Nogueira Leal, da Silva E, de Werczler Queiroz R, Nejaim Y, Ilídio Vespasiano Silva A, Haiter-Neto F, Silberman A, Cohenca N. Evaluation of root canal configuration of maxillary and mandibular anterior teeth using cone beam computed tomography: An in-vivo study. Quintessence Int. 2016;47:19–24. https://doi.org/10.3290/j.qi.a34807 . Ahmed HMA. 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Worldwide Prevalence of Mandibular Second Molar C-Shaped Morphologies Evaluated by Cone-Beam Computed Tomography. J Endod. 2017;43(9):1442–7. https://doi.org/10.1016/j.joen.2017.04.016 . Abella F, Teixidó LM, Patel S, Sosa F, Duran-Sindreu F, Roig M. Cone-beam Computed Tomography Analysis of the Root Canal Morphology of Maxillary First and Second Premolars in a Spanish Population. J Endod. 2015;41(8):1241–7. https://doi.org/10.1016/j.joen.2015.03.026 . Alfawaz H, Alqedairi A, Alkhayyal AK, Almobarak AA, Alhusain MF, Martins JNR. Prevalence of C-shaped canal system in mandibular first and second molars in a Saudi population assessed via cone beam computed tomography: a retrospective study. Clin Oral Invest. 2019;23(1):107–12. https://doi.org/10.1007/s00784-018-2415-0 . Abarca J, Abarca J, Duran M, Parra D, Steinfort K, Zaror C, Monardes H. Root morphology of mandibular molars: A cone-beam computed tomography study. 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Supplementary Files TablesBMCMedicalImaging.docx Cite Share Download PDF Status: Published Journal Publication published 02 Jan, 2025 Read the published version in BMC Medical Imaging → Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Editor assigned by journal 21 Oct, 2024 Submission checks completed at journal 21 Oct, 2024 First submitted to journal 17 Oct, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-5285143","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":369030681,"identity":"3111bc0b-2a5c-497f-8e0e-fca4fd653420","order_by":0,"name":"Hüseyin Gürkan GÜNEÇ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYFADHiD+AMRs7KRoYZwB0sJMihZmkE0MhLTIR+QefPCDoTZxe8/hZ49tfm2T52NmYPzwMQe3FsMbecmGPQzHE+ecbTM3zu27bdjGzMAsOXMbHi0zcsykGRiOJc7gZzCTzu25zQjUwsbMi1+L+W+IFvZv0pY9t+0JapGXyDED+rcmcQZvD9C6H7cTCWox4HljLNljcMB4Bs+ZMsnehtvJbcyMzXj9It+eY/jhR0Wd7Aye9G0SP/7ctp3f3nzww0d8thwAk4chPMY2MNmAWz3IFoh0HZT7B6/iUTAKRsEoGKEAAK8IS5uJ1WWkAAAAAElFTkSuQmCC","orcid":"","institution":"Health Sciences University","correspondingAuthor":true,"prefix":"","firstName":"Hüseyin","middleName":"Gürkan","lastName":"GÜNEÇ","suffix":""},{"id":369030682,"identity":"f641699d-7dde-4962-82db-87276dd86661","order_by":1,"name":"İpek ÖREROĞLU","email":"","orcid":"","institution":"İstanbul Yeni Yüzyıl University","correspondingAuthor":false,"prefix":"","firstName":"İpek","middleName":"","lastName":"ÖREROĞLU","suffix":""},{"id":369030683,"identity":"e66efeff-92f2-4e8e-9927-336f1d914615","order_by":2,"name":"Kemal ÇAĞLAR","email":"","orcid":"","institution":"Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Kemal","middleName":"","lastName":"ÇAĞLAR","suffix":""},{"id":369030684,"identity":"39d997b9-77cd-4424-a157-d225395f46ff","order_by":3,"name":"Kader CESUR AYDIN","email":"","orcid":"","institution":"İstanbul Medipol University","correspondingAuthor":false,"prefix":"","firstName":"Kader","middleName":"CESUR","lastName":"AYDIN","suffix":""}],"badges":[],"createdAt":"2024-10-17 20:53:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5285143/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5285143/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12880-024-01545-5","type":"published","date":"2025-01-02T15:57:38+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68655343,"identity":"fc521f0d-a588-41e2-9ebd-1594964cdf85","added_by":"auto","created_at":"2024-11-10 14:04:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1230177,"visible":true,"origin":"","legend":"\u003cp\u003eCanal configurations as originally described by Vertucci in 1984. The configurations are described as follows: (a) type I, (b) type II, (c) type III, (d) type IV, (e) type V, (f) type VI, (g) type VII, and (h) type VIII\u003c/p\u003e","description":"","filename":"Figure1BMCMI.png","url":"https://assets-eu.researchsquare.com/files/rs-5285143/v1/41dcab6867c24dc0d2197130.png"},{"id":68655339,"identity":"2671d1a6-f9ed-430d-a6e4-053bcf465852","added_by":"auto","created_at":"2024-11-10 14:04:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":402604,"visible":true,"origin":"","legend":"\u003cp\u003eAccording to Brisen˜ o Marroquı´n et al. classification \u003csup\u003e2\u003c/sup\u003e47D\u003csup\u003e1-2 \u003c/sup\u003erepresents the lower right of the molar distal root (A). According to Vertucci Classification Type V\u003csup\u003e \u003c/sup\u003erepresents the lower left of the molar distal root (B).\u003c/p\u003e","description":"","filename":"Figure2BMCMI.png","url":"https://assets-eu.researchsquare.com/files/rs-5285143/v1/8b7fcc3f62f3a56da07200a2.png"},{"id":68655340,"identity":"9d99fd31-40c5-433a-87a0-3bdc604ddcfd","added_by":"auto","created_at":"2024-11-10 14:04:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":961375,"visible":true,"origin":"","legend":"\u003cp\u003eExamples of cases found in second molar teeth: According to Brisen˜ o Marroquı´n et al. classification \u003csup\u003e1\u003c/sup\u003e47\u003csup\u003e2-1 \u003c/sup\u003e(A), \u003csup\u003e1\u003c/sup\u003e47\u003csup\u003e2-3-2 \u003c/sup\u003e(B), \u003csup\u003e1\u003c/sup\u003e17\u003csup\u003e3-1 \u003c/sup\u003e(C), \u003csup\u003e2\u003c/sup\u003e17M\u003csup\u003e2 \u003c/sup\u003e(D), \u003csup\u003e1\u003c/sup\u003e47\u003csup\u003e2-1 \u003c/sup\u003e(E), \u003csup\u003e3\u003c/sup\u003e17P\u003csup\u003e1-2-1 \u003c/sup\u003e(F), \u003csup\u003e1\u003c/sup\u003e27\u003csup\u003e1-2 \u003c/sup\u003e(G)\u003csup\u003e\u0026nbsp; \u003c/sup\u003e\u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure3BMCMI.png","url":"https://assets-eu.researchsquare.com/files/rs-5285143/v1/ee5c0b1f19f568e965a7a0eb.png"},{"id":73093347,"identity":"64728ea8-612e-4e41-a560-1a9273a00e97","added_by":"auto","created_at":"2025-01-06 16:14:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3106471,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5285143/v1/9866fa4c-de6e-450c-8c4e-f6f9301cdfae.pdf"},{"id":68655341,"identity":"0c9b3119-e52f-4608-8d21-cbf99e18c3cf","added_by":"auto","created_at":"2024-11-10 14:04:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":42907,"visible":true,"origin":"","legend":"","description":"","filename":"TablesBMCMedicalImaging.docx","url":"https://assets-eu.researchsquare.com/files/rs-5285143/v1/69cf91ae79dfbb40eb910a91.