Endodontology Enhanced CPD DO C

Ajinkya M Pawar

Shishir Singh

Significance of the Coronal

Pulp Chamber Floor Anatomy in
the Human Dentition:
A Narrative Review
Abstract: In root canal treatment, the foundation on which all surgical procedures are performed is a thorough knowledge of the anatomy
of the pulp chamber and the root canal system. The endodontic triad comprises biomechanical preparation, microbial control and complete
obturation of the root canal space. Knowledge of the pulp chamber floor anatomy is important in locating the numbers and orifices of root
canals present within the tooth being root canal treated. This is particularly important while treating teeth that are heavily restored, mal-
positioned, or calcified. The current review attempts to explain the complex anatomy of the pulp chamber floor and its significance in root
canal treatment.
CPD/Clinical Relevance: To allow the location of all root canal orifices in the pulp chamber and to perform successful root canal treatment,
knowledge of pulp chamber floor anatomy is essential. The clinician should consider that, as the external morphology of the tooth varies in
individuals, so does the internal morphology.
Dent Update 2021; 48: 58–61

The pulp complex should be visualized pulp complex, the coronal portion must One of the major reasons for root
as beginning occlusally at the pulp horns be accessed in a manner that will permit canal treatment failure is 'missed canals.'
and ending at the apical foramina. In order pulp removal and facilitate the location The access to the pulp chamber is also
to remove pulp tissue entirely from the and debridement of the root canals determined by a preset and well-defined
without unnecessarily compromising set of laws. These are the laws of centrality,
the strength of the coronal enamel and concentricity, cemento-enamel junction
Ajinkya M Pawar, BDS, MDS, Assistant dentine. The variation of the pulp chamber (CEJ), symmetries, colour change, and
Professor, Department of Conservative floor, especially in multi-rooted teeth, orifice location. CEJ, an anatomical
Dentistry and Endodontics, Nair Hospital is a constant challenge for diagnosis landmark, still remains the pilot guiding
Dental College and PhD Scholar, and subsequent root canal treatment.1 towards an ideal access cavity preparation
Department of Conservative Dentistry Attempting to treat the root canal system aiding the location of all the root canals.3
and Endodontics, TPCT’s Terna Dental without detailed anatomical information There is a generic description of the
College and Hospital, Mumbai, India. could be potentially disastrous. There is average number of canals in different
Shishir Singh, BDS, MDS, PhD, Professor an abundance of literature describing root teeth. While the average number of canals
and Head, Department of Conservative canal anatomies, but the studies that have in a tooth is of some value, it may vary
Dentistry and Endodontics, TPCT’s
considered pulp chamber anatomy have in the individual tooth of an individual
Terna Dental College and Hospital,
been very generic and offer little insight on person. The available literature regarding
Mumbai, India.
how to determine the orifice number and the location of canal orifices has been
email: [email protected]
location of root canals.2 presented in an unsystematic manner.
58 DentalUpdate January 2021
 Endodontology

