A New System For Classifying Tooth, Root and Canal Anomalies PDF

doi:10.1111/iej.
12867
REVIEW
A new system for classifying tooth, root and canal
anomalies
H. M. A. Ahmed1 & P. M. H. Dummer2

1
Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; and 2School of
Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
Abstract classifications have categorized tooth, root and canal

anomalies; however, several important details are
Ahmed HMA, Dummer PMH. A new system for
often missed making the classifications less than ideal
classifying tooth, root and canal anomalies. International
and potentially confusing. Recently, a new coding
Endodontic Journal, 51, 389–404, 2018.
system for classifying root, root canal and accessory
Understanding the normal anatomical features as well canal morphology has been introduced. The purpose
as the more unusual developmental anomalies of of this article is to introduce a new system for classi-
teeth, roots and root canals is essential for successful fying tooth, root and canal anomalies for use in
root canal treatment. In addition to various types of research, clinical practice and training, which can
root canal configuration and accessory canal mor- serve as complementary codes to the recently
phology, a wide range of developmental tooth, root described system for classifying root, as well as main
and canal anomalies exists, including C-shaped and accessory canal morphology.
canals, dens invaginatus, taurodontism, root fusion,
Keywords: anomalies, classification, c-shaped
dilacerations and palato-gingival grooves. There is a
canals, dens invaginatus, palato-gingival groove, tau-
direct association between developmental anomalies
rodontism.
and pulp and periradicular diseases that usually
require a multidisciplinary treatment approach to Received 5 August 2017; accepted 9 October 2017
achieve a successful outcome. A number of
reported and the deficiencies of the existing systems

Introduction
becoming more apparent, new systems for classifying
Knowledge and understanding of the complexity of root, root canal (Ahmed et al. 2017a) and accessory
root and root canal systems are basic requirements canal morphology (Ahmed et al. 2017b) have been
for successful root canal treatment (Vertucci 2005). proposed to provide detailed information for use by
Root and canal anatomy is complex with several sys- clinicians, trainees and academics.
tems being available for classifying root canals and The development of a tooth is a complex biological
accessory canal morphology (Yoshiuchi et al. 1972, process moderated by a series of epithelial–mesenchy-
Vertucci et al. 1974, Yoshida et al. 1975, Matsunaga mal interactions (Shrestha et al. 2015). Disturbance of
et al. 2014, Versiani & Ordinola-Zapata 2015). With the epithelial–mesenchymal interactions can alter nor-
an increasing range of anatomical complexities being mal odontogenesis causing a developmental anomaly
[anomaly is a Greek word meaning ‘irregular’; a devia-
tion from what is regarded as normal] (Shrestha et al.
Correspondence: Hany Mohamed Aly Ahmed, Department of 2015). Depending on the stage of tooth development,
Restorative Dentistry, Faculty of Dentistry, University of various anomalies either in root/canal number, size
Malaya, 50603 Kuala Lumpur, Malaysia (Tel.: and/or shape can occur (Shrestha et al. 2015). The
+60129857937; e-mail: [email protected]).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 389–404, 2018 389
New classification for anomalies Ahmed & Dummer
Table 1 Classifications for root and root canal anomalies applied in this system
Anomaly (Author(s)/year) Classification
C-shaped canals Type I (Merging Type) – canal images merged into one major canal before exiting from
(Fan et al. 2007) (Figure 1) the apical foramen. Partial radiolucent area might appear in the coronal and/or middle
portion of the canal system
Type II (Symmetrical Type) – there were separate mesial and distal canals. The mesial
and distal canals appear to be symmetrical in their size and continued on their own
pathway to the apex. The mesial and distal borders of each canal are very clear over
the canal length
Type III (Asymmetrical Type) – there are separate mesial and distal canals. The mesial
and distal canals appear to be asymmetrical in their size and continue on their own
pathway to the apex. The distal border of distal canal and both borders of mesial canal
are clear, but the mesial border of the distal canal is blurred, which makes the distal
canal seem wider than the mesial canal
Dens invaginatus Type I – it is an enamel-lined minor form that occurs within the confines of the crown
(Oehlers 1957) (Figure 2) not extending beyond the amelocemental junction
Type II – it is an enamel-lined form that invades the root but remains confined as a
blind sac. Communication with the dental pulp may or may not occur in this type
Type III – it is a form that penetrates through the root perforating at the apical area
showing a ‘second foramen’ in the apical or periodontal area (no immediate
communication occurs with the pulp). The invagination may be completely lined by
enamel, but cementum is frequently found lining the invagination
Palato-gingival groove Type I – the groove is short (not beyond the coronal third of the root)
(Gu 2011) (Figure 3) Type II – the groove is long (beyond the coronal third of the root) but shallow,
corresponding to a normal or simple root canal
Type III – the groove is long (beyond the coronal third of the root) and deep,
corresponding to a complex root canal system
Radix entomolaris (Distolingual root) Type I – no curvature
(Song et al. 2010a) (Figure 4) Type II – curvature in the coronal third and straight continuation to the apex
Type III – curvature in the coronal third and additional buccal curvature from the middle
third to the apical third of the root
Small type – root length less than half that of the distobuccal root
Conical type – cone-shaped (extension with no root canal)
Root fusion Type 1 – MBR fused with DBR
(Zhang et al. 2014) (Figure 5) Type 2 – MBR fused with PR
Type 3 – DBR fused with PR
Type 4 – MBR fused with DBR, PR fused MBR, or DBR
Type 5 – PR fused with MBR and DBR
Type 6 – PR MBR, and DBR fused to a cone-shaped root
[MBR – mesiobuccal root, DBR – distobuccal root, PR – palatal root]
Taurodontism Hypotaurodont (Hypo) – if CB : R ratio ranges from 1.10 to 1.29
(Seow & Lai 1989) (Figure 6) Mesotaurodont (Meso) – if CB : R ranges from 1.30 to 2.00
Hypertaurodont (Hyper) – if CB : R is >2.00
(C: Crown, B: Body, R: Root)
most common root malformations in humans arise