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Mandibular and Maxillary Second Molar Root Canal Anatomy in a Turkish Subpopulation Using CBCT: Comparison of Briseno-Marroquin and Vertucci Classifications","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe success of endodontic treatments relies heavily on several critical factors, including the intricate anatomy and morphology of the root canal system, thorough disinfection of the root canal, and effective sealing [\u003cspan\u003e1\u003c/span\u003e\u0026ndash;\u003cspan\u003e6\u003c/span\u003e]. A deep understanding of root canal anatomy and morphology is crucial for the success of endodontic treatments [\u003cspan\u003e7\u003c/span\u003e\u0026ndash;\u003cspan\u003e10\u003c/span\u003e]. Among many factors, the root canal system stands out as paramount due to the complexity of its anatomy and morphology. However, the root canal system may be complex and/or colonised by a variety of microorganisms. Thus, detailed knowledge of tooth anatomy is vital to pursuing endodontic treatment because the inability to detect and treat all identified canals may result in treatment failure [\u003cspan\u003e4\u003c/span\u003e, \u003cspan\u003e11\u003c/span\u003e, \u003cspan\u003e12\u003c/span\u003e]. Knowledge of root canal morphology is important for clinicians to master therapeutic techniques and clinical outcomes are improved. Understanding the root canal system involves identifying the number of roots and canals, the canal configurations, and their cross-sectional shapes [\u003cspan\u003e6\u003c/span\u003e, \u003cspan\u003e13\u003c/span\u003e, \u003cspan\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWeine et al. were the first to classify root canal morphology [\u003cspan\u003e7\u003c/span\u003e] within a single root, also they added an additional type in 1982 [\u003cspan\u003e7\u003c/span\u003e]. They focused on single-rooted teeth in their classification, creating four main categories. This classification is based on whether the canal is single, there are two canals from beginning to end, or the root is divided into two at the middle or apex.\u003c/p\u003e\n\u003cp\u003eIn 1974, Vertucci et al. recognized [\u003cspan\u003e7\u003c/span\u003e, \u003cspan\u003e10\u003c/span\u003e, \u003cspan\u003e16\u003c/span\u003e] further complex root canal systems and reported eight types of configurations according to the pattern of division in the main root canal from the pulp chamber to the apex of the root. However, Vertucci\u0026rsquo;s classification may not allow for unambiguous description given their classification variability according to the Vertucci system. Sert and Bayirli [\u003cspan\u003e10\u003c/span\u003e] added fourteen supplemental types to Vertucci\u0026apos;s classification system. A new classification was introduced n Brisen\u0026tilde; o Marroquı\u0026acute;n et al in the year 2015, which is simple, easy to understand, and more accurate at classifying root canal configurations compared to earlier systems [\u003cspan\u003e7\u003c/span\u003e, \u003cspan\u003e17\u003c/span\u003e]. This system uses the three-dimensional diagnostic imaging advantages. The benefit of Benjamı\u0026acute;n Brisen\u0026tilde; o Marroquı\u0026acute;n classification is its user-friendly coding system, which is accessible to both students and dentists [\u003cspan\u003e17\u003c/span\u003e]. The coding system assigns individual codes for the tooth number, the number of roots, and the configuration of the canals.\u003c/p\u003e\n\u003cp\u003eVertucci classified root canal morphology into eight types. This classification is more detailed than Weine\u0026rsquo;s classification. The first 3 types have single apical foramen and contain separation inside them, except type I. From type IV to type VII, teeth have two apical foramina. Type VIII differs from the others by having three apical foramens (Fig. \u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSert and Bayirli added supplementary configurations to Vertucci\u0026rsquo;s Classification due to the systems\u0026rsquo; limitations. The authors evaluated the root canal configuration in maxillary and mandibular permanent teeth amongst the Turkish population using a clearing technique. They added fourteen types to Vertucci\u0026rsquo;s classification, numbering them from Type IX to Type XXIII [\u003cspan\u003e4\u003c/span\u003e, \u003cspan\u003e10\u003c/span\u003e]. These added classes were developed to better describe intra-canal branching accounting for situations with more than two canal openings and more than three apical foramina. The Vertucci classification does not consider the number of roots in the anterior and posterior teeth which is a major shortcoming, this insufficiency in explaining the root canal anatomy creates a necessity for a new classification [\u003cspan\u003e4\u003c/span\u003e, \u003cspan\u003e7\u003c/span\u003e, \u003cspan\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe new four-digit coding system describes the anatomical features of roots in a consistent manner regardless of the tooth type and whether a tooth is single or multi rooted [\u003cspan\u003e18\u003c/span\u003e]. This new system for classifying root and canal morphology has defined any \u0026lsquo;division\u0026rsquo; of a root, whether in the coronal, middle or apical third, is coded as two or more roots. To enable researchers to interpret the configuration of the root canal consistently, the components of the pulp cavity, including the pulp chamber and root canal, should be defined accurately. For correct use of this classification correctly, it is essential to utilise three-dimensional imaging systems such as CBCT or Micro-CT [\u003cspan\u003e3\u003c/span\u003e, \u003cspan\u003e19\u003c/span\u003e, \u003cspan\u003e20\u003c/span\u003e]. Due to its high radiation exposure, micro-CT is not safe enough to use on patients. Conversely, CBCT has a lower radiation level, is more cost-effective, and provides sufficient information about the root canal system [\u003cspan\u003e11\u003c/span\u003e]. Several studies have found root canal configurations to be highly complex and found Non classifiable canal configurations during evaluation of internal and external anatomical canal variation using 3D imaging techniques [\u003cspan\u003e4\u003c/span\u003e, \u003cspan\u003e11\u003c/span\u003e, \u003cspan\u003e22\u003c/span\u003e, \u003cspan\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe new system for root and canal morphology defines the root canal configuration with a start (root canal orifice) passing through the canal and ends at the apical foramen. The root canal orifice is located at the level of the cervicomental junction (CEJ) in single-rooted teeth, and at the level of root bi/trifurcation (floor of the pulp chamber) in double and multi-rooted teeth [\u003cspan\u003e2\u003c/span\u003e, \u003cspan\u003e7\u003c/span\u003e, \u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e] (Table \u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA single-rooted tooth is\u003c/em\u003e defined as any tooth that clearly displayed no bifurcation, or roots with a bifurcation in the apical-most portion of the root. This distinction is important to understand the root canal anatomy clearly. Multiple-rooted teeth, whether two-or three-rooted, include teeth that demonstrate clearly bifurcated roots, whether partial or complete. The proposed morphological description of the root canal configuration starts with two root canals at the pulp chamber floor level. The digits describe the canal number at the coronal level of the respective third limit. The number of foramina is separated using a slash to facilitate understanding of the meaning of the digits.\u003c/p\u003e\n\u003cp\u003eFor \u003cem\u003eDouble-rooted teeth\u003c/em\u003e, If a researcher considers root fusion as a separate entity and would like to follow a defined classification to describe the type of root fusion, then the abbreviation for root fusion and its type can be added on the left of the tooth number, just as with other dental anomalies.\u003c/p\u003e\n\u003cp\u003eRegarding \u003cem\u003eThree-rooted teeth\u003c/em\u003e, Root fusion in three-rooted teeth can have several presentations, as described by Zhang et al.[\u003cspan\u003e25\u003c/span\u003e], which can be used in the new coding system. When it is difficult to differentiate between a single root with deep developmental grooves, and roots that have complete fusion along the root length, categorization can be based on the common number of roots for that particular tooth. As an example, a double-rooted maxillary premolar tooth may exhibit deep buccal and palatal grooves in the buccal root. On some occasions, research studies related to anatomy or mechanical instrumentation may focus on specific roots, such as the mesiobuccal or mesial root in maxillary or mandibular molars, respectively.