be misleading.2
The law of concentricity states that
the walls of the pulp chamber are always
concentric to the external surface of the
tooth at the level of the CEJ. This law helps
the clinician in extending access to the
cavity efficiently. If there is a presence
of any bulge of the CEJ in a particular
direction, the pulp chamber also extends in
that direction (Figure 2).2
The law of symmetry 1 states that,
except for maxillary molars, the orifices
of the canals are equidistant from a line
Figure 1. Coronally cut sample exhibiting law Figure 3. Coronally cut sample exhibiting law of drawn in a mesial-distal direction through
of centrality. symmetry 1 (red line) and symmetry 2 the pulp chamber floor (Figure 3). The law
(white line). of symmetry 2 states that, except for the
maxillary molars, the orifices of the canals
lie on a line perpendicular to a line drawn in
a mesial-distal direction across the centre of
canal bleeding points.7
the floor of the pulp chamber (Figure 3).
The aim of this review is to highlight the
The law of colour change states that the
importance of the anatomy of the coronal colour of the pulp-chamber floor is always
pulp chamber floor. darker than the walls. The law of orifice
location 1 states that the orifices of the root
Anatomy of the coronal pulp canals are always located at the junction of
chamber floor the walls and the floor. The law of orifice
Knowledge of the anatomy of the tooth location 2 states that the orifices of the root
Figure 2. Coronally cut sample exhibiting law canals are located at the angles in the floor-
being root canal treated, with the anatomy
of concentricity.
of the adjacent tissue, is most important for wall junction. The law of orifice location
successful removal of the pulpal tissue. For 3 states that the orifices of the root canals
successfully removing the contents of an are located at the terminus of the root
Typically, it has been suggested that developmental fusion lines (Figure 4).
entire root canal system, the coronal pulpal
access to the cavity should be made in an The law of orifice location 1 and 2 may
chamber and the radicular pulpal tissue
approximate position in the clinical crown, be used to identify the number and position
must be identified.
and then a search for the orifices made of the root canal orifices, as all the orifices
Krasner and Rankow formulated new
in the hopes of finding them. However, are located along the floor–wall junction.
laws, providing guidelines for locating the
locating canal orifices in teeth that are These two laws, in conjunction with the
pulp chamber and root canal orifice. The
heavily restored, broken down due to law of colour change, are the only reliable
extensive caries, or have had improper existence of constant landmarks makes it
easy to locate orifices systematically and indicator for the location of second canals in
earlier access cavities is extremely mesiobuccal roots of maxillary molars.9 The
problematical, as normal anatomy is more successfully, especially in cases where
locating orifices has become difficult.8 law of orifice location 2 may guide towards
often badly damaged.2 Also, factors such the actual location of the root canal orifices,
as physiological ageing, pathology and The coronal anatomical laws have been
proposed to aid in access cavity preparation with the vertices (ie a point where two or
production of secondary and tertiary more lines/walls meet) and/or angles of the
dentine may increase the difficulty in and are discussed below.2
The law of centrality states that the darker chamber floor specifying the position
locating canal orifices.4–6
floor of the pulp chamber is always located of the root canal orifices. In cases of calcified
Clinically, there are a number of
in the center of the tooth at the level of canals, the position of the vertex will dictate
diagnostic measures that can be taken
the penetration of the bur, aiding in removal
to locate root canal orifices, including the CEJ (Figure 1). This law can be used
of reparative dentine from above the root
multiple pre-operative radiographs, cone as a guide to prepare to access the cavity.
canal orifice (Figure 5). The laws of symmetry
beam computed tomography (CBCT), But care should be taken, as this law only
1 and 2 (except for the maxillary molars),
examination of the pulp chamber floor applies at the level of CEJ and is not related
colour change, and orifice locations 1 and 2
with a sharp explorer, troughing of to the occlusal anatomy of the tooth
can be applied to any tooth.2
grooves with ultrasonic tips, staining the being root canal treated. This law may not
chamber floor with 1% methylene blue apply when treating a tooth that is heavily
dye, performing the sodium hypochlorite restored with an oversized crown, since the Discussion
'champagne bubble' test and visualizing location of the center of the tooth might A major cause of failure in root canal
January 2021 DentalUpdate 59
 Endodontology