Justification for a new classification
from either developmental disorders of the root alone,
system
such as root dilaceration and taurodontism, or disor-
ders of root development as a part of a general tooth The present systems for classifying root and canal
dysplasia, such as dentine dysplasia type 1 (Luder anomalies focus on describing details of the anomaly
2015). There is a direct association of such develop- and categorizing them into types based on severity or
mental variations with pulp and periradicular diseases specific morphological characteristics (Oehlers 1957,
that may necessitate a multidisciplinary treatment Fan et al. 2007, Song et al. 2010a, Gu 2011, Ahmed
approach. However, even then, a wide range of clinical & Abbott 2012, Zhang et al. 2014). However, a prac-
outcomes may occur (Jafarzadeh & Abbott 2007, Kre- tical classification addressing root/canal anomalies
meier & H€ ulsmann 2007, Alani & Bishop 2008, Jafar- together with the morphology of the root, main canal
zadeh et al. 2008, Kato et al. 2014, Kim et al. 2017). system and accessory canals has not been developed.
390 International Endodontic Journal, 51, 389–404, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Ahmed & Dummer New classification for anomalies
Figure 1 Canal variation and 3D reconstructed canal configuration of three radiographic types of C-shaped canals (a–e) (Fan
et al. 2007). Type I (a, radiograph; b, reconstructed canal image; c, coronal third point; d, middle point; e, apical third point);
(f–j) Type II (f, radiograph; g, reconstructed canal image; h, coronal third point; i, middle point; j, apical third point); (k–o)
Type III (k, radiograph; l, reconstructed canal image; m, coronal third point; n, middle point; o, apical third point) (modified
from Fan et al. 2007, reproduced with permission from Elsevier).
In addition, existing classifications do not address (a) standardized approach to classify tooth anomalies
the concurrent occurrence of more than one anomaly using existing classifications but with additional
in a tooth, such as the association of a palato-gingival details on root and canal morphology that will pro-
groove with a talon cusp (Fabra-Campos 1990), dens vide more clinical relevance and impact.
invaginatus with dilaceration (Gound & Maixner
2004) or with dens evaginatus (Satvati et al. 2014)
New classification system for anomalies
or with gemination (Pallivathukal et al. 2015), or (b)
the presence of multiple examples of the same anom-
Terminology
aly in one tooth, such as multiple talon cusps
(Shashikiran et al. 2005), dilaceration of more than C-shaped canal (CsC)
one root in a double- or multirooted tooth (Malcic A cross-sectional shape similar to the letter ‘C’, usu-
et al. 2006). ally found in mandibular second molar teeth in which
The new system suggested in this article provides there is a single C-shaped root or where the mesial
students/trainees, clinicians and scientists with a and distal canals communicate (or remain separate)
Figure 2 Classification for dens invaginatus (Oehlers 1957).
due to fusion of the mesial and distal roots (Kato et al. tooth that has a double or ‘twin’ crown, usually not
2014, American Association of Endodontics 2016). completely separated; there is a common shared root
and pulp space (American Association of Endodontics
Concrescence (C) 2016).
A cemental fusion of roots of at least two teeth
(American Association of Endodontics 2016). It can Palato-gingival groove (PGG)
be of developmental or nondevelopmental origin A developmental anomaly that is usually found on
(Shrestha et al. 2015). the palatal aspect of the root of a maxillary incisor
tooth, also known as radicular lingual groove or dis-
Dens evaginatus (DE) tolingual groove. It usually begins in the central fossa
A developmental anomaly of a tooth resulting in for- area, extends over the cingulum and continues api-
mation of an accessory cusp whose morphology has cally down the root surface (Peikoff et al. 1985, Lara
been variously described as an abnormal tubercle, ele- et al. 2000).
vation, protuberance, excrescence, extrusion or bulge
(Levitan & Himel 2006). Some reports define an Root dilaceration (RD)
accessory cusp on an anterior tooth as a ‘Talon cusp’ A deformity characterized by displacement of the root
(Hegde et al. 2010). of a tooth from its normal alignment with the crown;
this may occur as a consequence of injury during
Dens invaginatus (DI) tooth development. Common usage has extended the
A developmental anomaly that results in an invagina- term to include sharply angular or deformed roots
tion of the enamel organ into the dental papilla prior to (American Association of Endodontics 2016). Crown
calcification of the dental tissues (Alani & Bishop 2008). dilaceration is another less common anomaly, com-
pared to root dilaceration, which usually occurs in
Enamel pearl (EP) maxillary permanent incisors (Jafarzadeh & Abbott
A focal mass of enamel located apical to the cemento- 2007).
enamel junction (American Association of Endodon-
tics 2016). Radix entomolaris (RE) (accessory distolingual (DL)
roots)
Gemination (G) A supernumerary root in a mandibular molar, usu-
A disturbance during odontogenesis in which partial ally located distolingually (American Association of
cleavage of the tooth germ occurs and results in a Endodontics 2016).
Figure 3 Classification for palato-gingival grooves (Gu 2011). Maxillary lateral incisors with radicular grooves. (a) A mesial
groove (type I); (b) a distal groove (type I); (c) double grooves (type I, a mesial and a distal); (d) a cross-sectional V-shaped
groove (type II) extends to the apex at the mesial aspect; (e) a distal groove (type II) initiates from incisal notching (arrow) and
the mesiodistal width of the tooth is larger than usual; (f) a V-shaped groove (type II) runs distally, corresponding to a cross-
sectional teardrop-like root canal; (g) a type III radicular groove corresponds to a C-shaped canal; (h) a type III radicular
groove combined with an additional root and canal at the distal aspect (arrow); and (i) an additional root and canal at the
mesial aspect. The invagination communicates with pulp cavity via an accessory canal (arrow). (reproduced with permission
from Elsevier).
Figure 4 Classification for distolingual roots (Song et al. 2010a). Three-dimensionally reconstructed images of molars with a DL
root (arrows). The apical, lingual and distal views of the five types classified according to their morphologic characteristics (type
I: no curvature; type II: curvature in the coronal third and straight continuation to the apex; type III: curvature in the coronal
third and additional buccal curvature from the middle third to the apical third of the root; small type: root length less than half
that of the distobuccal root; conical type: cone-shaped extension with no root canal) (reproduced with permission from Elsevier).
Figure 5 Classification of root fusions (Zhang et al. 2014) (upper row: buccal view of root fusion; bottom row: apical view of
root fusion) (reproduced with permission from Elsevier).
Radix paramolaris (RP) proper horizontal level. An enlarged pulp chamber,