\u003c/p\u003e\n\u003cp\u003eThe two-dimensional nature of periapical radiographs may result in missed roots and canals [\u003cspan\u003e21\u003c/span\u003e, \u003cspan\u003e26\u003c/span\u003e]. Changing the horizontal tube angulation may improve visualisation of the tooth anatomy, however this technique\u0026apos;s applicability may be limited in patients who have a smaller mouth space [\u003cspan\u003e27\u003c/span\u003e]. With the improving technologies, three-dimensional diagnostic imaging modalities such as CBCT allow greater detection of root and canal morphology prior to endodontic treatment.\u003c/p\u003e\n\u003cp\u003eMicro-CT has become the \u0026ldquo;gold-standard\u0026rdquo; for evaluating bone morphology and microstructure in the ex vivo models [\u003cspan\u003e4\u003c/span\u003e, \u003cspan\u003e14\u003c/span\u003e, \u003cspan\u003e28\u003c/span\u003e]. On the other hand, clinical CBCT has been widely applied in dentistry for over two decades, offering high image quality with low radiation dose at a low cost. Compared to micro CBCT, CBCT is less invasive but still an accurate method that can be used in clinical works. Moreover, CBCT is superior to periapical radiography in successfully detecting root canal anatomy. The root can be easily examined in more detail with different sections [\u003cspan\u003e4\u003c/span\u003e, \u003cspan\u003e10\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e]. Difficulty working in molar teeth and the complex anatomy of root canals may cause treatment failure. Two-Dimensional images taken from periapical radiographs may not always provide accurate results due to superpositions. At this point, treatment success increases when the relevant tooth is examined with 3D imaging methods such as CBCT and the canal anatomy is understood correctly [\u003cspan\u003e11\u003c/span\u003e, \u003cspan\u003e30\u003c/span\u003e, \u003cspan\u003e31\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThis study aims to investigate the differences among Vertucci and the Benjamı\u0026acute;n Brisen\u0026tilde; o Marroquı\u0026acute;n classifications using CBCT evaluations of mandibular and maxillary second molars in a Turkish subpopulation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample selection\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003efor this study was obtained from the Non- Interventional Ethics Committee of the xxxx University (protocol no. 309/2024). Statistical analyses were performed using the G Power version 3.1 software program (Heinrich University, Dusseldorf, Germany). The Chi square test was used for analysing contingency tables, 764 samples of each subgroup, consisting of four sections. This was determined with an (error margin)\u0026thinsp;=\u0026thinsp;0.05, 0.15 effect (w), 0.95 power (1-) level, yielding a minimum sample size of 382.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSubjects\u003c/h3\u003e\n\u003cp\u003eThis cross-sectional retrospective study evaluated 1084 second molar images (523 upper; 266 right and 257 left sides and 561 lower; 285 right and 276 left sides second molars, respectively) obtained from 320 CBCT scans. CBCT exams showing mandibular and maxillary second molars with complete root formation and integrity were included and subjects aged between 18 and 76 years.\u003c/p\u003e \u003cp\u003eThe images were used to determine the root number and canal configurations of maxillary and mandibular molars. Both left and right second molars were included. Scans from both male (n\u0026thinsp;=\u0026thinsp;503) and female (n\u0026thinsp;=\u0026thinsp;581) subjects were evaluated. Participant age at the time of the scan was recorded, but no information on race or ethnicity was collected. The existing CBCT database was used, and no new scans were acquired for this study. Scans were assessed chronologically back from the most recently acquired one until the necessary sample size was achieved. The study time period ranged from 2021 to 2024.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eScans containing fully formed maxillary and mandibular molars were included in this research. The scans were needed to exhibit adequate quality for visualising individual roots and canals. CBCT images that met the following criteria were included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eScans that included the entire pulp chamber and root canal system were considered (496 upper and 545 lower second molars).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePresence of a fully mature and erupted maxillary and mandibular second molar.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eParticipants must be over 18 years old\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eParticipants must be Turkish citizens.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eTeeth were excluded for the following reasons:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003emolars with open apex,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eincompletely visualised teeth,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eevidence of previous endodontic treatment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ethe presence of posts and crowns,\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003esurgical or pathological alterations made to tooth anatomy, or\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ethe existence of artefacts that impede proper visualisation of tooth anatomy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eRegarding these criteria, 27 maxillary and 16 mandibular second molars were excluded.\u003c/p\u003e\n\u003ch3\u003eEvaluation of Radiological images\u003c/h3\u003e\n\u003cp\u003eAll scans were acquired by using an I-CAT Next Generation CBCT (Hatfield, USA) unit in the Department of Dentomaxillofacial Radiology at Istanbul Medipol University. The principle of \u0026ldquo;as low as reasonably achievable,\u0026rdquo; (ALARA) concerning the exposure of patients to ionising radiation, was strictly adhered to at the time of image acquisition. The images were viewed using the i-CAT Next Generation Vision software (Imaging Sciences International, Hatfield, USA). The scans were originally taken for several reasons including the diagnosis of maxillofacial trauma, implant planning, and decision making for endodontic and orthodontic treatment cases. All scans were retrospectively analysed, and no new scans were acquired for the purpose of this study. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe CBCT unit resolution ranged from 100 to 600 \u0026micro;m, with 300 to 750 basic frames. The anode current was 1 to 14 mA and the anode voltage was 54 to 90 kV. The focal spot was 0.6 \u0026times; 0.6 mm (about 0.02 in) in diameter. The unit was capable of producing scans with a voxel size ranging from 100 to 600 \u0026micro;m, with fields of view ranging between 5.0 \u0026times; 5.7 cm and 23.0 \u0026times; 27.5 cm in size. During evaluation of the images, sagittal, axial, coronal slices with a thickness of 0.1 mm were evaluated. Also the \u0026lsquo;line\u0026rsquo; property of the software was used to reform additional planes through the coronal, sagittal and axial planes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation of Endodontic scans\u003c/h2\u003e \u003cp\u003eImages were evaluated simultaneously by two calibrated examiners with 10 years of experience in endodontics through the planes as mentioned above, and a joint decision was made. In case of uncertainty, a dentomaxillofacial radiologist was consulted for a final opinion. A maximum allowed voxel size of 200 \u0026micro;m was selected. Scans exceeding these thresholds are deemed insufficient quality for evaluation.