canals, knowledge of the coronal pulp access to the pulp chamber, as it is

chamber floor of these teeth is most located centrally at the level of the CEJ.
important.15 If the clinician is not familiar The clinician may use the CEJ as a target
with the chamber floor, the chances of irrespective of the anatomical alteration
missing root canals are high. Walton and of the coronal structure.
Torabinejad16 and Ash and Nelson17 have The law of concentricity helps
rightly reported that the pulp morphology clinicians to extend their access
of teeth is often extremely complex and appropriately. The clinician may refer
highly variable. to the bulge of the CEJ and extend
Distinct laws have been proposed for the access cavity in that direction. For
locating pulp chambers and the multiple example, in cases where the tooth
orifices present on the pulp-chamber floor, is narrow mesiodistally, the clinician
on the basis of precise patterns and the can infer the pulp chamber is also
Figure 4. Coronally cut sample exhibiting law of
relationship between the pulp chamber narrow mesiodistally.
orifice location 3. Arrows mark the developmental
root fusion lines. and the pulp-chamber floor. Knowledge of In order to be sure that the access
the laws of orifice location helps prevent cavity is adequate, the clinician needs
clinicians from causing crown perforations to know the law of colour change.2
in a lateral direction. For example, as The access cavity is deemed complete
the law of centrality states that the pulp when the clinician can successfully
chamber is always centrally located at visualize the entire pulp chamber floor.
the level of the CEJ, the operator can use The law states that the colour of the
the CEJ as a circular target regardless of pulp chamber is always darker than
how non-anatomical the clinical crown or the surrounding walls. As the cut walls
restoration may be. Even if the crown sits are lighter, there is a junction, which is
at an obtuse angle to the root, the CEJ can formed by light walls and the dark pulpal
still be a reliable landmark for locating the floor. If this junction is not observed at
pulp chamber. Also, after restoration of a the pulp chamber floor, it is a hint to the
Figure 5. Coronally cut sample exhibiting tooth, the occlusal anatomy may have no clinician that the i cavity preparation
calcified pulp stone (arrow) and vertices on the relevance to the position of the underlying is incomplete and the overlying tooth
pulp chamber floor. pulp chamber.2 structure must be removed. Establishing
Many clinicians have preconceived this junction clearly helps in applying
ideas of the anatomy and position of the the laws of symmetry and orifice
pulp chambers and root canals, based on location to find the exact positions and
the conventional clinical presentation of numbers of orifices. Knowledge of the
faultless teeth in textbooks. Gaining access laws of symmetry 1 and 2 immediately
to the pulp chamber is recommended indicates the presence of a fourth canal.
from the external surface of the tooth to Indeed, it not only implies the presence
the internal surface (ie the pulp chamber), of a fourth canal, but exactly where it
based on this ideal anatomy. However, this is located (Figure 6). The law of orifice
recommendation has little relevance when locations 1 and 2 may be used to locate
treating pretreated, restored, or crowned the position and number of root canal
teeth, and may lead to perforation. orifices, because all of the orifices are
The first step in endodontic treatment is located along the floor–wall junction,
the preparation of the access cavity, which and any black and white markings or
provides an opening in the dental crown indentations, observed anywhere else
Figure 6. Coronally cut sample exhibiting that allows localization, cleaning, shaping, must be ignored to avoid any possible
four canals. disinfection and obturation of the entire perforations. If the canal is calcified, then
root canal system. An access cavity that this position at the vertex will indicate
has been prepared improperly in terms with certainty where the operator
of position, depth, or extent will hamper should begin to penetrate with the bur
treatment is the inability to locate, debride the achievement of optimal results.18 The to remove reparative dentine from the
and obturate extra canals. There are CEJ is the most accepted and established upper portion of the root canal. The law
numerous studies reported in the literature anatomical landmark and is regarded as of orifice location 1 and 2, in conjunction
on the root canal anatomies of multi- the paramount landmark for locating the with law of colour change, is often the
rooted teeth (premolars and molars).10–14 pulp chamber.2 only reliable indicator of the presence
These teeth often exhibit multiple canals. The law of centrality helps to prevent and location of extra canals.
If they are considered to have multiple coronal lateral perforations when gaining In cases with anatomical variations,
60 DentalUpdate January 2021
 Endodontology

