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195
ENDO (Lond Engl) 2012;6(3):195205

REVIEW ARTICLE
Key words accessory root, accessory root canal, mandibular molar, middle mesial canal, root,
root canal
Hany Mohamed
Aly Ahmed
Department of Restora-
tive Dentistry, School of
Dental Sciences, Universiti
Sains Malaysia, Kelantan,
Malaysia
Norhayati Luddin
Department of Restora-
tive Dentistry, School of
Dental Sciences, Universiti
Sains Malaysia, Kelantan,
Malaysia
Correspondence to:
Dr Hany Mohamed Aly
Ahmed
Department of Restorative
Dentistry,
School of Dental Sciences,
Universiti Sains Malaysia,
Kubang Kerian, 16150,
Kelantan, Malaysia
Tel: 00-601-29857937
Email: hany_endodontist@
hotmail.com
Hany Mohamed Aly Ahmed, Norhayati Luddin
Accessory mesial roots and root canals in
mandibular molar teeth: Case reports, SEM analysis
and literature review
Introduction
Thorough knowledge on root and root canal morph-
ology is a fundamental prerequisite for successful
root canal treatment
1
. Accessory roots in mandibular
permanent molar teeth have been comprehensively
investigated in previous studies
2-7,
and it can be
concluded that the occasion of this anatomical ab-
erration varies according to ethnicity, gender and
association with some diseases
4, 8-10
. While the oc-
currence of radix entomolaris (accessory disto lingual
roots) and radix paramolaris (accessory buccal roots)
is usually mentioned as the typical clinical nding
for three-rooted mandibular permanent molar
teeth
6,11
, the occasion of three-rooted mandibular
Adequate knowledge on the root and root canal morphological variations is essential for successful
endodontic treatment. Mandibular molar teeth show considerable variability and complexity in their
external and internal radicular morphology that require special attention from dental practitioners to
provide the best clinical outcomes for the patients. This report aims to describe two clinical cases of
mandibular molar teeth with accessory mesial roots/root canals. The rst case demonstrates a suc-
cessful identication and endodontic management of a three-rooted mandibular second molar with
an accessory mesial root, and the second case presents a mandibular rst molar with ve root canals,
in which three separate mesial root canals were identied. With the aid of SEM and radiographic
examination, both external and internal radicular morphological analysis were also performed on
an extracted mandibular second molar tooth having an apical mesial root bifurcation. In addition,
a review on the literature was undertaken to identify the available in vitro and in vivo studies that
demonstrated these anatomical aberrations in the mesial root of mandibular molar teeth.
molar tooth with an accessory mesial root can be
rather common
4,12-18
. In addition, some studies and
reported cases demonstrated the occurrence of four-
rooted mandibular molar teeth having double mesial
roots
4,5,16,18-22
.
Apart from this external anatomical aberration,
mandibular molar teeth show an increased likelihood
for internal morphological variations including root
canals with unusual congurations, lateral and furca-
tion canals and inter-canal communications
1,23-25
.
Within this complex anatomy of the root canal sys-
tem, the increased prevalence of additional root
canals, which is signicantly inuenced by ethnicity
and age
1,26
, is considered at the forefront of chal-
lenges facing clinicians while performing endodontic
Ahmed/Luddin Accessory mesial roots and root canals in mandibular molar teeth 196
ENDO (Lond Engl) 2012;6(3):195205
therapy. Even though mandibular molar teeth are
usually presented with double mesial root canals, as
many as four canals have been reported in the mesial
root of mandibular molar teeth
27-30
.
Because of these external and internal anatom-
ical discrepancies, it is of prime importance for the
clinicians to clearly identify their morphological land-
marks. Hence, this article aims to present two clin-
ical cases and one extracted mandibular molar tooth
having these anatomical aberrations in the mesial
root. In addition, a literature search for the available
and relevant articles, cited in PubMed and Google
Scholar from 1971 to 2011, was undertaken to iden-
tify the available in vitro and in vivo studies that
demonstrated this aberrant anatomy.