\u003c/p\u003e \u003cp\u003eA single-rooted tooth was defined as follows: any that clearly displayed no bifurcation or roots with a bifurcation in the apical-most portion of the root. Multiple-rooted teeth, whether two or three-rooted, included teeth that demonstrated clearly bifurcated roots, whether partial or complete. In three rooted teeth, if fusion was present along the entire root length or partial fusion with common canals, the tooth was classified according to the criteria set out by Zhang et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], including the modifications suggested by Ahmed and Dummer [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eInterobserver reliability was calculated using percentage agreements. Statistical analyses were performed using the SPSS version 26.0 software program (IBM Corp., Armonk, NY, USA). Within the scope of the study, measurement data for basic descriptive statistics were categorical and expressed as frequency and percentage. Chi-square analysis was used to compare the data from the study. Statistical significance level was accepted as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe outcomes of the study suggest that there is a statistically significant relationship between the number of roots in the upper molars and the age of the patients (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;48.528, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Four-rooted tooth samples were not observed in patients over the age of 50 years. On the other hand, the lowest rate of three-rooted teeth was observed in the 18\u0026ndash;20 age group, and the highest rate in the 41\u0026ndash;50 age group. Similarly, a statistically significant correlation was found between the number of roots in the lower molars and the age of the patients (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;57.455, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In patients over 60 years of age, no tooth samples with 3 roots were found. Meanwhile, the lowest rate was observed in the 18\u0026ndash;20 age group and the highest rate was observed in the 41\u0026ndash;50 age group (Table\u0026nbsp;2).\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eRoot morphology and number of roots\u003c/h2\u003e\n \u003cp\u003eThe data demonstrated a significant correlation between the number of roots in the upper molars and the gender of the patients (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;12.784, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The ratio of teeth with three roots was found to be higher in male patients. A substantial correlation was found between the number of roots in the lower molars and the gender of the patients (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;12.970, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The ratio of teeth with two roots was found to be higher in male patients. In the upper molar single-rooted teeth analysed, the proportion of female patients was 58.3% and the proportion of male patients was 41.7%. In two-rooted teeth, the proportion of female patients was 57.9% and the proportion of male patients was 42.1%. In three-rooted teeth, the proportion of female and male patients was 47.1% and 52.9%. In four-rooted teeth, the ratio of female and male patients was 50% each. Moreover, there is a statistically significant difference in the gender distribution of patients based on the number of roots in the upper molars (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;11.060, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). While the proportion of female patients was higher in single-rooted and two-rooted samples, the proportion of male patients was higher in three-rooted teeth.\u003c/p\u003e\n \u003cp\u003eIn the analysed lower molar single-rooted teeth, the proportion of female patients was 75.4% and the proportion of male patients was 24.6%. In two-rooted teeth, the proportion of female patients was 53.9% and the proportion of male patients was 46.1%. In teeth with three roots, the ratio of female patients was 66.7% and the ratio of male patients was 33.3%. There is a notable statistical difference between the gender distributions of the patients according to the number of roots in the lower molar teeth (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;13.332, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The proportion of female patients was found to be significantly higher than male patients (Table\u0026nbsp;3).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eRoot canals configuration of second upper molars according to Vertucci\u0026rsquo;s classification\u003c/h2\u003e\n \u003cp\u003eAs seen in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, the most prevalent vertucci classification among the single-rooted upper teeth examined in the upper right region was XV (n:4, 28.6%). For the analysed two-rooted upper molars, the most common classification for the buccal root was IV (n:17, 37.8%). while type I (n:43, 95.5%) was the most frequently observed classification for the palatal root. Among the three-rooted upper molars analysed, the highest vertucci classification for specimens located in the mesiobuccal root was type II (n:67, 36.8%). In the distobuccal root, type I (n:169, 91.4%) was the most common classification, and similarly, type I (n:165, 89.2%) was the most frequently observed for the palatal root. Among the four rooted upper molars analysed, the highest vertucci classification was type I (n:2, 50.0%) for the specimens located in the mesiobuccal root. The Vertucci classification for all specimens in the distobuccal root was type I (n:1, 100%), and type I (n:1, 100%) was also the highest classification for teeth in the palatal root (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe most common vertucci classification in the single-rooted upper teeth examined in the upper left region was XVIII (n:5, 33.3%). For the analysed two-rooted upper molars, the most prevalent classification in the buccal root was type IV (n:17, 33.4%). While type I (n:43, 84.3%) was the most frequently observed classification for the palatal root. Among the three rooted upper molars examined, the highest vertucci classification was type II for specimens located in the mesiobuccal root (n:53, 30.5%). The highest vertucci classification for the specimens located in the distobuccal root was type I (n:160, 90.9%) and the highest vertucci classification for the teeth located in the palatal root was type I (n:158, 89.8%). Among the four rooted upper molars examined, type I (n:2, 50.0%) was the highest classification for specimens in the mesiobuccal root. All specimens in the distobuccal root were classified as type I (n:4, 100%) likewise the highest vertucci classification for teeth in the palatal root was type I (n:4, 100%). There was a statistically significant difference between the Vertucci classifications according to the distribution of the teeth analysed (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;117.111, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eRoot canals configuration of second lower molars according to Vertucci\u0026rsquo;s classification\u003c/h2\u003e\n \u003cp\u003eThe most common Vertucci classification for the examined lower left single-rooted teeth was type II (n:4, 20%). Among the two-rooted lower molars analysed, type IV (n:114, 50.4%) was the most frequently observed classification in the mesial root. In contrast, type I (n:170, 70.4%) was predominant in the distal root. For the three-rooted lower molars, type I was again the most common classification, found in the mesiobuccal root (n:7, 70.0%), the distal root (n:5, 50%), and the mesiolingual root (n:5, 50%). Turning to the lower right single-rooted teeth, type II was also the most common classification (n:8, 26.7%). In the analysed two-rooted lower molars, the mesial root again shows type IV as the most prevalent classification (n:125, 53.0%), while the distal root predominantly features type I (n:173, 73.0%).