A supernumerary root in a mandibular molar, usu- apical displacement of the pulpal floor and no constric-
ally located mesiobuccally (American Association of tion at the level of the cemento-enamel junction are
Endodontics 2016). the characteristic features (Jafarzadeh et al. 2008).
Taurodontism (T) Tooth fusion (TF)

A change in tooth shape caused by the failure of Her- A ‘double’ tooth resulting from the union of two adja-
twig’s epithelial sheath diaphragm to invaginate at the cent tooth germs (American Association of Endodontics
Table 2 A summary of the codes for tooth, root and canal

anomalies
Configuration Code
A tooth with a single anomaly (A)

A tooth with two or more (2A), (3A), (nA)
of the same anomaly
A tooth with two or more (A1,A2), (A1,A2,An)
of different anomalies
Tooth fusion or C-shaped canals in TN1/TN2
fused double roots with no
intercanal communication
Tooth fusion or C-shaped canals in TN1//TN2
fused double roots with
intercommunications in the root
canal and/or pulp chamber.
A, Anomaly; n, number.
one of the same anomaly exists in one tooth, then

the number is written on the left of the anomaly.
Thus, (2A) describes a tooth with two of the same
anomaly; thus, (2DE) describes a tooth with two
dens evaginatus.
Figure 6 Classification of Taurodontism (Seow & Lai 1989).
• When the tooth has two or more different develop-
mental anomalies, a comma (,) should be added
between the initial letters of each anomaly (A1,
2016). Fusion of roots in double- or multirooted teeth A2). Thus, (DI,RD) describes a tooth with both a
is referred to as ‘root fusion’ (RF) (Zhang et al. 2014). dens invaginatus and a root dilaceration.
• A slash (/) should be used in fused teeth, for
example, fusion of one tooth to a supernumerary
New coding system for root and canal tooth, or fused roots in double-rooted teeth such
anomalies as C-shaped canals occurring in fused double-
rooted mandibular molars (Kato et al. 2014). Two
General guidelines slashes (//) should be used in fused teeth or roots
The new system does not reclassify anomalies already with intercommunications in the root canal and/
reported in the literature but rather aims to provide or pulp chamber. (C) should be added between
more comprehensive information on the morphologi- teeth that demonstrate a concrescence.
cal features of a specific tooth, root and canal within • The subtype of each classified anomaly (if present)
a single code. For simplicity and to prevent confusion, should be written as a superscript after the abbre-
only one commonly used existing classification for viation of the anomaly. Thus, (DII) describes a
each anomaly will be taken as a reference to describe tooth with a dens invaginatus type I (Oehlers
anomalies (Table 1; Figs 1–6) with the additional 1957). In some instances, it may be impossible to
integration of the new coding system. define a subtype of the anomaly during an exami-
The new coding system can be adapted for tooth, nation (such as during conventional radiographic
root and canal anomalies. It includes codes for anoma- examination), or when it is not relevant within a
lies and their subtypes (if present) as described below. specific clinical or experimental report; in such
Appendix S1 provides general guidelines and several cases, writing the abbreviation of the anomaly
examples of codes allocated for various anomalies. without a subtype would be sufficient.
• The abbreviation of the anomaly (A) is added • For simplicity, the tooth number (TN) and configu-
between brackets. For example, (DE) refers to dens rations of the root (in double- and multirooted
evaginatus affecting a given tooth. If more than teeth), root canal and accessory canals (if present)
Figure 7 Micro-CT 3D models of single-rooted teeth with root anomalies (DE = dens evaginatus. PGG = Palato-gingival
groove) (modified from Ahmed et al. 2017a, reproduced with permission from Wiley).
should be written as described previously (Ahmed On the other hand, anomalies such as radix entomo-
et al. 2017a,b). laris may have a cone-shaped root with no obvious
Table 2 summarizes the general guidelines for the root canal space (Song et al. 2010a). Because current
coding system of anomalies. three-dimensional computed tomography devices used
Anomalies such as dens invaginatus type III may in clinical settings do not provide sufficient resolution
complicate the morphology of the root canal system to identify narrow canals, in such situation, the canal
forming a ‘pseudo-canal’ (as a result of the invagina- should be described as ‘undefined’ with the abbrevia-
tion) that communicates with the periodontal liga- tion of ‘un’.
ment space through a ‘pseudo-foramen’ (Goncßalves If individuals want to use, for whatever reason,
et al. 2002, Alani & Bishop 2008). Such morphologi- another classification of an anomaly to highlight
cal features are not included in the codes allocated for other categories, or wish other morphological charac-
roots and canals as they are not a part of the canal teristics to be described, such as classifications pro-
system (Goncßalves et al. 2002, Alani & Bishop 2008). posed for describing the morphological features of
New classification for anomalies in