Case 1
A 30-year-old male patient was referred with the
chief complaint of a dull pain while chewing on
the mandibular right side. The medical history was
noncontributory. The clinical examination revealed
a large and deep carious cavity related to the man-
dibular right second molar with slight pain on per-
cussion. There was no evidence of current swelling or
tooth mobility. Radiographically, the tooth showed
widening of the periodontal ligament spaces around
the mesial and distal roots (Fig 1a). A second mesial
root was identied (Fig 1a). The pulp of the tooth
was provisionally diagnosed as necrotic with asym-
tomatic apical periodontitis. Following caries excava-
tion, the pulp was conrmed to be necrotic and a
root canal treatment was scheduled.
All endodontic procedures were performed with
the aid of magnication using 4 prismatic dental
loupes (Heine, Herrsching, Germany), accessory
light emitting diode illumination (LED) (3S, Heine,
Herrsching, Germany) and rhodium plated front
surface mirror (Hahnenkratt, Knigsbach-Stein, Ger-
many). After the administration of local anaesthesia
and rubber dam isolation, the access cavity prep-
aration was completed. During exploration of the
pulp chamber, a wide buccolingual dimension of the
mesial access cavity wall was noted, indicating the
complete division of the mesial root into two well-
separated mesial root components (Fig 1b).
Following this, the mesiobuccal (MB), mesio-
lingual (ML) and distal (D) root canals were coronally
shaped using sizes 2 and 3 Gates-Glidden drills (Mani,
Tochigi, Japan ). The working length was determined
using electronic apex locator (Element Diagnostic
Unit, SybronEndo, Orange, California, USA), and the
canals were initially instrumented using hand K-Flex-
oles (Dentsply Maillefer, Ballaigues, Switzerland) up
to sizes 25 and 30 for the mesial and distal canals,
respectively. Subsequently, with the aid of a NaviTip
needle gauge 29 (Ultradent, South Jordan, Utah,
USA), the canals were injected with an aqueous
radiopaque calcium hydroxide paste (UltraCal XS,
Ultradent, South Jordan, Utah, USA), and the access
cavity was then temporized using a fast set highly
viscous conventional glass ionomer cement (Ionol
Molar AC Quick, Voco, Cuxhaven, Germany). In the
following visit, the hand mechanical instrumentation
was continued up to sizes 35 and 45 for the mesial
and distal root canals, respectively. Finally, the canals
were obturated using the lateral compaction tech-
nique (Figs 1c and d).
Case 2
A 40-year-old male patient presented with the main
complaint of severe pain while chewing on man-
dibular left side of the jaw. Clinical and radiographic
examinations revealed a large proximal carious le-
sion related to his mandibular left rst molar with
severe pain on percussion and loss of periapical
periodontal ligament space (Fig 2a). Following
l ocal anaesthesia, the caries was excavated, and
root canal treatment was initiated after the pulp
exposure was conrmed.
Similar to the previous case, all treatment steps
were employed with the aid of assisted magni-
cation and accessory illumination. The tooth was
isolated and the access cavity was prepared, after
restoring the distal wall using a fast set highly vis-
cous conventional glass ionomer cement (Ionol
Molar AC Quick, Voco). The working lengths were
determined for the four root canals (MB mesio-
buccal; ML mesiolingual; DB distobuccal; DL
distolingual) using electronic apex locator (Element
Diagnostic Unit, SybronEndo). The DB and DL root
canals were connected at the apical third of the root
by one apical foramen. The canals were coronally
shaped using Gates-Glidden drills (Mani) (sizes 2
and 3) and apically instrumented to a exible le
ENDO (Lond Engl) 2012;6(3):195205
size 25 (Mani). Then, an aqueous radiopaque cal-
cium hydroxide paste (UltraCal, Ultradent) was in-
troduced into the canals as intracanal medicament
using NaviTip needles gauge 29 (Ultradent), and
the access cavity was then temporized using glass
ionomer cement (Ionol Molar AC Quick, Voco).