\u003c/p\u003e\n \u003cp\u003eAmong the three-rooted lower molars on the right side, type I was the highest classification observed in the mesiobuccal root (n\u0026thinsp;=\u0026thinsp;3, 60.0%), distal root (n:4, 80.0%), and mesiolingual root (n:4, 80.0%). Overall, there is a statistically significant difference between the Vertucci classifications based on the distribution of the examined teeth (x\u0026sup2; = 256.074, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRoot canals configuration of second upper and lower molars according to Benjamı\u0026acute;n Brisen\u0026tilde; o Marroquı\u0026acute;n classification\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFor the proposed Benjamı\u0026acute;n Brisen\u0026tilde; o Marroquı\u0026acute;n classification, the most common configuration for upper right single-rooted teeth was \u003csup\u003e1\u003c/sup\u003e17\u003csup\u003e3\u0026minus;2\u003c/sup\u003e (n:4, 20%). The most common configuration for two-rooted teeth; buccal root was \u003csup\u003e2\u003c/sup\u003e17\u003csup\u003e2\u003c/sup\u003e (n:17, 37.8%) and palatal root was \u003csup\u003e2\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e (n:43, 95. 5%). The most common configuration for upper right three-rooted teeth; mesial root was \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e2\u0026minus;1\u003c/sup\u003e (n:66, 35.7%), in distal root was \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e (n:169, 91.4%), and in palatal root was \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e (n:165, 89.2%). Only \u003csup\u003e4\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e configuration was observed in all roots of upper right second molars with four roots.\u003c/p\u003e\n \u003cp\u003eFor the Benjam\u0026iacute;n Brise\u0026ntilde;o Marroqu\u0026iacute;n classification, the most common configuration in the upper left single-rooted teeth was \u003csup\u003e1\u003c/sup\u003e27\u003csup\u003e3\u0026minus;1\u003c/sup\u003e (n:5, 31.3%). In the two-rooted teeth, the most prevalent configuration in buccal root was \u003csup\u003e2\u003c/sup\u003e27\u003csup\u003e2\u003c/sup\u003e (n:17, 33.4%), while in the palatal root was \u003csup\u003e2\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e (n:43, 84.3%). For the Benjamı\u0026acute;n Brisen\u0026tilde; o Marroquı\u0026acute;n classification, the most common configuration for upper left three-rooted teeth; mesial root was \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e2\u0026minus;1\u003c/sup\u003e (n:52, 29.5%), in contrast the most prevalent configuration for distal root was \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e (n:160, 90.9%), and the most common configuration for palatal root was \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e (n:158, 89.8%). Notably, only \u003csup\u003e4\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e configuration was observed in all roots of upper right second molars with four roots (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eAccording to the Benjamı\u0026acute;n Brisen\u0026tilde; o Marroquı\u0026acute;n classification, the most frequent configuration in the lower left single-rooted teeth was 37\u003csup\u003e2\u0026minus;1\u003c/sup\u003e (n:4, 14.8%), In the case of two-rooted teeth; the most common configuration in the mesial root was \u003csup\u003e2\u003c/sup\u003e37\u003csup\u003e2\u003c/sup\u003e (n:114, 49.4%), while the distal root exhibited the configuration \u003csup\u003e2\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e (n:170, 73.6%). For lower left three-rooted teeth, the configuration \u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e was the most frequent for the mesiobuccal root (n:7, 70%), and this same configuration also appeared most often in both the distal root \u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e (n:5, 50%), and the mesiolingual root \u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e (n:5, 50.0%).\u003c/p\u003e\n \u003cp\u003eIn the lower right single-rooted teeth, the predominant configuration was \u003csup\u003e1\u003c/sup\u003e47\u003csup\u003e2\u0026minus;1\u003c/sup\u003e (n:8, 23.5%), For two-rooted teeth, \u003csup\u003e2\u003c/sup\u003e47\u003csup\u003e2\u003c/sup\u003e was the most common configuration in the mesial root (n:125, 52.5%) and the distal root showed \u003csup\u003e2\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e (n:173, 72.7%). When examining lower right three-rooted teeth, the most common configuration for the mesial root was \u003csup\u003e3\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e (n:3, 60%), which was also the case for both the distal root \u003csup\u003e3\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e (n:4, 80%), and the mesiolingual root \u003csup\u003e3\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e (n:4, 80.0%). There is a statistically significant difference exists among the new configuration according to the distribution of the teeth analysed (x\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;343.068, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe outcome of root canal treatment can be influenced by several factors. The presence of bacteria is the main cause of most non-healed root canal treatments. Additionally, use of improper radiographic projections, including different mesiodistal angulations to identify various root canal system aberrations, such as extra canals often result in failure, even with a correct diagnosis [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Other morphologic factors include lateral and accessory canals, canal curvatures, canal wall irregularities, fins, and isthmuses [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA thorough understanding and accurate characterization of root and canal anatomy are crucial prerequisites for successful root canal treatment. Three-dimensional diagnostic imaging modalities such as CBCT, allow for greater detection of root and canal morphology prior to endodontic treatment [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Over the decades, various methodologies have been developed to study the morphology of root canal systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. One of the Technologies that has advanced this process is the CBCT which non-invasive technology that allows 1:1 accurate three-dimensional evaluation of tooth dimensions and root and canal morphology [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] CBCT has been utilised to examine various tooth types both experimentally and clinically [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. CBCT has been formerly presented as a viable three-dimensional option for in vivo studies, with low radiation