single-, double- and multirooted teeth
Single-rooted teeth
The abbreviation of the anomaly (A) is added between
brackets before the tooth number (TN), that is (A)TN.
For instance, a dens evaginatus (DE) in a single-
rooted maxillary right central incisor tooth (111)
(Fig. 7a) would be described as (DE)111 (Fig. 7b).
(2DE)111 describes a single-rooted tooth 11 having 2
DE (Fig. 7c). (DE,PGG)111 describes a single-rooted
tooth 11 having a DE and a palato-gingival groove
(PGG) (Fig. 7d). (PGGI)111 describes a single-rooted
tooth 11 with a PGG type I (Fig. 7e). Figure 7f,g illus-
trates other subtypes of PGG. 1ST/111 describes a sin-
Figure 8 (a) An example for tooth fusion with a supernu- gle-rooted tooth 11 fused to a single-rooted
merary tooth (ST) with no canal communication ST1/111. Supernumerary Tooth (ST) (Fig. 8a), whilst 1ST//111
(b) tooth fusion with intercanal communication with the describes a single-rooted tooth 11 fused to a single-
code of ST1//111 (modified from Ahmed et al. 2017a, repro- rooted ST with intercanal communication(s) (Fig. 8b).
duced with permission from Wiley).
Double- and multirooted teeth
four-rooted maxillary molars (Christie et al. 1991, If the anomaly is related to all roots of a double/mul-
Baratto-Filho et al. 2002), or would like to add tirooted tooth (such as root dilaceration) or crown
another anomaly not described here, such as dentino- (such as dens evaginatus) or furcation [such as
genesis imperfecta (Pettiette et al. 1998) and dentine Enamel Pearl (EP)] or the tooth has an accessory root
dysplasia (Ravanshad & Khayat (2006), then the clas- (s) (such as three-rooted mandibular molar), the code
sification/characteristic would need to be described in should be written before the TN – as with single-
detail with abbreviations developed for each anomaly rooted teeth. Thus, (RD)237 M D describes a double-
and its subtypes (if present) in order for the proposed rooted tooth 37 having a dilaceration of both roots
new system to be used alongside. [mesial (M) and distal (D)] (Fig. 9a). (DE)244 B L
Figure 9 Micro-CT 3D models showing examples for anomalies affecting (a) all roots, (b) crown, (c) furcation of double/multi-
rooted teeth or (d) tooth with an accessory root (a, b, d modified from Ahmed et al. 2017a, reproduced with permission from
Wiley, c, modified from Kato et al. 2014, reproduced with permission from Wiley).
Figure 10 Micro-CT 3D models showing codes for C-shaped canals in mandibular second molars (modified from Kato et al.
2014, reproduced with permission from Wiley).
anomaly should be written after the abbreviation of