In the subsequent visit, a thorough exploration
of the mesial groove between the MB and ML canal
orices was performed using an endodontic explorer
under magnication and a middle mesial (MM) root
canal was located (Fig 2b). The canal showed a sep-
arate apical foramen (Fig 2c). The orice and about
2 mm of the coronal third of the MM canal were
ared using a Gates-Glidden drill (Mani) (size 2), and
the mechanical instrumentation was continued using
stainless steel exible hand les (Mani) until only size
30 to reduce the risk of perforation, while the MB
and ML canals were prepared at size 35. The distal
root canal was instrumented up to size 50. Finally,
the canals were obturated using the lateral compac-
tion technique (Fig 2d).
b
c d
Fig 1 (a) Periapical
radiograph showing the
external outlines of the
two mesial roots (white
arrows). (b) An intraoral
photograph showing
the wide buccolingual
dimension of the me-
sial orices. (c and d)
Postoperative periapical
radiograph.
a
ENDO (Lond Engl) 2012;6(3):195205
Scanning electron microscope (SEM)
and radiographic evaluation of a
mandibular molar with unusual
anatomy of the mesial root
The external and internal morphological features of
a badly decayed mandibular second molar extracted
from an 18-year-old male patient with an apically
bifurcated mesial root were evaluated (Fig 3a). After
resection of the bifurcated mesial root using a hard
tissue microtome (Exakt, Norderstedt, Germany), it
was applied to a small piece of plasticine attached
onto a metal stub for SEM. The stub was then t-
ted into a charge reduction sample holder for non-
conductive samples, and the sample was examined
under a desktop SEM (FEI Phenom, Eindhoven, The
Netherlands). The SEM analysis revealed the pres-
ence of furcation, lateral canals and multiple for-
amina at both apices (Figs 3b to 3i). The radiographic
examination showed three mesial canals, in which
the mesiobuccal and middle mesial root canals were
connected at the middle third of the root (Fig 3j).
Discussion
The incidence of missed roots and root canals in
root canal treated teeth has been reported as high
as 42%
31
. This high percentage indicates that the
a b
c d
Fig 2 (a) Preoperative
radiograph showing
large proximal cavitation
and loss of periapical
periodontal ligament
space. (b) Intraoral
photograph showing
the orices of the three
mesial canals. (c) The
three master cones in
place after mechanical
instrumentation. (d)
Postoperative periapical
radiograph.
ENDO (Lond Engl) 2012;6(3):195205
variability in intra- and extra-radicular anatomy is
the rule rather than the exception. Due to these mor-
phological complexities, it is of prime importance for
the clinician to ignore the absolute condence of the
pre-estimated number of roots and root canals. This
broad anticipation, accompanied with clinical thor-
oughness by utilising well exposed and processed
periapical radiographs with different angulations,
assisted magnication and accessory illumination,
front surface mirrors, proper access cavity prepar-
ation and accurate intra- and inter-canal exploration,
would facilitate the detection of these anatomical
aberrations
6,32,33
.
An accessory root, also known as an extra root,
supernumerary root, supplementary root or addi-
tional root, refers to the development of an increased
number of roots in teeth compared with that clas-
sically described in dental anatomy
34
. Its forma-
tion usually occurs either by splitting the Hertwigs
epithelial root sheath (HERS) to form two similar
roots (usually not possible to dene which one is
the accessory), or by folding of the HERS to form an
independent root
35
. The splitting or folding of the
HERS results in the formation of a bifurcation area,
which may have furcation canals. The specimen for
SEM analysis used in the present study exhibited this
anatomical variation at the furcation area, located
apically, between the mesial roots (Figs 3b and 3c).
This apical location of the furcation area, encasing
the furcation canals, together with the increased
prevalence for lateral canals, apical ramications
and accessory foramina in this apical part of the root
(Figs 3d to 3i), would serve as a well-protected en-
vironment for micro-organisms that may complicate
the optimisation of root canal preparation.
Interestingly, some controversial opinions do exist
with regard to the application of the term accessory
roots. In 1971, De Souza-Freitas et al
12
studied the
anatomical variations of mandibular rst molar roots
in two ethnic groups, and commented that disto-
Fig 3 (a) Mandibular second molar with an apically
bifurcated mesial root. (b and c) Identication of a furcation
canal. (d and e) Detection of a lateral canal at the buccal
surface of the mesiolingual root component. (f to i) Multiple
foramina in the mesiobuccal and mesiolingual roots. (j) The
middle mesial canal was identied, and was connected to
the mesiobuccal canal.
a b d
i
e f h
c
h
MB ML
MM
j
ENDO (Lond Engl) 2012;6(3):195205
lingual roots are the real supplementary roots, and
they did not consider the mesial root bifurcation as
a third root, even though many authors dened this
mesial root bifurcation as extra roots
4,8,15,16,18,22,36
.