doses when compared with spiral CT [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. To address deficiencies in existing systems, a new coding system for classifying root and canal morphology, accessory canals and anomalies has been introduced. In recent years, micro-computed tomography (micro-CT) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and cone beam computed tomography (CBCT) have been extensively used to study the details of root and canal anatomy in extracted teeth and within clinical settings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37 CR38 CR39\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering these findings, CBCT has been employed to evaluate the root morphologies in the present study. The number of root teeth were classified according to Vertucci\u0026rsquo;s classification, whereas canal configurations and numbers were classified by using Benjamı\u0026acute;n Brisen˜ o Marroquı\u0026acute;n [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and Ahmad et al\u0026rsquo;s [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] system. Voxel size was determined as 200\u0026micro;m, similar to other studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Some of the previous studies focused on the comparison of C-shaped configurations in mandibular second molars between different populations in the world. In the present study, only the Turkish subpopulations root canal numbers and configurations were evaluated. Additionally, gender and age were considered as other criterias during classification in this study, similar to other previous studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the most common Vertucci classification in buccal roots of two rooted upper molars was type IV, on the other hand Type I was most prevalent in palatinal roots. For three rooted upper molars, the highest Vertucci Classifications for Mesiobuccal, Distobuccal and Palatinal roots were; Type II, Type I and Type I respectively. Four rooted upper molars each root classified in Type I. No difference found between the right and left region of upper second molars. The results which are belong to two rooted upper molars are consistent with the findings of Buchanan et al\u0026rsquo;s [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] who studied the maxillary second premolars, as well as Mheiri et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], who examined the morphology of maxillary first molars, palatal and distal roots. Similarly, in the lower molars, type I was the most common Vertucci classification, followed by type IV. These results align with the findings reported by Kim et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the most common type of Vertucci classification in lower molar single rooted teeth was Type II. In two rooted teeth, the most common Vertucci classification in the Mesial root was type IV, while Type I was the most common in Distal root. These findings are agreement with Saber et al\u0026rsquo;s findings [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Among the examined lower molar three rooted teeth, the highest Vertucci classification was Type I for Mesibuccal, mesiolingual and distal canals. The findings found similar for both left and right regions. These findings indicate that both round-shape canals and single-canal anatomy are usually classified in Vertucci\u0026rsquo;s classification Type I. Mesial roots which contain 2 canals, may be classified as Type IV or Type II. These results compatible with the other studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]; however, those studies evaluated the teeth by using micro-CT and four-digit classifying system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The roots which have round shape, generally classified in Type I. Senan et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], in agreement with our findings on a large scale. Type II was found in higher rate in mesial root of mandibular second molars whereas our findings mainly referred Type IV.\u003c/p\u003e \u003cp\u003eIn the present study, when the teeth root configurations based on the region of the localisation according to Benjamin Brisen Marroquin\u0026rsquo;s classification, it was found that the results were mostly similar for both right and left regions in the upper second molars, also it\u0026rsquo;s similar for lower second molars. The most common configuration for upper right two-rooted teeth buccal root is \u003csup\u003e2\u003c/sup\u003e17\u003csup\u003e2\u003c/sup\u003e and but then for upper left two rooted teeth buccal root is \u003csup\u003e2\u003c/sup\u003e27\u003csup\u003e2\u003c/sup\u003e. For the palatinal canals, the findings were similar both left (\u003csup\u003e2\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e) and right (\u003csup\u003e2\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e) regions. For the Benjamin Brisen Marroquin\u0026rsquo;s classification, the most common configuration for upper right three-rooted mesial root is \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e2\u0026minus;1\u003c/sup\u003e, whereas for upper left three rooted mesial root is \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e2\u0026minus;1\u003c/sup\u003e, the most common configuration for distal root is \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e in upper right molars; \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e is the most prevalent type in upper left second molars. For palatinal root configuration is commonly \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e in upper right second molars; \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e in upper left second molars. These findings are correlated with the Wolf et al\u0026rsquo;s study which evaluated the teeth by using microct [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. They suggested that the root canal configuration of maxillary 2. Molar is heterogeneous [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, comparison of the single rooted teeth results were quite different according to the region. The configuration canal results were for upper right second molar and upper left second molars; \u003csup\u003e1\u003c/sup\u003e17\u003csup\u003e3\u0026minus;2\u003c/sup\u003e, \u003csup\u003e1\u003c/sup\u003e27\u003csup\u003e3\u0026minus;1\u003c/sup\u003e respectively. In upper second molars with three roots, it was found that mesial roots have 2 canals which are fusing near the apex. Distal and palatinal roots have 1 canal for each. These findings are expected by the examiners in this study.