the affected root. Thus, 247 M D(RD) describes a dou-
ble-rooted tooth in which the distal root has a dilacer-
ation (Fig. 11a). 237 M D(EP) describes tooth 37
having an enamel pearl related to the D root
(Fig. 11b).
Root fusion (RF) in three-rooted teeth is an excep-
tion from the above in which all types should be writ-
ten before the tooth number (TN). (RF1)316 MB DB P
describes a three-rooted tooth 16 having fused MB
and DB roots whilst the P is not fused (Zhang et al.
2014). (RF6)314 MB DB P describes a three-rooted
tooth 14 in which all roots are fused (Fig. 12a). Fig-
ure 12b provides an example of concrescence associ-
ated with two molar teeth. Figure 13 shows the
Figure 11 Micro-CT 3D models showing codes for anomalies application of the new system with several anomalies.
affecting one of the roots in molars. (a, modified from Ahmed
et al. 2017a, reproduced with permission from Wiley, b,
Clinical implications
modified from Kato et al. 2014, reproduced with permission
from Wiley). For practicability and simplicity, the codes for tooth,
root and canal anomalies presented in this new sys-
describes tooth 44 with two roots [buccal (B) and lin- tem can serve as complementary codes to the recently
gual (L)] having a dens evaginatus (Fig. 9b). described system for classifying root, as well as main
(EP)237 M D describes tooth 37 with two roots hav- and accessory canal morphology (Ahmed et al.
ing an enamel pearl in the furcation (Fig. 9c). 2017a,b; Figs 14–17; Appendix S1), and this has sev-
(REI)337 M D DL describes tooth 37 with a type I eral clinical implications.
radix entomolaris (RE) (Fig. 9d). (CsCI)237 M//D • Including the anomaly in the root and canal coding
describes tooth 37 with two fused roots encasing a C- system provides more detailed information on the
shaped canal type I (merging type) (Fig. 10a). morphological characteristics of a given tooth, thus
(CsCII)237 M/D and (CsCIII)237 M/D describe tooth 37 allowing proper diagnostic procedures and appro-
with two fused roots encasing C-shaped canal types II priate treatment planning. Including the anomaly
and III (symmetrical and unsymmetrical), respectively subtype is advantageous as they usually require dif-
(Fig. 10b,c). ferent treatment protocols. For instance, the mor-
If the anomaly is related to one or more roots in phological features and radiographic landmarks of
double- or multirooted teeth, respectively, then the dens invaginatus type I vary from types II and III
Figure 12 Micro-CT models showing codes for root fusion (RF) and concrescence (C). (modified from Ahmed et al. 2017a,
reproduced with permission from Wiley).
(Bishop & Alani 2008). Similarly, the treatment

