ORIGINAL ARTICLE Hong Kong Dental Journal 2008;5:27-30

HK
DJ
C-shaped canals in mandibular second molars
in the Hong Kong population: a computed
tomographic study
Ruwan Duminda Jayasinghe *, BDS, MS
Thomas Ka-Lun Li †, BDS, MSc, DGDP, DDRRCR, FCDSHK, FHKAM (Dental Surgery)

ABSTRACT Objectives. To investigate the frequency and type of C-shaped root canals in mandibular second
molars of the Hong Kong Chinese population, using spiral computed tomographic images. Methods. Spiral computed
tomographic images belonging to 116 patients were studied. All teeth were examined in axial computed tomographic
sections from pulpal floor to the apex to determine the presence of C-shaped canals. The teeth with C-shaped canals
were classified using Melton’s classification. A total of 207 mandibular second molars were studied; 66 (57%) of the
subjects were females, and subject ages ranged from 15 to 72 years, with a mean of 34 years. Results. Sixty-two teeth
had C-shaped root canals. Of these, 17 (27%) teeth were type I (continuous C-shaped root canals), 28 (45%) were type
II (semicolon-shaped canals), and the rest (27%) were type III (two separate canals). All were grooved lingually. Fourteen
patients had one mandibular second molar with a C-shaped root canal configuration and one normal mandibular second
molar, whereas 24 had bilateral mandibular second molars with C-shaped root canals. Conclusion. The frequency of
C-shaped root canals in mandibular second molars is high in the Hong Kong Chinese patients.

Key words: Asian continental ancestry group; Hong Kong; Tomography, spiral computed; Tooth abnormalities

Introduction molars, and mandibular first 5 and second premolars 6,

The study of root anatomy of teeth has an endodontic as
well as anthropological significance. Mandibular second
molars usually have two roots and three root canals
but variations in the number of roots as well as canal
morphology are not uncommon. In 1979, Cooke and
Cox 1 first described the term C-shaped root canal. They
reported three cases where the root canals were like the
English capital letter ‘C’, in which canals were connected
by a continuous slit. C-shaped canals are commonly found
in permanent mandibular second molars but they can also
be found in maxillary first molars 2-4, maxillary second
* Department of Oral Medicine and Periodontology, Faculty of
Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
†
Oral Radiology Unit, Faculty of Dentistry, The University of Hong
Kong, Prince Philip Dental Hospital, Hong Kong
Correspondence to:
Dr. Thomas Ka-Lun Li
Oral Radiology Unit, Faculty of Dentistry, The University of Hong
Kong, Prince Philip Dental Hospital, 34 Hospital Road, Hong Kong
Tel : (852) 2859 0241
Fax : (852) 2547 0164
e-mail : thomasli@hkucc.hku.hk
third molars 7, as well as in mandibular first molars 7. The
mandibular second molars with C-shaped root canals vary
in their configurations and many methods have been used
to classify such canals 8,9.
This study was undertaken to determine the frequency
of C-shaped root canals in second permanent mandibular
molars in a sample of spiral computed tomographic (CT)
images of teeth in a Hong Kong population.
Methods
Spiral CT images of the mandible of Chinese patients
taken at the Oral Radiology Unit, the Faculty of Dentistry
of the University of Hong Kong during the year 2006 were
selected and examined. The CT images were obtained
using a helical single slice CT Hispeed scanner (FX/I CT;
General Electric, Milwaukee [WI], USA). The exposure
settings were between 120-140 kV and 150 mA with an
image resolution of 512 x 512 pixels. The slice thickness
was 2 mm. All molars were evaluated in axial sections
from the pulpal floor to the root apices so as to identify
C-shaped canals (Figure). All CT images were examined

Hong Kong Dent J Vol 5 No 1 June 2008 27

Jayasinghe and Li

Results

Of the 116 patients studied, a total of 91 (78%) patients

Figure Spiral computed tomographic image (axial view)
showing C-shaped second molar (arrow)
had both mandibular second molars but 25 (22%) had
only a single second molar, so 207 mandibular second
molars were studied. Sixty-six (57%) of the subjects were
females. Subject ages ranged from 15 to 72 years, with a
mean of 34 years. Sixty-two (30%) of 207 teeth had C-
shaped root canals; 17 (27%) were type I (continuous C-
shaped canals), 28 (45%) were type II (semicolon-shaped
canals), and the rest (27%) were type III (two separate
canals). All were grooved lingually. Fourteen patients had
one C-shaped and one normal mandibular second molar,
whereas 24 had bilateral C-shaped canal configurations.
Discussion

Although rare in Caucasians 10, C-shaped canals in mandi-

once by the main author. Age and gender of the patients
were recorded. C-shaped canals at the sub-pulpal level
were classified into the following three categories using
Melton’s classification 8;
I: C-shaped outline without any separation (continuous
C-shaped canal);
II: canals separated by dentin into one canal distant from
a buccal or lingual C-shaped canal (semicolon-shaped
canal); and
III: two or more separated and discrete canals (separate
canals).
bular second molars are relatively common in Asians 11,
being present in 10-52% of individuals (Table) 7,10-20. In the
present study, we observed a 30% prevalence in the Hong
Kong population, which was lower than that reported by
Walker 12 (52%) and Yang et al. 13 (32%). Most prior studies
had used extracted teeth, whereas we used CT images of
teeth in vivo. Although Cimmili et al. 14 used spiral CT
images in their study, they were of extracted teeth. Jin et al. 15
also used CT images in a Korean population in 2006 and
reported a prevalence of 45%.
Studies of the root canal system of mandibular second