\u003c/p\u003e \u003cp\u003eThe evaluation of lower second molars root configuration according to Benjamin Brisen Marroquin\u0026rsquo;s classification revealed to comment about the symmetrical structure of the teeth. The findings indicated that the root canal configurations were so similar in lower second molars. The most frequent type for lower left single rooted was \u003csup\u003e1\u003c/sup\u003e37\u003csup\u003e2\u0026minus;1\u003c/sup\u003e, while it was \u003csup\u003e1\u003c/sup\u003e47\u003csup\u003e2\u0026minus;1\u003c/sup\u003e for lower right single rooted second molars for both left and right regions. In two rooted teeth\u0026rsquo;s mesial canal configuration for lower left second molars and lower right second molars was \u003csup\u003e2\u003c/sup\u003e37\u003csup\u003e2\u003c/sup\u003e and \u003csup\u003e2\u003c/sup\u003e47\u003csup\u003e2\u003c/sup\u003e respectively. Distal roots findings were similar again both right (\u003csup\u003e2\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e) and left lower (\u003csup\u003e2\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e) second molars. The distribution of root canal configurations in lower left three rooted teeth was for all root canal types; MB:\u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e, D:\u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e and P:\u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e, on the other hand the results were so similar in lower right second three rooted molars. The most configuration in left second molars for mesiobuccal root, distal root and mesiolingual root was \u003csup\u003e3\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e. In the right region of mandibula, the findings were the similar. For MB:\u003csup\u003e3\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e, D:\u003csup\u003e3\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e also ML: \u003csup\u003e3\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e, Abarca et al. evaluated the mandibular 1. and 2. molar root canals morphology using by CBCT, and classified the canals according to Ahmad et al\u0026rsquo;s classification. They found the similar results with our findings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese results obviously revealed that symmetrical structure of root canals commonly in Turkish subpopulation. In Contrary, Alfawaz et al found the unilateral presence of C shaped root canal system more common [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The other studies suggested the symmetrically configuration of root canals [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] In the present study; canal orifices generally begin with two canals and than canals are getting fused in the single rooted lower second molars. The root canal may have only a foramen near the apex. In two rooted lower second molar teeth, number of mesial canals were 2, while distal canals were 1. It was a predicted result for this study. When the three roots examined in lower second molars, it was seen that all the roots have 1 canal for each. If we adapt the Benjamin Brisen Marroquin\u0026rsquo;s classification to Vertucci\u0026lsquo;s Classification system, all results of this study are coherent. The previous CBCT studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] mainly based on Vertucci\u0026rsquo;s classification, whereas Buchanan et al.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], Abarca et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] classified the root canals in order to adapt the system that Ahmad et al\u0026rsquo;s classification [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The results of studies that examined the micro-CT [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] evaluated according to the 4 digit system. So, the comparison of the results between our study and the previous studies can achieve the explanation of the other classifications. The four digit system could be described; dividing the roots into thirds. Each of part includes coronal, middle and apical thirds, respectively. The fourth digit indicates the number of foramina [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. If the litreature is searched, it can clearly seen that number of studies that had classified the roots according to the new classifications are so restricted. Because of these limitations, we compared our findings associated with the CBCT in addition to this microct studies.\u003c/p\u003e \u003cp\u003eA statistically significant relationship was found between the number of roots in the upper molars and the gender of the patient with a higher ratio of three-rooted teeth observed in male patients. Similarly, a significant relationship was identified between the number of roots in lower molars and patient gender. In single rooted and two rooted upper molars the ratio of female patients higher than male patients. In contrast, in three rooted teeth, the proportion of male was higher than female. Despite the numerous studies about the analysis of gender and root anatomy, it was seen that the findings were not compatible in the studies. Previous studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] investigated the connection between root numbers and canal configurations associated with gender, revealing similarities to Kim et al.\u0026rsquo;s study [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] as well as studies focusing on premolar root anatomy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Some of the studies suggested that there is no correlation between the gender and the root canal anatomy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, Varrela suggested that there is some correlation between root development and. The X chromosome [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] Abarca et al found that the anatomical variation was more in women than men, and difference was statistically significant [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], Nejaim claimed the similar results in correlation between C canal variations and female rates [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Alfawaz, claimed that female patients had a higher C canal variations than male patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Conversely, different studies found no correlation between the gender and the roots [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe outcomes of the study suggest that there is a statistically significant correlation between the number of roots in the both upper and lower molars and the age of the patients. Four-rooted tooth samples were not observed in patients over the age of 50 years. On the other hand, the lowest rate of three-rooted teeth was observed in the 18\u0026ndash;20 age group, and the highest rate in the 41\u0026ndash;50 age group. In patients over 60 years of age, no tooth samples with 3 roots were found. Meanwhile, the lowest rate was observed in the 18\u0026ndash;20 age group and the highest rate was observed in the 41\u0026ndash;50 age group. Razumova et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] examined the crosssectional root canal shape using CBCT in different age groups. They found that cross sectional shape of root canal becomes round in apical third with age. In addition to this, they described that the root canal shape changed in the young and middle age group. For the elderly group, the stable shape of the canals in the M and D roots was most characteristic. In upper molars, the round or oval shape existed in both palatinal and distal root canals. Whereas MB canals showed variable structure oval to ribbon, from the coronal 1/3 to apical 1/3. Despite the differences between the methods of studies, these findings are considered in agreement with our results. This study revealed that mesial canal of molar teeth may classified commonly in Vertucci Type IV,VI and other complicated structures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In contrary, Kaplan et al didn\u0026rsquo;t find any correlation between the ages and the root canal configurations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Brief, the configuration of root canal morphologies classified according to Vertucci and Benjamin Brisen Marroquin\u0026rsquo;s systems. Most of the findings exhibited that the anatomical structure is symmetrical for both sides in Turkish Subpopulation. Mesial canals configuratios can be variable when the compared with other roots. Palatinal roots and distal root canals indicated Type I (single structure) commonly. Mesial root canals both in maxillary and mandibulary teeth, exhibited Type IV and rarely Type II. The correlation between the gender and the root number was assesed. In terms of anatomic variation of root canals, the increased rate was found in female than male patients.