Besides this disagreement, it is not clear whether
the level of root bifurcation and degree of separation
should also be considered or not before dening any
root component as an accessory root. Onda et al
20
ex-
amined the shape and number of roots in mandibular
molar teeth extracted from Indian skulls. Interestingly,
the authors dened and correlated the increase in
root number with the presence of distolingual root,
accessory lingual root and bifurcation of the mesial
root. Those samples were then divided according to
the level of mesial root bifurcation, either more or less
than one third of the root length. Accordingly, it seems
sensible that all root bifurcations that have their own
root canals dened as extra roots which can then be
classied according to their level of bifurcation (apical,
middle or cervical) and whether they are separated
or fused. As such, the extracted tooth sample in this
study would be classied as three-rooted mandibular
molar tooth with well separated, double mesial roots
in which the level of bifurcation is at the apical third.
These criteria have almost been followed with other
teeth such as three-rooted maxillary premolars with
double buccal roots
37
.
A review on the literature indicates that the oc-
casion of accessory mesial roots in mandibular molar
teeth, commonly in the 1st molar, ranges from about
0.2% to over 20%
4
,
8,12-14,16,18,38,39
(Table 1). This
was found more frequently in some populations
such as Taiwanese Han Chinese
16,18
, that can reach
22.5%
18
, and to a lesser extent in the Middle East
(Saudi Arabians and Egyptians)
4
, Chinese
39
, and some
populations with European and Japanese descents
12
.
Table 1 Summary for the occurrence of accessory mesial roots in mandibular molar teeth.
(CBCT: cone beam computed tomography, M: Molar, *: unpublished data).
Author/s Year Type of study Percentage % (number of teeth/total)
de Souza-Freitas
et al
12
1971 In vivo (clinical survey)
(radiographic)
4.5% (38/844) of children with European descent (1
st
M)
2.8% (13/466) of children with Japanese descent (1
st
M)
Barker
13
1973 In vitro (extracted teeth) % not listed (2
nd
M).
Specimens from Department of Anatomy, University of
Sydney, Australia
Barker et al
38
1974 In vitro (radiographic) % not listed (2
nd
M).
Specimens from Department of Anatomy, University of
Sydney, Australia
Manning
14
1990 In vitro
(clearing technique)
2% (3/149) (2
nd
M)
Younes et al
4
1990 Phase I: In vitro
(extracted teeth)
0.51% (2/385) of Saudi Arabian (1
st
M)
0.21% (1/457) of Egyptian (1
st
M)
Midtb and
Halse
8
(radiographic)
6.1% (2/33 patients) Turner syndrome (1
st
M)
9.1% (3/33 patients) Turner syndrome (2
nd
M)
Huang et al
16
2007 In vivo (radiographic)
Taiwanese Han Chinese
patients
6.3% (21/332) (3-rooted 1
st
M)
4.5% (15/332) (4-rooted 1
st
M)
Huang et al
18
(CBCT)
Taiwanese Han Chinese
patients
22.5% (117/521) (3-rooted 1
st
M)
18% (94/521) (4-rooted 1
st
M)
Zhang et al
39
(CBCT)
0.4% (1/232) (4-rooted 1
st
M)
Ahmed* 2011 In vivo (clinical survey) 4.44% (2/45) of Saudi Arabian (1
st
and 2
nd
M)
1.81% (1/55) of Egyptian (1
st
and 2
nd
M)
ENDO (Lond Engl) 2012;6(3):195205
In addition, this anatomical variant has been reported
in patients with Turner syndrome
8
.
It can be noted from the rst case that the me-
sial access cavity wall was wide in a buccolingual di-
mension (Fig 1b). The alteration in the access cavity
conguration is usually a common landmark for teeth
having accessory roots
6
, especially when they are well
separated with a coronal bifurcation (Figs 1a and 1b,
and Fig 5b). During the mechanical preparation of
three-rooted mandibular molar teeth, it is important
to evaluate the dentine wall thickness and curvature
of accessory roots
6,17
. This is because when these
roots are relatively thin, the root canal instrumenta-
tion should be performed with caution to avoid strip
perforation caused by over-enlargement of the en-
cased root canals. Additionally, accessory mesial roots
can also be presented with severe curvatures
17
. These
curved roots should be treated carefully, using exible
les and suitable sized irrigation needles with lubrica-
tion
40
, to preserve the normal root canal geometry,
and prevent the incidence of unexpected complica-
tions such as instrument separation
6
.