Table Reported prevalence of C-shaped root canals in mandibular second molars 7,10-20

Study Year Ethnic origin Total no. of mandibular second molars studied
(% with C-shaped canals)
Walker 12 1988 Hong Kong Chinese 100 (52%)
Yang et al. 13 1988 Hong Kong and Taiwan Chinese 581 (32%)
Manning 11
1990 Unknown 149 (13%)
Weine 16
1998 Mixed 811 (8%)
Haddad et al. 17
1999 Lebanese 94 (19%)
Gulabivala et al. 18
2001 Burmese 134 (22%)
Gulabivala et al. 7
2002 Thai 60 (10%)
Lambrianidis et al. 10
2001 Greek 480 (5%)
Al-Fouzan 19
2002 Saudi Arabian 151 (11%)
Seo and Park 20
2004 Korean 272 (clinical; 33%)
96 (in vitro; 31%)
Cimilli et al. 14 2005 Turkish 491 (8%)
Jin et al. 15
2006 Korean 220 (45%)
Present study 2006 Hong Kong Chinese 207 (30%)

28 Hong Kong Dent J Vol 5 No 1 June 2008


molars have demonstrated variations in numbers as well as
distribution of root canals, possibly due to differences in
examination methods. Other explanations for differences
between studies include: numbers of teeth evaluated,
classification systems used, and ethnic background of the
patients. For example, the examination methods varied
from extracted teeth, clinical observations, radiographs to
CT scans 9,10,14,15.
Most studies on the prevalence and anatomical
characteristics of C-shaped canals in mandibular second
molars used extracted teeth or teeth that had been treated
endodontically. Such teeth may have undergone many
aging changes in the pulpo-dentinal complex, and hence
in the root canal system 9. Most of the teeth examined
in the present study were relatively young (mean age, 34
years). The value of intraoral periapical radiographs for
diagnosing C-shaped canals is debatable. Cooke and Cox 1
reported that they were not helpful, but Haddad et al. 17
found common characteristics in almost all preoperative
radiographs. Lambrianidis et al. 10 reported that preoperative
and working length periapical radiographs are of little
value in identifying C-shaped root canals, whereas
simultaneous interpretation of preoperative, working
length, and postoperative radiographs could be helpful.
In this study and the one by Jin et al. 15, CT images of teeth
with C-shaped canals were not verified by other means
(clinical observations or microscopic examination), but
the accuracy of CT imaging is well documented 21.
Teeth with single C-shaped canals are exceptions
rather than the rule 13. Canal configuration can vary at the
sub-pulpal floor levels. Yang et al. 13 found the category I
configuration to be the least common variant. Category
II was the most frequent in their study (45%), which was
consistent with the findings of Seo and Park 20 (64% for
clinical observations and 57% for laboratory analysis),
Yang et al. 13 and Haddad et al. 17 but not those of Jin et al. 15.
However continuous or semicolon-typed canals have a
high tendency to divide into two or three canals in the apical
regions 21. These findings taken collectively illustrate that
C-shaped canals can vary in number as well as form, along
the length of the root, causing debridement, obturation
and restoration difficulties during endodontic treatment 8.
Due to changing canal configurations at different levels
of the root, Melton’s classification has been adapted with
various modifications 19,22.
Inability to detect C-shaped root canals could lead to
endodontic treatment failure. It is therefore important
to identify the presence of C-shaped root canals in
C-shaped canals in mandibular second molars
single-rooted mandibular second molars. Conventional
radiographs give only a 2-dimensional view of the teeth,
whereas spiral CT images can show 3-dimensional images,
and therefore much detail. For this reason, CT has been
used in many aspects of clinical dentistry including
implantology. Computed tomographic images have been
used to measure the mesiodistal and buccolingual length
of teeth as well as their relationship to vital structures 23.
Such images can also be used to assess root canal filling
materials, posts, dental caries, and root fractures 24, and the
morphology of the root canal system can be accurately
visualized 25. Spiral CT imaging can also be used as a
useful tool for diagnosing the morphology of mandibular
molars 26, but the radiation risk involved must be considered.
In conclusion, the frequency of C-shaped root
canals in second mandibular molars in the Hong Kong
population noted in this study was high, but less than
previously reported, which might be due to the use of
CT imaging rather than examination of extracted teeth or
radiographs. The high frequency of C-shaped root canals
in the Hong Kong population has important clinical
as well as anthropological implications. The findings
reported here could be regarded as a pilot project for
a larger anthropological study with multiple calibrated
assessors. The clinical significance of using CT for the
detection of C-shaped canals in different endodontic
cases is yet to be evaluated.
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