endodontic treatment initiation, Compliance with Ethical Standards Root anatomy and canal configuration
instrumentation and completion may be Conflict of Interest: The authors declare that of the permanent mandibular first molar:
carried successfully with the clinician being they have no conflict of interest. a systematic review. J Endod 2010; 36:
familiar with basic knowledge of the laws.4 Informed Consent: Informed consent was 1919–1931.
While gaining access during root canal obtained from all individual participants 14. Cleghorn BM, Christie WH, Dong CC.
treatment, magnification with illumination included in the article. Root and root canal morphology of the
by either dental operating microscope or human permanent maxillary first molar:
dental loupes enhances the quality of vision References a literature review. J Endod 2006; 32:
for identifying the root canal orifices more 1. Cohen S, Hargreaves K. Pathways of the 813–821.
easily.19,20 Pulp. 9th edn. St Louis, MO: Mosby, 2006. 15. Pawar AM, Kokate SR, Hegde VR.
Each tooth demonstrates a variety of 2. Krasner P, Rankow HJ. Anatomy of the Contemporary approach in successful
root canal configurations that must be pulp-chamber floor. J Endod 2003; 30: endodontic intervention in radix
thoroughly disinfected, increasing the 5–16. entomolaris. World J Dent 2013; 4:
success rate of root canal treatment. With 3. Raturi P, Girija S, Subash TS, Mangala 208–213.
the development of CBCT, it has become TM. Unravelling the mysteries of pulp 16. Walton RE, Torabinejad M (eds). Principles
possible to visualize the anatomy and root chamber. Endod 2007; 19: 23–29. and Practice of Endodontics. 2nd edn.
canal system of the teeth, owing to the 4. Vertucci F. Root canal morphology and its
three-dimensional (3D) images obtained. Philadelphia, PA: Saunders, 1996.
relationship to endodontic procedures. 17. Ash MM, Nelson SJ (eds). Introduction
Cases with unusual root formations, such as
Endod Topics 2005; 10: 3–29. to dental anatomy. In: Wheeler's Dental
dens in dente (tooth within a tooth), multi-
5. Poorni S, Anil Kumar R, Indira R. Canal
rooted lower premolars, C-shaped molars, Anatomy, Physiology and Occlusion. 8th
complexity of a mandibular first molar. J
or cases with excessively curved canals, may edn. St Louis, MO: Saunders, 2003: 1–44.
Conserv Dent 2009; 12: 37–40.
benefit from a CBCT scan. Many studies 18. Ruddle C. Endodontic access prep: tools
6. Nair PNR. Non-microbial etiology:
have used this technique to finvestigate the for success. Dent Products 2007: 1–9.
Foreign body reaction maintaining post-
anatomy of the root canal system especially 19. Saunders WP, Saunders EM. Conventional
treatment apical periodontitis. Endod
in multi-rooted teeth.21–24 endodontics and the operating
Topics 2003; 6: 96–113.
This article correctly recommends microscope. Dent Clin North Am 1997; 41:
7. Bueno MR, Estrela C, Figueiredo JAP,
the use of the CEJ as a reference level for 415–428.
Azevedo BC. Map-reading strategy to
correct access orientation. However, to 20. Jayasinghe RD, Li T. C-shaped canals
diagnose root perforations near metallic
use the CEJ as an anatomical reference, in mandibular second molars in the
intracanal posts by using cone beam
we suggest that beginners use retentive Hong Kong population: a computed
computed tomography. J Endod 2011; 37:
rubber dam clamps with narrow jaws,
85–90. tomographic study. Hong Kong Dent J
curved and slightly inverted, to help with
8. Tikku AP, Pandey WP, Shukla I. Intricate 2008; 5: 27–30.
gingival displacement when placed below
internal anatomy of teeth and its clinical 21. Brown J, Jacobs R, Levring Jäghagen
the maximum diameter of the crown of the
significance in endodontics. A review. E et al. Basic training requirements for
tooth being treated.
Endod 2012; 24: 160–169. the use of dental CBCT by dentists:
9. Kulild JC, Peters DD. Incidence and a position paper prepared by the
Conclusion configuration of canal systems in the European Academy of DentoMaxilloFacial
In spite of all of our best efforts, problems mesiobuccal root of maxillary molar first Radiology. Dentomaxillofac Radiol 2014;
during root canal treatment can occur. The and second molars. J Endod 1990; 16: 43: 20130291.
above description can help to overcome 311–316. 22. Patel S, Brown J, Pimentel T et al.
and remedy the most common problems 10. Jha P, Nikhil V, Arora V, Jha M. The root
Cone beam computed tomography in
that a practitioner might encounter. The and root canal morphology of the human
endodontics – a review of the literature.
observer should be cautioned, however, mandibular premolars: a literature review.
that the number of orifices does not Int Endod J 2019; 52: 1138–1152.
J Res Dent 2013; 1: 3–10.
necessarily correlate to the number of 23. Patel S, Dawood A, Whaites E, Pitt Ford T.
11. Versiani MA, Ordinola-Zapata R, Keleş A
canals. Sometimes, more than one canal can New dimensions in endodontic imaging:
et al. Middle mesial canals in mandibular
be present in a single orifice.  first molars: a micro-CT study in different part 1. Conventional and alternative
populations. Arch Oral Biol 2016; 61: radiographic systems. Int Endod J 2009; 6:
Acknowledgements 130–137. 447–462.
This review is a part of PhD dissertation 12. Ahmad IA, Alenezi MA. Root and root 24. Plotino G, Tocci L, Grande NM, et al.
being carried out in the Department of canal morphology of maxillary first Symmetry of root and root canal
Conservative Dentistry and Endodontics premolars: a Literature review and morphology of maxillary and mandibular
at Terna Dental College and Hospital, Navi clinical considerations. J Endod 2016; 42: molars in a white population: a cone-
Mumbai affiliated to the Maharashtra 861–872. beam computed tomography study in
University of Health Sciences, Nashik. 13. De Pablo ÓV, Estevez R, Sánchez MP et al. vivo. J Endod 2013; 12: 1545–1548.

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