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOverall, this study emphasises the importance of employing comprehensive classification systems to accurately characterise root canal morphology and highlights the significance of adequate sample size determination for robust statistical analysis. The insights gained from this study contribute to enhancing the understanding of root canal anatomy, ultimately improving the success rates of endodontic treatments in clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBCT Cone\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebeam computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMicro\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCT Micro-computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.G.G: Writing \u0026ndash; Original draft, Conceptualisation, Methodology, Validation, Investigation, Project administration; İ.\u0026Ouml;: Writing \u0026ndash; review and editing, Supervision, Visualisation, Resources, Formal analysis; K.\u0026Ccedil;: Data curation, Funding acquisition, Investigation; K.C.A: Data curation, Investigation, Software, Formal analysis.\u0026nbsp;All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial support or sponsorship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-Interventional Clinical Research Ethics Committee of Istanbul Medipol University approved the study and informed consent to participate was waived (E-10840098-202.3.02-2246).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors of this study provide complete consent for publication of this article in BMC Medical Imaging after approval from the review process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBrise\u0026ntilde; Marroqu\u0026iacute;n B, El-Sayed A, M. 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J Endod. 2017;43(9):1442\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.joen.2017.04.016\u003c/span\u003e\u003cspan address=\"10.1016/j.joen.2017.04.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbella F, Teixid\u0026oacute; LM, Patel S, Sosa F, Duran-Sindreu F, Roig M. Cone-beam Computed Tomography Analysis of the Root Canal Morphology of Maxillary First and Second Premolars in a Spanish Population. J Endod. 2015;41(8):1241\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.joen.2015.03.026\u003c/span\u003e\u003cspan address=\"10.1016/j.joen.2015.03.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlfawaz H, Alqedairi A, Alkhayyal AK, Almobarak AA, Alhusain MF, Martins JNR. Prevalence of C-shaped canal system in mandibular first and second molars in a Saudi population assessed via cone beam computed tomography: a retrospective study. 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Saudi Dent J. 2016;28(4):162\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.sdentj.2016.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.sdentj.2016.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 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-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CBCT, Root canal morphology, Vertucci classification, Benjamı´n Brisen˜ o Marroquı´n classification, Second molars","lastPublishedDoi":"10.21203/rs.3.rs-5285143/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5285143/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis retrospective study aims to characterise the root canal morphology of maxillary and mandibular molars using cone-beam computed tomography (CBCT). The number of roots and canal configurations were evaluated using both the Vertucci and Benjamı\u0026acute;n Brisen˜ o Marroquı\u0026acute;n classification systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTotal of 1084 second molar images (523 upper; 266 right and 257 left sides \u0026amp; 561 lower; 285 right and 276 left sides) were obtained from 320 CBCT scans that were analysed. CBCT imaging provided superior visualisation of root canal anatomy compared to periapical radiography. The findings revealed diverse root canal configurations, with variations observed even within the same population. Statistical analyses, including the chi-squared test, were used to assess correlations between root number and demographic variables such as age and sex.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAccording to Benjamı\u0026acute;n Brisen˜ o Marroquı\u0026acute;n classification system, the most common configuration for upper right three-rooted teeth mesial root was \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e2\u0026minus;1\u003c/sup\u003e (n:66, 35.7%), for distal root was \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e (n:169, 91.4%), and for palatal root was \u003csup\u003e3\u003c/sup\u003e17\u003csup\u003e1\u003c/sup\u003e (n:165, 89.2%). Additionally, the most common configuration for upper left three-rooted teeth mesial root was \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e (n:50, 28.4%), for distal root was \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e (n:160, 90.9%), and for palatal root was \u003csup\u003e3\u003c/sup\u003e27\u003csup\u003e1\u003c/sup\u003e (n:158, 89.8%). In lower left molars, the most common configuration in the two-rooted teeth mesial root was \u003csup\u003e2\u003c/sup\u003e37\u003csup\u003e2\u003c/sup\u003e (n:114, 49.4%), and for the distal root was \u003csup\u003e2\u003c/sup\u003e37\u003csup\u003e1\u003c/sup\u003e (n:170, 73.6%). For lower right the most common configuration for two-rooted teeth mesial root was \u003csup\u003e2\u003c/sup\u003e47\u003csup\u003e2\u003c/sup\u003e (n:125, 52.5%), and for distal root was \u003csup\u003e2\u003c/sup\u003e47\u003csup\u003e1\u003c/sup\u003e (n:173, 72.7%)( p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDue to highly variable morphological features observed in the upper- and lower-second molars of the Turkish subpopulation, CBCT is strongly recommended on a case-by-case basis. The results revealed extensive variations in root canal morphology.\u003c/p\u003e","manuscriptTitle":"Evaluation of Mandibular and Maxillary Second Molar Root Canal Anatomy in a Turkish Subpopulation Using CBCT: Comparison of Briseno-Marroquin and Vertucci Classifications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-10 14:04:47","doi":"10.21203/rs.3.rs-5285143/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T11:14:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-21T14:04:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-21T14:03:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Imaging","date":"2024-10-17T20:40:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cc28879-fa96-495d-bde8-cc7b120f922a","owner":[],"postedDate":"November 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T16:03:05+00:00","versionOfRecord":{"articleIdentity":"rs-5285143","link":"https://doi.org/10.1186/s12880-024-01545-5","journal":{"identity":"bmc-medical-imaging","isVorOnly":false,"title":"BMC Medical Imaging"},"publishedOn":"2025-01-02 15:57:38","publishedOnDateReadable":"January 2nd, 2025"},"versionCreatedAt":"2024-11-10 14:04:47","video":"","vorDoi":"10.1186/s12880-024-01545-5","vorDoiUrl":"https://doi.org/10.1186/s12880-024-01545-5","workflowStages":[]},"version":"v1","identity":"rs-5285143","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5285143","identity":"rs-5285143","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}