Similar to accessory roots, accessory root canals in-
dicate an increased number of root canals compared
with that classically described
41,42
. The occurrence of
an accessory mesial root canal in mandibular molar
teeth (commonly the 1
st
molar) shows a wide preva-
lence from 0.4 to over 18%
25,38,42-62
(Table 2). This is
commonly observed in patients of a young age
43,46,48
.
Many studies demonstrated this anatomical variation
in some population groups such as Chinese
47,61,62
, Tai-
wan Chinese
59
, Turkish
49,55
, South Asian Pakistanis
51
,
Burmese
52
, Thai
53
, Japanese
54,58
, Sudanese
56
, Sri
Lankan
58
and Jordanian
60
. However, many of these
studies did not consider the patients age with regard
to their ndings
49,51-53,55,60
. As such, the comparison
between these population groups might not be entirely
relevant as the age factor might have greater contribu-
tion, or more closely associated, with the presence of
accessory root canal rather than ethnicity.
Owing to the morphological variations of the
middle mesial canal, also named as intermediate
canal
46
, Pomeranz et al
43
classied it into three
classes:
a) A n when at any stage during debridement,
the instrument could pass freely between the
mesiobuccal or mesiolingual canal and the mid-
dle mesial canal.
b) A conuent when the prepared canal origin-
ated as a separate orice but apically joined the
mesiobuccal or mesiolingual canal (Figs 3 and 4).
c) The least frequent variant is the independent
when the prepared canal originated as a sep-
arate orice and terminated as a separate for-
amen (Fig 2). Even when the middle mesial
canal is conuent or independent, its orice lo-
cation shows considerable variations. It can be
located near the mesiolingual orice
45,63
, equi-
distant between the mesiobuccal and mesiolin-
gual canals
46,63
(Fig 2), or near the mesiobuc-
cal orice
64
(Figs 3 and 4). The close proximity
of the orice to either the mesiobuccal or me-
siolingual orice does not necessarily indicate its
commun ication to that nearby canal. Sometimes
it is connected to the one with the far orice
64

(Fig 4), or even remains separate
65
.
In order to locate these canals, the clinicians should
be aware of the clinical landmarks and diagnostic
aids that would help in identifying the anatomy of
the root canal space to prevent the undesirable con-
sequences when they are left untreated
66
. These are
summarised in the following points:
The wide buccolingual dimension of the access
cavity may indicate the presence of more than
two mesial canals
29
(Fig 5).
In some instances, a bleeding point or bubbling
on the middle mesial canal orice resulting
from the interaction between sodium hypo-
chlorite and the remaining soft tissues can be
observed
48
.
Fig 4 (a) A mesial root in mandibular molar with a middle mesial (MM) canal orice
close to the mesiobuccal canal (MB). (b) Despite this, the MM canal communicates with
mesiolingual canal (ML). (c) The MM was shaped to size 35.
c
ML
MB
MM
MB MM ML
b a
ENDO (Lond Engl) 2012;6(3):195205
Table 2 Summary for the occurrence of accessory mesial root canals in mandibular molar teeth. Root canal congurations
(3-3, 3-2, 2-3, 3-1, 3-4, 3-2-1, 3-2-3) are included. (CT: computed tomography, microCT: micro-computed tomography;
CBCT: cone beam computed tomography, M: molar, *: unpublished data).