options for these anomalies would vary from the
application of a fissure sealant for type I to complex
root canal treatment procedures for dens invagina-
tus type III (Bishop & Alani 2008, Zhu et al. 2017).
• Defining the anomaly and listing the code before
the tooth number, root and canal morphology are
beneficial because it would explain the reason for
subsequent complex morphological variation
‘codes’ of the root and canal usually observed in
severe forms of the anomaly.
• Listing the anomaly code after the affected root(s)
if other roots are not affected is more appropriate
because unique root canal treatment procedures
are usually considered for that affected root(s) Figure 14 A micro-CT model showing an integrated formula
for the coding system for root, main canal, accessory canals
such as root dilacerations, which require consider-
and anomalies. (modified from Ahmed et al. 2017a, repro-
able skill to avoid intra-operative complications
duced with permission from Wiley).
(Jafarzadeh & Abbott (2007).
Figure 13 Drawings showing the application of the new system on several anomalies (G: gemination; RD: root dilaceration;
DI: dens invaginatus; T: taurodontism).
Figure 15 Drawings and micro-CT models showing the application of the new system on several anomalies using the new sys-
tem in an integrated manner (main canal and anomalies). (a) A single-rooted tooth 11 with dens invaginatus type I. The root
canal configuration is type 1. (b) A geminated single-rooted tooth 11 with a root canal configuration type I. (c) A double-
rooted tooth (hypertaurodont) 37. The mesial and distal root canals are type 1, and there is a common single canal coronal to
the level of root bifurcation. (d) A single-rooted tooth 11 fused to a single-rooted supernumerary tooth (ST). Both teeth have a
root canal configuration type 1 with an intercanal communication. (e) A double-rooted tooth 37 with a dilacerated distal root.
Both canals in the mesial and distal roots are type 1 (d, e, modified from Ahmed et al. 2017a, reproduced with permission from
Wiley).
• Defining tooth fusion with or without intercanal anomalies (Turell & Zmener 1999, Ballal et al.
communications is beneficial because each has its 2007). Hence, irreversible damage to the pulp of
own radiographic landmarks and treatment proto- one tooth may involve the pulp of the other tooth,
col. Clinicians should consider the pulp status in and usually both teeth will require root canal
instances of fusion where there is no apparent treatment. Indeed, cone beam computed tomogra-
communication between the root canal systems phy (CBCT) aids in the decision-making for other
(Song et al. 2010b, Cunha et al. 2015). In such treatment options such as hemisection, which can
cases, the root canal treatment may be performed be delayed until the pulp chamber is separated,
on the affected tooth only, preserving the health of and a precise 3D cutting plane can be planned
the pulp in the unaffected counterpart (Cunha (Kim et al. 2011).
et al. 2015). Communication between pulp cham- • The ability to add other developmental anomalies
bers of fused teeth is a common feature in such that have rarely been reported in the endodontic
Figure 16 Drawings and micro-CT models showing the application of the new system on several anomalies using the new sys-
tem in an integrated manner (main and accessory canals as well as anomalies). (a) A single-rooted tooth 11 fused to a single-
rooted supernumerary tooth (ST). Both teeth have a root canal configuration type 1. The tooth 11 has an accessory canal in
the apical (A) third of the root configuration type 1 (A1). (b) A single-rooted tooth 11 fused to a single-rooted supernumerary