Author/s Year Type of study Percentage (number of teeth/total)
Barker et al
38
1974 In vitro (radiographic and epoxy
resin moulds)
% not listed (1
st
M)
Pomeranz et al
43
1981 In vivo (clinical survey) 11.5% (7/61) (1
st
M)
12.8% (5/39) (2
nd
M)
Vertucci
44
1984 In vitro (clearing technique) 1% (1/100) (1
st
M)
Martinez-Berna and
Badanelli
45
st
M)
0.42% (4/944) (2
nd
M)
Fabra-Campos
46
st
M)
Walker
47
1988 In vitro (radiographic) 1% (1/100) (1
st
M)
Fabra-Campos
48
st
M)
alikan et al
49
1995 In vitro (clearing technique) 3.39% (1
st
M)
1.96% (2
nd
M)
de Carvalho and Zuolo
50
2000 In vitro (operating microscope) 17.2% (16/93) (1
st
M)
4.5% (5/111) (2
nd
M)
Wasti et al
51
2001 In vitro (clearing technique) 3.3% (1/30) (1
st
M)
Gulabivala et al
52
st
M)
Gulabivala et al
53
st
M)
3.33% (2/60) (2
nd
M)
Villegas et al
54
st
M)
Sert and Bayirli
55
st
M)(Male)
Ahmed et al
56
2007 In vitro (clearing technique) 4% (4/100) (1
st
M)
Navarro et al
57
2007 In vitro (CT)
In vitro (SEM)
14.8% (4/27) (1
st
M)
12% (3/25) (1
st
M)
Peiris
58
2008 In vitro (clearing technique) 1% (1
st
M) (Sri-Lankan)
2.6% (1
st
M) (Japanese)
Peiris et al
25
st
M)
Chen et al
59
st
M)
Al-Qudah and
Awawdeh
60
st
M)
1.41% (5/355) (2
nd
M)
Gu et al
61
2010 In vitro (microCT) 2.2% (1/45) (3-rooted 1
st
M)
Karapinar-Kazandag
et al
42
2010 In vitro (loupes followed by
operating microscope) (negoti-
ated canals)
14.58% (7/48) (1
st
M)
18.75% (9/48) (2
nd
M)
Wang et al
62
2010 In vitro (CBCT) 2.68% (11/410) (2-rooted 1
st
M)
0.69% (1/144) (3-rooted 1
st
M)
Ahmed* 2011 In vivo (clinical survey) 1.81% (1/55) (Egyptian) (1
st
and 2
nd
M)
Adequate magnication and illumination pro-
vide a great precision while troughing the
groove between the mesiobuccal and mesio-
lingual canals
1
. This can be performed using a
long shank small round bur or ultrasonic tips
67
.
After troughing, a sharp endodontic explorer
and/or small K-les (size 8 or 10) can be used.
Sometimes, the use of methylene blue staining
is helpful
1
.
Cone beam computed tomography (CBCT) can
also provide a supportive diagnostic tool, which
is recommended when conventional periapical
radiographs provide limited information and fur-
ther anatomical details are required to be iden-
tied
68
. This advanced technology can also be
performed when the mesial root is scheduled
for endodontic surgery. The identication of an
undetected independent middle mesial canal by
ENDO (Lond Engl) 2012;6(3):195205
CBCT helps the operator to optimise the retro-
grade cavity preparation, or may even change
the treatment plan to an attempt for orthograde
endodontic approach. Despite these benets and
due to the possibility of some misleading ndings
in CBCT views, it should adjunctly be correlated
with the clinical picture
69
.
Once found, great consideration should be given
to the external anatomy of the mesial root while
performing mechanical instrumentation. Berutti
and Fedon
70
demonstrated that the distal surface
of the mesial root is concave, and that the dentine/
cementum thickness at this area is one fth less than
its usual appearance in the radiograph. In addition
to this distal concavity, the mesial root can also be
presented with a mesial depression (Fig 5f). As a
result of this anatomical landmark, the middle mesial
canal, which sometimes has a lesser diameter than
the other two canals
46
, should not be over-enlarged
to prevent the danger of perforation. Gates-Glidden
drills should be avoided or used with great caution
when required. The use of enlarging les to size 30
or 35 is considered safe and adequate
45,64,71
(Fig 4).
Conclusion
The mesial root in mandibular molar teeth shows
an increased prevalence for external and internal
radicular aberrations. Adequate knowledge and
good anticipation of these anatomical variations,
as well as clinical thoroughness during every root
canal treatment procedure, are essential for the op-
timisation of root canal therapy, thus maintaining a
high rate of clinical success.
Acknowledgement
The SEM images were taken with the kind assistance
of Mr Chairul Sopian and Ms Nora Aziz, technolo-
gists at the Craniofacial Science Laboratory, School
of Dental Sciences, Universiti Sains Malaysia.
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Fig 5 Schematic illustration showing the orices location in mandibular molar teeth with accessory mesial roots/root canals:
(a) Normal location of the mesial orices in a single mesial root. (b) The presence of a well-separated accessory mesial root
can be corresponded by a wide buccolingual dimension (blue double arrow) of the mesial access cavity wall. (c) A third
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f a b c d e
Buccal
Lingual
M D
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