tooth (ST). Both teeth have a root canal configuration type 1 with an intercanal communication. The ST has an accessory
canal in the middle (M) third of the root with a configuration type 1-0 (no accessory foramen – blind). (c) A single-rooted
tooth 11 with a dens invaginatus type II. The root canal configuration is type 2-1, and an accessory canal exists in the apical
third of the root with a configuration type 2-1-0 (loop). (d) A single-rooted tooth 11 with a palato-gingival groove type III.
The tooth has a configuration type 1 canal, and an apical delta (D). (e) A double-rooted tooth 37 with fused mesial and distal
roots having a C-shaped canal type II. The root canal configuration in each root is type 1. An accessory canal type 1-2 exits
in the middle third of the distal root. (f) A single-rooted tooth 11 with a dens invaginatus type III. The root canal configuration
is type 1, and two accessory canals of configuration type 1 exist in the middle and apical thirds of the root (a, b, d, modified
from Ahmed et al. 2017a, reproduced with permission from Wiley, e, modified from Kato et al. 2014, reproduced with permis-
sion from Wiley).
literature, such as dentinogenesis imperfecta and detailed and accurate information on this challenging
dentine dysplasia (de Coster 2009), allows the subject in a systematic manner. Indeed, it is one
opportunity for a much wider application of the promising way to translate current advances in
new system. endodontic research and the growing body of evi-
The ability to use this classification as an ‘inte- dence obtained from contemporary technological pro-
grated system’ to describe common and unusual vari- cedures to clinical practice.
ations of the root and canal morphology (main,
accessory and anomalies) could be a direction for
Conclusions
future application in preclinical and clinical educa-
tional programmes for undergraduate and postgradu- The new system for classifying root and canal anoma-
ate students. This could help students gain more lies as well as other tooth anomalies related to
Figure 17 Micro-CT models showing the application of the new system on (a–c) three-rooted mandibular left second molar,
(d–f) three-rooted maxillary right first premolar (TR3 three-rooted type 3 according to Bellizzi & Hartwell 1981 classification) –
(a, d) root and main canal morphology, (b, e) root, main and accessory canal morphology, (c, f) root, main and accessory
canals as well as anomaly subtypes (integrated manner). (modified from Ahmed et al. 2017a, reproduced with permission from
Wiley).
endodontics provides an integrated, accurate and Ahmed HMA, Versiani MA, De-Deus G, Dummer PMH
practical system that allows students, dental practi- (2017a) A new system for classifying root and root
tioners and researchers to classify root and canal canal morphology. International Endodontic Journal 50,
anomalies together with anatomical variations of root 761–70.
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doi:10.1111/iej.

H. M. A. Ahmed1 & P. M. H. Dummer2

Abstract classifications have categorized tooth, root and canal

reported and the deficiencies of the existing systems

Anomaly (Author(s)/year) Classification

most common root malformations in humans arise

Figure 2 Classification for dens invaginatus (Oehlers 1957).

Radix paramolaris (RP) proper horizontal level. An enlarged pulp chamber,

Taurodontism (T) Tooth fusion (TF)

Table 2 A summary of the codes for tooth, root and canal

A tooth with a single anomaly (A)

one of the same anomaly exists in one tooth, then

New classification for anomalies in

Double- and multirooted teeth

anomaly should be written after the abbreviation of

(Bishop & Alani 2008). Similarly, the treatment

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